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Post by katevaughn on Dec 1, 2018 13:01:24 GMT -5
This month’s journal club is presented by Kelsie Johnson. She chose a great article that provides a review of the use of Metoclopramide. PONV is usually the most uncomfortable reported side effect of anesthesia and affects up to 20-30% of patients receiving general anesthesia. Especially in the ambulatory setting where patients and staff strive for fast turnover, PONV can delay PACU discharge. This is a nice review of a medication that most CRNAs don’t typically administer as a first line defense agent. Here is a link to the article. The questions to encompass within your response: 1.) In general, what are your thoughts/experiences with Metoclopramide? 2.) Will you make any changes in your practice after reading this article?
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Post by Jackie Howell on Dec 3, 2018 11:13:50 GMT -5
1.) In general, what are your thoughts/experiences with Metoclopramide? I have found in practice we don’t really utilize reglan for routine use unless it’s a higher risk patient. Even with higher risk patients we opt for a scopolamine patch in preop and decadron and Zofran after induction. I know reglan is contraindicated in patients with Parkinsons and SBO.
2.) Will you make any changes in your practice after reading this article? This article is very interesting and after reading it I will be more likely to implement reglan into my anesthesia plan for managing post operative nausea and vomiting.
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Post by jkim54 on Dec 3, 2018 14:00:37 GMT -5
1. The most widely used 'triple therapy' for PONV here at Bayview is scopolamine patch, decadron, and Zofran. It seems to be fairly successful in warding off PONV in patients with risk factors. In my own practice I don't generally use Metoclopramide on a regular basis, unless I have a very high risk PONV patient with multiple instances of PONV with past anesthetics despite being given our usual adjuvant therapy. In my early days as a CRNA, I did have one patient (healthy, ASA 1 patient with no comorbidities) wake up in the PACU (having been given 10mg Metoclopramide IV intraop) with tardive dyskinesia. It was a mild response and resolved by the time she was discharged home, but it understandably upset her. Although the incidence of tardive dyskinesia is very small for those given Reglan, this is always on the back of my mind as a potential side effect to this drug.
2. This article certainly encourages me to consider giving Metoclopramide more often in moderate to high risk pts with PONV. It is very helpful to know that there is strong evidence showing a synergistic effect when other anti-nausea drugs are used with Reglan.
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Post by Moishe Mayer on Dec 3, 2018 14:29:01 GMT -5
I do not use Reglan frequently. I have used it as a last resort, when all other agents have failed. I do not think evidence is overwhelming to use Reglan routinely. However, Reglan should be used where a prokinetic agent is particularly helpful. For example, in the OB population, Reglan may achieve greater results. I'd be interested to see if this is discussed in the literature.
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Post by Kristen Horsman on Dec 5, 2018 11:55:09 GMT -5
1. I do not typical give reglan nor do I routinely order it for the PACU unless decadron, Zofran, and Phenergan have all been unsuccessful. 2. I do not think I will change my practice. I will continue to use it only in circumstances when other modalities have been unsuccessful. In my opinion, other medications have a safer side effect profile.
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Post by Lu Lin on Dec 5, 2018 15:23:19 GMT -5
1.) In general, what are your thoughts/experiences with Metoclopramide?
This is a great article for us have better understanding of Metoclopramide useage. In general, I only use Decadron and Zofran for PONV. I only use Reglan if after I gave Zofran and decadron , pt still has PONV.
2.) Will you make any changes in your practice after reading this article? I will definitely reconsider my PONV treatment and put Metoclopramide into practice.
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Post by LarSharVeA Bennett on Dec 7, 2018 12:23:50 GMT -5
PACU nurses routinely ask for reglan. I've heard from senior providers that reglan was historically given to patients at increased risk for aspiration with the added benefit of being an antiemetic in the preoperative phase. One caution that I did not see in the article is to avoid it in patients that are at an increased risk for extrapyramidal effects (those on other dopamine antagonist and those with parkinsons - to name a couple). Because of this risk, reglan's routine use fell out of favor. In the event of EPS, Benadryl 50mg will act as a strong antidote. My mom has had to do give it to treat reglan associated tardive dyskinesia.
We routinely run neurosurgery patients on 70% nitrous to facilitate rapid wake ups, but the imminent risk of PONV increases dramatically with the high concentration of nitrous. If these patients wake up nauseous, I then give reglan, in addition to the previously administered decadron and zofran. On the short trip to the NCCU, it seems to be affective.
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Post by Jessica Hadley on Dec 7, 2018 17:27:06 GMT -5
I do not routinely give Reglan in practice, typically I triple treat with decadron, Zofran, and either a scopolamine patch or small dose of promethazine. Reglan could be useful in cases where either decadron is contraindicated (bone marrow transplant, IDDM, etc.) It also could be used in place of promethazine when over sedation is a concern as with OSA patients. My personal experience with Reglan is that it was ineffective for nausea while Zofran was highly effective, however this was not in the perioperative setting.
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Post by Maggy Diaz on Dec 10, 2018 7:31:59 GMT -5
Thank you Kelsie for submitting this article! It is very interesting to read how Reglan is coming into favor once again. I have predominantly used it in the OB population for its gastrokinetic properties in mothers endorsing a history of PONV or actively nauseous. I have hesitated in the past to routinely use it as an antiemetic in general surgery cases due to its known extrapyramidal side effects, but after reading this article I will consider giving it with Zofran and decadron to my patients with Apfel scores of 3 or 4 due to the synergistic effect that the article describes. I remember learning that it is best prior to induction (10 minutes) and so I wonder if this is something that we can give right as someone enters the OR if they have a high Apfel score and reglan is not contraindicated? I also agree with Jessica's comment- good to consider Reglan in IDDM and those cases where decadron may me contraindicated.
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Post by Wai-Ling Lo on Dec 10, 2018 10:00:45 GMT -5
1.) In general, what are your thoughts/experiences with Metoclopramide?
I don't use Reglan as the single first line treatment for PONV because it is not as effective as Zofran for treating nausea (as evidence in some research studies) and I too worry about the potential extrapyramidal effects. However, I do use it often for pts with gastroparesis to promote gastric emptying if it's not contraindicated.
2.) Will you make any changes in your practice after reading this article?
No, I won't change my practice. For low risk case of PONV, I still prefer to use Zofran as single agent since it's more effective in treating nausea. For high risk of PONV, I will do TIVA and/or triple therapy like Scopolamine patch, Zofran, Decadron (with added benefit as pain relief adjuvants) or promethazine. I will still use Reglan to promote gastric emptying or if other antiemetics are contraindicated.
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kty67
New Member
Posts: 22
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Post by kty67 on Dec 12, 2018 12:57:18 GMT -5
1. I don't use Reglan as a 1st line treatment for PONV, but some PACU RNs prefer it as a 1st line if patient still complain of nausea after dose of Zofran in a PACU. I do give them order to do so. 2. No, I won't change my practice. I prefer Zofran, Decadron for low risk patients and do TIVA with addition of small dose of Promethazine (5-6.25 mg). I did not have a patient with tardive dyskinesia after Reglan dose, but why take a risk if we can prevent it.
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Post by sarahrollison on Dec 15, 2018 11:42:32 GMT -5
1.) In general, what are your thoughts/experiences with Metoclopramide? I don't frequently use Metoclopramide, however I do use it in the OB population along with zofran and ranitidine. Additionally, I feel that I encounter a lot of patients with a contraindication to use of Metoclopramide, or who may have a comorbidity that I would be concerned about the side effects with. Like a few others have stated though, I've found that many PACU nurses like for it to be ordered and I typically add it to my post op orders if indicated.
2.) Will you make any changes in your practice after reading this article? The article did surprise me - I found it interesting that the combination of metoclopramide + zofran was better than the combination of those with decadron. I may be less hesitant to use it now, however I will most likely only include it in my anesthetic if other agents have failed or if the patient is a good candidate.
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Post by aileenm4 on Dec 17, 2018 19:12:12 GMT -5
I do not routinely use Reglan these days in pediatrics. We use TIVA with Propofol and Dexmedetomidine and it works well for high risk patients or high risk surgeries. I will not be changing my practice from this article but it is something to thinkabout for pediatrics.
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Post by Jocelyn Datud on Dec 18, 2018 11:16:18 GMT -5
My exposure with Metoclopramide is mostly with OB patients. This article only didn't give good information about Metoclopramide but it also had a good discussion about PONV. After reading this article, I will be reading more information about the medication and try to incorporate more in my practice especially with patients who are high risk for PONV.
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Post by krechti1 on Dec 18, 2018 12:58:48 GMT -5
1) I do not routinely use Reglan in my practice. I used to work at a hospital where we gave all of our patients reglan before entering the OR. One of the surgeons strongly objected to this because he had several patients who had tardive dyskinesia. This strongly influenced my opinion of reglan and I stopped using it. I now use TIVA on almost all of my patients and give decadron and Zofran when appropriate. If there is strong history of PONV, I also add in either scopolamine patch or Phenergan. The only time I consider the benefits to outweigh the potential side effects of reglan is when the patient has a full stomach, or during a case where there may be blood in the stomach, such as a sinus case.
2) This article will not change my practice. I feel that the antiemetics we typically use are superior to reglan, without the potential side effects. And if using TIVA, the incidence of PONV is greatly reduced to begin with.
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