Sodium thiopental recovery?

[Healthinfo104]

Does sodium thiopental, or other barbiturate anesthetics for that matter have a high or low incidence of post operative nausea and vomiting?

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[btbam]

Does sodium thiopental, or other barbiturate anesthetics for that matter have a high or low incidence of post operative nausea and vomiting?

When’s the last time you used thiopental?

 

[Noyac]

Higher incidence. This is the main advantage of propofol in my opinion. STP has less hemodynamic changes than propofol because while causing vasodilation it also causes an increase in HR which will counter the hypotension somewhat. It’s a good drug but it’s a nasty recovery when compared to propofol.

 

[Healthinfo104]

Higher incidence. This is the main advantage of propofol in my opinion. STP has less hemodynamic changes than propofol because while causing vasodilation it also causes an increase in HR which will counter the hypotension somewhat. It’s a good drug but it’s a nasty recovery when compared to propofol.

Does it actually cause nausea and vomiting? Or does it just not have antiemetic properties and help to mitigate PONV from the surgery like propofol does?

 

[Planktonmd]

Does it actually cause nausea and vomiting? Or does it just not have antiemetic properties and help to mitigate PONV from the surgery like propofol does?

I think it is actually the lack of anti-emetic effect. We also have to remember that when STP was the main induction agent two decades ago, people in general used to give more opiates than today and frequently used Nitrous Oxide, which might be the cause of the perceived increase in PONV.

 

[deleted697535]

It's a great drug. You give 500 of thio to a pregnant lady and she's out long before the sux. 200 of propofol and some of them are still talking to you...

 

[pgg]

Doesn’t burn the way propofol does, too. I used to like it for pediatric IV inductions for that reason. Too bad we lost it.

 

[deleted162650]

It's a great drug. You give 500 of thio to a pregnant lady and she's out long before the sux. 200 of propofol and some of them are still talking to you...

How often are you inducing pregnant ladies??

 

[Healthinfo104]

I think it is actually the lack of anti-emetic effect. We also have to remember that when STP was the main induction agent two decades ago, people in general used to give more opiates than today and frequently used Nitrous Oxide, which might be the cause of the perceived increase in PONV.

Thank you. I always wondered this, when it is said that such an such anesthetic has a higher incidence of PONV is it actually the drug itself? Or is it just the lack of antimetic effects like propofol that help to fight nausea induced by other factors in surgery (ie, opioids, muscle relaxants, surgery location, etc.)

 

[nimbus]

I agree it's more the lack of an antiemetic effect. We used to use methohexital or thiopental with sux for ECTs. None of those patients got nausea. It's not emetogenic by itself.

 

[deleted162650]

I have a hard time believing a single induction dose of propofol has any significant anti-emetic effect post-op. I do believe in the low dose prop gtt for PONV though.

 

[Healthinfo104]

I have a hard time believing a single induction dose of propofol has any significant anti-emetic effect post-op. I do believe in the low dose prop gtt though PONV.

What is it that you believe in?

 

[deleted162650]

What is it that you believe in?

Running sub-hypnotic dose prop at 25ish mcg/kg/min for PONV prophylaxis. Even more effective though is running prop a bit higher and reducing the volatile to MAC aware levels (0.4 MACish). I have done the latter in a number of patients now with a Hx of severe PONV with great results and avoided the PITA that is pure TIVA.

 

[Lecithin5]

Running sub-hypnotic dose prop at 25ish mcg/kg/min for PONV prophylaxis. Even more effective though is running prop a bit higher and reducing the volatile to MAC aware levels (0.4 MACish). I have done the latter in a number of patients now with a Hx of severe PONV with great results and avoided the PITA that is pure TIVA.

Although I've never used propofol as a last-resort solution to ponv, I was under the impression that a simple 10 to 20 mg push of propofol does the trick. Any truth to this?

 

[Healthinfo104]

I have a hard time believing a single induction dose of propofol has any significant anti-emetic effect post-op. I do believe in the low dose prop gtt for PONV though.

So in your opinion, what do you think a count for the difference in PONV rates between propofol and Thiopental?

 

[deleted162650]

So in your opinion, what do you think a count for the difference in PONV rates between propofol and Thiopental?

Never given Thiopental - I trained after it went the way of the dinosaurs, so I have zero first hand experience with it. It just makes no sense to me from a pharmacological standpoint that a single dose of prop would prevent you from puking a few hours after it was given when it redistributes in 5 minutes.

 

[Healthinfo104]

Never given Thiopental - I trained after it went the way of the dinosaurs, so I have zero first hand experience with it. It just makes no sense to me from a pharmacological standpoint that a single dose of prop would prevent you from puking a few hours after it was given when it redistributes in 5 minutes.

True, so maybe it's just the type of surgery they are performing, the amount of opioids and other factors like that that are effecting the PONV rates and not necessarily the induction agent itself.

 

[nimbus]

The difference wasn't just nausea. Even more prevalent was that many patients felt "hung over" and not clear headed for hours after a full induction dose of Pentothal. Propofol does not cause this.

 

[drmwvr]

Doesn’t burn the way propofol does, too. I used to like it for pediatric IV inductions for that reason. Too bad we lost it.

Brevital is just as good (I liked it more than STP) and you can still get that. Probably not as cheap as it used to be.

 

[deleted59964]

It's a great drug. You give 500 of thio to a pregnant lady and she's out long before the sux. 200 of propofol and some of them are still talking to you...

and yet accidental awareness on induction is more common with thio.

5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: summary of main findings and risk factors † ‡ | BJA: British Journal of Anaesthesia | Oxford Academic

 

[deleted697535]

and yet accidental awareness on induction is more common with thio.

5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: summary of main findings and risk factors † ‡ | BJA: British Journal of Anaesthesia | Oxford Academic

Many reasons for that incl half the flipping powder left in the vial on reconstitution.

Nap5 is interesting reading but a self reported survey. Hardly top quality evidence

 

[Healthinfo104]

Brevital is just as good (I liked it more than STP) and you can still get that. Probably not as cheap as it used to be.

Brevital is just as good as what?

 

[pgg]

Brevital is just as good (I liked it more than STP) and you can still get that. Probably not as cheap as it used to be.

We used Brevital for routine inductions a few years ago during the propofol shortage. The incidence of myoclonic movement is so high, that if you want to stick an LMA in someone after inducing with Brevital, you need to use muscle relaxant too. It's a fine drug if you flush it through the IV with some rocuronium.

 

[Healthinfo104]

We used Brevital for routine inductions a few years ago during the propofol shortage. The incidence of myoclonic movement is so high, that if you want to stick an LMA in someone after inducing with Brevital, you need to use muscle relaxant too. It's a fine drug if you flush it through the IV with some rocuronium.

Did you find a lot of PONV with Brevital?

 

[deleted59964]

Many reasons for that incl half the flipping powder left in the vial on reconstitution.

Nap5 is interesting reading but a self reported survey. Hardly top quality evidence

it's the best evidence you're going to get. no one is going to do a prospective randomised blinded study on thio vs propofol.

it's a self reporting survey sure ... but it's a BIG self reporting survey.

 

[drmwvr]

We used Brevital for routine inductions a few years ago during the propofol shortage. The incidence of myoclonic movement is so high, that if you want to stick an LMA in someone after inducing with Brevital, you need to use muscle relaxant too. It's a fine drug if you flush it through the IV with some rocuronium.

No doubt. Pentothal wasn't much better for lma's either.

 

[deleted126335]

pentothal had plusses and minuses.

+s: faster than propofol. Doesn't burn, slightly less myocardial depression than propofol.

-s: Precipitates with vecuronium. Don't remember using it with rocuronium, doesn't blunt laryngeal reflexes as well so it S@cked for inserting LMAs, slower emergence and longer discharge times.

 

[Noyac]

How often are you inducing pregnant ladies??

Three today. I can’t stand the whining.

 

[Psai]

Never given Thiopental - I trained after it went the way of the dinosaurs, so I have zero first hand experience with it. It just makes no sense to me from a pharmacological standpoint that a single dose of prop would prevent you from puking a few hours after it was given when it redistributes in 5 minutes.

Then I guess you don't believe in ERAS and all the data that shows that giving some ketamine, gabapentin, tylenol, etc. improves pain several months later.

 

[pgg]

Did you find a lot of PONV with Brevital?

I don't remember it being any different than propofol in that regard.

 

[deleted162650]

Then I guess you don't believe in ERAS and all the data that shows that giving some ketamine, gabapentin, tylenol, etc. improves pain several months later.

Well, at the risk of catching a lot a lot of flack - no not really. I think demonizing opioids has sorta become en vogue over the last 5 or so years. Combine that with the subjectivity of pain and the data manipulation that is so common in modern research, and I just don't buy a lot of it. This is a topic for another thread though.

I will at least admit that pain (especially chronic pain) is a very physiologically complex process, and I'd be more inclined to believe that short courses of meds acutely can have some lasting effects on chronic pain than I would be to believe that a single dose of prop has long term anti-emetic benefits.

 

[Noyac]

I have a hard time believing a single induction dose of propofol has any significant anti-emetic effect post-op. I do believe in the low dose prop gtt for PONV though.

I don’t have any solid data to refute this. But, I do a few things that prove to me that there is an antiemetic effect of propofol that can be harnessed in one dose. While many of my partners like to run a propofol gtts for PONV prevention I typically give 20-40mg of propofol at the time of emergence to pr vent PONV. My results were actually better than most when we looked at it. But I will admit it is multifactorial. Good blocks, judicious narcotics, no reversal when not needed, etc.
But more importantly, when a pt at our surg center is nauseated the nurses like to call me because I give 20mg of propofol while many of my partners don’t. It works like magic.

 

[Noyac]

Running sub-hypnotic dose prop at 25ish mcg/kg/min for PONV prophylaxis. Even more effective though is running prop a bit higher and reducing the volatile to MAC aware levels (0.4 MACish). I have done the latter in a number of patients now with a Hx of severe PONV with great results and avoided the PITA that is pure TIVA.

I do this exact thing.

 

[Noyac]

Although I've never used propofol as a last-resort solution to ponv, I was under the impression that a simple 10 to 20 mg push of propofol does the trick. Any truth to this?

Yes. Absolutely.

 

[deleted162650]

I don’t have any solid data to refute this. But, I do a few things that prove to me that there is an antiemetic effect of propofol that can be harnessed in one dose. While many of my partners like to run a propofol gtts for PONV prevention I typically give 20-40mg of propofol at the time of emergence to pr vent PONV. My results were actually better than most when we looked at it. But I will admit it is multifactorial. Good blocks, judicious narcotics, no reversal when not needed, etc.
But more importantly, when a pt at our surg center is nauseated the nurses like to call me because I give 20mg of propofol while many of my partners don’t. It works like magic.

I'll buy that a dose at the end or in PACU helps, but not your induction dose.

 

[Noyac]

I'll buy that a dose at the end or in PACU helps, but not your induction dose.

Agreed!

 

[Planktonmd]

Three today. I can’t stand the whining.

🙂

 

[dhb]

So in your opinion, what do you think a count for the difference in PONV rates between propofol and Thiopental?

Halothane, tons of fentanyl, surgical technique, preventive meds a lot has changed in 30 years

 

[Aether2000]

We used methohexital for 6 years in over 1000 patients per year for pain cases, and had no PONV in 99%+. Granted, it was a single drug being used and it was used for deep sedation in boluses, but had vomiting in only one patient I can remember, and transient nausea in only a few. Myoclonus was indeed seen as were hiccoughs not infrequently. We had one case of superficial tissue necrosis when an IV migrated subcutaneously. Compared with propofol, the onset and offset are both more rapid.

 

[Healthinfo104]

Halothane, tons of fentanyl, surgical technique, preventive meds a lot has changed in 30 years

So it was more the other antiquated factors/ techniques that happened to be used at that time with the thiopental (ie, type of inhalation anesthetic used, opioid use, etc) rather than just the thiopental being emetogenic in and of itself.

 

[Healthinfo104]

We used methohexital for 6 years in over 1000 patients per year for pain cases, and had no PONV in 99%+. Granted, it was a single drug being used and it was used for deep sedation in boluses, but had vomiting in only one patient I can remember, and transient nausea in only a few. Myoclonus was indeed seen as were hiccoughs not infrequently. We had one case of superficial tissue necrosis when an IV migrated subcutaneously. Compared with propofol, the onset and offset are both more rapid.

Oh wow, and even in that one case of vomiting and few cases of mild nausea, there could have been other factors I'm guessing that lead to the stomach upset rather than the methohexital itself... they could have had an upset stomach due stress from post emergence delerium and anxiety, dehydration, hypoxia, the pain itself, etc.

 

[dhb]

So it was more the other antiquated factors/ techniques that happened to be used at that time with the thiopental (ie, type of inhalation anesthetic used, opioid use, etc) rather than just the thiopental being emetogenic in and of itself.

Yes imho

 

[Twiggidy]

Does sodium thiopental, or other barbiturate anesthetics for that matter have a high or low incidence of post operative nausea and vomiting?

irrelevant. i dont think the drug is available at any hospital

 

[Healthinfo104]

Yes imho

irrelevant. i dont think the drug is available at any hospital

I understand that, I'm saying when it was used

 

[deleted697535]

no reversal when not needed, etc.
But more importantly, when a pt at our surg center is nauseated the nurses like to call me because I give 20mg of propofol while many of my partners don’t. It works like magic.

Neo glyco or bridion does not contribute to ponv from a recent lit search

 

[narcusprince]

I don’t have any solid data to refute this. But, I do a few things that prove to me that there is an antiemetic effect of propofol that can be harnessed in one dose. While many of my partners like to run a propofol gtts for PONV prevention I typically give 20-40mg of propofol at the time of emergence to pr vent PONV. My results were actually better than most when we looked at it. But I will admit it is multifactorial. Good blocks, judicious narcotics, no reversal when not needed, etc.
But more importantly, when a pt at our surg center is nauseated the nurses like to call me because I give 20mg of propofol while many of my partners don’t. It works like magic.

I also believe that you can safely run gas on patients with Ponv as long as you emerge them with propofol and have as much end tidal agent off as possible.

 

[Twiggidy]

my hospital will hate me for this, but i propofol infuse just about everyone. i know it’s ridiculous but i just dont want nauseated patients and people complain enough. i try to stack the deck in my favor. ive gotten no gripes from pharmacy or a “propofol bill” yet

plus. i like the way old folks wake up with propofol vs gas. no evidence, but they seem less agitated than with gas

 

[Lecithin5]

my hospital will hate me for this, but i propofol infuse just about everyone. i know it’s ridiculous but i just dont want nauseated patients and people complain enough. i try to stack the deck in my favor. ive gotten no gripes from pharmacy or a “propofol bill” yet

plus. i like the way old folks wake up with propofol vs gas. no evidence, but they seem less agitated than with gas

Is propofol that expensive? I'm ignorant when it comes to prices, but I'd like to think sevo is more expensive than propofol. You should be thanked (maybe?)!

 

[Noyac]

Neo glyco or bridion does not contribute to ponv from a recent lit search

Anticholinesterase side-effects
The increase in Ach concentration induced by an anticholinesterase is not limited to the NMJ, but also occurs at muscarinic sites where Ach is the neurotransmitter. Muscarinic side-effects of anticholinesterases include nausea and vomiting, bradycardia and prolongation of the QT interval of the electrocardiograph (ECG),54bronchoconstriction,101 stimulation of salivary glands,22 miosis, and increased intestinal tone


But I will agree with you that the incidence of PONV with reversal is controversial. It is however my opinion that the less medications given to a pt the better they tend to do. Subjective maybe.

 

[AdmiralChz]

irrelevant. i dont think the drug is available at any hospital

Separate (just curious) question - I know the history of Thiopental and all, but why hasn't any domestic companies picked up production? Or literally anyone other than Italy? People seem to really like the med and a producer/supplier might be able to sell it for relatively big bucks.

This holds true for just about all other drugs that go on shortage too, but sorta a separate discussion.