Scopolamine patch usage?

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Trying to get a sense of the practice patterns of those on the board regarding use of scopolamine patches:

Do you use them heavily particularly in outpatients?, avoid in elderly?, reserve for use in patients with significant history of N/V? Use them heavily for emetogenic procedures regardless of individual history? Are you terribly concerned about issues regarding falls or disorientation post op?

Reason I ask is that I use them heavily but am reconsidering. Put one on myself before going out on a friends boat. Felt a little goofy and dysphoric. Not sure if it was related but...
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Hello Doze. I use a scop patch after most other antiemetics have been exhausted. It's a tertiary amine and the main reason I keep it in the backburner.


"Since drowsiness, disorientation, and confusion may occur with the use of scopolamine, patients should be warned of the possibility and cautioned against engaging in activities that require mental alertness, such as driving a motor vehicle or operating dangerous machinery.

Rarely, idiosyncratic reactions may occur with ordinary therapeutic doses of scopolamine. The most serious of these that have been reported are: acute toxic psychosis, including confusion, agitation, rambling speech, hallucinations, paranoid behaviors, and delusions."
 
dr doze said:
Trying to get a sense of the practice patterns of those on the board regarding use of scopolamine patches:

Do you use them heavily particularly in outpatients?, avoid in elderly?, reserve for use in patients with significant history of N/V? Use them heavily for emetogenic procedures regardless of individual history? Are you terribly concerned about issues regarding falls or disorientation post op?

Reason I ask is that I use them heavily but am reconsidering. Put one on myself before going out on a friends boat. Felt a little goofy and dysphoric. Not sure if it was related but...
Click to expand...

I use it on pts at higher risk for PONV (3 or more risk factors).
 
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I believe I read a paper a few years back that stated that they worked best if they were applied four hours before emergence.

I also use them if the pt has a strong hx of PONV or motion sickness, but I really try to get them on before induction.
 
Dejavu said:
I believe I read a paper a few years back that stated that they worked best if they were applied four hours before emergence.

I also use them if the pt has a strong hx of PONV or motion sickness, but I really try to get them on before induction.
Click to expand...

Yep. Def. works best if you have preselected your patients pre-op and placed the patch early. For outpatients who have a strong history + abdominal/breast surgery/etc., I'll put them on before I bring them into the OR.

But usually, I keep them at .5 MAC at low flows, use IV Tylenol, mag, dex with induction drugs, toradol, low dose ketofol gtt, time my paralytics carefully or opt to omit them all together (no neostigmine if possible) and employ regional when appropriate. Paravertebral blocks for breasts/TAP blocks for abdominal incisions. Keep BP high end of normal. Zofran 15 minutes before emergence. This works >95% of the time... but every now and again a sheep will get out of the barn. These are the ones I'm trying to pick up and administer a preop scop patch.

I have tried a scop patch before. I did not like the feeling. Definitely felt an altered sensorium. But I'm a light weight... 🙄
 
So for the HTNsive patient with a presumed normal systolic B.P. of 175, an intraop record that shows train tract systolics in the 100-110's during induction and maintanence of anesthesia might not be as peachy as it may appear. I believe that this divergence from normal will contribute to post-operative nausea and vomiting. For this patient, I would try and keep my B.P.'s around 150's if there are no contraindicaitons or end organ isssues that may benefit from a lower B.P. (i.e. active arterial bleeding or 7cm AAA for emergent whatever).

Autoregulation is shifted to the right in these chronically HTNsive patients and many key organs like the B.P. higher (heart, brain, kidneys, etc..). There are exceptions such as the uterus which is a pressure dependant organ- and pretty resistant organ in terms of tolerable high and low B.P.'s).

I can't find the exact study, but here is one that describes a decrease in B.P. > 35% on induction and it's resultant effects on nausea and vomiting.

http://www.anesthesia-analgesia.org/content/94/6/1652.full

I liked this paragraph:

A temporary decrease in splanchnic perfusion may result (8). Intestinal tissues are highly metabolically active and have a poor tolerance for even brief periods of ischemia. One consequence of isch-emia is the release of 5-hydroxytryptamine from the intestine where it acts as a local vasodilator. Large serotonin concentrations are frequently associated with PONV (9). Rapid ΔSBP during the induction of anesthesia may also reduce the blood flow to the brainstem and influence the chemoreceptor trigger zone. This may intensify adverse effects of anesthetics such as dizziness, disturbance of the vestibular system, nausea, and vomiting.
 
One thing I keep in mind with these high risk PONV patients is that: In an adult, HTN and Tachycardia can be attenuated/abolished by agents such as precedex (20-40mcg), clonidine (50-100mcgs), esmolol, or small boluses of propofol during stimulating parts of the procedure. They are devoid of N/V risks and in some cases protective (propofol).

Removal of opiods and .5 MAC anesthesia along with a multimodal approach to anesthetic delivery (including regional and ketofol) in a patient at high risk for PONV is a good formula to avoid dissatisfied patients in the PACU. It is more cumbersome than prop,sux, tube, but well worth it in selected cases.

I was recently informed that medicare might be looking at patient satisfaction surveys as a means for determining a certain percent of reimbursement for surgical procedures. Something one of my partners heard at the ASA.
 
sevoflurane said:
But usually, I keep them at .5 MAC at low flows, use IV Tylenol, mag, dex with induction drugs, toradol, low dose ketofol gtt, time my paralytics carefully or opt to omit them all together (no neostigmine if possible) and employ regional when appropriate. Paravertebral blocks for breasts/TAP blocks for abdominal incisions. Keep BP high end of normal. Zofran 15 minutes before emergence. This works >95% of the time... but every now and again a sheep will get out of the barn. These are the ones I'm trying to pick up and administer a preop scop patch.
Click to expand...

Thoughts on low dose Haldol?
 
I pretty much agree with everything you are saying although the last time I checked I seem to recall that the association of PONV with reversal agent was tenuous at the very best.

sevoflurane said:
Yep. Def. works best if you have preselected your patients pre-op and placed the patch early. For outpatients who have a strong history + abdominal/breast surgery/etc., I'll put them on before I bring them into the OR.

But usually, I keep them at .5 MAC at low flows, use IV Tylenol, mag, dex with induction drugs, toradol, low dose ketofol gtt, time my paralytics carefully or opt to omit them all together (no neostigmine if possible) and employ regional when appropriate. Paravertebral blocks for breasts/TAP blocks for abdominal incisions. Keep BP high end of normal. Zofran 15 minutes before emergence. This works >95% of the time... but every now and again a sheep will get out of the barn. These are the ones I'm trying to pick up and administer a preop scop patch.

I have tried a scop patch before. I did not like the feeling. Definitely felt an altered sensorium. But I'm a light weight... 🙄
Click to expand...
 
Arch Guillotti said:
I pretty much agree with everything you are saying although the last time I checked I seem to recall that the association of PONV with reversal agent was tenuous at the very best.
Click to expand...


I think I remember hearing this, but I look at it from a different perspective:

In general, side effects of anticholinesterases include bradycardia, hypotension, bronchospasm, increased respiratory secretions, nausea and vomiting (although this is controversial as you stated), increased GI motility and secretions, miosis, and decreased intraocular pressure.

The GI motility is 100% true.

During residency, there was a particular colo-rectal surgeon who was a notorious arsehole (no pun intended). I loved to be passive aggressive and reverse early as he was putting on the ostomy bag. You know what happened next. :meanie: 😀

Increased GI motility, I think in and of itself can cause some degree of nausea especially in a case where the intra-abdominal cavity has been manipulated or the bowels have been "run" for some reason or the other (or maybe it's just running to bowels). It is my impression that when neostigmine is administered abdominal cramping and diarrhea 2/2 high parastaltic tone most certainly can happen. Think of a small non-obstructive stricture/adhesion and the increased parastalsis with neostigmine. Would this increase N/V? I don't think it helps.

But I hear you and honeslty, I have to look at the studies you are referring to.

The way I see it, in most of my cases I try to keep my paralytics to a minimal and if there is a small benefit of not giving neostigmine or reducing the amount given, then great. I have nothing to loose and possibly something to gain.

PONV is multifactorial event and I try to chip away at anything that may give me an edge over this PACU annoyance.
 
dr doze said:
Do you use them heavily particularly in outpatients?, avoid in elderly?, reserve for use in patients with significant history of N/V? Use them heavily for emetogenic procedures regardless of individual history? Are you terribly concerned about issues regarding falls or disorientation post op?
Click to expand...

I'll apply them preop in young patients who tell me they had terrible postop nausea previously. If they say they had a little nausea, then I typically just do what I usually do, + one more IV antiemetic. I miss having droperidol available at one of our hospitals, but there's just no reasoning with the pharmacy.

I don't use them in old people.
 
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sevoflurane said:
So for the HTNsive patient with a presumed normal systolic B.P. of 175, an intraop record that shows train tract systolics in the 100-110's during induction and maintanence of anesthesia might not be as peachy as it may appear. I believe that this divergence from normal will contribute to post-operative nausea and vomiting. For this patient, I would try and keep my B.P.'s around 150's if there are no contraindicaitons or end organ isssues that may benefit from a lower B.P. (i.e. active arterial bleeding or 7cm AAA for emergent whatever).

Autoregulation is shifted to the right in these chronically HTNsive patients and many key organs like the B.P. higher (heart, brain, kidneys, etc..). There are exceptions such as the uterus which is a pressure dependant organ- and pretty resistant organ in terms of tolerable high and low B.P.'s).

[/B]
Click to expand...

Isn't the standard of care to maintain BP within 20% of baseline in all patients intraoperatively unless specific situations mandate otherwise? IMHO a BP 30-40% below baseline is never OK and a prolonged course of low BP contributes to intraoperative stroke and MI as well as PONV.

I've gone through anesthetic records from patients that never woke up from massive CVA during surgery and seen train track vitals with BP well below baseline. For a chronically hypertensive patient, particularly elderly, you need to keep their BP up in the case.
 
I don't know about standard of care.

But yeah... 120/80 isn't for everybody. Not even the mildly hypertensive otherwise healthy 30 y/o that is coming in for a inguinal hernia repair.

Deliberate Hypotension isn't mandatory, and it has it's place in certain scenarios where blood conservation is an issue. Risks vs Benefits.

http://www.anesthesia-analgesia.org/content/97/5/1529.full

http://journals.lww.com/rapm/Abstra...sive_Epidural_Anesthesia_in_Total_Knee.3.aspx

Abstract
Background and Objectives:: For decades, hypotensive anesthesia has been used in an attempt to reduce intraoperative blood loss. Hypotensive epidural anesthesia (HEA) is a relatively new technique in hypotensive anesthesia. Use of a tourniquet has been shown to be associated with a higher risk of cardiovascular and thromboembolic complications. The effect of HEA on blood loss and need for transfusion in total knee replacement (TKR) is not known.

Conclusions:: We conclude that HEA is a safe technique that allows TKR without a tourniquet. Compared with spinal anesthesia, the use of HEA for TKR significantly reduces blood loss and the need for blood transfusion.



I personally don't use deliberate hypotension unless there is a real reason: Jehova's witness.

I might use it for big back whacks. Scoli/big fusion in otherwise healthy individuals. I think a little nausea is better than iatrogenic blood products... and I'm not dramatic about how low I might go. I might accept 30% in the right person
 
Last edited:
Mman said:
Isn't the standard of care to maintain BP within 20% of baseline in all patients intraoperatively unless specific situations mandate otherwise? IMHO a BP 30-40% below baseline is never OK and a prolonged course of low BP contributes to intraoperative stroke and MI as well as PONV.
Click to expand...

I'm with you. It annoys the hell out of me to go relieve a member of Clan 3 PM and find that they've been charting BPs of 80/whatever for the last 90 minutes on "just a healthy ASA 2, has a bit of hypertension" ...
 
http://www.ncbi.nlm.nih.gov/pubmed/18511238

In terms of risk, no significant changes in cerebral, cardiovascular, renal and hepatic functions in patients receiving hypotensive anaesthesia compared to control were reported. In conclusion, hypotensive anaesthesia appears to be effective in reducing blood loss. Serious consequences due to organ hypoperfusion are uncommon. Hypotensive anaesthesia can be justified as a routine procedure for orthognathic surgery especially bimaxillary osteotomy. Patient selection and appropriate monitoring are mandatory for this technique to be carried out safely.

Still... not a big fan. A lot of these individuals have plenty of comorbid conditions.
 
Can't argue with any of that.

sevoflurane said:
I think I remember hearing this, but I look at it from a different perspective:

In general, side effects of anticholinesterases include bradycardia, hypotension, bronchospasm, increased respiratory secretions, nausea and vomiting (although this is controversial as you stated), increased GI motility and secretions, miosis, and decreased intraocular pressure.

The GI motility is 100% true.

During residency, there was a particular colo-rectal surgeon who was a notorious arsehole (no pun intended). I loved to be passive aggressive and reverse early as he was putting on the ostomy bag. You know what happened next. :meanie: 😀

Increased GI motility, I think in and of itself can cause some degree of nausea especially in a case where the intra-abdominal cavity has been manipulated or the bowels have been “run” for some reason or the other (or maybe it's just running to bowels). It is my impression that when neostigmine is administered abdominal cramping and diarrhea 2/2 high parastaltic tone most certainly can happen. Think of a small non-obstructive stricture/adhesion and the increased parastalsis with neostigmine. Would this increase N/V? I don't think it helps.

But I hear you and honeslty, I have to look at the studies you are referring to.

The way I see it, in most of my cases I try to keep my paralytics to a minimal and if there is a small benefit of not giving neostigmine or reducing the amount given, then great. I have nothing to loose and possibly something to gain.

PONV is multifactorial event and I try to chip away at anything that may give me an edge over this PACU annoyance.
Click to expand...
 
Bumping an old thread because I no longer have droperidol for those who have failed the normal cocktail of decadron/Zofran. I hate scopolamine unless a patient has a history of motion sickness/vertigo or specifically requests. Anyone using aripepitant (emend)? I've heard the data is decent.
 
Yangkower said:
Bumping an old thread because I no longer have droperidol for those who have failed the normal cocktail of decadron/Zofran. I hate scopolamine unless a patient has a history of motion sickness/vertigo or specifically requests. Anyone using aripepitant (emend)? I've heard the data is decent.
Click to expand...

Isn't that the one they have to take several hours preop to be effective?
 
Yes, which could make it logistically difficult unless they are prescribed ahead of time.
 
I have been using haldol and propofol in low doses. Also Benadryl but try to avoid that if I used scop and haldol. Iv hydration for some works too.
 
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