PDA

View Full Version : are many people still using droperidol? What do you use for PONV?



MmacFN
06-07-2007, 11:46 AM
I have been using drop. for 10 years The stuff is great for nv at 0.625-1.25 IV (not to mention mild anxiolytic effects).

Are you using drop at all?

Why or Why not?

Also, take a peek at the poll

kmchugh
06-07-2007, 01:30 PM
Generally, everybody gets at least 4 of Zofran near the end of the case. I also will give decadron (4 mg), reglan, pepcid, and bicitra, depending on the severity of post operative nausea. For those with a history of severe post op nausea, I give reglan (10 mg) and decadron (4 mg) in pre-op. Then, I will give 8 of Zofran near emergence. I have also started using Emend, 40 mg po in the day surgery unit prior to having patients with a history of nausea. It's new, and seems to work pretty well.

Kevin

MmacFN
06-07-2007, 01:40 PM
Hey kev

Why 8 of zofran? From what ive read, 4mg of zofran will fill all the receptors for 20-24 hour and so anymore is of little benefit (or none)?

RN29306
06-07-2007, 03:19 PM
Decadron 4-8 mg added to IVF bag in PreOp. Just squirt it in the bad and let it run in as usual. For those of you who have never IV pushed Decadron to awake patients....for a similar experience, just go find an antbed, stir up the ants by kickin half the bed off, then sit on it naked...same feeling. Trust me.....you'll only do this once.

Zofran 4 mg during last 30 minutes of procedure end. Plenty of fluids during case. Also, I won't run the case on nitrous, but will use it waking up in order to get the gas off (don't have the luxury of Des at my facility). Our chief CRNA, during one of our last M&Ms, quoted some study that concluded if a person doesn't suffer from acute motion sickness, then that person will not get PONV from using nitrous on wakeup only.

Patients with documented PONV in the past get a Scop patch.

Anzemet? You might as well be giving saline, tell the patient this is God's gift to PONV prevention and hope for a placebo effect in my opinion. I realize it is a pro-drug and takes time, but in my limited experience, it is not worth the effort of drawing it up. I'm all ears for someone who has found this drug to be useful.

Phenergan, even 6.25mg early in the case, has always seemed to burn me on wake up and I have crappy PACU scores. Patients are not sick, but extremely hung over. I realize its all about synergy, but I have gotten to the point that phenergan can be my 'rescue' dose. I can get by without this drug as an intraop medication.

As far as narcotics, I don't withhold on PONV patients. I will usually not use morphine, but will give patients whatever amount of fentanyl they need. I've never said..."I'm not going to give this extra ml of fentanyl because they are prone to PONV". I wish we had Dilaudid, but our OR pharmacist won't authorize it despite the fact the institution has it and the PACU nurses have it. I have given up beating my head against the wall on this issue.

Knock on wood.......genetics will trump your efforts at times, but I have never had a patient get sick or nauseated when I pulled out all the stops. I follow up with our PACU nurses and follow patients up on the floor for the first day if something about them interests me....such as a challenging PONV case that the patient states "I get sick with every anesthetic".

This approach seems to work well at the facility I am at.

It is O so nice when someone thanks you for an anesthetic unlike any other they've ever had. Thats when I remind them I'm a nurse anesthetist. :marchmellow:

MmacFN
06-07-2007, 03:30 PM
Your OR pharmacist wont "allow" it?

Since when do they have control of prescriptive decisions? Is that their job there?

RN29306
06-07-2007, 03:40 PM
Your OR pharmacist wont "allow" it?

Since when do they have control of prescriptive decisions? Is that their job there?


If its not on the OR formulary (approved by committies and other such BS), then you ain't getting it.
No remi, no sister su, no alfent. Various substituitions for ABX and other stuff.

Its just how it is dealing with a large trauma hospital. Use what you got. Ours just seems to be fairly restrictive. I'm sure I'm not the only one with this problem.

Other CRNAs at other institutions seem to have free run with the pharmacological world. Lucky them.

armygas
06-07-2007, 07:01 PM
For those of you who have never IV pushed Decadron to awake patients....for a similar experience, just go find an antbed, stir up the ants by kickin half the bed off, then sit on it naked...same feeling. Trust me.....you'll only do this once.

bwahahahah, ain't it the truth!

armygas
06-07-2007, 07:04 PM
About 20 minutes after induction I will give 4mg Zofran and 0.625 Inapsine, if the patient has had severe N/V history I give another 4 mg Zofran roughly ten minutes before the end of the case.

I use alot of morphine and fentanyl and rarely have had nausea issues, I also use 2-5 mg versed preop/preinduction and when I don't I find more nausea in my patients.

armygas
06-07-2007, 07:08 PM
Show this to your pharmacist (many hospitals don't carry inapsine anymore but ondansetron is all over the place):

"But what clinched the decision to include droperidol as a first-line agent was data from the 2003 consensus guidelines for managing PONV (Anesth Analg 2003; 97:62-71). That article noted that "there has not been a single case report in a peer-reviewed journal in which droperidol in doses used for the management of PONV has been associated with QT prolongation, arrhythmias or cardiac arrest."

www.pharmhs.com/Forms/PONV%20-%20Sakai.pdf

Ondansetron Is Similar to Droperidol in Causing QT Prolongation

Ondansetron appears to cause QT prolongation similar to that with droperidol; this finding raises serious questions about the basis for the FDA's black box warning about droperidol.

Data analyses that have been performed since the FDA’s controversial "black box" warning about droperidol in 2001 have strongly challenged the basis for the warning. Although the adverse cardiac events occurred at doses greatly exceeding those used for postoperative nausea and vomiting (PONV), the warning was issued in blanket fashion, and use of droperidol, an inexpensive and highly effective antiemetic and sedation agent, effectively ceased.

In a prospective study from France, researchers evaluated the electrocardiographic effects of standardized doses of droperidol and ondansetron in 85 consecutive patients undergoing elective general anesthesia who experienced PONV in the recovery room. At the attending anesthesiologist’s discretion, patients received either 4 mg of ondansetron or 0.75 mg of droperidol in nonrandomized fashion. ECGs were recorded in all patients before and at 1, 2, 3, 5, 10, and 15 minutes after drug administration. Eight patients in each group had additional ECGs at 30, 45, 60, 90, 120, and 180 minutes. All ECGs were interpreted by one anesthesiologist, who was blinded to the drug used.

A total of 43 patients received droperidol, and 42 received ondansetron. Overall, 21% of patients had QTc prolongation before drug administration (similar incidence and magnitude in both groups). Significant QTc prolongation occurred in both groups during the 15 minutes after drug administration. Droperidol and ondansetron patients exhibited maximal QTc prolongation of 17±9 ms at 2 minutes and 20±13 ms at 3 minutes, respectively. QTc prolongation was significant and occurred throughout the study period, failing to reach significance at only one time point for each drug.

In another study, from the U.S., investigators assessed the effect of low doses of droperidol on the QTc interval in 120 patients undergoing general anesthesia. Sixty patients were randomized to receive 0.625 mg of droperidol, 1.25 mg of droperidol, or saline placebo; they were monitored by single-lead ECG at 1-minute intervals for 10 minutes after the injection. Another 60 patients who had received either 1.25 mg droperidol or saline underwent 12-lead ECG 1 and 2 hours after arrival in the recovery room. All ECGs were interpreted by two investigators who were blinded to the treatment group.

Mean maximal QTc prolongation occurred at 3–6 minutes; it was 15±40 ms in the 0.625-mg droperidol group, 22±41 ms in the 1.25-mg droperidol group, and 12±35 ms in the placebo group; the differences were not significant. There was no delayed prolongation among patients who underwent ECG at 1 and 2 hours.

Comment: An editorialist points out that the doses implicated in droperidol-induced torsades de pointes were much higher than those used for PONV, and, even with the higher doses, the link is tenuous at best. He also raises a fascinating possibility: The FDA might have been influenced by people associated with the manufacturers of 5-HT3 antagonists, such as ondansetron. In any case, the low doses of droperidol used in the emergency department for nausea and vomiting have little, if any, potential to cause lethal dysrhythmia, and we lament the loss of this inexpensive and highly effective agent. One wonders whether the FDA will be inclined to warn us about the 5-HT3 antagonists, or even saline, in light of these studies.

— Ron M. Walls, MD, FRCPC, FACEP, FAAEM

Published in Journal Watch Emergency Medicine June 28, 2005

halothane
06-07-2007, 09:23 PM
Pharmacy seems to have too much control over what drugs are available and what certain agents can be rx'd for.

TranMan
06-10-2007, 08:24 PM
Most of my patients get 4mg of Zofran pre-extubation. Those with a history may get some or all of the following depending on their surgery, etc.
-4mg of Decadron, 10mg Reglan, 20mg Pepcid post induction.
-plenty of IVFs if not contraindicated.
-Minimize Narcotics and more local where possible
-No Nitrous.
-decrease stimulation, ambulation postop
-Increase PO fluid intake at home
-Easy on the eating and drinking postop.

stanman1968
06-17-2007, 02:24 PM
For PONV prophylaxis in patients who have HX of, I use Drop. .625 at the end of the case with reglan and zofran, and at induction 4 of zofran with 4 of decodron. I never skimp on narcotics, and have had good results thus far.

CRNA06
06-17-2007, 04:59 PM
I generally give 8 mg decadron after induction and 4 mg Zofran near the end of the case. For certain cases or in higher risk pts I will also add Reglan 10 mg. With adequate IV fluid and narcs, I seem to be having a pretty good success rate so far.

vigilent1
06-20-2007, 05:12 PM
I primarily use zofran....and contrary to what reps say I use it up front before induction....I have not had a ponv case in over 1000 cases....and I am counting. If reallllllllly bad hx ponv, I supplement with Inapsine 0.625 mg.....Reglan based on wt and Decadron if not a diabetic.......stay away from N20.....I use nitrous some but if hx of ponv....no way............nonsmokers especially get sick.......so I watch them closely. Hope this note helps.....like I said no ponv in over 1000 cases...and counting.
vigilent1:flybye:

deliciousbass
06-20-2007, 06:33 PM
I did my thesis on PONV and the relatively new NK-1 receptor antagonist, emend. While doing my lit review I came across some great articles by Dr. Christian Apfel and Dr. Gan. Both are leading researchers in the field of PONV and co-authored Consensus guidelines for treating PONV. If droperidol didn't have the black box warning, it would have been the first choice for PONV. Dexamethasone became the first choice because its cheap, low side-effect profile, and found to be as effective as zofran and droperidol (4mg dose). They also found that repeated doses of zofran did not improve efficacy and reglan 10-20mg was not an effective antiemetic. They also helped identify the four risk factors for PONV and recommended prophylaxis if the patient met 2 or more risk factors. There is a great website: www.ponv.org authored by Apfel. It has some great info. Based on what I learned from the research I did for my thesis, I use decadron 4mg and zofran 4mg on induction for patients that have identified risk factors or for surgeries where ponv could be harmful to the patient. If patients have 3 or 4 risk factors, I add another antiemetic to the mix (i.e droperidol, etc.) and use other techniques like TIVA, regional, and so on.

MmacFN
06-20-2007, 06:44 PM
Nice addition DB.

If you would id love for you to post your conclusions or whatever part of your thesis you feel comfortable posting so we can all learn from it!

deliciousbass
06-22-2007, 03:42 AM
My thesis is rather boring other than the bit of info I gleaned from reading alot of articles. So instead of posting parts of it, I'd prefer to point people to www.ponv.org if you wanted to look at current research and guidelines about tx ponv.

BASS

m_playman
02-09-2009, 07:30 PM
For PONV prophylaxis in patients who have HX of, I use Drop. .625 at the end of the case with reglan and zofran, and at induction 4 of zofran with 4 of decodron. I never skimp on narcotics, and have had good results thus far.

This is essentially how I've gone about it...
I will occasionally add in benadryl if the patient has motion sickness problems.

iceemike1
11-10-2012, 11:49 AM
This is essentially how I've gone about it...
I will occasionally add in benadryl if the patient has motion sickness problems.

1 risk factor--drop or zofran
2 risk factors--decadron with induction and zofran or drop at end.
3 risk factors or more--decadron and benadryl (usually 12.5 mg) induction and zofran or drop at end.

I almost never give more than 3 antiemetics, I will add scop patch for motion sickness and give benadryl preinduction. Like the timing--scop patch kicks in gear 4 hrs so think the benadryl is nice bridge.

I will hold off on decradron in out of control diabetics or infected cases I may give 25 mg benadryl to young pts, otherwise I give 12.5 or even 6.25 mg usually hold to elderly as linked with POCD

Emend is going to be huge. However, gotta give my kidney to get it as pharmacy says it's $50 a pop now. Great results with people who say they puke everytime.

jagger67
11-10-2012, 12:01 PM
Generally, everybody gets at least 4 of Zofran near the end of the case. I also will give decadron (4 mg), reglan, pepcid, and bicitra, depending on the severity of post operative nausea. For those with a history of severe post op nausea, I give reglan (10 mg) and decadron (4 mg) in pre-op. Then, I will give 8 of Zofran near emergence. I have also started using Emend, 40 mg po in the day surgery unit prior to having patients with a history of nausea. It's new, and seems to work pretty well.

Kevin

Emend is great but I thought you had to have a cancer diagnosis in order to get insurance companies to pay for it. It is very expensive....or was a few years ago when a friend, with cancer, was taking it.

gaspass3
11-10-2012, 12:12 PM
Emend is great but I thought you had to have a cancer diagnosis in order to get insurance companies to pay for it. It is very expensive....or was a few years ago when a friend, with cancer, was taking it.

We are allowed to order it if the patient has history of PONV. It pays for itself in these patients, no questions asked.

Sent from my SAMSUNG-SGH-I747 using Tapatalk 2

jagger67
11-10-2012, 12:22 PM
If I had access to Droperidol, I would give it on every case. And, would need no other antiemetics. I worked in a PACU for 4 years during the Droperidol hay day years. There were 2 anesthesiologists who gave modest doses, 5mg,...I know most would not consider this a modest dose....this was before the days of outpatient anesthesia....and they both used very stiff doses of either Demerol or Dilaudid, ran Nitrous the whole case and I don't ever remember treating any of their patients for PONV. I do have access to Haldol and will give it on occasion but am trying to fly below the radar so that this doesn't get taken away too. Now, ideally I would like to give a little Benadryl to just about every patient in preop. A couple of reasons. It's an excellent antisialogue. It produces some sedation and allows you to judge, based on how they arrive in the OR, if they are "light weights" or if the Benadryl had NO effect at all. And, it does have antiemetic properties....not first line, granted. Then, just about everybody gets Zofran 4mg and Decadron 4 - 8mg. I usually run a background of Propofol during the case as well and wake up just about everybody on Nitrous for the last 20 minutes or so of the case. I don't even write orderds for PONV....just leave my cell #. Haven't had a call in quite a while.

iceemike1
11-10-2012, 01:23 PM
Emend is great but I thought you had to have a cancer diagnosis in order to get insurance companies to pay for it. It is very expensive....or was a few years ago when a friend, with cancer, was taking it.

Yeah our rph reserves for CA or severe cases ponv refractory to previous treatments. Used to give it to all gastric bandings until they were picking up night before and complain of outpt cost

bgcornel
11-10-2012, 09:42 PM
I generally give 8mg of Decadron after induction for pain and PONV. Towards the end of the case I give 4mg Zofran. If it's someone with a history of PONV I'll give 10 of Reglan after they get the versed on the way back. If it's someone young or high risk I also give 12.5-25mg of Benadryl after induction. I also try to make sure they get a liter of fluid unless there's a CI. The combo seems to work well and keeps the PONV monster away without impacting my narcotics administration. A couple times I've also run a Propofol gtt for severe PONV and reduced my VAA. I generally try to avoid N2O if I know they have a hx but never had trouble in the times I've used it in high risk cases.

JadamR15
11-10-2012, 10:46 PM
N2O gets a bum rap. Run it in 50%, it's shown not to be an emetic.

Anyway, I use the same stuff....Zofran/Decadron/Pepcid/Benadryl/Reglan/Drop.

Essentially, I try to cover all the CTZ receptors, save the NK-1.

ethernaut
11-11-2012, 08:31 AM
since i don't have access to droperidol, of which works great btw, all high risk (hx of PONV/motion sickness/etc...) get scop patch, zofran, dex and robinul. i try to save the benadryl, due to potentially slowing the recovery/discharge process, but have used 12.5 mg as an adjunct. IV fluids works well too!

i think i've only seen a couple come through that have taken emend pre-op. i recommended emend to a friend (where nothing else was working), and she said it worked. must be good.

phronesis153
11-11-2012, 09:26 AM
8mg Decadron up front, 4mg Zofran 30 min b4 end, and drop if many risk factors....here is the evidence/rationale.

Gan TJ, et al. Society for Ambulatory Anesthesia guidelines for the management of postoperative nausea and vomiting. Anesth Analg. 2007 Dec;105(6):1615-28.

https://www.dropbox.com/s/utkhlz11jqzzda7/2007%20PONV%20Consensus%20Guidelines.pdf

iceemike1
11-11-2012, 09:54 AM
N2O gets a bum rap. Run it in 50%, it's shown not to be an emetic. Anyway, I use the same stuff....Zofran/Decadron/Pepcid/Benadryl/Reglan/Drop.

Essentially, I try to cover all the CTZ receptors, save the NK-1.

agree with you man. And I usually only use it the lat 15 minutes or so when blowing off gas and haven't had a problem.

RAYMAN
11-15-2012, 08:31 PM
Such a great drug! Did a case this afternoon....young healthy girl for drainage of seroma couple weeks post breast aug. As soon as we moved her to the stretcher she sat up and started heaving....would not stop....gave her 1mg of drop and BAM...all better.

wtbcrna
11-17-2012, 05:17 PM
N2O gets a bum rap. Run it in 50%, it's shown not to be an emetic.

Anyway, I use the same stuff....Zofran/Decadron/Pepcid/Benadryl/Reglan/Drop.

Essentially, I try to cover all the CTZ receptors, save the NK-1.

Now, correct if I am wrong but droperidol is a dopamine, serotonin, histamine, and alpha 1 antagonist (mostly known for being a dopamine antagonist), and it is my understanding that is why it is such an effective antiemetic because it effects several receptors. I don't understand the reason to add Reglan, benadryl, and possibly even zofran when giving droperidol. In my known PONV patients I generally use a scopolamine patch, decadron (>0.1mg/kg usually 10mg because it has been shown to help with post op pain in a variety of surgeries), droperidol 0.625mg, and occasionally zofran. This combination seems to work on most PONV patients.

iceemike1
11-17-2012, 05:40 PM
Now, correct if I am wrong but droperidol is a dopamine, serotonin, histamine, and alpha 1 antagonist (mostly known for being a dopamine antagonist), and it is my understanding that is why it is such an effective antiemetic because it effects several receptors. I don't understand the reason to add Reglan, benadryl, and possibly even zofran when giving droperidol. In my known PONV patients I generally use a scopolamine patch, decadron (>0.1mg/kg usually 10mg because it has been shown to help with post op pain in a variety of surgeries), droperidol 0.625mg, and occasionally zofran. This combination seems to work on most PONV patients.

I believe it's the degree of receptor antagonism. While drop does hit the antimuscarinic and 5ht3, it's primarily the D2 (which is nice because most others don't hit this one). That's what's nice about adding benadryl and scopalamine. They hit the antimuscarinic and antihistamine receptors better, scopalamine really kicks in at about 4 hours, which is when benadryl starts waning so it's a nice combo. Add the zofran to knock the 5ht3 and you really bombarded all the CTZ receptors.
And if Emend ever gets cheaper, I think it'll be on everyone's PONV cocktail. Unbelievable how well that works. Think we'll start hearing tons more on nk-1/substance p antagonsits for PONV

J-Dubya
11-17-2012, 06:44 PM
And if Emend ever gets cheaper, I think it'll be on everyone's PONV cocktail. Unbelievable how well that works. Think we'll start hearing tons more on nk-1/substance p antagonsits for PONV

I wish I could get my paws on some of that stuff :(

jagger67
11-17-2012, 07:18 PM
Such a great drug! Did a case this afternoon....young healthy girl for drainage of seroma couple weeks post breast aug. As soon as we moved her to the stretcher she sat up and started heaving....would not stop....gave her 1mg of drop and BAM...all better.

Nothing works faster! They will stop mid puke! Perfect for C/S's.

RAYMAN
11-17-2012, 07:36 PM
Nothing works faster! They will stop mid puke! Perfect for C/S's.

Exactly!

Skeebum
11-21-2012, 06:13 AM
Exactly!

I use it rarely, people around here tend to have their heads spin around a few times and damn near fall off when I suggest it. You would think I was advocating an open drop anesthesia technique.

For those that use it routinely, do you check a 12 lead, or document QT before administration?

LouisiAnimal
11-21-2012, 06:40 AM
I use it rarely, people around here tend to have their heads spin around a few times and damn near fall off when I suggest it. You would think I was advocating an open drop anesthesia technique.

For those that use it routinely, do you check a 12 lead, or document QT before administration?

I use it and don't check 12 leads

Bad Apple
11-21-2012, 07:00 AM
For those that use it routinely, do you check a 12 lead, or document QT before administration?

No. If they have had a 12-lead recently I review it as part of my normal pre-op assessment whether they are getting droperidol or not. I never order a 12-lead just because I want to give it, nor do I withhold it from patients who do not have a 12-lead on file. I just document the actual administration of the med, I do not do any "special" documentation.

Sent from my ADR6400L using Tapatalk 2

RAYMAN
11-21-2012, 07:09 AM
No. If they have had a 12-lead recently I review it as part of my normal pre-op assessment whether they are getting droperidol or not. I never order a 12-lead just because I want to give it, nor do I withhold it from patients who do not have a 12-lead on file. I just document the actual administration of the med, I do not do any "special" documentation.

Sent from my ADR6400L using Tapatalk 2

Ditto

ethernaut
11-21-2012, 07:32 AM
if they already have EKG, I'll look at the QTc. if not, I always make it a habit to eyeball the QTi on the monitor, even though its not specific like a 12lead.

Teillard
11-21-2012, 04:53 PM
I'll be so bold as to publicly admit that, not only would I give it without a 12 lead, I've given it and zofran to patients not even on ekg monitors.

Here come da Feds...

http://www.fda.gov/drugs/drugsafety/ucm271913.htm

"protecting and promoting your health"

armygas
11-22-2012, 07:52 AM
I'll be so bold as to publicly admit that, not only would I give it without a 12 lead, I've given it and zofran to patients not even on ekg monitors.

Here come da Feds...

http://www.fda.gov/drugs/drugsafety/ucm271913.htm

"protecting and promoting your health"

Ditto!

Bad Apple
11-22-2012, 08:37 AM
I'll be so bold as to publicly admit that, not only would I give it without a 12 lead, I've given it and zofran to patients not even on ekg monitors.

So do I, commonly.

Sent from my ADR6400L using Tapatalk 2

skipaway
11-22-2012, 10:36 AM
.
And if Emend ever gets cheaper, I think it'll be on everyone's PONV cocktail. Unbelievable how well that works. Think we'll start hearing tons more on nk-1/substance p antagonsits for PONV

Be careful with Emend in women of childbearing age on contraceptives.


• The efficacy of hormonal contraceptives during and for 28 days
following the last dose of EMEND may be reduced. Alternative or
back-up methods of contraception should be used. (5.3, 7.1)

armygas
11-22-2012, 11:23 AM
I'll be so bold as to publicly admit that, not only would I give it without a 12 lead, I've given it and zofran to patients not even on ekg monitors.

Here come da Feds...

http://www.fda.gov/drugs/drugsafety/ucm271913.htm

"protecting and promoting your health"

I love the God called "Black Box Warning"...... I call it "God" because people follow it with blind faith.

Teillard
11-22-2012, 03:23 PM
I love the God called "Black Box Warning"...... I call it "God" because people follow it with blind faith.

Ha!

What do you suppose the FDA will do when they find out what anesthesia and surgery do to QTc? Talk about a god complex. There won't be a black box big enough.

armygas
11-22-2012, 04:03 PM
Ha!

What do you suppose the FDA will do when they find out what anesthesia and surgery do to QTc?.

They will send out the UN Secretary with the "best evidence available" :)

BuckeyeRN
11-28-2012, 03:25 PM
0.625 is my usual rescue antiemetic of choice (and it normally works really well) but today it didnt work at all to stop my patient from trying to vomit, gave 20 mg of propofol and got an "atta boy" from the crna when the pt stoped and was fine within seconds.

Posted via tapatalk, helping people post from odd locations everyday

armygas
11-30-2012, 04:09 AM
I will usually do the following: mix 1.25 mg droperidol in 5 mg midazolam and give have preop and then the rest in the room before induction. Works beautifully!

mummer43
11-30-2012, 09:36 AM
I will usually do the following: mix 1.25 mg droperidol in 5 mg midazolam and give have preop and then the rest in the room before induction. Works beautifully!

Why so much droperidol??

RAYMAN
11-30-2012, 10:16 AM
Why so much droperidol??

You think that's a lot of droperidol?

armygas
11-30-2012, 02:07 PM
Why so much droperidol??

SMH....

mummer43
11-30-2012, 02:08 PM
SMH....

Care to translate?

mummer43
11-30-2012, 02:17 PM
You think that's a lot of droperidol?

I guess in the context that I've only ever given it once and that one dose I gave was .625... I was wondering why he gave double that when .625 seems to work.

armygas
11-30-2012, 02:20 PM
Care to translate?

Shaking my head

mummer43
11-30-2012, 02:21 PM
Shaking my head

And why's that?

armygas
11-30-2012, 02:42 PM
And why's that?

B/c it is not alot at all

mummer43
11-30-2012, 02:44 PM
B/c it is not alot at all

Ok, but why couldn't you just post that rather than the SMH bullshit? You're shaking your head why? Because I'm a CRNA and don't have much experience with droperidol? What did I say that possibly could have made you want to "shake your head?"

RAYMAN
11-30-2012, 03:24 PM
I guess in the context that I've only ever given it once and that one dose I gave was .625... I was wondering why he gave double that when .625 seems to work.

Gotcha....Ever talk to any of the old timers about narcoleptic anesthesia? Impressive

Teillard
11-30-2012, 03:55 PM
Gotcha....Ever talk to any of the old timers about narcoleptic anesthesia? Impressive

It was 'neuroleptanesthesia' and there are good reasons why you don't see it today, black box warnings aside. Excessively excessive residual sedation and insane patients are two of them. I've always started with .625 and waited to see if I needed more. I really try to avoid it. It can make patients pretty sleepy.

gaspass3
11-30-2012, 04:39 PM
Ok, but why couldn't you just post that rather than the SMH bullshit? You're shaking your head why? Because I'm a CRNA and don't have much experience with droperidol? What did I say that possibly could have made you want to "shake your head?"

+1. It was a reasonable question. Especially since most dont have access to the drug and have never used it. Teach, dont judge.

Sent from my SAMSUNG-SGH-I747 using Tapatalk 2

armygas
11-30-2012, 05:06 PM
Ok, but why couldn't you just post that rather than the SMH bullshit? You're shaking your head why? Because I'm a CRNA and don't have much experience with droperidol? What did I say that possibly could have made you want to "shake your head?"

Relax Francis

armygas
11-30-2012, 05:09 PM
+1. It was a reasonable question. Especially since most dont have access to the drug and have never used it. Teach, dont judge.

Sent from my SAMSUNG-SGH-I747 using Tapatalk 2

Really? As hard as people come down on students here and then a CRNA doesn't seem to know how to open up a drug book before asking a question like that??? Really??

armygas
11-30-2012, 05:11 PM
If one does a search, one will find "low dose" droperidol to be 0.625 to 1.25 mg

armygas
11-30-2012, 05:17 PM
It wasn't personal..... but an extensive knowledge of our drugs is our life. I am positive that it is a level one drug question on boards.

armygas
11-30-2012, 05:26 PM
I will make this observation..... there have been many questions like this by CRNAs that should be concerning if we are marketing ourselves as independent practitioners.

Don't stop opening textbooks just because you get your blue card.

RAYMAN
11-30-2012, 06:45 PM
It was 'neuroleptanesthesia' .

Correct...I was typing quickly on my phone in the OR

mummer43
11-30-2012, 06:56 PM
I will make this observation..... there have been many questions like this by CRNAs that should be concerning if we are marketing ourselves as independent practitioners.

Don't stop opening textbooks just because you get your blue card.

Guess we can't all be rock stars like you.

mummer43
11-30-2012, 06:57 PM
Relax Francis

What's that? Can't hear you way up there on your high horse.

mummer43
11-30-2012, 07:14 PM
If one does a search, one will find "low dose" droperidol to be 0.625 to 1.25 mg

One should go piss up a rope.

mummer43
11-30-2012, 07:16 PM
Really? As hard as people come down on students here and then a CRNA doesn't seem to know how to open up a drug book before asking a question like that??? Really??

Are you serious?? I didn't know I had to keep my copy of Barash with me at all times in case I wanted to make a post about a drug I used one time over 2 years ago. Get over yourself.

armygas
11-30-2012, 07:18 PM
Are you serious?? I didn't know I had to keep my copy of Barash with me at all times in case I wanted to make a post about a drug I used one time over 2 years ago. Get over yourself.

Relax Francis :)

mummer43
11-30-2012, 07:21 PM
Relax Francis :)

Is Stripes your favorite movie or something?

jagger67
11-30-2012, 08:22 PM
Gotcha....Ever talk to any of the old timers about narcoleptic anesthesia? Impressive

It's neuroleptanesthesia, Ray.:happy: I probably qualify as an "old timer" here. I have given droperidol in doses that would curl your hair....2.5mg/25#'s of body weight. Soooo....70kg patient would get 15mg of Droperidol. Did well over 1000 cases in school like that and probably another 2-3000 since graduation. No problems with EKG. No extrapyramidal effects. Patients awakened very nicely, pain free for hours and absolutely NO nausea/vomitting. This was only for inpatients as there was almost NO outpatient anesthesia in those days.

Bad Apple
11-30-2012, 08:40 PM
I learned to do lots of fun things with Innovar and droperidol, never had any problems. I still use it sometimes for awake intubations and other unpleasantries.

Sent from my ADR6400L using Tapatalk 2

jcaSRNA
11-30-2012, 08:51 PM
Armygas has been getting pounced on lately for some relatively benign posts. He's the one who got relatively aggressively questioned about the droperidol dosing. Who cares if he said "SMH".....go look up the dosing before you question it...

jagger67
11-30-2012, 09:28 PM
I learned to do lots of fun things with Innovar and droperidol, never had any problems. I still use it sometimes for awake intubations and other unpleasantries.

Sent from my ADR6400L using Tapatalk 2

One of the more fun things I did with droperidol was to pimp one of the newer, very tightly wrapped MDA's in the group.

Me: Hey, Dr. X. Want to have a little fun?
MDA: Aaaa.....whaddya mean?
Me: My next patient has Parkinson's
MDA: Yea....so?
Me: Let's give him about 5mg of Droperidol!!!

:pop2:

mummer43
12-01-2012, 04:50 AM
Armygas has been getting pounced on lately for some relatively benign posts. He's the one who got relatively aggressively questioned about the droperidol dosing. Who cares if he said "SMH".....go look up the dosing before you question it...

Sticking up for Army... How cute.

Bad Apple
12-01-2012, 05:42 AM
Droperidol is an anesthetic adjunct that is still clinically relevant. If people are graduating without any idea of how to administer it, then I think SMH is a perfectly reasonable response to the questioning of one's own standard dosing technique.

Sent from my ADR6400L using Tapatalk 2

armygas
12-01-2012, 06:12 AM
mummer.... the only reason you are so upset is because you know how basic the knowledge of droperidol is....lemme guess you aren't aware of the whole "black box" controversy and the kickback from the anesthetic community. Again it wasn't personal but keep throwing insults and it certainly can become personal.

mummer43
12-01-2012, 06:43 AM
mummer.... the only reason you are so upset is because you know how basic the knowledge of droperidol is....lemme guess you aren't aware of the whole "black box" controversy and the kickback from the anesthetic community. Again it wasn't personal but keep throwing insults and it certainly can become personal.

Yeah, I know nothing of the black box controversy. :noidea: BTW, I really don't think it was personal and, no, that's not at all what upset me.

mummer43
12-01-2012, 06:55 AM
Droperidol is an anesthetic adjunct that is still clinically relevant. If people are graduating without any idea of how to administer it, then I think SMH is a perfectly reasonable response to the questioning of one's own standard dosing technique.

Sent from my ADR6400L using Tapatalk 2

I'm not questioning it's relevancy at all. Does it make me a sub-standard provider that I didn't train in, nor will I be working in an institution that commonly administers droperidol? Guess, I'm just a stool monkey who doesn't make any independent decisions and waits for the doc to tell me what to do. SMH.

armygas
12-01-2012, 07:03 AM
I'm not questioning it's relevancy at all. Does it make me a sub-standard provider that I didn't train in, nor will I be working in an institution that commonly administers droperidol? Guess, I'm just a stool monkey who doesn't make any independent decisions and waits for the doc to tell me what to do. SMH.

There is the problem..... an institution shouldn't dictate what you do or don't give.... if you provide the administration with a BCA on the drug and how it is cost effective, watch how quickly it becomes available. In many places all the CRNA has to do is ask the pharmacy to order it and Viola... it becomes available.

Point of the story.... why would you say "why so much" if you haven't a clue on the drug?

armygas
12-01-2012, 07:06 AM
If someone is dictating how you give anesthesia then you are not an independent practitioner.

mummer43
12-01-2012, 07:07 AM
There is the problem..... an institution shouldn't dictate what you do or don't give.... if you provide the administration with a BCA on the drug and how it is cost effective, watch how quickly it becomes available. In many places all the CRNA has to do is ask the pharmacy to order it and Viola... it becomes available.

Point of the story.... why would you say "why so much" if you haven't a clue on the drug? I've already posted why I said "why so much." I do have a clue about the drug, just very little experience with it. I know you think it might be easy for us to just hand the pharmacy some information about a drug and have them make it available to us, but that's not the real world. It may work in some smaller places, but not where I work... 110+ CRNA's, 11,000+ employees... they'd throw it in the trash as soon as I walked away.

mummer43
12-01-2012, 07:09 AM
If someone is dictating how you give anesthesia then you are not an independent practitioner.

When did I ever make that claim?

armygas
12-01-2012, 07:10 AM
When did I ever make that claim?

By your own admission the institution tells you what you can and cannot give.

armygas
12-01-2012, 07:12 AM
I've already posted why I said "why so much." I do have a clue about the drug, just very little experience with it. I know you think it might be easy for us to just hand the pharmacy some information about a drug and have them make it available to us, but that's not the real world. It may work in some smaller places, but not where I work... 110+ CRNA's, 11,000+ employees... they'd throw it in the trash as soon as I walked away.

Real world? Wonder where I have been over the last 12 years...... hmmmm

mummer43
12-01-2012, 07:13 AM
By your own admission the institution tells you what you can and cannot give. Do you think that everyone works in this magical world where we can just make a request and "voila," it's magically granted. Doesn't work that way in the real world. I'd love to use Prececex on a regular basis, but it's just not gonna happen.

armygas
12-01-2012, 07:13 AM
Question mummer .... are you in a direction or supervision model?

mummer43
12-01-2012, 07:15 AM
Real world? Wonder where I have been over the last 12 years...... hmmmm

Look man, I'm not questioning your practice or doubting your knowledge and experience. You just seem to think that, because it's true for you, it's true for everyone. That's just not the case.

armygas
12-01-2012, 07:16 AM
Do you think that everyone works in this magical world where we can just make a request and "voila," it's magically granted. Doesn't work that way in the real world. I'd love to use Prececex on a regular basis, but it's just not gonna happen.

Ahhh compare the costs/benefits of the two kiddo. Apples to oranges. Again if someone is dictating what you give then you are not an LIP.

mummer43
12-01-2012, 07:17 AM
Ahhh compare the costs/benefits of the two kiddo. Apples to oranges. Again if someone is dictating what you give then you are not an LIP.

I'm aware of the differences, I was just making the point that just because we may want to give a drug and it may be the best thing for our patients, we don't always get to make those decisions.

armygas
12-01-2012, 07:18 AM
Do you think that everyone works in this magical world where we can just make a request and "voila," it's magically granted. Doesn't work that way in the real world. I'd love to use Prececex on a regular basis, but it's just not gonna happen.

Riggghhht.....

mummer43
12-01-2012, 07:19 AM
Again if someone is dictating what you give then you are not an LIP.

Again, I never maid any statements or claims about being independent. Why do you keep coming back to that?

mummer43
12-01-2012, 07:21 AM
Riggghhht.....

Do you think everyone works in the same type of environment?

armygas
12-01-2012, 07:23 AM
Again, I never maid any statements or claims about being independent. Why do you keep coming back to that?

Because if one never has to think about what they give then they become lax in the requirements to continually reinforce the knowledge required to stay current. Again not personal, just reality. I see too many CRNAs that have practiced in a direction model for years and they forget everything they learned because the doc tells them what to do..... how can a person think critically if they quit thinking?

armygas
12-01-2012, 07:28 AM
Do you think everyone works in the same type of environment?

Nope, but I also know that one chooses the environment they work. But again I have seen and currently work with many CRNAs (when I work the occasional day in a direction model per diem) that are dangerous because they have forgotten most of the fundamental knowledge required of a CRNA. (Which is why I am a fan of testing....) again a person can't critically think if they are not required to think.

mummer43
12-01-2012, 07:30 AM
Because if one never has to think about what they give then they become lax in the requirements to continually reinforce the knowledge required to stay current. Again not personal, just reality. I see too many CRNAs that have practiced in a direction model for years and they forget everything they learned because the doc tells them what to do..... how can a person think critically if they quit thinking?

Not every CRNA who is medically directed has the doc telling them what to do. I have seen that in some places, but it's certainly not the case where I work. You have a habit of making broad generalizations.

armygas
12-01-2012, 07:32 AM
Not every CRNA who is medically directed has the doc telling them what to do. I have seen that in some places, but it's certainly not the case where I work. You have a habit of making broad generalizations.

I never said you specifically, but thou dost protest too much.

mummer43
12-01-2012, 07:38 AM
I never said you specifically, but thou dost protest too much.

We can go round and round all day about this. I'm only protesting because it seems that you feel that those of us who don't practice in the same environment you do are second class citizens. I really enjoy where I work and I'm happy with my situation. I wouldn't be if I had someone micromanaging my every move. Yes, I'm medically directed, but only as far as the doc comes in and signs the chart, watches me intubate, and leaves.

armygas
12-01-2012, 07:40 AM
We can go round and round all day about this. I'm only protesting because it seems that you feel that those of us who don't practice in the same environment you do are second class citizens. I really enjoy where I work and I'm happy with my situation. I wouldn't be if I had someone micromanaging my every move. Yes, I'm medically directed, but only as far as the doc comes in and signs the chart, watches me intubate, and leaves.

Wow when did I say second class citizens? I said those who do not stay knowledgeable are dangerous. Again thou dost protest too much

pdsr
12-01-2012, 07:42 AM
Ahhh compare the costs/benefits of the two kiddo. Apples to oranges. Again if someone is dictating what you give then you are not an LIP.
I dare say we all practice under some constraints as to our available formulary. Currently, I can no longer use isoflurane because the system I work in has decided not to stock three different inhalationals. Are there times when I'd use forane instead of sevo? Yes, but does the fact that I don't have that choice make me a "dependent" provider? Well, if it does, then I doubt any of us are actually truly "independent" practitioners.

I get really tired of the sniping and baiting that goes on over this issue. When I'm facing a pt in the ER at 0300 who has smashed his face on a fence post after being ejected from his rolling pickup, the fact that I don't have droperidol available does not make me any more or less an independent practitioner, and the only one in a 70 mile radius who can secure this airway.

Even when I was working in a team environment, I considered myself an independent practitioner. Yes, I was "supervised", but I made and accepted responsibility for my decisions, I did my own inductions, planned my own anesthetics, fixed my own problems. It was this approach that allowed me to move into a solo environment with confidence that I could function safely and effectively.

I think we spend far too much time trying to tear down each other instead of encouraging excellence.

RAYMAN
12-01-2012, 07:43 AM
There is the problem..... an institution shouldn't dictate what you do or don't give.... if you provide the administration with a BCA on the drug and how it is cost effective, watch how quickly it becomes available. In many places all the CRNA has to do is ask the pharmacy to order it and Viola... it becomes available.



Dude I've never seen a pharmacy like that....they argue with us, admin, surgeons, everybody...took an act of congress and months of arguing from surgeons and anesthesia just for us to begrudgingly get Ofirmev

mummer43
12-01-2012, 07:44 AM
Wow when did I say second class citizens? I said those who do not stay knowledgeable are dangerous. Again thou dost protest too much

You never did say that. It's implied. I'm not protesting at all, just trying to make the point that, just because some CRNA's may not be labeled as "independent," doesn't mean they don't make independent decisions. That's all, man.

armygas
12-01-2012, 07:45 AM
Pdsr.... was asking "why so much" not an attempt to tear someone down? Especially when the person had not a clue about the drug? The knowledge deficit was apparent yet the need to question the dose as "too high" was present.

Your thoughts?

mummer43
12-01-2012, 07:48 AM
Pdsr.... was asking "why so much" not an attempt to tear someone down? Especially when the person had not a clue about the drug? The knowledge deficit was apparent yet the need to question the dose as "too high" was present.

Your thoughts?

Again, you're making an assumption that I have "no clue" about the drug. I honestly see why you might think that based on my question, but just because I have only given the drug one time, doesn't mean I know absolutely nothing about it. Your habit of making assumptions is tiring.

armygas
12-01-2012, 07:50 AM
Dude I've never seen a pharmacy like that....they argue with us, admin, surgeons, everybody...took an act of congress and months of arguing from surgeons and anesthesia just for us to begrudgingly get Ofirmev

Well I have done it on 3 occasions when I went to work per diem. It wasn't hard.

armygas
12-01-2012, 07:52 AM
Again, you're making an assumption that I have "no clue" about the drug. I honestly see why you might think that based on my question, but just because I have only given the drug one time, doesn't mean I know absolutely nothing about it. Your habit of making assumptions is tiring.

Then why the need to ask "why so much" if you knew that 0.625 to 2.5 (actually) mg is considered low dose?

pdsr
12-01-2012, 07:57 AM
Pdsr.... was asking "why so much" not an attempt to tear someone down? Especially when the person had not a clue about the drug? The knowledge deficit was apparent yet the need to question the dose as "too high" was present.

Your thoughts?
My thoughts are that the general level of condescension in your posts leads to the appearance that you are more interested in sniping than educating in this forum. Yes, I realize you are a professional educator, but I also have spent much of my life teaching, and I am convinced that it is, generally, those educators who are most lacking in confidence who try to educate by attacking and belittling. Not saying that's the case with you, just a general observation. In any case, I believe that we could make this forum much more useful if the level of snideness was diminished a bit.

armygas
12-01-2012, 07:58 AM
Again, you're making an assumption that I have "no clue" about the drug. I honestly see why you might think that based on my question, but just because I have only given the drug one time, doesn't mean I know absolutely nothing about it. Your habit of making assumptions is tiring.

I didn't make an assumption, you asked the question which spoke for itself.

ethernaut
12-01-2012, 08:00 AM
aside from the fact that this thread is now completely ridiculous, i'm with Ray on this one. as much as i'd like droperidol, our pharmacy swiped it off the shelves when black box came around, put it back on the shelf when new literature surfaced, and our chief has made it known to not use droperidol. some decisions are not always in our hands.

armygas
12-01-2012, 08:07 AM
our chief has made it know to not use droperidol. some decisions are not always in our hands.
Exactly my point. But that doesn't excuse (not saying you Ether) the fact that many in this model go to work, put in and pull tubes, call the doc when there is a problem, go home, and never think about what they are doing. Hasn't this been a topic of recent conversation regarding the training of new grads?

armygas
12-01-2012, 08:08 AM
My thoughts are that the general level of condescension in your posts leads to the appearance that you are more interested in sniping than educating in this forum. Yes, I realize you are a professional educator, but I also have spent much of my life teaching, and I am convinced that it is, generally, those educators who are most lacking in confidence who try to educate by attacking and belittling. Not saying that's the case with you, just a general observation. In any case, I believe that we could make this forum much more useful if the level of snideness was diminished a bit.

Wow.... all I did was type SMH..... and then got cursed at.

armygas
12-01-2012, 08:10 AM
My thoughts are that the general level of condescension in your posts leads to the appearance that you are more interested in sniping than educating in this forum. Yes, I realize you are a professional educator, but I also have spent much of my life teaching, and I am convinced that it is, generally, those educators who are most lacking in confidence who try to educate by attacking and belittling. Not saying that's the case with you, just a general observation. In any case, I believe that we could make this forum much more useful if the level of snideness was diminished a bit.

I will remember that I can't do anesthesia when I am alone with the FST in June in the 'stan!

gaspass3
12-01-2012, 08:15 AM
I have never seen a pharmacy that gives a damn what we want to use. Maybe tiny, one OR hospitals in rural America do have this because of the relationships and trust that are able to be built. But, most large hospitals have "Pharmacy & Therapeutics" committees in some form and THEY decide what drugs are going to be available in that institution. Period. It is almost comical to think of a CRNA, or any provider for that matter, going down and telling them what they are going to do. If anyone thinks otherwise, well that is truly naive.

Sent from my SAMSUNG-SGH-I747 using Tapatalk 2

pdsr
12-01-2012, 08:17 AM
I will remember that I can't do anesthesia when I am alone with the FST in June in the 'stan!

Not my intent at all... I'm sure you are quite capable and confident in your practice. Just disagree with your style at times.

ethernaut
12-01-2012, 08:18 AM
Exactly my point. But that doesn't excuse (not saying you Ether) the fact that many in this model go to work, put in and pull tubes, call the doc when there is a problem, go home, and never think about what they are doing. Hasn't this been a topic of recent conversation regarding the training of new grads?
absolutely! and yes it has been (and still is) a hot topic. i've noticed this with many CRNAs i work with, as well as the past few classes coming thru the OR. i've addressed/discussed this with several attendings and the program faculty, on many occasions. i still can't understand some of the admission choices each year. i've even asked several times to be part of the selection committee, but apparently CRNAs, who are in the trenches day in and day out, are not considered necessary to be on the panel. makes sense, right?

armygas
12-01-2012, 08:20 AM
I have never seen a pharmacy that gives a damn what we want to use. Maybe tiny, one OR hospitals in rural America do have this because of the relationships and trust that are able to be built. But, most large hospitals have "Pharmacy & Therapeutics" committees in some form and THEY decide what drugs are going to be available in that institution. Period. It is almost comical to think of a CRNA, or any provider for that matter, going down and telling them what they are going to do. If anyone thinks otherwise, well that is truly naive.

Sent from my SAMSUNG-SGH-I747 using Tapatalk 2

Community Hospitals will, I have done it. First you create a presentation that reviews the drug, the controversies, the supporting evidence, and how the use of the drug can save the institution money each year based upon projections and then schedule a meeting with the CEO, director of pharmacy, and the Director of Anesthesia. It takes work but it has been done (by me).

RAYMAN
12-01-2012, 08:34 AM
Community Hospitals will, I have done it. First you create a presentation that reviews the drug, the controversies, the supporting evidence, and how the use of the drug can save the institution money each year based upon projections and then schedule a meeting with the CEO, director of pharmacy, and the Director of Anesthesia. It takes work but it has been done (by me).



Ah, and now we know the rest of the story! Like I said, it takes an act of congress....you initially presented like "just go down and tell them how good it is and will decrease costs and voila, it magically appears". As others have said, some decisions are taken out of the providers hands....this is only going to get worse as it has been getting worse the last couple of decades...

armygas
12-01-2012, 08:39 AM
Ah, and now we know the rest of the story! Like I said, it takes an act of congress....you initially presented like "just go down and tell them how good it is and will decrease costs and voila, it magically appears". As others have said, some decisions are taken out of the providers hands....this is only going to get worse as it has been getting worse the last couple of decades...

But it isn't that hard, on the other two occasions, I just went to the pharmacy and asked them to order it and they did.

mummer43
12-01-2012, 09:05 AM
But it isn't that hard, on the other two occasions, I just went to the pharmacy and asked them to order it and they did.

In your neck of the woods it might be that simple, but I assure you that I would be laughed out of the room if I tried this.

mummer43
12-01-2012, 09:14 AM
Pdsr.... was asking "why so much" not an attempt to tear someone down? Especially when the person had not a clue about the drug? The knowledge deficit was apparent yet the need to question the dose as "too high" was present.

Your thoughts?

You keeps saying I " had not a clue." I've already explained that, in my extremely limited experience with the drug, I've given a dose on the low end of the range. That dose was effective, so I questioned the need to give a higher dose. Admittedly, a sample size of one should have precluded me from even asking the question, but I was curious why you gave that dose so I asked. Not sure how many more ways I can explain it.

armygas
12-01-2012, 09:15 AM
In your neck of the woods it might be that simple, but I assure you that I would be laughed out of the room if I tried this.

You will never get anything if you do not ask.

armygas
12-01-2012, 09:21 AM
Look, again this isn't personal.... my point is that we have to be experts in the drugs that are common in anesthesia. How much do you want to bet that this comes back into fashion as money gets tight?

armygas
12-01-2012, 09:22 AM
You keeps saying I " had not a clue." I've already explained that, in my extremely limited experience with the drug, I've given dose on the low end of the range. That dose was effective, so I questioned the need to give a higher dose. Admittedly, a sample size of one should have precluded me from even asking the question, but I was curious why you gave that dose so I asked. Not sure how many more ways I can explain it.

That isn't how you asked the question.

armygas
12-01-2012, 09:23 AM
Armygas has been getting pounced on lately for some relatively benign posts...

You have noticed that too huh?

mummer43
12-01-2012, 09:53 AM
That isn't how you asked the question.

Ahhhh, these are the problems we sometimes face when communicating on the Internet. Someone as smart as you should have realized that.

ethernaut
12-01-2012, 10:40 AM
Look, again this isn't personal.... my point is that we have to be experts in the drugs that are common in anesthesia. How much do you want to bet that this comes back into fashion as money gets tight?
in mummer's defense, what was common years ago, may not be common today. if one trains at many clinical sites that never carry droperidol, for example, and is only exposed to it in some anesthesia class touching upon neurolept anesthesia, how can one (why should one) be an expert on such a drug. as for being experts in the drugs that are common, i agree. if we were talking about neosynephrine, fentanyl, rocuronium, etc...then i'd have more of a concern than lacking knowledge in, say, edrophonium, because only few locales around the country might have it.

Teillard
12-01-2012, 08:59 PM
If someone is dictating how you give anesthesia then you are not an independent practitioner.


There hasn't been an independent practitioner since SCIP, CMS and jacho.

Suxit
12-19-2012, 08:50 PM
Curious, who gives Zofran before induction vs. 30 minutes prior to end of case? Drug pamphlet states giving it before induction, citing several studies etc. I'm going to have to look to see if there are any studies about the efficacy of using before or after induction, and vice versa? Does anyone know about this? I like the whole idea of give the medication before the stress release of serotonin from the gastrochromaffin cells etc and filling up those receptors in the area postrema prior to serotonin getting there, but is this just intellectual masturbation? In any event, in my youthful experience as an SRNA, the whole give before induction seems to work well (must mean I am still a greenhorn ;) I do like using a multimodal approach especially in high risk patients.

wtbcrna
12-19-2012, 08:58 PM
http://www.ncbi.nlm.nih.gov/pubmed/18450232

P R Health Sci J. 2008 Mar;27(1):43-7.
Timing of ondansetron administration to prevent postoperative nausea and vomiting.
Cruz NI, Portilla P, Vela RE.
Source
Division of Plastic Surgery, Department of Surgery, University of Puerto Rico School of Medicine, San Juan, Puerto Rico. normacruz@sanjuanstar.net
Abstract
BACKGROUND:
The original guidelines for using ondansetron recommending its administration prior to induction of anesthesia have been questioned.
METHOD:
In an effort to determine the most effective timing of ondansetron administration to prevent postoperative nausea and vomiting (PONV), a prospective, randomized, double-blind study was performed. Patients undergoing ambulatory plastic surgery procedures estimated to last two hours or more and who had at least two risk factors for PONV (female gender, non-smoker, previous history of PONV and postoperative opioids) participated in the study. General anesthesia for all patients followed the same standard institutional protocol and all patients received dexamethasone 4 mg intravenously at the start of surgery. The control group (n = 188) received 4 mg of ondansetron intravenously prior to the induction of anesthesia. The study group (n = 184) received 4 mg of ondansetron intravenously 30 minutes prior to completion of the surgery. The incidence of PONV during the early (0-2 hours) and delayed (2-24 hours) postoperative periods was recorded.
RESULTS:
No significant difference was found between the groups regarding early postoperative nausea or vomiting (p > 0.05). However, a significant difference (p < 0.05) was noted in both late postoperative nausea (control: 30% vs. study group: 20%) and late postoperative vomiting (control: 17% vs. study group: 8%).
CONCLUSION:
This clinical study indicates that when performing prolonged surgical procedures, late administration of ondansetron (within 30 minutes prior to completing the surgery) is significantly more effective in the prevention of late PONV than when administered prior to the induction of anesthesia.


This is a decent sized study.

Anthony
12-19-2012, 09:02 PM
Well if you really want to dissect it look at this and tell me if what youre saying makes any sense focusing on the etiology of primary triggers with PIAs and PONV - Ill give you a hint - youre missing the bigger picture
3748 Heres a direct link for a better look http://www.gasshead.com/class/CTZboxess.jpeg

Goose
12-19-2012, 10:07 PM
Tone,

I would love to come out and spend some time and pick your brain. After graduation of course. I have found all of your posts full of knowledge and tricks of the trade.

So thank you,

Dan


Sent from my iPad using Tapatalk HD

Anthony
12-20-2012, 06:42 AM
thanks Dan - anytime bud...anywho.... dont tell anyone but I make it all up anyways ;)....

..
but for the adventurous... here's what awaits a visit ...its a view pushing off of my dock paddling south towards the mission range in Northwestern MT...

3751

NickAngelis
12-20-2012, 08:46 AM
I've regretted giving Droperidol to patients over 65 (although giving Benadryl seems to attenuate the side effects), but I'll often use half the dose in patients (using a TB syringe to measure 1/8th of a cc) and consider giving the rest of it if they're not squirrely in PACU. My favorite combination for someone with serious PONV history is Zofran, Decadron, Benadryl or Phenergan (sometimes only 5mg of the latter), and a low-dose Propofol infusion when we have adequate amounts of that precious drug.

ethernaut
12-20-2012, 12:25 PM
I've regretted giving Droperidol to patients over 65 (although giving Benadryl seems to attenuate the side effects), but I'll often use half the dose in patients (using a TB syringe to measure 1/8th of a cc) and consider giving the rest of it if they're not squirrely in PACU. My favorite combination for someone with serious PONV history is Zofran, Decadron, Benadryl or Phenergan (sometimes only 5mg of the latter), and a low-dose Propofol infusion when we have adequate amounts of that precious drug.

you'll avoid droperidol in the elderly but not Benadryl? interesting.

Bad Apple
12-20-2012, 12:57 PM
How often do you all seriously have a problem with PONV in an elderly patient? Like, never? I avoid all these drugs in most elderly patients simply because they aren't indicated.

Sent from my ADR6400L using Tapatalk 2

ethernaut
12-20-2012, 01:15 PM
How often do you all seriously have a problem with PONV in an elderly patient? Like, never? I avoid all these drugs in most elderly patients simply because they aren't indicated.

Sent from my ADR6400L using Tapatalk 2

rarely for me. however, just last month, a 79 y.o. female needed antiemetics for PONV after having bilateral upper lid bleph. and all she had was some propofol for block.

NickAngelis
12-20-2012, 03:56 PM
We were out of Zofran and low on Phenergan at the time. Also, I use an embarrassing amount of nitrous. As an ICU nurse I had elderly patients wig out on Benadryl, but I love combining it with other agents for many of my cases (though generally, the fewer drugs the better for older patients). That said, the large, PONV patient I gave Phenergan to shortly after my last post did have an SpO2 of 91% for the first few minutes in the PACU, but any drug will burn you occasionally--hopefully not in the "sit naked on an anthill" way mentioned earlier.

Suxit
12-20-2012, 05:30 PM
http://www.ncbi.nlm.nih.gov/pubmed/18450232

P R Health Sci J. 2008 Mar;27(1):43-7.
Timing of ondansetron administration to prevent postoperative nausea and vomiting.
Cruz NI, Portilla P, Vela RE.
Source
Division of Plastic Surgery, Department of Surgery, University of Puerto Rico School of Medicine, San Juan, Puerto Rico. normacruz@sanjuanstar.net
Abstract
BACKGROUND:
The original guidelines for using ondansetron recommending its administration prior to induction of anesthesia have been questioned.
METHOD:
In an effort to determine the most effective timing of ondansetron administration to prevent postoperative nausea and vomiting (PONV), a prospective, randomized, double-blind study was performed. Patients undergoing ambulatory plastic surgery procedures estimated to last two hours or more and who had at least two risk factors for PONV (female gender, non-smoker, previous history of PONV and postoperative opioids) participated in the study. General anesthesia for all patients followed the same standard institutional protocol and all patients received dexamethasone 4 mg intravenously at the start of surgery. The control group (n = 188) received 4 mg of ondansetron intravenously prior to the induction of anesthesia. The study group (n = 184) received 4 mg of ondansetron intravenously 30 minutes prior to completion of the surgery. The incidence of PONV during the early (0-2 hours) and delayed (2-24 hours) postoperative periods was recorded.
RESULTS:
No significant difference was found between the groups regarding early postoperative nausea or vomiting (p > 0.05). However, a significant difference (p < 0.05) was noted in both late postoperative nausea (control: 30% vs. study group: 20%) and late postoperative vomiting (control: 17% vs. study group: 8%).
CONCLUSION:
This clinical study indicates that when performing prolonged surgical procedures, late administration of ondansetron (within 30 minutes prior to completing the surgery) is significantly more effective in the prevention of late PONV than when administered prior to the induction of anesthesia.


This is a decent sized study.



Awesome, thanks!

iceemike1
12-21-2012, 01:10 PM
you'll avoid droperidol in the elderly but not Benadryl? interesting.

+1

Question to students--what classes of drugs are biggest culprits for pocd in elderly?

ckh23
12-22-2012, 11:40 AM
+1

Question to students--what classes of drugs are biggest culprits for pocd in elderly?

Benzodiazepines

iceemike1
12-22-2012, 11:48 AM
Benzodiazepines

and . . . ???

iceemike1
01-08-2013, 03:21 PM
and . . . ???

Any students?

lvl1micuRN
01-08-2013, 04:16 PM
+1

Question to students--what classes of drugs are biggest culprits for pocd in elderly?

Scopolamine
Atropine can do it as well
Volatile agents
Ketamine

Orthopedic surgery itself is a risk factor

Come to think of it, what doesn't have the opportunity to cause POCD in the elderly? ;)

Teillard
01-08-2013, 07:53 PM
Scopolamine
Atropine can do it as well
Volatile agents
Ketamine

Orthopedic surgery itself is a risk factor

Come to think of it, what doesn't have the opportunity to cause POCD in the elderly? ;)

Ketamine? Not to play gotcha, but that's news given the doses for analgesia given these days.

iceemike1
01-09-2013, 11:21 AM
Scopolamine
Atropine can do it as well
Volatile agents
Ketamine

Orthopedic surgery itself is a risk factor

Come to think of it, what doesn't have the opportunity to cause POCD in the elderly? ;)

Type of surgery definitely matters with ortho being the biggest culprit. But there's a drug many of us use almost daily that is a big culprit along with benzos.

Goose
01-09-2013, 07:32 PM
Mike,

Are you looking for narcs (fentanyl)?


Sent from my iPad using Tapatalk HD

ckh23
01-13-2013, 04:42 PM
Type of surgery definitely matters with ortho being the biggest culprit. But there's a drug many of us use almost daily that is a big culprit along with benzos.

How about propofol?

ethernaut
01-13-2013, 05:35 PM
How about propofol?

how about it?

Bad Apple
01-15-2013, 09:06 PM
there's a drug many of us use almost daily that is a big culprit along with benzos.

Marijuana?

Sent from my ADR6400L using Tapatalk 2

ethernaut
01-16-2013, 06:09 AM
Marijuana?

Sent from my ADR6400L using Tapatalk 2

i'm sorry, but are you asking.. or telling? :hat:

Bad Apple
01-16-2013, 06:28 AM
i'm sorry, but are you asking.. or telling? :hat:

Oh neither, of course. Just guessing that IF there were "one drug that many of us use almost daily" that would be the one. But I meant to type "caffeine" and my smartphone autocorrected it.

jagger67
01-16-2013, 07:02 AM
With both "smart phones" and e-mail, it is so easy to send the wrong message.:lol:

jagger67
01-16-2013, 07:02 AM
I would have guessed caffeine too.

ethernaut
01-16-2013, 07:09 AM
Oh neither, of course. Just guessing that IF there were "one drug that many of us use almost daily" that would be the one. But I meant to type "caffeine" and my smartphone autocorrected it.

i hate when that happens

hutchinsoncrna
02-04-2013, 06:36 PM
is Emend expensive?

Shane
02-04-2013, 06:41 PM
is Emend expensive?

Very. I don't know the exact price though.

ethernaut
02-04-2013, 06:46 PM
Very. I don't know the exact price though.
15-30$ last i knew

iceemike1
02-06-2013, 06:09 AM
15-30$ last i knew

That number is higher by us both for out and in pt pharmacy (pt cost). Not sure what hospital cost is--will try to find out

iceemike1
02-07-2013, 07:44 PM
That number is higher by us both for out and in pt pharmacy (pt cost). Not sure what hospital cost is--will try to find out

Pt cost $160. Hospital cost $40ish

Happyin09
02-09-2013, 04:42 PM
Love my Drop and Decadrone mix!!! :)

Teillard
02-11-2013, 06:09 PM
is Emend expensive?

probably cheaper than an admission for vomiting.

ethernaut
02-11-2013, 09:03 PM
probably cheaper than an admission for vomiting.

or prolonged ASC stay

Harris4crna
02-19-2013, 08:53 PM
As SRNA, our research project included testing Emend in combo with standard therapy of zofran and decadron and placebo. We concluded after 80 subjects that Emend did not prevent Post discharge nausea, but did prevent vomiting. Secondary, we assessed post op pain and amount of narcotics used since Emend a NK1 antagonist. Again, no evidence found decrease pain and need for post surgical narcotics at the antiemetic dose. We are in the process of publishing. When i get the chance i will post here. Take it for what its worth, cheers.

ethernaut
02-20-2013, 07:44 AM
As SRNA, our research project included testing Emend in combo with standard therapy of zofran and decadron and placebo. We concluded after 80 subjects that Emend did not prevent Post discharge nausea, but did prevent vomiting. Secondary, we assessed post op pain and amount of narcotics used since Emend a NK1 antagonist. Again, no evidence found decrease pain and need for post surgical narcotics at the antiemetic dose. We are in the process of publishing. When i get the chance i will post here. Take it for what its worth, cheers.

were all these subjects medicated the night before (with emend)? i thought i remember the rep mentioning this, but this was 3 or so years ago.

Harris4crna
02-20-2013, 08:32 PM
Yes they were. Yeah, we did the study 2007-2009 in San Diego. Would i use Emend for PDNV, sure, but i did not find it the wonder drug for sure. Just another adjunct to treat PONV at a bit of a heftier price.

Burnt2
03-10-2013, 06:39 PM
for the really bad hx of PONV:

Meclozine 25mg PO chewable, pepcid/reglan, scop patch (preop), zofran prior to heading back to OR, then versed, decadron after they're asleep. +/- another 4mg zofran at the end of the case (I'm not sold on this for reasons already discussed, but it's cheap and in the absence of a strong migraine hx I sometimess do it).

iceemike1
03-11-2013, 04:56 PM
for the really bad hx of PONV:

Meclozine 25mg PO chewable, pepcid/reglan, scop patch (preop), zofran prior to heading back to OR, then versed, decadron after they're asleep. +/- another 4mg zofran at the end of the case (I'm not sold on this for reasons already discussed, but it's cheap and in the absence of a strong migraine hx I sometimess do it).

Anyone got article saying more than 3 agents better than just 3

ethernaut
03-11-2013, 05:22 PM
Anyone got article saying more than 3 agents better than just 3

why not hit all the receptors in the high risk population(s)?

iceemike1
03-11-2013, 06:17 PM
why not hit all the receptors in the high risk population(s)?

Total agree, but some drugs hit more than 1 receptor, and last I recall was article showing no diff between 3 or more drugs with PONV. Just curious if any new evidence for different dosing

Burnt2
03-11-2013, 08:05 PM
Total agree, but some drugs hit more than 1 receptor, and last I recall was article showing no diff between 3 or more drugs with PONV. Just curious if any new evidence for different dosing

No, you're right that the literature supports 3 drugs; I just choose to step beyond that line sometimes for the bad PONV. In my view it just broadens the scope and depth of receptor coverage. There is some overlap, sure, but I don't think it's detrimental. I've had good success with it. In the (admittedly few) cases where I've been able to obtain previous anesthetic records, there have been better results than the prior anesthetic.....sample size and investigator bias notwithstanding........

ethernaut
03-11-2013, 08:52 PM
No, you're right that the literature supports 3 drugs; I just choose to step beyond that line sometimes for the bad PONV. In my view it just broadens the scope and depth of receptor coverage. There is some overlap, sure, but I don't think it's detrimental. I've had good success with it. In the (admittedly few) cases where I've been able to obtain previous anesthetic records, there have been better results than the prior anesthetic.....sample size and investigator bias notwithstanding........

previous anesthetic records and notes are quite beneficial to a future success. without contraindications, why not cover more than less?!

iceemike1
03-12-2013, 11:44 AM
previous anesthetic records and notes are quite beneficial to a future success. without contraindications, why not cover more than less?!

Well, I could argue why give more than 3 if a) no increase success supported by literature b) cost to pt c) I could give a few reasons to avoid every antiemetic And I realize PONV is more costly and if someone got 3 and our still having PONV I agree

Carol2012
03-28-2013, 03:17 PM
At my facility we don't use droperidol, although I think we can get it from the omnicell....we use scop patches on lots of patients, pepcid, zofran and decadron on everyone. I don't always use reglan because I don't like it, but for the appropriate patient I will use it. Our incidence of PONV is very low, so I think the "cocktail" is effective. As a former PACU nurse though, droperidol was a godsend. I will also add post op phenergan to the orders if the patient needs it, but I don't give it to old people (who historically have a lower incidence of PONV anyway)

Carol2012
03-28-2013, 03:18 PM
Also, a couple of our plastic surgeons give Emend to their patients along with a scop patch to use the AM of surgery. As a former chemo patient, I can tell you that Emend is the best thing out there. I was never sick once, but got explosive headaches from PO zofran. Just my .02

ethernaut
03-28-2013, 10:18 PM
Also, a couple of our plastic surgeons give Emend to their patients along with a scop patch to use the AM of surgery. As a former chemo patient, I can tell you that Emend is the best thing out there. I was never sick once, but got explosive headaches from PO zofran. Just my .02

I believe headaches are about 30% with zofran