[kmchugh]

Gowkout

Did you get my response to how to do the remi gtt for carotids?

Kevin McHugh

[Gowkout]

Yes I did, I sent you an email yesterday about it. I cant wait to try it. I am trying to experiment with the different ways to give anesthesia. What do you guys use for labor epidurals that end up with a window? Here we use nesacaine 3%, seems to work well. Do you have any other ways to pre-tx high risk patients for PONV. Right now I use the zofran 4mg and/or droperidol pre and post op if needed. I limit the use of N20 but I have some of my attendings that say it doesnt matter and then there are others that will shy away from N20 with the high risk PONV surgerys. What are your thoughts. I am all ready lined up to use your remi formula on my next carotid. I will have to wait till I get assigned to the vascular room to do it. Here at my hospital you are assigned a room and what ever gets put in that room thats what you do. I will know a day ahead of time if I have a carotid. I have got about 30 carotids under my belt right now and I always seem like I am chasing my blood pressure. This cant be good for the patient as I have studied in my research. Looking forward to talking to you some more, Lee.

[kmchugh]

Lee

Our group does not do OB anesthesia, so can't answer your question about labor epidurals. As for PONV, I give almost EVERY patient 4 of Zofran about 15-30 minutes prior to extubation. Those who tell me they have a strong history for PONV, I add decadron, 4 mg to the anesthetic shortly after induction. There is some pretty good research to indicate that this helps prevent vomiting after surgery. If the history for PONV is REALLY strong, I give 0.625 of droperidol and the decadron shortly after induction, and 4 - 8 of Zofran prior to emergence. (I usually only use the droperidol on patients having longer surgeries now, though. Hospital policy says these patients must have an ekg monitor for three hours after administration, which can lead to some really LONG times in the PACU. Knee jerk reaction to some rather flimsy data, in my book.) I don't think I've had a patient with post op vomiting in a long (more than a year) time. BTW, most articles I have read indicate that Zofran is most effective in the prevention of PONV if given in the time frames I gave above. Pre treatment does not seem to work as well, and post op treatment, especially once vomiting has started, leaves you fighting an uphill battle.

Kevin McHugh

[Gowkout]

What about utilization of N20 and PONV? The droperidol scare went thru our group as well and it was pulled for awhile, we have it back in our drawers but the patient doesnt have to stay in PACU for 3 hrs for monitoring. Lee

[nilepoc]

Hy guys, I hope you don't mind, I moved this to keep the otherr thread on track.

I like the nature of this more clinical content though. Keep it up please. I will try and contribute once I have a clue about what to talk about.

Craig

[kmchugh]

I don't routinely use N2O, though I do use it to deepen an anesthetic without actually increasing the inhaled concentration of volatile agent. I generally use it as needed, and I don't think it significantly contributes to PONV. I've seen a couple of studies on this, and I don't think there was any strong connection between N2O and PONV. I tend to think most of the evidence was circumstantial. The problem is, how do you separate out whether the cause of vomiting was the N2O, the agent, or one of the other drugs you gave. (Narcotics are famous for causing nausea.) In any event, the anti-nausea cocktail I use seems to work really well.

Oh yeah, with the exception of some patients with significant heart disease, I routinely use propofol for induction. I think there are strong anti-emetic properties to propofol, as well.

Kevin McHugh

[WntrMute2]

What do you guys think of anzemet? We don't have droperidol available in our rooms anymore. We can still get it but no-one bothers. Also, I just saw some data about clusters of surgical wound infections related to inductions with propofol. Didn't read it closely tho. I may go back to STP if this turns out to be anything more than an anomaly. we use a lot more propofol now that our hospital started controlling STP more closely.

[lgcv]

Anzemet and Zofran both seem to do a good job. The PACU nurses here say that Zofran works a little faster when the patient is already complaining of nausea. So I tend to use Zofran with Reglan, sometimes add decadron.

Have not seen the studies on propofol and infections, if you see it online post it here i would be interested to read it.

[meandragonbrett]

We mostly use zofran b\c there are standing orders for it.

[kmchugh]

The problem with anzemet is that it has a much tighter window to administer it. I talked with a pharmacist about it. Basically, anzemet works as well as Zofran, but you must give it almost exactly 15 minutes before emergence. Given the way some surgeons work, and the differences in the way patients will come out of anesthesia, this can be very difficult. That's why I prefer Zofran.

Kevin McHugh