Ondanestron for Awake Intubation

A listener, Brian Katan, wrote to suggest adding ondansetron to the awake intubation procedure. Now this is interesting, because I don’t want the patient to vomit from ramming things into the back of her throat, but the mechanism is not nausea–it is the gag reflex. So, the question is: does ondansetron affect the gag reflex? Turns out it does…

Evaluation of the efficacy of oral ondansetron on gag reflex in soft palate and palatine tonsil areas

So now, ondansetron 4 mg IVP has been added to the airway checklist. Thanks Brian!

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  1. John Hinds says

    IV Granisteron has also been looked at (successfully, though small groups but blinded and placebo control)

    I used to use it for this reason (when it was still in our cupboards) for ENT lists; have since switched to Ondansetron

    Never occured to me to use it in AFO intubation as well though; good tip!


  2. Jimmy D says

    OK, interesting information. I just administered Ondansetron 4 mg IVP to my patient I am sedating just now.

    Some 15 years ago, I was privy to an unusual side effect of Ondansetron in a patient I cared for that underwent anterior cervical discectomy and fusion. He was a tall, thin gentleman in his early 40’s with a history of herniated cervical discs. Surgical procedure, airway management and anesthetic was unremarkable, and I was making a brief visit to the patient the afternoon of postop day 1 when the story gets interesting.

    The patient was recovering well, and had just returned from physical therapy when I paid him a visit postop day 1. He was otherwise without complaint, save for feeling nauseated. I reassured him, ordered Ondansetron 4 mg IV for nausea, and took my leave for the doctors’ locker room to change out of scrubs and leave the hospital. As I was exiting the hospital, a cardio-pulmonary arrest alert was called over the hospital PA system to that patient’s room. I ran up to assist with the crisis, and found the patient receiving bag-valve-mask ventilation from a respiratory therapist, patient visibly awake, with eyes wide open in terror. I slid to the head of the bed, took control of the BVM from the respiratory therapist (while politely stopping him from inserting a nasal airway in an obviously awake patient), and looked the guy over. He was awake, but his airway was obstructed. I took the approach of gentle positive airway CPAP with the BVM, and with a calming voice, I told the patient that he was going to be alright. The airway obstruction soon abated, the patient was able to be ventilated, and 2 short minutes later, the crisis was over.

    Diagnosis? Laryngospasm following rapid IV bolus of Ondansetron.

    The patient related to me that his nurse administered the drug in a manner inconsistent with its labeling. This drug is to be given slow IV push. The patient stated that his nurse blustered into his room after I placed the order, connected the syringe to the IV line, then injected the medication as if she were trying to clear an obstructed toilet, then turned on her heels and exited the patient’s room. His total inability to breathe came shortly thereafter.

    So, just be on notice–this stuff does affect airway reflexes. Dude, I’ve seen it.

    • Don says

      I never, ever, ever just walk up to an IV and jam the medication in unless it is clearly indicated, i.e. adenosine challenge or RSI procedure. I teach and stress the need to dilute and administer slowly most medications as we give it. Working in the ED, I hang a bag of NS after I start most of my IV’s to ensure the pain and nasea medications are given with a little dilution to avoid deleterious effects. Thoughts.


  1. […] is also an interesting article on the EMCrit Blog suggesting that ondanstron suppresses the gag reflex and may be useful in awake […]

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