TIVA for PONV

[aredoubleyou]

What's everyone's favorite TIVA regimen for severe PONV. Also, would your plan change if you were at a surgery center.

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[Jay K]

My hospital only recently got dexmed approved for OR (outside of the ICU), so I hadn't run any since residency.

So, up until recently I've been running ketafol (ketamine 1mg/ml in propofol) +/- sufentanil infusion. Sometimes I run remifol (remifentanil 5mcg/ml in propofol). I'm not certain what my regimen's gonna be now that I've got dexmed to play with.

Interestingly enough, we've got an ENT who likes us to TIVA our pt's with propofol solely to prevent nausea and run low BP's to assist w/ limiting blood loss. I didn't know that was his "plan" when I first met him, so I'd run my typical ketafol, and he had difficulty with the fact my pressures didn't sag.

 

[sevoflurane]

What's everyone's favorite TIVA regimen for severe PONV. Also, would your plan change if you were at a surgery center.

Precedex, ketafol, magnesium. Don't let systolics drop below 120 or keep even higher if autoregulation curve is shifted to the right. Make sure the tank is full. Decadron up front. Reglan, zofran 15 minutes before extubation. Toradol + minimal to no narcotics (choose short acting ones if need be). Keep patient at .5 Mac (not a true tiva). Try not to use paralytics (and therefore neostigmine). LMA over ETT. Suction stomach if blood has made it's way down there for whatever reason.

This does not change for outpatient (I may decrease the amount of ketamine they get). A little bit longer to set up... but not by much.

 

[Gern Blansten]

Just give them ondansetron plus a scopolamine patch 1.5 mg an hour prior to induction and proceed as usual. I have really been impressed. Scopolamine transdermal has tamed even the worst offenders I have seen over the last 2 years.
The only thing more reliable is regional anesthesia, IMHO.

 

[periopdoc]

Unless you get a patient with an idiosyncratic reaction to the scop patch.

I spent 14 days sick offshore the first time I tried the patch for prophylaxis. I couldn't understand why I was so sick and dizzy (1st year of med school at the time). I couldn't focus on the charts, but I could see the boats on the horizon just fine. Couldn't eat anything but cream of wheat. Took the patch off and 12 hours later I was cooking spicy basil beef and asking if we brought any beer on the trip.

Thought it was just my imagination until a few months later. I had the day off and I noticed one leftover patch in my medicine cabinet. Put it on and within a few hours the room was spinning and I was puking.

- pod

 

[aredoubleyou]

So, up until recently I've been running ketafol (ketamine 1mg/ml in propofol) +/- sufentanil infusion. Sometimes I run remifol (remifentanil 5mcg/ml in propofol). .

No problems running opiod gtt for PONV?

 

[Salt Creep]

In all my vast experience as a CA-1, I've typically just used decadron up front and zofran 20 minutes before wake-up +/- scop patch depending on Hx. Did do a TIVA for one patient that had a history of PONV despite all that having been given before, and she woke up fine (albeit slow, since in my newness at the time, I didn't account very well for the context sensitive half-time of propofol).

A quick question though - according to Miller, midazolam also acts as an anti-emetic. Anyone here use it specifically for that purpose (and not just for routine premed), maybe in somebody with a significant PONV history?

I was thinking the next time I have a patient with a significant history of it, I might give a small dose at the end of the case.

 

[Jay K]

No problems running opiod gtt for PONV?

To be honest, I haven't run that many TIVA's solely for severe PONV. I was just detailing my TIVA regimen; Have run more TIVA's for h/o MH than PONV. I don't have a big enough "n" to know if a narcotic GTT added to TIVA would result in PONV. How 'bout you? Any experience w/ the GTT's causing problems?

Like most everyone else, h/o PONV usually entails scop patch, intraop decadron 10mg/metoclopramide 10mg/famotidine 20mg and ondansetron 4mg +/- OGT to evacuate the stomach, no morphine and mainly fentanyl or dilaudid. Depending on case, if the pain requirements aren't that bad, then the ketafol +/- toradol +/- local at end of case by surgeon typically do well enough for the patient.

 

[aredoubleyou]

Only on principle do I avoid narcs with TIVA for PONV when possible...unless its a big surgery in which case I figure its better to have pain control on wakeup than 4 mg dilaudid in the pacu.

Also my 'n' is very small as well.