Bolusing vasopressin

[McPoyle]

Hey y'all, just finishing my first month of CA-1 and had a quick question. Seems my go to for intraop hypotension has been fluid and ephedrine/phenylephrine. However, I have one attending I work with fairly regularly who will try one dose of either ephedrine or phenyl and then immediately go to bolusing 2-4 units of vasopressin at a time. Seems to work well, but I have never seen this done, especially so regularly, and it made me wonder if maybe this is something odd...

Also, same attending is the only one I've seen that uses sux to place an LMA. The reasoning being it "provides optimal conditions for placement". Again, seems to work well, but also have not met anyone else who does this...

So, is it common to bolus vasopressin and use sux with LMA placement?

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[BobBarker]

Turn down your volatile.

 

[urge]

As a CA1 you must be doing the healthiest patients of them all. I don't see any good reason to use vaso in that patient population.

The sux seems unnecessary to me, but I'm sure it works.

 

[TaoistDoc]

I rarely use vasopressin. A good clinical scenario for it I think is hypotension resistant to phenylephrine/ephedrine due to patient taking ACEi. But yeah definitely turn down your gas as well. If you have muscle relaxant on board, 0.6 MAC is all you need for amnesia. Some say 0.4 or 0.5 MAC. I play it a little safer and do 0.6 age adjusted MAC.

Remember you can also use small dose epinephrine if hypotension is resistant to above treatments. 10 to 50 micrograms. Your patient may be having an anaphylactic reaction.

 

[BuzzPhreed]

Routinely gives 2-4 units? I start with 0.5 units. Usually that's enough. As stated only for refractory hypotension and usually when they took their ACE-I/ARB despite being told not to (which is not a reason to postpone a case, by the way).

And using sux to place an LMA? That's just stupid. This is one of those REALLY bad habits you should not pick-up during residency.

 

[BobBarker]

Is he inducing his LMAs with etomidate??

 

[OUAnesthesia]

Is he inducing his LMAs with etomidate??

Probably a narcotic induction...

 

[McPoyle]

Turn down your volatile.

Yeah lately I've noticed it always to be up around 1.2 mac which also seemed odd to me...

 

[deleted171991]

Yeah lately I've noticed it always to be up around 1.2 mac which also seemed odd to me...

Most of the time, you should aim for less than 1 MAC of volatile (especially with LMAs, which are less stimulating). If you need more, you are not practicing balanced anesthesia.

Correction: if you need more, you are a CRNA.

 

[Planktonmd]

These doses of Vaso are too large, I bet you the patient looks awful and gray because of the severe vaso-constriction.
One of the advantages of using an LMA is simplifying the anesthetic, adding Sux is a step backward.

 

[RxBoy]

Also, same attending is the only one I've seen that uses sux to place an LMA. The reasoning being it "provides optimal conditions for placement". Again, seems to work well, but also have not met anyone else who does this...

So, is it common to bolus vasopressin and use sux with LMA placement?

Dont make sux a habit, especially this early in your career. However it does have a role for my cases occasionally. When i have big ol pt with a cardiac history, i give lighter dose of propofol and a cc (20 mg) of sux. Helps prevent laryngospasm and lets me get away with a lot less anesthetic on induction.

Side note, if theyre really obese I tube. Im not a fan of using lma's on bmi 40+.

 

[Ronin2258]

Routinely gives 2-4 units? I start with 0.5 units. Usually that's enough. As stated only for refractory hypotension and usually when they took their ACE-I/ARB despite being told not to (which is not a reason to postpone a case, by the way).

And using sux to place an LMA? That's just stupid. This is one of those REALLY bad habits you should not pick-up during residency.

That is about the only time I use it. 0.5-2units tends to be enough.

However, stopping ACE-I/ARBs just the day before may not sufficient. The patient population I had in training was still having problems with hypotension even after a day without it. While it reduces the risk of it happening, it is not a complete solution.

Also, it may be the only thing holding their pressure down. If the ACE-I/ARB is the lynchpin of treatment for their hypertension (i.e. the only thing keeping the patient normotensive,) it may be taken.

http://www.ccjm.org/content/76/Suppl_4/S126.full

 

[Vaporized]

Most of the time, you should aim for less than 1 MAC of volatile (especially with LMAs, which are less stimulating). If you need more, you are not practicing balanced anesthesia.

Correction: if you need more, you are a CRNA.

After just finishing my ca 1 year I definitely have come to realize using less gas. However, with an LMA I would be uncomfortable with less than a MAC given that I am not using paralysis. This means over half these patients will move to surgical stimulus. I always err on deeper is better for LMA for this reason (not to the extent of needing the purple stuff, though).

 

[Arch Guillotti]

That's a lot of vasopressin. Sometimes I will use it for refractory hypotension but only after running through a good amount of neo/ephedrine. .5-1 unit to start.

Sux for an LMA is stupid.

 

[pgg]

I don't tell patients to stop their ACE or ARB for most surgeries.


During the propofol shortage, we were using methohexital for inductions. That drug makes patients wiggle and twitch and hiccup like crazy, so I would use muscle relaxant with LMAs - usually about 20-40 mg of succ, just to soften them up a bit so I could easily put them on the vent.

If you routinely feel like you need succinylcholine to get an LMA in, you're probably not giving enough propofol. Young patients sometimes need 300 mg or more of propofol to get them down, especially if you're not also giving midaz or fentanyl prior to induction (which I don't for LMA cases).

 

[narcusprince]

If my patients have taken their ACE-I or ARB's DOS. I usually try to tank them up before induction IE 500-1000 of LR or NS prior to induction. And I would have 20units of vaso in a 20cc syringe. What concentration of vaso do you guys use?

PGG I once had an EOD guy(80kg) I had to give 400 mg of propofol to get him to calm down. If I remember correctly he could top out the anesthesia machines when he exhaled during pre-oxygenation >3000ml. I called him wolverine because anesthesia does not work on him.

 

[pgg]

PGG I once had an EOD guy(80kg) I had to give 400 mg of propofol to get him to calm down. If I remember correctly he could top out the anesthesia machines when he exhaled during pre-oxygenation >3000ml. I called him wolverine because anesthesia does not work on him.

Yeah, a lot of those young burly military guys are metabolic machine super athletes. When they come in freshly amped up and pissed off it's frankly amazing how much anesthesia they need. Even a day or two later when it's washout time and an LMA is appropriate ... I just got in the habit of starting with 400.

 

[Urzuz]

The old dogma of holding everyone's ACEi/ARB before surgery to prevent hypotension is being revisited. As more work is being done in this area, some would suggest that maintaining homeostasis (or what that patient's homeostasis has been leading up to the surgery with all the medications they are on) on the DOS is probably a good thing.

I'm still undecided/unclear on the whole issue since no good prospective trials exist, but some food for thought:

*Edit: Just to be clear, I know these articles are talking about resuming ACE inhibitors after surgery, but the idea of "maintaining homeostasis" even in the OR still exists.

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http://circ.ahajournals.org/content/126/3/261.long

http://www.ncbi.nlm.nih.gov/pubmed/24799360


Patterns of Use of Perioperative Angiotensin-Converting Enzyme Inhibitors in Coronary Artery Bypass Graft Surgery With Cardiopulmonary Bypass
Effects on In-Hospital Morbidity and Mortality
CONCLUSIONS:
Our study suggests that withdrawal of ACEI treatment after coronary artery bypass graft surgery is associated with nonfatal in-hospital ischemic events. Furthermore, continuation of ACEI or de novo ACEI therapy early after cardiac surgery is associated with improved in-hospital outcomes.


Thirty-day mortality risk associated with the postoperative nonresumption of angiotensin-convertingenzyme inhibitors: a retrospective study of the Veterans Affairs Healthcare System.
CONCLUSIONS:
Nonresumption of an ACE-I is common after major inpatient surgery in the large VA Health Care System. Restarting of an ACE-I within postoperative day 0 to 14 is, however, associated with decreased 30-day mortality. Careful attention to the issue of timely reinstitution of chronic medications such as an ACE-I is indicated.

 

[deleted9493]

Just today I had a vasculopathic cath lab patient who had taken his ACEi, metoprolol and norvasc this morning. Hypotensive with .5 MAC and paralytic. Vasopressin was just the fix for his ailing hypotension. I was infusing at 2u/hr to settle him out. Ephedrine had no effect and phenylephrine only a mild effect. To keep it interesting, they were infusing nitroglycerin and verapamil into his artery to reduce vasospasm.

Infusing, as opposed to bolusing, seems to give a more desirable effect...as long as you're willing to be patient for the titration.

 

[Mman]

Just today I had a vasculopathic cath lab patient who had taken his ACEi, metoprolol and norvasc this morning. Hypotensive with .5 MAC and paralytic. Vasopressin was just the fix for his ailing hypotension. I was infusing at 2u/hr to settle him out. Ephedrine had no effect and phenylephrine only a mild effect. To keep it interesting, they were infusing nitroglycerin and verapamil into his artery to reduce vasospasm.

Infusing, as opposed to bolusing, seems to give a more desirable effect...as long as you're willing to be patient for the titration.

You are also less likely with an infusion to end up giving a massive dose in a short period of time that leads to low cardiac output state.

 

[WholeLottaGame7]

After just finishing my ca 1 year I definitely have come to realize using less gas. However, with an LMA I would be uncomfortable with less than a MAC given that I am not using paralysis. This means over half these patients will move to surgical stimulus. I always err on deeper is better for LMA for this reason (not to the extent of needing the purple stuff, though).

Only if the only agent you're using is volatile. If they have reasonable narcotic on-board they are probably closer to 1.3 MAC.

 

[ranvier]

It's fun to work with the occasional attending who does something different compared to the usual "keep them with at least one twitch and don't give too much narcotic." I had an attending that was always suggesting weird stuff like extubating first then giving reversal or methylene blue for vasoplegia before even levophed if the phenyl wasnt enough. It helps you figure out what you want to do when it is up to you and think about physiology.

That said, until ca-3 year, just get good at plain vanilla anesthetics. As a brand new grad, I appreciate why so many do things similarly....if it ain't broke

P.s. Are those patients getting vaso pushes nauseated in pacu?

 

[anes]

That sounds crazy! 4 units of vasopressin for any normal person will likely send their blood pressure into the mid 200s. But if it works and patients do well, then it's cool.

But sux for LMAs is definitely a step backward. Why use a drug that is not necessary, and not without significant risk?

 

[OB1🤙]

Of all that's wrong with giving sux to place an LMA, the myalgias may be the worst.

Hey, let's make the patient feel like they got run over by a truck for three days just to make a super easy procedure marginally easier!

 

[deleted171991]

I am wondering whether the problem is not with sux, but with the dose of sux. I am sure we don't need 1 mg/kg for an elective intubation, pretty sure we don't need even the 0.6 mg/kg I tend to use.

It would be interesting to see what happens for lower doses, or even when not using sux at all. I did the latter (or used a minimal dose of roc just to avoid laryngospasm) and it worked perfectly for many intubations in the ICU during a severe sux shortage. (I won't leave patients paralyzed for the 30 minutes it takes the ICU nurses to set up their sedative infusions.)

 

[RxBoy]

J Cardiovasc Thorac Res. 2013;5(1):17-21. doi: 10.5681/jcvtr.2013.004. Epub 2013 Mar 17.
Assessment of Mini-dose Succinylcholine Effect on FacilitatingLaryngeal Mask Airway Insertion.
Aghamohammadi D1, Eydi M, Hosseinzadeh H, Amiri Rahimi M, Golzari SE.
Author information

Abstract
Introduction: Laryngeal Mask Airway (LMA) has gained wide acceptance for routine airway management and with increasing emphasis on day care surgery it is widely used. The aim of this study was to assess the effects of mini dose succinylcholine (0.1mg/kg) with semi-inflated cuff on facilitation of laryngeal mask airway insertion in order to achieve more satisfaction yet less complications . Methods: In a randomized double-blinded study, sixty ASA 1, 2 and 3 patients aged 20-60 years scheduled for urologic surgical procedures were included. Thirty patients received succinylcholine (Group S), and thirty received 0.9% sodium choride as a placebo (Group C). Results: Coughing occured in 33.3% of patients in the control group and there was no incidence in succ group (P=0.002). Head or limb movement occurred in 70% of the patients in the control group vs. 10% in succ group (P<0.001). Laryngospasm occurred in 36.6 % of the patients in the control group but there was no incidence in succ group (P=0.004). Additional propofol was required in 53% of the patients in control group vs. 10% for succ group (P=0.001). Ease of insertion and first successfull attempt of LMA were achieved in 93.3% and 90% of the patients respectively in group S (P<0.05). Myalgia and sore throat occurred in 66.7 % of patients in the group C in comparison with 33.3% in group S (P=0.06).Conclusion: The combination of propofol with mini dose succinylcholine, provided a significantly better method for LMA insertion, while reduced propofol doses were needed and number of attempts decreased.


Back to what I said, I think it has a role in the cardiac pt needing an lma with small doses of propofol. All you need is 20 mg sux and I find it works pretty damn well. However, routine use for LMA insertion is just plain stupid. No reason to subjugate pts to 3 day myalgias for a 2 sec procedure.

 

[pgg]

Of all that's wrong with giving sux to place an LMA, the myalgias may be the worst.

Hey, let's make the patient feel like they got run over by a truck for three days just to make a super easy procedure marginally easier!

Almost 20 years ago I had a radius and ulna ORIF. My smashed up and bolted-back-together arm felt OK after surgery, but I thought maybe they did CPR on me, my body hurt so much. Succ myalgias are real and they really, really suck. I avoid using it whenever I can.

 

[dhb]

I am wondering whether the problem is not with sux, but with the dose of sux. I am sure we don't need 1 mg/kg for an elective intubation, pretty sure we don't need even the 0.6 mg/kg I tend to use.

ED95 is 0.4mg/kg

 

[Urzuz]

I am wondering whether the problem is not with sux, but with the dose of sux. I am sure we don't need 1 mg/kg for an elective intubation, pretty sure we don't need even the 0.6 mg/kg I tend to use.

Not sure what your practice setting is like, but if you can, next time you use sux 0.6 mg/kg (or 0.4 mg/kg as dhb suggested?), attach a TOF/NMT monitor and see if you get complete abolition of twitches before you put the tube in. I would be interested to know the results, and it would probably influence my practice! Obviously I know you don't need 100% paralysis in a patient who you just slugged with propofol, but I would be interested to see what happens to the twitch height after those lower doses. I was always under the impression that the relative overdose of sux was to make sure you get enough drug to the NMJ without it getting metabolized in transit.

 

[OB1🤙]

If I recall, specifically as it relates to myalgias, the more you give the less the myalgia. Go figure.

I'll try to rustle up a reference.

 

[OB1🤙]

http://www.ncbi.nlm.nih.gov/m/pubmed/16192781/

 

[deleted171991]

The question is whether the patient still has myalgia if one gives less than the fasciculating dose.

 

[Mman]

The question is whether the patient still has myalgia if one gives less than the fasciculating dose.

since patients can have no visible fasciculations and still have myalgia, I assume the answer is yes

 

[deleted171991]

since patients can have no visible fasciculations and still have myalgia, I assume the answer is yes

Sorry, let me rephrase. If 50% of the patients will have myalgias when 95% of the patients fasciculate, if we give a dose at which nobody fasciculates, how many will still have myalgias?