PONV- use of decadron and zofran

Specialties CRNA

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Hi All,

Haven't posted in awhile-started clinicals in January...Sorry

Have a question- What is the rationale behind using decadron with zofran in PONV. The info I found was limited and not very helpful. It appears that the MOA of decadron in this instance is unknown??? Is that correct? Any other resources out there on this would be greatly appreciated ( or just a "point" in the right direction). Also, if you practice this method-what doses have you used?

Thanks to all!

Jamie

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Hopefully this will get you started:

The first part of this is verbatim from my notes- Corticosteroids inhibit prostaglandin synthesis and prevent the inflammatory release of serotonin in the gut or block corticoreceptors in the Nucleus Tractus Solitarius. In P&P, Stoelting mentions a study where 8 mg dexamethosone with ondansetron or granisetron was more effective than a 5-HT blocker alone.

I just started clinical in January too, and it's been a bit of a struggle trying to assimilate everything that was presented over last semester. Best of luck!

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The prevailing current wisdom regarding PONV is that there is no single "magic bullet" that will work 100% of the time in 100% of the people. Instead it is better to cover alot of ground, with a variety of approaches and drug types.

Most providers have their own favorite recipe. Choices include zofran or anzemet, reglan, droperidol (I know it is not available as it once was, but I think you can still use it if you can document a healthy EKG), etc.

I used to have the documentation for decadron as an ant-emetic, but I can't seem to put my hands on it right now. As you have found out, it is not exactly the most well known use for the drug. I have heard anecdotal evidence (from other providers) that decadron works very well, when given in combination with other drugs, like zofran.

Appropriate dose is a good question. It seems reasonable to give the smallest dose possible, because after all there are some heavy duty side effects from steroids. There can be interference with the immune system, and hence the possibility of poor wound healing. Probably unlikely from a single dose, but a significant issue for our surgical population.

People who include decadron in their regime report that patient complain of significant groin burning, especially with higher doses. And some patients will get an uncomfortable "steroid rush". They get way too energized for their allowable level of activity postoperatively.

I think the most common dose is in the 2-4 mg range. But some people use as little as 1mg, and it seems to work. To my knowledge, there isn't a research "evidence based" answer to the question of dosing.

Here is an article I found with a quick web search. It is not an anesthesia source, but it is a start. I did not read every word, but on quick scan it seems reasonably accurate, based on my knowledge. Maybe the reference list can help you find out something more definite, from more well accepted sources.

http://www.ponvupdate.org/online_monograph.asp

A pretty interesting subject, don't ya think?

Loisane crna

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For those with PONV history we are giving:

Pepcid 20mg and Reglan 10 mg IV in pre-op holding;

then Zofran 4mg and Decadron 6-8 mg (depending on the size of the patient) at the end of the case.

Just trying to hit all the receptors.

I have been to some clinical sites that also add a scop patch in pre-op holding.

Blazeboy

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Most providers in my setting are using Decadron 10mg and Anzemet 12.5.

From one of my earlier readings, it seemed that Reglan was very ineffective as for PONV prophylaxis when given alone. In combination though, effectiveness should increase.

Very few providers are giving an antihistamine for PONV prophylaxis.

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Specializes in Nurse Anesthetist.

Decadron's metabolite is the actual PONV relief, not actual decadron. Therefore, it must be given at the beginning of the case. Anzemet or Zofran at the end will cover the other receptors. (This from journal club, I don't remember the article name)

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Interesting, a Dexamethasone metabolite. Hmmmm, this does require further reading. Anyone have the reference Qwiigley is refering to??

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Thank you everybody for your informative and timely responses! As always, above and beyond and very helpful!!!

Interesting in that it is believed to be the metabolite of the drug that is effective here-I hadn't heard that before.

Loisane, I printed out that article and will read as I drift off tonight!

Thanks again,

Jamie;)

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you aren't going to believe this - but we are studying low-dose haldol for PONV instead of phenergan or zofran (not prophylactically but in the recovery room) - and so far the FDA in their "infinite" wisdom hasn't black-boxed haldol yet!!! :)

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Although I haven't looked a the chemical structure of droperidol and haldol, apparently they very similiar drugs. According to my pharmacy instructor, their apparent different mechanisms of action are only related to drug marketing. It's interesting, but not surprising that haldol can be used as an antiemetic.

What dose are you using Tenesma?

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0.2 to 1mg IV post-op only if pt. is nauseated - great success...

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i worked w/ an ED doc who only used haldol or anzemet for nausea...

many times the haldol would be SQ 0.4 mg....very effective...and rarely any side effects other than drowsiness.

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