1st year out of residency Pearls

[Ezekiel2517]

Give some examples of when you would use epi as your first vasopressor.

It's been a long time since I've done OR anesthesia so I'm pretty removed from the nuances of vasopressor management, but I don't recall ever using epi as a first choice in residency, unless the patient was already in extremis when I got there. The cases which we most commonly used pressors were liver transpants and cardiac cases. We would keep norepi and vasopressin around to squirt as needed, but there was usually a drip going or at the ready.

You say you have used levophed to squirt as needed in certain situations. You can also squirt diluted epi to have the same effect. I'll simply inject 1 of epi into a 250 cc bag, and give 1/2 or 1 cc at a time as needed. When you give it like this, you pretty much get the same effect as giving levophed as needed. You get a nice pressure bump without the crazy tachycardia. I like to give epi or levophed as needed in certain situations like pts with bad heart failure or pts who are in shock or already on pressors.

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[pgg]

Give some examples of when you would use epi as your first vasopressor.

The classic example is a high spinal, usually on OB, where "high" is defined as any hint of bradycardia. Phenylephrine is the wrong answer, and ephredrine is too slow and too wimpy.

For that matter, just about any time hypotension is paired with significant bradycardia.

Anaphylaxis as pjl mentioned, but for another reason too. Epinephrine is a mast cell stabilizer, should always be given for allergic reactions, even if hemodynamics don't obviously demand it.

 

[mostwanted]

Give some examples of when you would use epi as your first vasopressor.

Severely depressed EF


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[BLADEMDA]

You say you have used levophed to squirt as needed in certain situations. You can also squirt diluted epi to have the same effect. I'll simply inject 1 of epi into a 250 cc bag, and give 1/2 or 1 cc at a time as needed. When you give it like this, you pretty much get the same effect as giving levophed as needed. You get a nice pressure bump without the crazy tachycardia. I like to give epi or levophed as needed in certain situations like pts with bad heart failure or pts who are in shock or already on pressors.

Good post. I've been doing this for 20 years with excellent results. Another drug I used to use often was Vasopressin 1-2 units IV but now that it is extremely expensive ($200 per vial) I'm using 4-8 ugs of EPI a lot more often.

 

[powermd]

We used to mix up 10 mcg/mL epi for cardiac cases. I don't recall frequently needing to use it, but the one time I do recall using epi, even at this does, it would precipitate PVCs.

Anaphylaxis, of course, is an appropriate use of epi as a first choice med. I was curious about other situations, which have been suggested. I didn't think of a high spinal but I can see the utility there.

 

[Arch Guillotti]

We used to mix up 10 mcg/mL epi for cardiac cases. I don't recall frequently needing to use it, but the one time I do recall using epi, even at this does, it would precipitate PVCs.

Anaphylaxis, of course, is an appropriate use of epi as a first choice med. I was curious about other situations, which have been suggested. I didn't think of a high spinal but I can see the utility there.

Any really sick patient you are about to induce.

I have never seen any ectopy when it is dosed 10 mcg at a time.

 

[powermd]

I recall really liking vasopressin for the long duration pressor pop from a single unit injected. I was using it most commonly in liver txp cases. This was, of course, in addition to optimizing calcium, running AVP/levo drips, and supplementing lots of blood products and albumin.

 

[easternether]

i would add....study, study, study... Residency programs will LOVE you if you keep their scores high. If you are great in hate OR but with low scores, they will not be so nice

 

[urge]

Now I'm 3 years out and feeling reflective. This my 2 cents for new grads.

1. Preoxygenate the hell out of every patient. still think this is one of the most important things I do, may be obvious but we tend to get lazy after several years and several thousand cases later
2. Learn to do a good deep extubation (you should be able to pull the tube before the drapes come down). pretty much still extubate everyone deep except people with scary airways or full stomach
3. Learn to love LMAs (I use a tongue depressor like a Laryngoscope when I place them) after a few mishaps over the past 3 years I have a greater respect for LMAs, tend to intubate edentulous old people and super obese with poor reserve rather than fool with a LMA (why bother with it)
4. Perform spinals with the patient sitting straight up on the OR table (no need to dangle their legs off the side it just wastes time and you can sit on the bed behind them). everytime, incidentally I love spinals and do them every chance I get.
5. Preoxygenate the hell out of kids if you can. yep, absolutely nothing scarier than a purple kid
6. If you have any concern about airway, have the glidescope in the room. yep, awake glidescope has pretty much replaced FOI for difficult airways in my practice
7. Give your C/S patient a small dose of phenylephrine after you place the spinal. I don't seem to do this as often, not sure why
8. Throw in a little calcium as a pressor from time to time. do this less than before, not sure why
9. Don't cancel cases unless it is obvious (I did 900 cases this year and cancelled 1, an EGD for a patient who ate a hamburger 2 hours prior, BP 250/110, BS >300). I've learned to talk my surgeons into cancelling/delaying cases (still very rare)
10. Don't be scared of the super old (>90 years) They lived that long because they are strong as hell. People who live to this age amaze me but I am definitely more nervous of them than I was a couple years ago
11. Don't be afraid of large doses of Propofol for a MAC, but always test the patient with a small dose first. I'm still surprised at which patient become apneic with 20mg and which are still talking after 150mg. yep, my record is 1g of propofol for a colonoscopy with the patient talking as soon as I stop pushing propofol (how is that possible?)
12. Don't struggle with a-lines, if you think it will be difficult use the US. yep, but I still try my first attempt without US just for fun
13. Strive to do a IS block from needle in to out in 2 minutes. pretty much, amazing how the snow on the screen becomes so familiar after hundreds of these things
14. Strive for "In Room" to "anesthesia ready" in 5-8 minutes (start pre-oxygenating before monitors and ready to push drugs as soon as you have a BP) i've actually slowed down, I happy with 10 minute, no one seems to care anymore

After my short 3 year career my biggest advice is to stay scared of scary things, my biggest disasters have happened when I get too sure of by ability. I should mention that I do all my own cases. I have no idea how applicable some of this is to a "team" based model. I just hope I never have to supervise. Finally for new grads. If you go into private practice, don't shake you head at what you see. Private practice guys have learned to adapt and likely provide very safe anesthesia. Don't go into a practice and preach about "how we did it where I trained" keep you mouth shut at keep learning. I practice completely different than I was trained.

Really cool to see you acknowledge evolving from the original thread.

So have I over the years. I read some of my old posts now and then, and wonder what the heck was I thinking back then.