toradol in TAH's

[Gas you down]

I had a case today, TAH in a COPD'er with a case of the crazies, allergic to everything! ok, so i'm discussing whether or not to give toradol with my CRNA in the room. I hear the gyn comment on how she has been given toradol in the past by the gyn, who said that "she felt itchy the next day." to me this is clearly not an allergy to toradol, so I say go ahead and give some.
in the pacu, the gyn is upset b/c she "never gives it within the first 24hrs" due to increased risk of bleeding, and was upset b/c i didn't ask her if it was ok. seriously, didn't you just hear me, do i have to spell it out for her? and what the heck is she talking about, i ask a surgeon if its a plastics case or something like that, but i've never really heard of a clinically significant increased risk of bleeding in gyn cases. (and i don't even consider it in neuro/vascular cases).
so i took a look at pubmed, and didn't really see anything involving a GA gyn case and this post-toradol bleeding problem. maybe one case report in a neuraxial anesthesia hyst.

anyone have any insight?

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[Arch Guillotti]

Gyn probably had a bring back for bleeding that had been given toradol (which probably didn't have anything to do with the bleeding). I have heard this before also. My guess is that the rationale is based on anecdotal experience of the gyn.

I had a case today, TAH in a COPD'er with a case of the crazies, allergic to everything! ok, so i'm discussing whether or not to give toradol with my CRNA in the room. I hear the gyn comment on how she has been given toradol in the past by the gyn, who said that "she felt itchy the next day." to me this is clearly not an allergy to toradol, so I say go ahead and give some.
in the pacu, the gyn is upset b/c she "never gives it within the first 24hrs" due to increased risk of bleeding, and was upset b/c i didn't ask her if it was ok. seriously, didn't you just hear me, do i have to spell it out for her? and what the heck is she talking about, i ask a surgeon if its a plastics case or something like that, but i've never really heard of a clinically significant increased risk of bleeding in gyn cases. (and i don't even consider it in neuro/vascular cases).
so i took a look at pubmed, and didn't really see anything involving a GA gyn case and this post-toradol bleeding problem. maybe one case report in a neuraxial anesthesia hyst.

anyone have any insight?

 

[Gas you down]

and we were on skin, it's not like we're pushing tPA here!
one of these days, i'm gonna stop being the bigger man, and just rip back into one of these guys...

 

[amyl]

i agree w you about giving the toradol... its a great drug... thankfully the ob/gyns here are okay with it whenever we want to give it. however, i have to respectfully disagree about the lack of bleeding in gyn cases.... i have almost needed the damn belmont in some of their cases and the only time I ever saw TURP syndrome was in an endless gyn case... you know what they same about those gyn docs -- a little bit of surgery, a little bit of medicine and not good at either
just kidding ;-)

 

[Gas you down]

i agree w you about giving the toradol... its a great drug... thankfully the ob/gyns here are okay with it whenever we want to give it. however, i have to respectfully disagree about the lack of bleeding in gyn cases.... i have almost needed the damn belmont in some of their cases and the only time I ever saw TURP syndrome was in an endless gyn case... you know what they same about those gyn docs -- a little bit of surgery, a little bit of medicine and not good at either
just kidding ;-)

i am not saying that gyn cases don't bleed. i'm saying that toradol given after the skin is closed (and thus clots already formed) does not result in spontaneous bleeding that would necessitate a bring-back.
just my two cents. i will listen to reason, but right now that's how i understand it....

 

[jwk]

i am not saying that gyn cases don't bleed. i'm saying that toradol given after the skin is closed (and thus clots already formed) does not result in spontaneous bleeding that would necessitate a bring-back.
just my two cents. i will listen to reason, but right now that's how i understand it....

We have a few that don't like it because they think it's a problem with bleeding along the vaginal cuff suture line.

Hemostasis is generally a surgical problem.

 

[pgg]

Hemostasis is generally a surgical problem.

QFT, but the sort who blame bleeding on Toradol don't want to hear it.

 

[RxBoy]

GYN are usually the only "surgeons" at my institution that don't mind toradol. But I just stopped giving it all together except for very small procedures like D&C's. Every time there is even the most minute post op bleeding, the surgeons blame the toradol. Now when patients have post op bleeding, the surgeons can blame only themselves.

Plus I dont believe that whole 30 mg IV toradol is equal to 10 mg IV morphine. Sure it has analgesia, but only as an adjunct. Opiates are still the gold standard.

 

[deleted126335]

Surg/gyn are the ones that have to deal with post op pain issues, PCAs, bleeding, renal failure. I always ask the question, "any objection to toradol?" I take no offense whatever the answer. I have worked with all-star surgeons some of whom love and some of whom hate toradol. This is a turf battle that I have no interest in fighting. Happy to yield on this issue.

 

[Arch Guillotti]

Surg/gyn are the ones that have to deal with post op pain issues, PCAs, bleeding, renal failure. I always ask the question, "any objection to toradol?" I take no offense whatever the answer. I have worked with all-star surgeons some of whom love and some of whom hate toradol. This is a turf battle that I have no interest in fighting. Happy to yield on this issue.

No kidding. I just ask if they have any objection and leave it at that.

 

[OB1🤙]

Seems like a situation you may want to think about IV acetaminophen in, when you're with a sturgeon that you know hates toradol, probably because it once failed to treat a prolene deficiency.

I've used it 5 times so far. Used it today on a minimally invasive AVR that I extubated in the OR. So far, I think I like it. And nobody can whine about bleeding with it.

Dunno if the economics work out in favor of it for gyn cases though.

 

[cincincyreds]

With an ultrasound, I do TAP blocks for these cases. I also do TAP blocks for C-sections. Look up TAP blocks. They are really nice for postop pain from my experience.

 

[pgg]

Surg/gyn are the ones that have to deal with post op pain issues, PCAs, bleeding, renal failure. I always ask the question, "any objection to toradol?" I take no offense whatever the answer. I have worked with all-star surgeons some of whom love and some of whom hate toradol. This is a turf battle that I have no interest in fighting. Happy to yield on this issue.

This is true but PACU pain and nausea and discharge times are my problem, so I love Toradol and now IV acetaminophen because they do reduce the amount of opiate I give in the OR.

I'll ask ortho if they object, because some of them have strong feelings about it and bone healing, but mostly I just give it in other cases if I think it's appropriate.

 

[jetproppilot]

Seems like a situation you may want to think about IV acetaminophen in, when you're with a sturgeon that you know hates toradol, probably because it once failed to treat a prolene deficiency.

I've used it 5 times so far. Used it today on a minimally invasive AVR that I extubated in the OR. So far, I think I like it. And nobody can whine about bleeding with it.

Dunno if the economics work out in favor of it for gyn cases though.

We took a look at IV tylenol but decided against it for the time being since it's a big 100mL bottle...cumbersome and another thing to have to hang.

If you wanna use Tylenol why not just give 1 gram PO in day surgery?

I'd be interested to see what you think after using it some more.

 

[cchoukal]

We took a look at IV tylenol but decided against it for the time being since it's a big 100mL bottle...cumbersome and another thing to have to hang.

If you wanna use Tylenol why not just give 1 gram PO in day surgery?

I'd be interested to see what you think after using it some more.

The rationale I keep hearing (in the literature and from reps) is that the serum level of the IV form is 2-3X as high (and much more consistent) than the PO/PR route. Now, one would think (and the reps would love for you to make the logical leap) that higher serum levels lead to better analgesia, but I've never seen this studied. The surgical pain literature on IV APAP seems only to compare IV APAP to IV pro-drug-APAP, or just looking at opiate reduction rather than pain, not to PO APAP. Which makes me very suspicious.

 

[Frank Rizzo]

Surg/gyn are the ones that have to deal with post op pain issues, PCAs, bleeding, renal failure. I always ask the question, "any objection to toradol?" I take no offense whatever the answer. I have worked with all-star surgeons some of whom love and some of whom hate toradol. This is a turf battle that I have no interest in fighting. Happy to yield on this issue.

Pretty much exactly what I do.

 

[Frank Rizzo]

We took a look at IV tylenol but decided against it for the time being since it's a big 100mL bottle...cumbersome and another thing to have to hang.

If you wanna use Tylenol why not just give 1 gram PO in day surgery?

I'd be interested to see what you think after using it some more.

It got added to formulary where I work about 6 months ago. I've used it a handful of times, with decent results. Its a very good adjunct, like toradol. The reps will quote you some $hiitt about how giving it IV avoids first-pass metabolism, resulting in greater efficacy. In theory it makes sense, but don't know how true it actually is in the real world. Big difference in cost, thats for sure. 1 gm PO costs pennies, 1gm IV costs $12.

 

[Mman]

Couple points.

1) ketorolac is good stuff. I never give 30 mg, though. There is reasonable evidence in the literature that you can give far smaller doses with equal pain relief and fewer side effects. I usually just go with 15 mg.

2) The IV acetaminophen drug rep hates me. We've got in on formulary and I supported having it because it can be a valuable tool in NPO patients in the ICU or postop. But if you are coming in for elective surgery, you can have some po meds in preop. They like to go on and on about higher serum levels and first pass metabolism. But guess what, I've still never seen any evidence that a higher serum level equals better pain relief. It doesn't. Acetaminophen doesn't work that way. If it did, I could just give a bigger dose PO preop. Opioids have dose dependent analgesic effects, NSAIDs don't. PO acetaminophen is far cheaper and equally efficacious to the IV stuff.

 

[OB1🤙]

We took a look at IV tylenol but decided against it for the time being since it's a big 100mL bottle...cumbersome and another thing to have to hang.

If you wanna use Tylenol why not just give 1 gram PO in day surgery?

I'd be interested to see what you think after using it some more.

PO preop wouldn't work in my specific subset of patients, who will have their stomachs suctioned and a TEE probe placed after induction.

You could wax philosophic on unknowable GI uptake for PO dosing, especially in the setting of potential relative gut hypoperfusion under anesthesia, and on more predictable serum levels when given IV. I dunno. In my mind, in the best case scenario, the stuff is about equivalent to toradol in terms of analgesia and opiate reduction. In the worst case, it's useless and expensive, but (mostly) harmless. I suspect the former is closest to being true. Those who have absolutely raved about it that I've met have been on the take from the company that sells it. Those who have said it's a potentially somewhat useful adjunct albeit a pricey one I think are probably correct.

I like it for these minimally invasive valves because it's a moderately (rather than severely) painful procedure, most have marginal renal function, are usually elderly and at risk of postop delirium, and I won't get blamed for any bleeding. Really the delirium issue is my primary reason for wanting to use it for these folks. Anything I can do to facilitate them staying lucid and getting the f out of the ICU and on the road to going home I'll do. Again, fairly specific to this kind of population.

We'll see how I feel once my N is more than 5. Anecdotally, my octogenarian from yesterday did great with it.

 

[sevoflurane]

We took a look at IV tylenol but decided against it for the time being since it's a big 100mL bottle...cumbersome and another thing to have to hang.

If you wanna use Tylenol why not just give 1 gram PO in day surgery?

I'd be interested to see what you think after using it some more.

It's pretty easy. Just use the same tubing for your abx.... Plug and go... Not cumbersome in the least.

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IMG_1655 by Crazyhorse75, on Flickr[/IMG]

It's not a silver bullet, but is part of my multimodal cocktail. As mentioned above, bioavailability is much better and cost is nothing compared to how much a typical OR case costs.

 

[sevoflurane]

It would be nice to see a well done study that compares PO vs. IV Tylenol. The only PO meds I give before an orthopedic anesthetic is gabapentin and celebrex.

One thing is for sure... it has been used extensively in Europe since 2002. Maybe DHB can comment on his experience with the IV formulation.

 

[jetproppilot]

It would be nice to see a well done study that compares PO vs. IV Tylenol. The only PO meds I give before an orthopedic anesthetic is gabapentin and celebrex.

One thing is for sure... it has been used extensively in Europe since 2002. Maybe DHB can comment on his experience with the IV formulation.

I just wish it was in a 2mL vial.

 

[imfrankie]

I just wish it was in a 2mL vial.

we stick a gram in the rear

 

[btbam]

I've used Ofirmev occasionally, mostly when I remember to grab a bottle for a case. When are you guys giving it? Pre-op, or if peri, at what point during the case?