Routine Lap Chole?

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: Anesth Analg. 2009 May;108(5):1498-504. Links

A randomized, double-blind, multicenter trial comparing transdermal scopolamine plus ondansetron to ondansetron alone for the prevention of postoperative nausea and vomiting in the outpatient setting.

Gan TJ, Sinha AC, Kovac AL, Jones RK, Cohen SA, Battikha JP, Deutsch JS, Pergolizzi JV Jr; TDS Study Group, Glass PS.
Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA. [email protected]
BACKGROUND: Postoperative nausea and vomiting (PONV) are common complications after ambulatory surgery. We sought to determine whether the use of transdermal scopolamine (TDS) in combination with IV ondansetron (OND) is more effective than one alone for reducing PONV in outpatient settings. METHODS: In a randomized, double blind, multicenter trial, 620 at-risk female patients undergoing outpatient laparoscopic or breast augmentation surgery received either an active TDS patch or a similar appearing sham 2 h before entering the operating room. All patients received IV OND (4 mg) 2-5 min before induction of anesthesia followed by a general anesthetic regimen. Complete antiemetic response, defined as no vomiting/retching or rescue medication use, was measured through 24 h and 48 h after surgery. The proportion of patients with vomiting/retching, nausea, or use of rescue medication, the time from the end of surgery to the first episode of these events and the time to discharge from the hospital/surgery center, as well as the number and severity of vomiting/retching and nausea episodes, and patient satisfaction with antiemetic therapy were also collected. RESULTS: The combination of TDS + OND statistically significantly reduced nausea and vomiting/retching compared with OND alone 24 h after surgery but not at 48 h. The proportion of patients who did not experience vomiting/retching and did not use rescue medication was 48% for TDS + OND and 39% for OND alone (P < 0.02). Total response (no nausea, no vomiting/retching, and no use of rescue medication) was also statistically higher for the TDS + OND group compared with the OND-only group (35% vs 25%, P < 0.01). The time to first nausea, vomiting/retching, or rescue episode was statistically significantly longer for the TDS + OND group compared with the OND-only group (P < 0.05). The cumulative overall incidence of adverse events was lower in the TDS + OND group compared with the OND group (36.7% vs 49%, P < 0.01). CONCLUSIONS: TDS + OND reduces PONV compared with OND alone. This is achieved with a reduction in adverse events

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Since nobody is willing to step up to the plate regarding Reglan (Metoclopramide) I guess it is up to me.

At the 10 mg I.V. dosage Reglan is a "weak" anti-emetic at best. Most studies show no effect if given as the solo anti-emetic; however, if Reglan is combined with other anti-emetics (multimodal therapy) then it has an effect (minor).

But, if Reglan is given at higher dosages (20 mg I.V.) then it is most likely more effective than placebo. It certainly will help to empty the stomach. If high dose Reglan is chosen it is important to give that extra 10 mg I.V. with induction.

Volume 305:905-909
October 15, 1981
Number 16[FONT=arial,helvetica][SIZE=-1]Next[/SIZE].

[FONT=Arial, Helvetica, sans-serif][SIZE=+2]Antiemetic efficacy of high-dose metoclopramide: randomized trials with placebo and prochlorperazine in patients with chemotherapy-induced nausea and vomiting[/SIZE].

[SIZE=+1]RJ Gralla, LM Itri, SE Pisko, AE Squillante, DP Kelsen, DW Braun, LA Bordin, TJ Braun, and CW Young [/SIZE]

[FONT=arial, helvetica][SIZE=+1]Abstract[/SIZE]. [FONT=arial, helvetica]In a study of the effectiveness of high intravenous doses of metoclopramide as an antiemetic, 41 patients with advanced cancer who were being treated with cisplatin were entered into two double-blind trials. In the first trial patients were randomly assigned to receive either metoclopramide or placebo, and in the second trial they received either metoclopramide or prochlorperazine. Patients given metoclopramide had significantly fewer episodes of emesis than patients given placebo (medians, 1.0 vs. 10.5; P = 0.001) or prochlorperazine (medians, 1.5 vs. 12.0; P = 0.005). Metoclopramide was superior to placebo and to prochlorperazine in reducing the volume of emesis (P = 0.001 and P = 0.022, respectively) and was more effective than placebo in shortening the duration of nausea (P = 0.042) and vomiting (P = 0.028). Side effects from metoclopramide were minor, with mild sedation frequently observed; one patient had a brief extrapyramidal reaction. We conclude that metoclopramide in high intravenous doses has greater antiemetic activity than placebo or prochlorperazine in patients receiving cisplatin chemotherapy. .
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Here is a patient describing Reglan:

"I had an extreme anxiety attack within minutes after receiving 10mg of Reglan IV. I felt like a was going to stop breathing and could not stop crying and screaming for help. It stopped after 5 minutes when the IV Benadryl kicked in. I would recommend having Benadryl given and then Reglan instead of vice versa. After I recovered from the anxiety attack, my migraine did go away. My chest is still heavy and I still feel jittery."

"Terrible panic attack almost immediately. Severe anxiety and very strange dark thoughts. I felt I was going to go crazy. I had gone into the ER for some pain medication for my 3 day migraine and they gave me Reglan in an IV. I thought I was going to die."
Posted On: July 28, 2009 by Jeff Lowe
FDA Requires Black Box Warning for Label of Gastrointestinal Drug Reglan

The U.S. Food and Drug Administration has ordered makers of a drug for digestive problems to add the strongest warning possible to its label, WebMD reported earlier this year. The “black box” warning will caution patients about the risk of developing a serious and potentially incurable muscle disorder called tardive dyskinesia after taking Reglan (metoclopramide). Patients with tardive dyskinesia have involuntary, repetitive muscle spasms, including pursing and smacking of the lips, grimacing, sticking out the tongue and rapid blinking. Patients taking Reglan who have noticed these effects are encouraged to contact the FDA to report any problems with the medication.
According to the FDA press release, two million Americans take some form of Reglan. It is used primarily to treat nausea and vomiting due to certain kinds of cancer treatments, infection, drug side effects and pregnancy, as well as for diabetics with digestion problems. Tardive dyskinesia is a known side effect of Reglan, which is why the FDA recommends that patients use the drug for no more than three months at a time. However, the agency ordered the more stringent warning after recent analyses found that Reglan is the most common cause of drug-induced movement disorders. The agency had also received continuing and spontaneous reports of patients developing tardive dyskinesia after using Reglan. Reglan was also the subject of a defective drug lawsuit in California, in which drug maker Wyeth was held liable for its failure to warn patients about the risk of tardive dyskinesia.
Tardive dyskinesia is a side effect of prolonged or high-dose use of dopamine antagonist medications, including antipsychotics and neurological drugs as well as Reglan and other gastrointestinal drugs. The condition may be mistaken for Parkinson’s disease, but while Parkinson’s patients have trouble moving, tardive dyskinesia patients have trouble not moving. These patients experience involuntary, rapid and repetitive movements, especially movement in the face, fingers and extremities. The movements may or may not disappear after the drug is stopped, and they may take years to subside. There is no known cure for tardive dyskinesia, which is why medical professionals focus on preventing it by limiting the use and dosage of the drugs that cause it.
As a dangerous drug injury attorney, I noticed that Reglan is part of a class of drugs normally used to manipulate the brain chemistry of patients with menal illness or neurological disorders. That’s one reason why Reglan’s side effects include tardive dyskinesia and other neurological symptoms, from drowsiness and dizziness to neuroleptic malignant syndrome. This is too high a price to pay for relief from nausea and vomiting. As the FDA said, this black box warning on Reglan should help patients and doctors make an informed decision about whether the risks are worth the benefits. But for the millions who have already taken Reglan, it may be too late. If an investigation shows that Wyeth and others failed to adequately warn patients of the risk of tardive dyskinesia before the labeling change, patients who develop this terrible, incurable disability have the right to sue the drug makers.
The Lowe Law Firm specializes in representing people who were seriously hurt by taking a prescription drug that was supposed to help. Our pharmaceutical injury attorneys help patients and their families hold drug manufacturers legally liable for injuries caused by flaws in their medication, or lack of warning about potentially dangerous side effects. In a lawsuit, these patients may claim all of the financial costs of the injuries and illnesses the drugs caused, including past and future medical costs to treat the effects of the drug as well as lost income when the victim cannot work. They can also claim compensation for their injuries, physical pain, emotional suffering and any permanent disability caused by the dangerous drug. Based in St. Louis and Belleville, Ill., we help people throughout the United States.
If you or a loved one developed severe side effects after taking Reglan or any other prescription drug, the Lowe Law Firm can help. To learn more about your options and your rights at a free, confidential consultation, you can call us toll-free at 1-877-678-3400 from anywhere in the United States or contact us via email.
Still, what is the likelihood she has at least some CAD? What about diastolic dsyfunction? Is mild diastolic dysfunction likely here?

Anybody care to take a stab at this question? Does it matter?

So everyone is saying no LMA for this lady. As a relatively new MS3 with no OR experience, why should she not have an LMA?
Still, what is the likelihood she has at least some CAD? What about diastolic dsyfunction? Is mild diastolic dysfunction likely here?

Anybody care to take a stab at this question? Does it matter?

The prevalence of diabetes mellitus is increasing rapidly and affects approximately 170 million individuals worldwide. The leading cause of death in diabetes is cardiovascular disease, and the presence of diabetes raises the risk of perioperative morbidity and mortality two- to threefold. There is a known association between diabetes and adverse cardiovascular outcomes, such as heart failure. From 36% to 47% of all patients with clinical heart failure have diabetes. The development of diabetic cardiomyopathy is not completely understood but typically manifests after four to five years of clinical diabetes and may be linked to chronic elevations in blood sugar. Diabetic cardiomyopathy appears to develop independent of coronary artery disease, valvular heart disease, or hypertension. The cardiomyopathy of diabetes typically presents with diastolic dysfunction ultimately progressing to overt heart failure. In patients with diabetes, heart failure is most frequently associated with preserved left ventricular systolic function, defined as an ejection fraction above 50%. However, it has been reported that as many as 60%—75% of asymptomatic, well-controlled type-2 diabetic patients have diastolic dysfunction and 28% develop severe diastolic dysfunction with elevated left ventricular filling pressures. In those who do develop heart failure, preserved systolic function does not appear to confer any benefits and there is no difference in mortality rates for patients with either preserved or decreased left ventricular function. The risk of developing heart failure in diabetes is sex dependent with women having three times the relative risk of men.
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  2. Bell DS. Heart failure in the diabetic patient. Cardiol Clin. 2007; 25:523—538.
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  4. Miller RD. Miller's Anesthesia. 6th ed. Philadelphia: Elsevier Churchill Livingstone; 2005:1019—1027, 1778