December FY20

[sarahrollison]

This months Journal Club is presented by Dahlia Rouchon. She chose an article that discusses a rare but life threatening potential complication from Gabapentin use, a drug frequently used by many of our patients.

Gabapentin and ERAS, a great multimodal adjunct to decrease opioid use but is it benign? Dahlia had an incident back in July that inspired her article choice. Her patient had PEA arrest after having recently started a new neuropathy management with gabapentin.

Here is a link to the article

Questions to engage in discussion:

1. Have you ever had a patient mention they had peripheral edema or changes in BP while on gabapentin?
2. Do you see prolonged somnolence or hypotensive episodes in PACU after gabapentin given in preop not associated with other possible causes, i.e. hypovolemia, over narcotized, benzodiazepine use, or residual anesthesia on board?
3. What is your opinion regarding gabapentin use for outpatient procedures as part of an ERAS protocol?

[jessica switzman]

I haven't had a patient mention peripheral edema or BP changes while on Gabapentin.
I have seen prolonged somnolence but not hypotention in the PACU after Gabapentin.
I use and like Gabapentin for outpatient procedures as an ERAS protocol.

[LarSharVeA Bailey]

I have not encountered any patients that reported edema or blood pressure changes while on gabapentin. In the neurosurgical population, which account for 50% of my cases, I have not observed
hypotensive episodes or prolonged somnolence. In these cases, hypotensive episodes would likely be attributed to under-resuscitation which would easily be supported by the hemoglobin or
analyzation of the arterial line wave form. Considering all the drugs in our toolkit and all of the various anesthesia plans, I do not subscribe to the dogma of one size fits all. For
some patients, gabapentin may smooth the transition into the postoperative period and facilitate discharge home; whereas, the risk profile for others may gravely outweigh the benefits.
This is true for most of the drugs we use.

[Ben Waldbaum]

1. Not that I'm aware of

2. Not that I'm aware of.

3. This is a broad question outside the scope of this article. For the case in the article, it is an unfortunate side effect. Given that this seems to be the only case reported, and her strong family history of heart disease, one must wonder if there was a genetic predisposition to this side effect from the gabapentin. Regarding using Gabapentin in ERAS, I am not sold on its utility.

[Katya]

1. No, I never had a patient with edema or BP changes.
2. I did see very prolonged sedation with patients and I don't like to use this drug for outpatient procedures.
3. I agree with Ben, it seems like unfortunate side effect of the drug to a patient that has strong family history of heart disease.

[jkim54]

1. No I have not had any patients mention to me of BP changes or peripheral edema on gabapentin.

2. No I have not seen prolonged sedation or HOTN in the recovery room for patients on gabapentin. But it is also difficult to attribute any of these side effects with gabapentin exclusively.

3. Overall, I am still in favor of prescribing gabapentin as part of the ERAS protocol. I believe its overall benefits for the general population are positive enough.

[Jessica Hadley]

Thanks for this article I was unaware of this potential complication.

1. I have not personally had any patient tell me about this complication.
2. I have not seen prolonged sedation or hypotension personally but I do not often do ERAS/ neuro cases where Gabapentin is used preoperatively more frequently.
3. I do not routinely give Gabapentin for outpatient surgery unless they are already taking it at home.

[Wai-Ling Lo]

1. I haven't had pt complaint about peripheral edema or hypotension related to gabapentin.
2. I do have patients comment that gabapentin make them sleepy. PACU RNs complaint about that too. But it may also be the synergistic effect of all the drugs that we give from ERAS protocol.
3. I too do not routinely order Gabapentin for outpatient surgery except for those who are narcotic dependent.

Although the case was rare as mentioned in the case report, it's still good to know that gabapentinoids may potentially induce heart failure exacerbations so that I can be more cautious when prescribing the drug in heart failure cases.

[Jennifer Hannon]

1. No, I've never had a patient mention edema or BP changes.
2. I have seen very prolonged sedation/wakeups with patients, but of the things listed above, they all had received one or two of them as well, so attributing slowness completely to gaba is impossible.
3. I agree with those that mentioned it above, a rare side effect of the drug on a patient that had a strong family history of heart disease. Outpatient flow goals prevent use of gabapentin in all patients.

[kels]

I have never had a patient mention they had peripheral edema or changes in BP while on gabapentin
I have not seen prolonged somnolence or hypotensive episodes in PACU after gabapentin given in preop
Gabapentin is nice to use for outpatient procedures as part of an ERAS protocol if the patient is currently taking it

[rboynton]

I have never had a patient complain of edema or BP issues with this drug
I have not noticed prolonged sedation with Gabapentin
It seems like a very rare complication with Gabapentin, but with a history of heart failure, is a good idea to avoid the drug until more studies have been done.

[Anne McNulty]

I have never had a pt c/O of peripheral edema from use of this drug. Most patients seem to like their gabapentin and it is very widely prescribed.  I have seen slow wake ups on era cases that have used this drug.  Amlodipine  is known for peripheral edema.  It is still interesting and worth reviewing especially for patients with heart failure that are on a large list of home meds

[kristenhorsman]

1. I have never specifically asked patients about peripheral edema or BP if they are on gabapentin

2. Unfortunately, I do not get the opportunity to spend a lot of the post-operative period with my patients as I am usually back in the OR with another patient

3. I believe gabapentin is a great adjunct that reduces opioid use and improves recovery time and I will continue to order it when appropriate. It's important to consider every patient's comorbidities before ordering ERAS drugs, even if they are on a protocol.

[Catherine Lawry]

Questions to engage in discussion:



1. Have you ever had a patient mention they had peripheral edema or changes in BP while on gabapentin?

2. Do you see prolonged somnolence or hypotensive episodes in PACU after gabapentin given in preop not associated with other possible causes, i.e. hypovolemia, over narcotized, benzodiazepine use, or residual anesthesia on board?

3. What is your opinion regarding gabapentin use for outpatient procedures as part of an ERAS protocol?


1. I have never had a patient mention any side effects related to gabapentin. 

2. Typically we don't see patients very often in the PACU so this is a tough question to answer. I would never think to attribute hypotension to gabapentin with all of the multimodal agents that we use in an ERAS protocol. 

3. I believe that it is a nice adjunct to use for multimodal pain management as a part of the ERAS protocol. As with all agents, we as anesthesia providers must weigh the risks and benefits with any drug that we order for our patients. All drugs have side effects that we need to take into consideration before administering or ordering to give in the pre-op area.

[Jocelyn Datud]

1. I haven't had a patient mention they had peripheral edema or changes in BP while on gabapentin.
2. I also haven't seen prolonged somnolence or hypotensive episodes in PACU after gabapentin given in preop.
3. I think that gabapentin is a good adjunct for pain management. This article is a good reminder to us about being vigilant about the medications that we give.