From James Xie MD commenting on IV aprepitant PAAD and Rescue Rx for PONV
At Stanford Children's we use the following dosing guideline for aprepitant for prevention of chemotherapy-induced nausea and vomiting: 5mg/kg for weight based dosing in kids <2 and 4mg/kg in kids 2-12.
Note:
1. Should be given with dexamethasone and a 5-HT3 antagonist
2. If administered with dexamethasone, reduce dexamethasone dose by 50% on days 1 and 2
Infants ≥6 months weighing ≥6 kg and Children <2 years: 5 mg/kg (max 150 mg/dose) on Day 1
Children ≥2 years and <12 years: 4 mg/kg (max 150 mg/dose) on Day 1
Children ≥12 years and Adults: 150 mg on Day 1
From George Gregory MD commenting on slaying the vampire: bicarb during CPR
What people do not realize is the 50 ml of bicarb produces 1,250 cc of CO2 when fully reacted with hydrogen ion. There is no barrier to CO2 entering myocardial and other cells and decreasing intracellular pH, so the changes are almost instantaneous, unless there is adequate ventilation, which there often is not. I fixed ventilation in rabbits and gave bicarb. The immediate CO2 was over 300mmHg!
From Marie Zestos MD Professor & Chair of Anesthesiology Wayne State University commenting on rescue Rx for PONV
Having done my fellowship at Sick Kids in Toronto, we routinely used dimenhydrinate (Dramamine, Gravol) and we now use it at Children’s Hospital of Michigan regularly as our rescue anti-emetic. It’s a great drug and approved for use in children over age 2 yrs. Jerry Lerman lead a lot of the studies. (From Myron: Dimenhydrinate is FDA labeled for pediatric motion sickness (not PONV) in children > 2 years).
1. Vener DF, Carr AS, Sikich N, Bissonnette B, Lerman J. Dimenhydrinate decreases vomiting after strabismus surgery in children. AnesthAnalg. 1996 1996;82(4):728-731. Not in File.
2. Uhlig U, Pfeil N, Gelbrich G, et al. Dimenhydrinate in children with infectious gastroenteritis: a prospective, RCT. Pediatrics. Oct 2009;124(4):e622-32. doi:10.1542/peds.2008-1650.
From Jeff Feldman MD Children’s Hospital of Philadelphia on rescue PONV meds
Nice article on PONV rescue. My preferred rescue for when usual PONV prophylaxis fails is Promethazine (Phenergan) by suppository. Bypasses the oral route in a patient who is nauseated and generally quite effective with relatively quick onset. Another advantage is that it is FDA approved for children > 2 yo. The biggest disadvantage is sedation as the kids will usually fail asleep and time to discharge ready from recovery is typically prolonged. That said, refractory will also delay discharge so on balance it is probably better to treat the N/V and if they sleep for a while so be it.
Like all dopamine antagonists, there is a risk of acute dystonia and, when I checked the CHOP formulary, I found out it is listed on the Key Inappropriate Drugs in Kids list (KIDs) – I suppose worthy of note but not an absolute contraindication. If IV access is maintained, diphenhydramine should readily treat the dystonia if it occurs. Another disadvantage is the fixed dosing strengths of the suppository at 12.5 and 25 mgms. If a different dose is desired especially in a small patient, it becomes an approximation to divide the suppository. Safe dosage range is relatively wide at 0.5-1 mg/kg/dose but the higher dose range will cause more sedation and increase change of dystonia.
I have not found a better IV alternative but interested in what others like to give. That said, our protocol at CHOP is IV metoclopramide then diphenhydramine for PONV rescue – I was not successful getting promethazine included! (From Myron: promethazine suppositories are FDA labeled for pediatric PONV. They also carry a black box warning to avoid in patients < 2 years.)
From Matt Careskey MD, Kapiolani Medical Center For Women And Children Honolulu, HI
One trick i use often for refractory ponv in the PACU is a bonus of 10-20mL/kg D5LR. For many kids and teenagers with ponv this amounts to 250-500mL of D5LR. Beyond my anecdotal experience i do not have any large randomized control trials to support this practice, but i can say confidently that this combination of volume repletion and an "IV can of soda"-worth of dextrose works wonders and gets kids out of the PACU and ambulatory. Obviously there are select patient populations for which a volume bolus and dextrose would be detrimental, but for the large majority of pediatric patients at-risk for PONV, D5LR is the magic trick up my sleeve.
I do not like using Reglan, because in my mind the juice isn't worth the squeeze. To treat nausea at this risk (albeit very very rare) of neuroleptic malignant syndrome and tardive dyskinesia seems too risky.