Friday, March 30, 2018

Reflex orders

Q: 52 year old male admitted to ICU with End Stage Liver Disease (ESLD) and awaiting transplant continues complain of debilitating nausea. Which of the following anti-emetic should be used with caution in this patient?

A) Ondansetron
B) Metoclopramide
C) Dexamethsone
D) Prochlorperazine 
E) Olanzapine

Answer:  A

The objective of above question is to highlight the habit of "reflex orders" in hospitals.

ESLD patients suffer from nausea due to bilirubinemia, ascites, and various other circulating toxins. Ondansetron is one of the most widely used, and "reflexly ordered" anti-emetic in hospital but in ESLD patients the dose should not exceed 8 mg per day. In ESLD patients metoclopramide can be used up to 60 mg per 24 hours and is very effective.



1. Rhee C, Broadbent AM. Palliation and liver failure: palliative medications dosage guidelines. J Palliat Med 2007; 10:677. 

2. Uribe M, Ballesteros A, Strauss R, et al. Successful administration of metoclopramide for the treatment of nausea in patients with advanced liver disease. A double-blind controlled trial. Gastroenterology 1985; 88:757.

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