Thoughts on PONV?

[TofuBalls]

Any thoughts from the Private Practice guys on PONV? i.e. Zofran for everybody or just the young ladies... Thanks!

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[VolatileAgent]

droperidol.

 

[supahfresh]

My new audio-digest lecture on PONV claims that the first anti-emetic will exhibit the dominant effect.

 

[TofuBalls]

My new audio-digest lecture on PONV claims that the first anti-emetic will exhibit the dominant effect.

Yeah, that's pretty much what I have gotten from review articles, etc. At my institution, my attendings will either blast everybody with Zofran or if the pt has a Hx of PONV give Zofran + Decadron with induction.

On a side note, as a CA1 I gave decadron to an awake young lady prior to induction. Needless to say, I haven't done that again!!!

 

[jwk]

Zofran for all, plus Decadron and Benadryl for those with hx of PONV and/or most plastic surgery cases (surgeon's preference, it's a touchy-feely thing )

 

[jetproppilot]

On a side note, as a CA1 I gave decadron to an awake young lady prior to induction. Needless to say, I haven't done that again!!!

I dont get it. Did she freak out or something?

They dont have to be asleep for you to give decadron.

 

[DrDre']

Doesn't it cx some weird reaction like a burning, tingling sensation? I remember there is a weird side effect but I am blanking...

I dont get it. Did she freak out or something?

They dont have to be asleep for you to give decadron.

 

[VolatileAgent]

i'm telling you guys - especially private practice guys - 0.625mg of droperidol in the pre-op area. it's a wonder drug. dirt cheap too. it's still widely used in europe. the QTc stuff has been way overhyped.

 

[DrDre']

I loved using inapsine for an anti-emetic. we also used it for a chemical restraint in the field before we got haldol.

Those 2 articles in Anesthesiology about 6 months ago showed a similar qt effect with zofran. I hate that inapsine has the black box. that said, one bad outcome and the lawyer will crucify you. "So you knew there was a black box label on this very dangerous drug and u still used it..."

Even though, zofran and many others have a similar effect. It's all about money and politics.

i'm telling you guys - especially private practice guys - 0.625mg of droperidol in the pre-op area. it's a wonder drug. dirt cheap too. it's still widely used in europe. the QTc stuff has been way overhyped.

 

[jetproppilot]

i'm telling you guys - especially private practice guys - 0.625mg of droperidol in the pre-op area. it's a wonder drug. dirt cheap too. it's still widely used in europe. the QTc stuff has been way overhyped.

I totally concur. Sucks when you have to modify the (best) way to practice because of the f ukking lawyers.

Unfortunately malpractice doesnt exist in Europe in the same fashion as here.

We are in dire need of tort reform. We'll see if Bush's promises pan out.

 

[VolatileAgent]

one attending at our institution - that's all he uses. he's even reminisced with me about the good ole days when folks used to get 5mg of the stuff! the recovery room nurses hate it, though, because everyone is so gorked after the surgery. even a whiff of the stuff knocks people down. it's so friggin' cheap. i guess he doesn't worry about lawsuits because he's indemnified by the university. maybe he's just an iconoclast. who knows? but, he's never had a bad outcome with the stuff in 30+ years of practice. it's not "devil may care", it's science and personal experience and refusing to kowtow to a black box that shouldn't be there.

BRING BACK INAPSINE, DAMMIT!!!

 

[militarymd]

I let them

 

[awolf]

doesn't haloperidol have a similar effect to droperidol (and without the Black Box warning)?

 

[ReefTiger]

I've gone to a few lectures on this including one at the NYSSA last month. Basically, what I learned was to stratify patients based on risk factors (it is not economical or necessary to just give everyone Zofran) and treat based on severity. Pts with most RF will recieve most prophylaxis/tx.

If a patient has history of motion sickness do a scopalamine patch in holding in addition to Zofran 4 mg IV 30 min prior to induction. Some can argue for 4-8 mg dexamethasone intra op.

If pt definitely has strong hx then do zofran pre-op, dex intra op. Also, I've done cases with propofol infusion successfully with its antiemetic effect. Try to limit opioids of course.

I will always order phenergan 6.25 mg up to four doses as rescue in PACU as there is data showing it to be as effective with less sedation (some with more experience than me state you can use even lower doses with the same results in older patients).

I know plenty of people who love droperidol and say it gets a bad rep. If you really like it because it's cheap and you'll save the patient money then let the patient decide the risk vs cost for themselves.

About the QT with Zofran- it mostly happens if you administer the drug incorrectly. It is not to be given iv in less than 30 seconds. I see almost everyone give it IV push.

Just my .02

 

[militarymd]

Jet,
Decadron can cause intense genital pruritis in the unsedated young lady.

 

[jetproppilot]

Jet,
Decadron can cause intense genital pruritis in the unsedated young lady.

HAHAHAHHAHAHHAHAHAHAHAHHAHAHAHAHAHHAHAHAHAHHAA

thanks for the heads up! I musta been asleep during that resident lecture.

 

[TofuBalls]

I dont get it. Did she freak out or something?

They dont have to be asleep for you to give decadron.

Sorry, I should have elaborated. She began squirming and YELLING, "My coochie is itching! My coochie is itching!".

I couldn't push the propofol fast enough!

My attending later told me rapid administration is associated with intense perineal itching

 

[seattledoc]

I routinely give decadron in the holding area shortly before going back to the OR. I've never seen this side effect but at least now I'll know the cause if I do see it!

peace

 

[foxtrot]

I have given Decadron twice up front my CA1 year and I will not do it again. The first lady told me that she felt like she was having an orgasm (no joke) and just started smiling widely. I had no idea how to explain that one because I had never heard that before. And then the second time I gave it slowly and the lady complained of tingliness and itching "down there". I asked some of the upper levels about this and a couple of them had the same experiences. All I have to say is thank God for versed.

 

[Noyac]

Yeah I have seen it twice in the last year. I use decadron quite often for pts with strong h/o N/V. Otherwise, just reglan (yes I still use it) or anzemet (not as good as zofran IMHO). I do risk stratify my pts and many get nothing except about 2cc propofol at the end of the case. I find that the propofol and plenty of IV fluids covers most pts.
No inapsine n my hosp.

 

[TofuBalls]

Yeah I have seen it twice in the last year. I use decadron quite often for pts with strong h/o N/V. Otherwise, just reglan (yes I still use it) or anzemet (not as good as zofran IMHO). I do risk stratify my pts and many get nothing except about 2cc propofol at the end of the case. I find that the propofol and plenty of IV fluids covers most pts.
No inapsine n my hosp.

Propofol is great. I use it for rescue but haven't used it prophylactically(sp?). I especially like it in the awake C-section pt who won't stop barfing on my shoes. At our institution the OB residents take 1.5 to 2 hrs per c-section so you really get to know your pt's well.

Great info guys! Thanks

 

[VolatileAgent]

If you really like it because it's cheap and you'll save the patient money then let the patient decide the risk vs cost for themselves.

uhh, i can just hear it now:

"mrs. so-and-so, we have these two medications that are shown to be effective in treating nausea when the surgery is over. in follow-up studies, they've both been show to cause a specific change in your ekg called a 'qt prolongation'. the fda has labeled one of those drugs with a black-box, but the risk is low of any true bad outcomes as a result of that. the other one is prohibitively expensive and not shown to be superior in controlling nausea. which drug would you like?

"what the heck is a cue-tee... huh? um, what would you do, doc?"

perhaps you have a more savvy, sophisticated patient population than i'm accustomed to. but, i've generally found that it inspires less confidence when you start to let patients micromanage their own case.

About the QT with Zofran- it mostly happens if you administer the drug incorrectly. It is not to be given iv in less than 30 seconds. I see almost everyone give it IV push.

hmmm. not sure that the recent anesthesiology article made a distinction in this regard, namely that the drug was administered "incorrectly" in the study. iirc, the QT effect with zofran both drugs peaked relatively early, even if given as described in the PI (i.e. over thirty seconds). the article didn't specifically make a distinction between the inherent risk between QTc and method of administration, but it seems reasonable that slowly pushing it or even dripping it in may reduce the risk based on the early peaking of the effect in both drugs. i'm not sure if you can make a strong cause-effect relationship based on what you've said here, other than an anecdotal, observational one based on your own personal experience. either way, it's very hard for me to justify the increased cost of ondansetron over droperidol, at least based on the implications of this study (albeit a single study). and with that being said, i've used both and never had a problem myself... so far and for whatever that's worth. just seems like 10 questionable cases throughout the 30+ years the drug has been on the market seems a little draconian to warrant a black box. if you're a conspiracy theorist, you might even say that gsk had something to do with that black box. of course, i'm not saying that myself.

but, other than that, great post. nice tips.

 

[VolatileAgent]

and, jet, i think you could site this article in court if you ever got sued for using the drope. just remember not to use it in a hypokalemic, bradycardic, and hypothermic patient and you shouldn't have any problems. of course, if that's your patient, you probably shouldn't be reaching for the zofran either.

 

[jetproppilot]

and, jet, i think you could site this article in court if you ever got sued for using the drope. just remember not to use it in a hypokalemic, bradycardic, and hypothermic patient and you shouldn't have any problems. of course, if that's your patient, you probably shouldn't be reaching for the zofran either.

I love drop...just dont use it anymore because of all the controversy. Not worth it with all the hype, but thats just me.

I remember doing awake intubations with the stuff in conjunction with the airway blocks...buzz 'em out with 5mg, incrementally, do your blocks, put the tube in..an attending at the VA (Mack Thomas) when I was a resident showed me this with the pt still on the stretcher...we did our thing, put the tube in, and Dr Thomas asked the pt to move over to the OR bed...pt sat up, and scooted over, then layed down...pretty cool with an ETT sticking out of his nose!

 

[toofache32]

one attending at our institution - that's all he uses. he's even reminisced with me about the good ole days when folks used to get 5mg of the stuff! the recovery room nurses hate it, though, because everyone is so gorked after the surgery....

I wonder if we're at the same institution...does this attending go by his 3 initials, cut the ET tubes at the dotted line, demand only ONE stop-cock, and use a clear-plastic "6-shooter?"

 

[VolatileAgent]

I wonder if we're at the same institution...does this attending go by his 3 initials, cut the ET tubes at the dotted line, demand only ONE stop-cock, and use a clear-plastic "6-shooter?"

haha! no. apparently there's more than one eccentric "old skool" anesthesiologist out there.

 

[toofache32]

haha! no. apparently there's more than one eccentric "old skool" anesthesiologist out there.

Any other UTSW people out there know who I'm talking about?

 

[jwk]

I love drop...just dont use it anymore because of all the controversy. Not worth it with all the hype, but thats just me.

I remember doing awake intubations with the stuff in conjunction with the airway blocks...buzz 'em out with 5mg, incrementally, do your blocks, put the tube in..an attending at the VA (Mack Thomas) when I was a resident showed me this with the pt still on the stretcher...we did our thing, put the tube in, and Dr Thomas asked the pt to move over to the OR bed...pt sat up, and scooted over, then layed down...pretty cool with an ETT sticking out of his nose!

We all loved drop - but black box warnings unfortunately are an issue. We don't even have it on our hospital formulary, so I couldn't even use it if I wanted to.

Most of y'all are far too young to remember Innovar - it had 2.5mg of droperidol and 50mcg of fentanyl per cc. Sure they were slow to wake up in recovery, but they sure felt good!

 

[Noyac]

I love drop...just dont use it anymore because of all the controversy. Not worth it with all the hype, but thats just me.

I remember doing awake intubations with the stuff in conjunction with the airway blocks...buzz 'em out with 5mg, incrementally, do your blocks, put the tube in..an attending at the VA (Mack Thomas) when I was a resident showed me this with the pt still on the stretcher...we did our thing, put the tube in, and Dr Thomas asked the pt to move over to the OR bed...pt sat up, and scooted over, then layed down...pretty cool with an ETT sticking out of his nose!

Now you can do this with Precedex.

 

[DrBom]

any thoughts on dolasetron--based on your experience, just as efficacious in ponv prophylaxis as ondansetron in high risk pt's? Also, what do you like to give for established ponv?

 

[Planktonmd]

I have given Decadron twice up front my CA1 year and I will not do it again. The first lady told me that she felt like she was having an orgasm (no joke) and just started smiling widely. I had no idea how to explain that one because I had never heard that before. And then the second time I gave it slowly and the lady complained of tingliness and itching "down there". I asked some of the upper levels about this and a couple of them had the same experiences. All I have to say is thank God for versed.

It does not happen if given really slowly, we have a standing order to our recovery room nurses to give it in very small increments.

 

[Planktonmd]

any thoughts on dolasetron--based on your experience, just as efficacious in ponv prophylaxis as ondansetron in high risk pt's? Also, what do you like to give for established ponv?

We only have Dolasetron (anzemet) and it works great in my opinion, although some people swear that Ondansetron (Zofran) is better!
I think they are all the same!

 

[Noyac]

We only have Dolasetron (anzemet) and it works great in my opinion, although some people swear that Ondansetron (Zofran) is better!
I think they are all the same!

they are not the same. Anzemet is a pro-drug. It needs 15-30 minutes to be converted.

 

[Planktonmd]

they are not the same. Anzemet is a pro-drug. It needs 15-30 minutes to be converted.

Thanks, I actually didn't know that.

 

[Anesthesia1979]

While only readily available in the cart at a few of the hospitals I work at... I think 25 Ephedrine with 25 hydroxizine IM in the middle of the case works well; lasts up to 24 hours, and makes for smooth wake-ups.

I like to use this as an adjunct to zofran at the end of the case.

Or with decadron and zofran in the very high risk as why not block every emetic promoting receptor.

 

[Noyac]

While only readily available in the cart at a few of the hospitals I work at... I think 2.5 Ephedrine with 25 hydroxizine IM in the middle of the case works well; lasts up to 24 hours, and makes for smooth wake-ups.

I like to use this as an adjunct to zofran at the end of the case.

Or with decadron and zofran in the very high risk as why not block every emetic promoting receptor.

This is new. I'm curious why the ephedrine? I understand the hydroxyzine but have personally never used it or maybe I don't understand the hydroxyzine.

 

[Anesthesia1979]

to be honest, I dunno and it may be hand waving... it may have to do with the fact that ephedrine crosses the BBB?!?!

it may augment some of the side-effects of the anti-histamine... all I can say is give it a shot some time.

25 hydroxizne (1/2 ml) & 25 ephedrine (1/2ml) together as a 1cc IM.

 

[rn29306]

Isn't the ephedrine given related to post-op hypotension and nausea, esp in the PACU setting?

Its a fairly old school trick from what I understand.

This is from Duke University Medical Center and is useful as a PONV review.
http://www.cja-jca.org/cgi/content/full/51/4/326

 

[joshmir]

one of our smartest attendings, who always has a reason for what he does, believes ephedrine has anti-emetic properties independent of BP support. i haven't seen the reference

does anyone know if you get a better anti-emetic effect with 50mg IM vistaril than with 25mg IM?

and has anyone used haldol with fentanyl to do neuroleptic anesthesia (ie, for a MAC)? i did a quick literature search and nothing came up...I know Mil mentioned using it...

 

[MTGas2B]

This is new. I'm curious why the ephedrine? I understand the hydroxyzine but have personally never used it or maybe I don't understand the hydroxyzine.

One of our ambulatory experts told us about this one, 1 mg/kg of ephedrine given IM. She says she usually reserves for a rescue therapy.

 

[UTSouthwestern]

I wonder if we're at the same institution...does this attending go by his 3 initials, cut the ET tubes at the dotted line, demand only ONE stop-cock, and use a clear-plastic "6-shooter?"

ERJ retired.

 

[toofache32]

ERJ retired.

Completely retired? Are you sure? I know he has been working every other month for a few years. I saw him maybe 1-2 months ago. When I don't see him for a few weeks I always assume it's his "off" month. When I see a post-op GYN patient sit in the PACU for 3 hours I know he's back.

 

[UTSouthwestern]

Completely retired? Are you sure? I know he has been working every other month for a few years. I saw him maybe 1-2 months ago. When I don't see him for a few weeks I always assume it's his "off" month. When I see a post-op GYN patient sit in the PACU for 3 hours I know he's back.

Retired completely was what I was told in the summer.

 

[jetproppilot]

Any thoughts from the Private Practice guys on PONV? i.e. Zofran for everybody or just the young ladies... Thanks!

.

 

[VolatileAgent]

anyone use Emend (apepritant) yet?

 

[Intubate]

I've used it a few times... Unfortunately, can't give it to women on "the pill". That really limits its usefulness in my opinion. Its also a hassle because its oral and needs to be given prior to surgery. I don't think it'll gain widespread use because of that alone. Scop patches are great too, but they're a pain in the ass because they have to be placed preop-- therefore I almost never use them unless I see the patient before the day of surgery.

 

[rmh149]

anyone use Emend (apepritant) yet?

Too expensive. We have one surgeon that gives an Rx to his patients to take in the morning prior to gastric bypass. The hospital will not accept it in their formulary.

Other than that....I stick to loading with ZOFRAN 8mg for everyone now that it is cheap. Decadron as well to those with a hx of PONV.

 

[Planktonmd]

Here is what you want to do to have less PONV:

1- Give less narcotics and manage pain with regional every time you can.
2- Try to avoid reversing muscle relaxants.
3- Try to avoid N2O.
4- Think about the risk factors: Females, Children, Nonsmokers, Long surgery, History of PONV, History of motion sickness, specific surgeries: GYN, Biliary, Ophtalmic....
If they have 2 or more risk factors consider chemical prophylaxis, and that could be any agent you like and fits your specific location and hospital formualry, if that doesn't work and they still vomit use a different agent that works on different receptors.

 

[Noyac]

Too expensive. We have one surgeon that gives an Rx to his patients to take in the morning prior to gastric bypass. The hospital will not accept it in their formulary.

Other than that....I stick to loading with ZOFRAN 8mg for everyone now that it is cheap. Decadron as well to those with a hx of PONV.

8mg Zofran, haven't we talked about this one? And the timing, didn't we touch on that as well? I guess everyone has their style.

 

[rmh149]

8mg Zofran, haven't we talked about this one? And the timing, didn't we touch on that as well? I guess everyone has their style.

Yes we did. I still feel the need to give it to them. But instead of giving it to them all at once, I now give them 4mg prior to induction, then repeat 4mg before leaving them in recovery.

For the patients that say they ALWAYS have PONV, give them decadron as well, 100% O2 and fluid load them as much as possible....and as plankton said, minimize narcotics (toradol if not worried about bleeding) and use regional when appropriate.

FOR OB: Right before peforming the spinal for a C-section, I often will give 30-50mg of propofol. Along with the antiemetic properties of propofol it chills them out so they dont puke on themselves for being so nervous. Sometimes they dont even remember the spinal....but they remember everything else that is important.