amisulpride (edited)

[anbuitachi]

Just want to ask the group here, who here has it in PACU/readily available, and if so how are you using it in your practice? For rescue only? What dose?

Thanks

EDIT: i meant amisulpride

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[Dr. Rude]

Just want to ask the group here, who here has it in PACU/readily available, and if so how are you using it in your practice? For rescue only? What dose?

Thanks

The P.O. form. In preop only. Never in PACU.

 

[USCTrojan11]

Had a very limited supply available via the pharmacy at the hospital in residency. When you put in the order, the $$$ next to it were to discourage use in Epic EMR. Don't know of anyone that ever used it.

 

[Hork Bajir]

As above, PO pre-op only. My understanding is that it works extremely well for prophylaxis, but not great as a rescue. It is quite expensive (something on the order of $300 per 40mg pill), and not always covered by insurance- for that reason I reserve it for people with a documented history of severe PONV, and usually talk to patients about it before ordering it. If people have met or are definitely going to meet their deductible, I’ll usually say let’s do it. If there’s a chance that they have to pay for it out of pocket, I let people choose if they want it or not (reminding them that an overnight admission for PONV is also very expensive)

 

[DocVapor]

As above, PO pre-op only. My understanding is that it works extremely well for prophylaxis, but not great as a rescue. It is quite expensive (something on the order of $300 per 40mg pill), and not always covered by insurance- for that reason I reserve it for people with a documented history of severe PONV, and usually talk to patients about it before ordering it. If people have met or are definitely going to meet their deductible, I’ll usually say let’s do it. If there’s a chance that they have to pay for it out of pocket, I let people choose if they want it or not (reminding them that an overnight admission for PONV is also very expensive)

Exactly my practice until pharmacy puckered up their pipeline and made it require an act of god or bribery to get it from them. Now patients just get to suffer because some bean counter somewhere wants to go cruising on a private yacht.

 

[staple]

At my hospital, had a 40F post cholecystectomy who was supposed to go home. Severe PONV —> tiva, scop, zofran, decadron, reglan, minimal narcotic, etc. essentially had intractable nausea in pacu. Before admitting her, I tried a Hail Mary.

I called pharmacy and they said we have IV fosprepitant. Different dose, cheaper. No nausea after 30 mins.

If your hospital pharmacy flat out rejects aprepitant, I encourage you to push for fosprepitant.

 

[nimbus]

We give it PO as soon as the patients check in to all our young female bariatric patients. However, only anesthesia can order it and we have to click through an eight item questionnaire every single time we order it. The answers are the same every time. It’s an annoying death by 1000 cuts.

 

[Gern Blansten]

As above, I have never heard of anyone using it as a rescue agent. It is almost always given as a preop prophylactic drug. The pro drug, Fosaprepitant, is now available but have never heard if it is any good or what the price point is. I think it is IV form, so maybe some may use that as rescue. I just don't know too much about it.

 

[anesthesiadoc]

Had it on formulary at a hospital I used to work with. Only used it in patients with severe PONV history having failed previous low nausea regimens. (TIVA, low opioid, decadron, scopolamine patch, etc).

Worked pretty well as I recall.

 

[Arch Guillotti]

At my hospital, had a 40F post cholecystectomy who was supposed to go home. Severe PONV —> tiva, scop, zofran, decadron, reglan, minimal narcotic, etc. essentially had intractable nausea in pacu. Before admitting her, I tried a Hail Mary.

I called pharmacy and they said we have IV fosprepitant. Different dose, cheaper. No nausea after 30 mins.

If your hospital pharmacy flat out rejects aprepitant, I encourage you to push for fosprepitant.

try haldol next time

 

[abolt18]

I use it quite frequently in pts with a HX of severe or refractory PONV. Only used as prophylaxis. Seems to work well. Our pharmacy even encouraged its use?

 

[DocMcCoy]

vaguely remember the potential to interfere with hormonal birth control for like a month? Same issue with fosprepitant?

 

[Gern Blansten]

vaguely remember the potential to interfere with hormonal birth control for like a month? Same issue with fosprepitant?

Yes. Potential...From what I have heard, there has never been a documented case of accidental pregnancy.

 

[anesthesiadoc]

Yes. Potential...From what I have heard, there has never been a documented case of accidental pregnancy.

With so many folks using sugammadex, contraception planning should become a larger part of our preop conversations. (Folks don’t seem to remember these talking points when raised in the recovery room.)

 

[amyl]

We don’t give it often in the hospital - I have called in a script for preop for plastics patients w severe histories- not sure the $$$. It does mess w birth control

 

[nimbus]

vaguely remember the potential to interfere with hormonal birth control for like a month? Same issue with fosprepitant?

We give a written information sheet whenever we administer it.

 

[markneil]

our pharmacy doesn't have it, but we did get droperidol again. that's been working like magic.

 

[nimbus]

our pharmacy doesn't have it, but we did get droperidol again. that's been working like magic.

I really hope to get it back soon. Multipurpose chill out drug.

 

[gcc322]

Had the PO prophylaxis form in residency. Seemed very effective. My hospital sent out an email last year that we had it available and I had high hopes..but it was an IV formulation that they claimed was a rescue agent. Tried it twice and had no effect.

I second the haldol. It is my go to rescue agent thanks to you guys.

 

[anaesthetic]

Use it all the time for bariatrics and hx severe PONV. Have had it not work twice but generally seems to do pretty well.

There’s a rescue drug called amisulpride that’s going around recently. Seems decently effective (and probably $$$).

 

[Bryan O’Blivion]

PO pre op, can interfere with contraceptives for nearly a month, but seems to work well. Have had it not work a few times, but overall seems beneficial. Expensive, upwards of $100/capsule. Most people would pay that to avoid protracted nausea. It’s also not the most expensive part of the day. I think it’s worth it if one has a high risk ponv patient who will likely require opioids post op.

 

[chessknt]

I cant even get access to this for people with refractory n/v requiring ICU for electrolyte abnormalities. Somehow it's cheaper to use an ICU bed then use it. It functionally doesn't exist

 

[woopedazz]

We "have it." But it's unreachable for anyone and anything except a mild case of the "not hungries" in chemo opd. I'm glad they have access, but I'm jealous

 

[Chrishel]

PO form is readily available at my place with no restrictions (e.g. every crani gets it ordered in preop by default). IV fosaprepitant is also available but needs an order and we're only supposed to use it for severe cases (hx of severe PONV refractory to multiple agents, unable to take PO, as a rescue in PACU if nothing else is working, etc.). My understanding is PO aprepitant is pretty cheap (<$100) and IV fosaprepitant is several thousand dollars.

 

[chessknt]

PO form is readily available at my place with no restrictions (e.g. every crani gets it ordered in preop by default). IV fosaprepitant is also available but needs an order and we're only supposed to use it for severe cases (hx of severe PONV refractory to multiple agents, unable to take PO, as a rescue in PACU if nothing else is working, etc.). My understanding is PO aprepitant is pretty cheap (<$100) and IV fosaprepitant is several thousand dollars.

Our pharmacy told us it was the other way around but we couldn't have either anyways.

 

[nimbus]

Some of you need better pharmacy managers. We were told it’s about $40/dose. One pharmacy near me has it for $15.

 

[narcusprince]

We don’t give it often in the hospital - I have called in a script for preop for plastics patients w severe histories- not sure the $$$. It does mess w birth control

Thats a smart move Amyl!

 

[anbuitachi]

Use it all the time for bariatrics and hx severe PONV. Have had it not work twice but generally seems to do pretty well.

There’s a rescue drug called amisulpride that’s going around recently. Seems decently effective (and probably $$$).

ok funny because i remembered wrong, and i guess its amisulpride i want ...

so anyone give amisulpride and how much? dose? brand?

 

[amyl]

For some reason our leadership has been pushing amisulpride. I’ve tried it for rescue - idk I’m not impressed.
Droperidol is cheaper but I don’t find it necessary either.
I just don’t have nausea problems - scop patch, phenergan, decadeon, zofran and fluids works for me. Even iv benadryl works - If someone have refractory ponv nothing works like 20 of propofol and a fluid bolus… maybe a little sugar in some form

 

[abolt18]

ok funny because i remembered wrong, and i guess its amisulpride i want ...

so anyone give amisulpride and how much? dose? brand?

Never even heard of it before reading this thread.

 

[anbuitachi]

For some reason our leadership has been pushing amisulpride. I’ve tried it for rescue - idk I’m not impressed.
Droperidol is cheaper but I don’t find it necessary either.
I just don’t have nausea problems - scop patch, phenergan, decadeon, zofran and fluids works for me. Even iv benadryl works - If someone have refractory ponv nothing works like 20 of propofol and a fluid bolus… maybe a little sugar in some form

you bolus dextrose and it works?

 

[narcusprince]

Why spend all this money on these costly measures. Wake the patients up on a propofol infusion and cut the gas of early. This works better than zofran, benadryl, emend, whatever. Nobody wakes up nauseous with prop, NOBODY…..

 

[anaesthetic]

Why spend all this money on these costly measures. Wake the patients up on a propofol infusion and cut the gas of early. This works better than zofran, benadryl, emend, whatever. Nobody wakes up nauseous with prop, NOBODY…..

I’m pretty sure there was a recent study showing propofol infusions in conjunction with volatile anesthetics did not decrease the incidence of PONV. Can’t find the study right now though so I could be making it up.

Edit: just an abstract. http://www.asaabstracts.com/strands/asaabstracts/abstract.htm?year=2021&index=17&absnum=6265

 

[BLADEMDA]

Why spend all this money on these costly measures. Wake the patients up on a propofol infusion and cut the gas of early. This works better than zofran, benadryl, emend, whatever. Nobody wakes up nauseous with prop, NOBODY…..

Not really true. There are patients who get nausea from psychological causes ( I have seen it) and others who get nausea from the procedure itself (laparoscopy, open eye cases, etc).

 

[BLADEMDA]

For decades we used low dose droperidol very effectively and cheaply to prevent N/V. I still use it from time to time and it's safety is well established at doses less than 1.25 mg IV. Please be sure to know its side-effects quite well before giving to an awake patient in PACU.

 

[Arch Guillotti]

no nauseated patients ever in the pacu = head stuck in the sand

 

[2Fast2Des]

Haldol 1mg does the trick if all else fails. I've had some people have nausea after propofol use but that is probably psychological

 

[amyl]

you bolus dextrose and it works?

Lol. I usually try to get them to take po - but no I usually don’t use the d50… it’s on back order half the time any ways - I have given a little d10.
Have also used a whiff of benzo as some pts just work themselves up. Gotta assess at the bedside to get my plan - emend is worth the $ to the pt for me - and easy to call in before - goodrx is often cheaper than their insurance. I haven’t seen amisulpride be worth the $

 

[circleK]

We’ve used amisulpride for about 6 months now for severe PACU N/V after all other measures have failed. Great results so far anecdotally. Our pharmacy told me $78/dose.

 

[narcusprince]

I’m pretty sure there was a recent study showing propofol infusions in conjunction with volatile anesthetics did not decrease the incidence of PONV. Can’t find the study right now though so I could be making it up.

Edit: just an abstract. http://www.asaabstracts.com/strands/asaabstracts/abstract.htm?year=2021&index=17&absnum=6265

So did they wake the patients up on the propofol infusion with minimal GAS. Low dose doesn’t do anything. Waking them up on propofol is the most effective method.

 

[anbuitachi]

For decades we used low dose droperidol very effectively and cheaply to prevent N/V. I still use it from time to time and it's safety is well established at doses less than 1.25 mg IV. Please be sure to know its side-effects quite well before giving to an awake patient in PACU.

which side effects quite well are you referring to?

Haldol 1mg does the trick if all else fails. I've had some people have nausea after propofol use but that is probably psychological

IM? or do you do IV

 

[anbuitachi]

So did they wake the patients up on the propofol infusion with minimal GAS. Low dose doesn’t do anything. Waking them up on propofol is the most effective method.

ive had patients on TIVA with propofol have PONV in pacu.

 

[nimbus]

which side effects quite well are you referring to?

They snooze for 2 hours which means they stop complaining of nausea for 2 hours.

 

[2Fast2Des]

which side effects quite well are you referring to?

IM? or do you do IV

IV

 

[amyl]

ive had patients on TIVA with propofol have PONV in pacu.

With minimal narcs emend versed phenergan zofran benadryl decadron and plenty of fluids?

 

[vector2]

It's probably fallen out of vogue in a lot of places but benzos are pretty potent antiemetics. IMO young healthy person with refractory PONV should also be getting 0.5-1 mg of Ativan as well.