Antacids

Simethicone? Or maybe you mean Protonix? We've been using continuous IV Protonix 40mg/250cc lately, especially in hepatic failure and gastrointestinal bleed patients. We run it at 8 mg/hr, or 25cc/hr.

we zap everybody with bicitra.

Brett

Originally posted by stevierae

Seems like we used something different for patients who were morbidly obese and for those with GERD or a hx of hiatal hernia. Thanks.

Generally, for these patients, a mix of differently acting agents is chosen. The idea is to attack the problem from a number of different angles. My current "cocktail" includes preop ranitidine and pepcid, with Zofran or Anzement given near the end of the case. The same applies to patients who complain of a history of severe post op nausea. All GERD patients also get to wake up with the tube in, and many to most get a rapid sequence induction.

Kevin McHugh, CRNA

Originally posted by kmchugh

Generally, for these patients, a mix of differently acting agents is chosen. The idea is to attack the problem from a number of different angles. My current "cocktail" includes preop ranitidine and pepcid, with Zofran or Anzement given near the end of the case. The same applies to patients who complain of a history of severe post op nausea. All GERD patients also get to wake up with the tube in, and many to most get a rapid sequence induction.

Kevin McHugh, CRNA

ZOFRAN!!! That's it!!

I thought it started with a "Z," but the only things that came to mind were "Zosyn" (the antibiotic) and Zantac (Ranitidine.) Having too many (prematurely!) senior moments these days.

Thanks, Kevin!

I have a routine that I use on most of my patients having general anesthesia or deep sedation. It is reglan 10 mg and Zantac 150 mg po with a sip of water about 30 minutes prior to induction. It works well--very little PONV. I rarely need to use zofran or anzemet, but have it for the occasional patient who needs it. I think several things are important in preventing PONV. Learn how to do mask ventilation without inflating the stomach, have the surgeon inject local anesthesia in the operative area at the end of the case, so you can avoid high dose narcotic use, keep the patient well hydrated, slow ambulation (nursing care!!) and post-op oxygen. I don't give decadron on a regular basis because one of the plastic surgeons I work with does not like the patients being so hyper post-op and doesn't want anything to compromise healing. The studies indicate that decadron does work.

Preventing PONV is one example of blending the art and science of anesthesia with good nursing care.

YogaCRNA

Yoga, I have heard good things about decadron for PONV also.

From what I understand, the "steroid rush" occurs when you give doses in the 4-8 mg range.

But as little as 1-2 mg will give you the anti-emetic effect, without the side effects. Don't know if this is documented, or just personal observations.

As Kevin described, the idea is to mix a cocktail, and hit many different receptors. We have come to realize that there is not one magic bullet drug that will prevent 100% of PONV in 100% of patients.

loisane crna

Does "PONV" stand for "post-op nausea and vomiting?" Oh, I guess it does; I just read about the anti-emetic effect as described by loisane.

Does this mean that, if one uses Decadron for its anti-emetic effect, one will NOT have to use Droperidol or some other antiemetic of choice before taking the patient to the PACU--or, if he is to remain intubated overnight (which, in my opinion, SHOULD be standard of care for morbidly obese/GERD/hx of hiatal hernia/hx of sleep apnea patients, but seems to vary according to institution, often with unfortunate results) to the ICU?

This brings up another question I asked earlier

(but no one responded--) Is it still thought that giving Decadron pre-op in patients with either a hx of difficult airway management or after a difficult intubation will reduce laryngeal edema? I know some anesthesia providers who swear by it, others who do it "just because it can't hurt" (and everyone else they know has done it for years) and others who state that the literature says it does no good whatsoever--at which point they get into arguments with the ENT surgeons who have written the literature that says it DOES.

This is something I have always wondered--should a patient aspirate DESPITE rapid sequence technique including (supposedly!) good cricoid pressure and having been given a pre-op antacid regimen--is the aspirate theoretically made base enough so that it would not do quite as much harm in the lungs as would an acidic aspirate? Or is aspiration pneumonia just as damaging to the lungs and to the patient's recovery, regardless of the pH of the aspirate? Simple chemistry would seem to support that a basic solution would be less harmful to the lungs than an acidic one would, but I don't know if that is true in reality. Would the two (base or acid) resultant aspiration pneumonias be treated differently post-op in the ICU?

"Does this mean that, if one uses Decadron for its anti-emetic effect, one will NOT have to use Droperidol or some other antiemetic of choice before taking the patient to the PACU"

Not neccessarily, the best approach is to hit different receptors, using several different classes of drugs. Everyone has their own favorite recipie. Kevin and Yoga shared theirs previously.

"...is to remain intubated overnight (which, in my opinion, SHOULD be standard of care for morbidly obese/GERD/hx of hiatal hernia/hx of sleep apnea patients"

I'm not familiar with this practice. I suppose for very invasive surgeries in these populations, post op ventilation might be indicated. But then you run the risk of more prolonged problems. Every decision needs to be evaluated for risk vs. benefit for each individual case.

"Is it still thought that giving Decadron pre-op in patients with either a hx of difficult airway management or after a difficult intubation will reduce laryngeal edema?"

I have never even questioned this practice, it is very common and accepted in my experience. But I don't guess I have ever looked it up, to see if it is an evidence based practice, or just a tradition. Again, it is all about risk vs. benefit. Even if the benefit is less-than-well documented, it might still be appropriate if the risk is low.

"is aspiration pneumonia just as damaging to the lungs and to the patient's recovery, regardless of the pH of the aspirate?'

The answer to this IS well documented. Every SRNA should be able to rattle this one off. Any takers?

loisane crna

To whomever uses Reglan: In my experience it's use almost always leads to bowl movements. Do you hate your bedside nurses?

About aspiration pneumonia:

Aspiration of foreign material (often the stomach contents) into the lung can be a result of disorders that affect normal swallowing, disorders of the esophagus (esophageal stricture, gastroesophageal reflux), or decreased or absent gag reflex (in unconscious, or semi-conscious individuals). Old age, dental problems, use of sedative drugs, anesthesia, coma, and excessive alcohol consumption are also causal or contributing factors. The response of the lungs depends upon the characteristics and amount of the aspirated substance. The more acidic the material, the greater the degree of lung injury, although this may not necessary lead to pneumonia.

Is the CRNA responsible for the aspiration pneumonia if the pt aspirates? I know CRNA's are responsible for the first 24 hrs, but are we responsible for treating the aspiration pneumonia? I've seen Vanc 1gm x1 ordered by MD's before along with sputum cultures x1.

Changing the PH will decrease damage to the lungs in the event of aspiration. The best drug for this is Bicitra pre-op.

All of our post of heart patients receive pepcid/reglan IV. When PO, they take protonix/reglan. We have inapsine ordered for nausea unless there are QTc issues.

Originally posted by Diprivan/Vented

To whomever uses Reglan: In my experience it's use almost always leads to bowl movements. Do you hate your bedside nurses?

Oh, so THAT'S the reason for so many "code browns" as the patient is waking up--always happens in the OR as we are moving patient from OR table to gurney--too bad they never wait until they get to PACU:roll