zofran and long qt

[lakersbaby]

if a patient is getting zofran scheduled and qtc becomes prolonged to say >500 would you stop the zofran even if the patient is having significant nausea? I read an article about droperidol having the potential to cause possible lethal dysrhythmia due to its QT effects and i believe zofran was a safer alternative. At what point would you guys stop giving the ondansetron.

---

Members don't see this ad.

 

[Gern Blansten]

the trons have all been implicated as well. I would just tell the patient to start smoking
Not positive, but I don't think a scopolamine patch has been associated with the long QT issue. I have found it to be pretty effective, although it takes a while to take effect.

 

[RxBoy]

if a patient is getting zofran scheduled and qtc becomes prolonged to say >500 would you stop the zofran even if the patient is having significant nausea? I read an article about droperidol having the potential to cause possible lethal dysrhythmia due to its QT effects and i believe zofran was a safer alternative. At what point would you guys stop giving the ondansetron.

I would try to figure out why they have qtc prolongation and why they have N/V and fix those issues.

Its unusual for zofran to cause such a long qt.

In any case if I was using zofran as a rescue treatment then I wouldn't hesitate giving the rescue treatment of 1 mg IV. If its for prophylaxis I would switch drugs. Decadron 4 mg IV works wonders.

Prolongation of QTc interval after postoperative nausea and vomiting treatment by droperidol or ondansetron. (From Charbit B, Albaladejo P, Funck-Brentano C, et al: Prolongation of QTc interval after postoperative nausea and vomiting treatment by droperidol or ondansetron. Anesthesiology 102:1094-1100, 2005.)

 

[amyl]

i have come across pts like this in the pacu. I usually just push a little propofol to buy some time to get some fluid in.... that usually works... but then there is always compazine... i haven't ever used scopolamine in this scenario as I was always told it takes too long to work and is pretty much ineffective as a rescue NV medication.

 

[jetproppilot]

i have come across pts like this in the pacu. I usually just push a little propofol to buy some time to get some fluid in.... that usually works... but then there is always compazine... i haven't ever used scopolamine in this scenario as I was always told it takes too long to work and is pretty much ineffective as a rescue NV medication.

I like phenergan in the PACU.

 

[okayplayer]

Do you guys feel obligated to get an EKG in a pt that otherwise doesn't have one if you want to give 0.4 mg of Droperidol? Or just monitor for 1-2 h on ECG in PACU after dosing? As you can see from the above figure it is basically equivalent in terms of QTC prolongation with Zofran at the 0.4 mg dosing, but it does have the black box warning for torsades (although I think most of these cases were at much larger doses like 10-15 mg total).

 

[pgg]

I like phenergan in the PACU.

Do you give it IV or IM?

If IV, do you have a protocol for it? (E.g. diluted and given over a minute into a free flowing IV?) We recently had an upper extremity DVT and PE that some are blaming on a dose of phenergan, so the issue is being reviewed.

 

[ssmallz]

Do you guys feel obligated to get an EKG in a pt that otherwise doesn't have one if you want to give 0.4 mg of Droperidol? Or just monitor for 1-2 h on ECG in PACU after dosing? As you can see from the above figure it is basically equivalent in terms of QTC prolongation with Zofran at the 0.4 mg dosing, but it does have the black box warning for torsades (although I think most of these cases were at much larger doses like 10-15 mg total).

At my old institution, when we used droperidol we gave it at the beginning of the case. Since they were monitored during the case and then in the PACU that usually constituted the 1-2hr monitoring on EKG

 

[jetproppilot]

Do you give it IV or IM?

If IV, do you have a protocol for it? (E.g. diluted and given over a minute into a free flowing IV?) We recently had an upper extremity DVT and PE that some are blaming on a dose of phenergan, so the issue is being reviewed.

IV. It's on our PACU standing orders. No protocol.

That's interesting. Never heard of DVT from phenergan.

 

[OB1🤙]

Back in the good old days of residency when I was in the business of extubating patients, my PACU phenergan order was "phenergan 12.5 mg slow IVPB". I'd usually verbally tell the nurse, "phenergan 12.5mg rapid intraarterial bolus" and wait to see how long it took them to figure out I wasn't serious.

Some were starting to advocate avoiding entirely given the possibility of liability exposure after events like this: http://articles.orlandosentinel.com/2007-05-08/news/ARM08_1_volusia-county-mangan-paramedic

 

[dhb]

If its for prophylaxis I would switch drugs. Decadron 4 mg IV works wonders.

We had several months of shortage of dexamethasone and quite frankly i did not see any difference in terms on N/V. But we do use droperidol liberally.
Decadron's effect on PONV is weak at best imho, maby it depends on patient population...

 

[pgg]

IV. It's on our PACU standing orders. No protocol.

That's interesting. Never heard of DVT from phenergan.

I'll post a couple references on Monday when I get back, too painful to re-find it all on a phone ...

Short version is that fear of extravasation injuries (usually from intraARTERIAL injection from what I could find), and thrombophlebitis has led some places to prohibit IV administration.

Our incident with the DVT was surrounded by some other unrelated drama so our current local freakout over it is, I think, partially motivated by some desire to burn a particular nurse. But there are some issues with phenergan that probably warrant a non-concentrated-IV-push protocol for administration, even if just for CYA reasons.

 

[proman]

I've found 6.25mg of promethazine to be all that it takes for rescue. But essentially all of the anti-emetics commonly used cause QT prolongation. Steroids aren't appropriate for rescue, only prophylaxis.

 

[pgg]

Re: phenergan extravasation injuries

Attached PDF is some "expert opinion" level guidance from the VA pharmacy benefits management services.


Highlights:

As of 2007 four case reports of injury in the published literature, the first in 1967. Three were intra-arterial. Four more case reports published by ISMP, all intra-arterial.


Their recommendations include

1. Local facilities must review their current practices regarding administration of promethazine HCl injection.
2. Local facilities must create individual protocols for use of promethazine HCl injection.
3. Local Pharmacy and Therapeutics (P&T) Committees must determine instances where use of promethazine HCl injection is absolutely necessary.



Also, in 2006, ISMP conducted a survey of hospital practices, and found that only 3% of facilities/respondents favored either banning IV promethazine or removing it from the formulary, and fewer than half favored instituting any special precautions for IV administration at all.

http://www.ismp.org/newsletters/acutecare/articles/20061102.asp

The chart isn't easy to read but only 3% of responding readers (appears to have been a mix of physicians and nurses) were in favor of banning IV use of promethazine or removing it from the formulary.

They do say 20% of survey respondents were AWARE of an extravasation injury within the last 5 years. I don't know what to make of that or how seriously to take it.

A) That's awfully vague and non-numeric, the worst kind of rumor-based risk assessment. I've certainly been AWARE of some wacky, bizarre complications from various procedures and treatments over the last 5 years, but it's insane to say my AWARENESS of someone else's complication for something they may or may not have done in the usual fashion constitutes grounds for enforcing some unexamined new practice guideline.

B) There's no information regarding how many of those injuries were intra-ARTERIAL injections.

The Institute for Safe Medication Practices (ISMP) has also released recommendations to minimize or prevent
serious tissue injury with intravenous promethazine:
1. Limit the concentration to < 25mg/mL.
2. Limit the dose with starting doses as low as 6.25mg &#8211; 12.5mg, especially for elderly patients.
3. Dilute the drug to reduce potential vesicant effects.
4. Avoid hand or wrist vessels and use large patent veins via a central venous access site.
5. Inject into the port furthest from the patient's vein.
6. Administer slowly over 10-15 minutes.
7. Revise order forms to include actions needed to minimize tissue injury.
8. Educate patients to notify healthcare staff of pain or burning during or after the injection.
9. Create computer generated alerts during the ordering process regarding the safety hazards and necessary
precautions to minimize tissue injury.
10. Although no successful management exists, treat accidental intra-arterial injection or extravasation by
sympathetic block and heparinization.
11. Use alternative agents to treat post-operative nausea and vomiting.
12. Remove promethazine HCl injection from the formulary.

VA MedSAFE recommendations include:
1. Local facilities must review their current practices regarding administration of promethazine HCl injection.
2. Local facilities must create individual protocols for use of promethazine HCl injection.
3. Local Pharmacy and Therapeutics (P&T) Committees must determine instances where use of promethazine HCl injection is absolutely necessary.
4. Providers and clinicians must refer to the Protocol for the Use of Antiemetics to Prevent Chemotherapy-Induced Nausea and Vomiting and Post-Operative Nausea and Vomiting at http://vaww.pbm.va.gov/criteria/antiemeticdosing.pdf for alternative agents, such as parenteral prochlorperazine and parenteral ondansetron.
5. If promethazine must be used, providers and clinicians must follow recommendations per the package insert, ISMP, and VA MedSAFE.
6. Establish safeguards and alerts at each step of the medication use process (ordering, verifying, dispensing, and administration) to prevent of the potential risk of tissue injury, limb impairment, and possible loss of extremity associated with the use of the injectable form of promethazine HCl.
7. Educate providers and other health care staff on the proper administration technique of promethazine HCl injection to prevent tissue injury.
8. Educate providers and other health care staff as to which signs/symptoms to monitor for inadvertent intraarterial injection or perivascular extravasation.
9. Educate patients to report symptoms of pain or burning during or after the administration of promethazine HCl injection.

 

[Gern Blansten]

I don't order more than promethazine 6.25mg to start. Our hospital does have a policy about promethazine and a short version reminder pops up on the pyxis screen when you confirm the order for promethazine before it will let you remove it.

 

[Idiopathic]

Do you guys feel obligated to get an EKG in a pt that otherwise doesn't have one if you want to give 0.4 mg of Droperidol? Or just monitor for 1-2 h on ECG in PACU after dosing? As you can see from the above figure it is basically equivalent in terms of QTC prolongation with Zofran at the 0.4 mg dosing, but it does have the black box warning for torsades (although I think most of these cases were at much larger doses like 10-15 mg total).

when i give that vile drug i never give more or less than 0.625mg, since that is 1/4 cc of our 5mg/2cc preparation. I do not order an EKG before, during or after dosing.

if you are worried, give haldol 1mg, similar effect, probably similar QT prolongation, no black box.

FYI here is the actual black box warning for droperidol. I may never give it again, as it is a liability nightmare

Proarrhythmic Effects
QT prolongation and/or torsades de pointes reported at or below recommended dose, some fatal cases, some pts w/o known QT prolongation risk factors; reserve for pts who fail tx alternatives; avoid use if prolonged baseline QT interval on 12-lead ECG; monitor ECG for arrhythmias prior to tx, continue x2-3h after tx completed; contraindicated if known/suspected QT prolongation incl. congenital long QT syndrome; use extreme caution if prolonged QT syndrome risk (CHF, bradycardia, diuretic use, cardiac hypertrophy, hypokalemia, hypomagnesemia, or in combo w/ drugs that prolong QT interval); other risk factors incl. >65yo, alcohol abuse, and use of benzodiazepines, volatile anesthetics, and IV opiates; initiate low dose, titrate w/ caution to desired effect

 

[Idiopathic]

We had several months of shortage of dexamethasone and quite frankly i did not see any difference in terms on N/V. But we do use droperidol liberally.
Decadron's effect on PONV is weak at best imho, maby it depends on patient population...

Its fairly well established in multiple studies, and I wouldnt call it weak. I think its the best preemptive treatment we have (outside of TIVA). It probably works better in women, but they tend to be at higher risk anyway.

 

[MTGas2B]

Its fairly well established in multiple studies, and I wouldnt call it weak. I think its the best preemptive treatment we have (outside of TIVA). It probably works better in women, but they tend to be at higher risk anyway.

So, my supply of anti-emetics is a bit limited. Generally okay as most of my patients now leave my care intubated, but when possible we try to extubate. So, for simplicity and to use fewer syringes, we've been mixing our dexamethasone with our lidocaine for induction. About half the time the last thing patients do before the propofol hits is reach down to itch their package.

Ah dexamethasone.

 

[Idiopathic]

So, my supply of anti-emetics is a bit limited. Generally okay as most of my patients now leave my care intubated, but when possible we try to extubate. So, for simplicity and to use fewer syringes, we've been mixing our dexamethasone with our lidocaine for induction. About half the time the last thing patients do before the propofol hits is reach down to itch their package.

Ah dexamethasone.

love it.

 

[J-Rad]

if you are worried, give haldol 1mg, similar effect, probably similar QT prolongation, no black box.

FYI here is the actual black box warning for droperidol. I may never give it again, as it is a liability nightmare

There is a black box warning for Haldol.

Also, if you go to this site (http://www.azcert.org/medical-pros/drug-lists/bycategory.cfm#) you will find an excellent resource on QTc prolonging drugs. This particlar page on the site stratisfies by "Risk", "Possible Risk", and "Conditional Risk" of Torsades. Haldol is on the "Risk" list whereas Zofran is on the Possible Risk list.

 

[dhb]

Its fairly well established in multiple studies, and I wouldnt call it weak.

True: 2 meta-analyses that confirm that:
http://www.ncbi.nlm.nih.gov/pubmed/11013774
http://www.ncbi.nlm.nih.gov/pubmed/10625002

Although i really didn't notice it during the shortage...

 

[Idiopathic]

There is a black box warning for Haldol.

Also, if you go to this site (http://www.azcert.org/medical-pros/drug-lists/bycategory.cfm#) you will find an excellent resource on QTc prolonging drugs. This particlar page on the site stratisfies by "Risk", "Possible Risk", and "Conditional Risk" of Torsades. Haldol is on the "Risk" list whereas Zofran is on the Possible Risk list.

not for QT prolongation

 

[J-Rad]

http://www.fda.gov/Drugs/DrugSafety...mationforHeathcareProfessionals/ucm085203.htm

At least for IV administration. The question I have is that if you have a drug more solidly associated with QT prolongation than another drug, would you use it as an alternative to the other drug with a lesser association, just for lack of a black box warning? I realize there are going to be situational influences on how this is answered (and I am not an anesthesiologist, just a pediatric cardiology fellow who is grateful for my anesthesiology colleagues and likes learning from others)

 

[Idiopathic]

http://www.fda.gov/Drugs/DrugSafety...mationforHeathcareProfessionals/ucm085203.htm

At least for IV administration. The question I have is that if you have a drug more solidly associated with QT prolongation than another drug, would you use it as an alternative to the other drug with a lesser association, just for lack of a black box warning? I realize there are going to be situational influences on how this is answered (and I am not an anesthesiologist, just a pediatric cardiology fellow who is grateful for my anesthesiology colleagues and likes learning from others)

i missed that but you are right, there it is. i thought it only had the psychiatric warning. well i guess i need to modify that practice, or start giving it IM in PACU

 

[RxBoy]

Its fairly well established in multiple studies, and I wouldnt call it weak. I think its the best preemptive treatment we have (outside of TIVA). It probably works better in women, but they tend to be at higher risk anyway.

My sentiments exactly. I was just too tired to argue or pull up the studies I read at some point in time that defend the awesomeness of Decadron.

And FYI for anyone who uses it, the ceiling dose for the anti-emetic effect based on newer studies is somewhere in the 4-5 mg range. Its almost devoid of side effects at that dose as well.

 

[pgg]

Its almost devoid of side effects at that dose as well.

I only give 4 mg, but it still produces the genital tinglies. I now push it juuuuuust before the propofol ... for every woman who says something about that side effect, you know there must be 10 who are silently freaking out.

Guys on the other hand, I think the ratio is reversed. They don't seem as inclined to hold back, especially if a couple mg of Versed are on board ... Maybe my sample is skewed because of all the Marines and young Navy guys though.

 

[OB1🤙]

Its almost devoid of side effects at that dose as well.

In asleep people I agree. Awake, not so much....

As a resident I once had a new attending who decided for some reason to give the decadron before the induction meds for some ortho case. Just before she went off to sleep the pt went wide-eyed and started yelling "CRABS CRABS OMG THERE ARE CRABS DOWN THERE" and then passed out.

 

[proman]

I only give 4 mg, but it still produces the genital tinglies. I now push it juuuuuust before the propofol ... for every woman who says something about that side effect, you know there must be 10 who are silently freaking out.

Guys on the other hand, I think the ratio is reversed. They don't seem as inclined to hold back, especially if a couple mg of Versed are on board ... Maybe my sample is skewed because of all the Marines and young Navy guys though.

I give it after the propofol. Come to think of it, I also give the heroin addicts fentanyl after the propofol.

 

[pgg]

In asleep people I agree. Awake, not so much....

As a resident I once had a new attending who decided for some reason to give the decadron before the induction meds for some ortho case. Just before she went off to sleep the pt went wide-eyed and started yelling "CRABS CRABS OMG THERE ARE CRABS DOWN THERE" and then passed out.

"Goodness gracious GREAT BALLS OF FIRE!!!"

Heh.

 

[imfrankie]

"Goodness gracious GREAT BALLS OF FIRE!!!"

Heh.

I gotta start giving that stuff earlier

 

[imfrankie]

Do you guys feel obligated to get an EKG in a pt that otherwise doesn't have one if you want to give 0.4 mg of Droperidol? Or just monitor for 1-2 h on ECG in PACU after dosing? As you can see from the above figure it is basically equivalent in terms of QTC prolongation with Zofran at the 0.4 mg dosing, but it does have the black box warning for torsades (although I think most of these cases were at much larger doses like 10-15 mg total).

During my residency I think everybody that didn't have Parkinsonism got 0.625.
It aint exactly neuroleptanesthesia dosing.

 

[okayplayer]

During my residency I think everybody that didn't have Parkinsonism got 0.625.
It aint exactly neuroleptanesthesia dosing.

Yeah, that's what I meant: 0.625 mg.

 

[RxBoy]

http://www.asahq.org/For-Members/FDA-Alerts-and-Recalls/Zofran-Drug-Safety-Communication.aspx

looks like the feds might be giving Zofran the black box soon just like droperidol.

Funny how these "adverse effects" always get revised after the drug goes generic.

 

[hoyden]

IV. It's on our PACU standing orders. No protocol.

That's interesting. Never heard of DVT from phenergan.

Phenergan was recently blackboxed exactly because of similar blame. I t is not being use in our institution anymore.

http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm182498.htm

and again, because of ONE (sic!) complication the very good, but cheap drug is off use :

http://cherryhill.injuryboard.com/f...box-warning-from-the-fda.aspx?googleid=271206



The most laughable that intramuscular use is NOT balackboxed.

Looks like all the government agencies are stupid and damaging by a default.