It's been a while since we have had a clinical case

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Trach and PEG planned for 5pm today.
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IlDestriero said:
That seems very quick. Too bad.
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It was a joke. Was waiting for someone to say, See that's why You should have cancelled the case.
The pt was d/c'd to the floor this morning. He is doing very well and will go home tomorrow. He is so pleased and happy with the surgery. It's hard to think of someone deciding on their own not to do this case because "they" feel it is too risky.
 
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Planktonmd said:
Gentle induction of GA, A line, good IV access, compensate for blood loss with blood products and some crystaloids without going crazy, return to spontaneous ventilation 30 minutes at least before the end then extubate.
Keep it simple.
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This is basically exactly how I did it. Aline pre-op, Central line post induction CVP=9, and a good 18g PIV
100mg propofol, 100mcg fent, 50mg Roc.
Easy mask ventilation as BIS approached 30's then LTA to the cords.
For mainentance: Remi at 0.1, Prop at 100mcg/kg/min and DES at 1.7.
Dilaudid 1mg at the end and spontaneous respiration at about 15 min before the end.

The tricky part is how did I manage the fluids. i maintained the CVP and checked an ABG every hour keeping his BE steady throughout. I kept the CO2 at baseline (40). Once the Hct started to fall below 28 I gave a small dose of Lasix in preparation for some PRBC's. I gave him 1unit PRBC and 300cc of cell saver. His ABG never changed.

This pt as with many dilated cardiomyopathy pts would not tolerate any loss of preload. It is imperative to maintain filling pressure in these pts. But you don't want to overload them either. Their heart is a stretched out bag with little contractility. Therefore, you must closely maintain volume status. I needed basically no pressors for the case until I gave the Lasix to make room for the PRBC's. Once I diuressed him he couldn't maintain good BP without some phenylephrine. Then the unit went in and he was back to normal.

Fun case. I enjoyed it.
 
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Interesting case.

Agree on not using etomidate. Etomidate is for ED physicians who don't understand the concept of careful titration. They like to push boluses quick. I bet if you pushed that 100mg propofol quickly, your patient would have tanked.

I would have done the case with a tight sphincter. Preinduction A line. Lido, Fent. Mixed 200mcg phenylephrine in 100mg propofol work that in over 1 minute. Sux if no significant myelopathy. Cordis after induction in case I need to float a swan for instability during case or in ICU after. Agree with keerping euvolemic and frequent ABGs. Type and cross 2 units. Mix up a bag of norepi and hook up in line. Have some dobutamine available in OR. Then just use judgements during case to keep MAP within 20% of baseline.
 
Noyac said:
This is basically exactly how I did it. Aline pre-op, Central line post induction CVP=9, and a good 18g PIV
100mg propofol, 100mcg fent, 50mg Roc.
Easy mask ventilation as BIS approached 30's then LTA to the cords.
For mainentance: Remi at 0.1, Prop at 100mcg/kg/min and DES at 1.7.
Dilaudid 1mg at the end and spontaneous respiration at about 15 min before the end.

The tricky part is how did I manage the fluids. i maintained the CVP and checked an ABG every hour keeping his BE steady throughout. I kept the CO2 at baseline (40). Once the Hct started to fall below 28 I gave a small dose of Lasix in preparation for some PRBC's. I gave him 1unit PRBC and 300cc of cell saver. His ABG never changed.

This pt as with many dilated cardiomyopathy pts would not tolerate any loss of preload. It is imperative to maintain filling pressure in these pts. But you don't want to overload them either. Their heart is a stretched out bag with little contractility. Therefore, you must closely maintain volume status. I needed basically no pressors for the case until I gave the Lasix to make room for the PRBC's. Once I diuressed him he couldn't maintain good BP without some phenylephrine. Then the unit went in and he was back to normal.

Fun case. I enjoyed it.
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Nice---thanks for putting up a good case, brings out a good discussion---should try and make this a weekly thing
 
Pain consult if he makes it through.

D/W surgeon staging the case, particularly if there is a lot of bleeding/hemodynamic instability. Not a must, but definitely worth knowing and factoring in.

Get cute and do some neurontin, ketamine, tylenol, or whatever other adjuncts that aren't going to do **** for this patient.

Other than that, do an arterial line(asleep or awake I don't care) and large bore access. May just go ahead and do central line for potential inotropes/CVP trending/good access.

See: cardiac induction, pacemaker management, SSEP/MEP/blah blah in some texts and do whatever floats your boat there. Nothing fancy there. Use magnet.

Counsel patient extensively.

Ask the surgeon why his referral base sucks so bad.

I think that covers it for now. Let's see what train wreck awaits.
 
While I commend Noyac on his care and the other posters here, I am still at a loss that some merely consider themselves to be cogs in the wheel who must do as the surgeon requests. If you ask me, it is this that should separate us from nurses.

I have had two instances where I refused a case or brought it up that this was inappropriate. One was a 60yo F with end-stage pulm HTN and CHF who was put on CMO status on a morphine drip who an orthop wanted to take to the OR for a hip pinning. Seriously, she was on a morphine drip and this guy rolled in and was ready to go. Second was a posterior cranial decompression where the patient had three codes in the minutes prior to the OR. It was debated preop whether to go and the attending neurosurgeon said "this is a good teaching case for my residents, they don't get to do many emergent posterior decompressions." I was a resident at the time and brought it up to my attending after several hours maxed out on pressors and providing max support that this was completely useless and keeping the patient alive for a teaching case was bull****. My point in all of this is that we have a role to play also.
 
Ignatius J said:
Pain consult if he makes it through.

D/W surgeon staging the case, particularly if there is a lot of bleeding/hemodynamic instability. Not a must, but definitely worth knowing and factoring in.

Get cute and do some neurontin, ketamine, tylenol, or whatever other adjuncts that aren't going to do **** for this patient.

Other than that, do an arterial line(asleep or awake I don't care) and large bore access. May just go ahead and do central line for potential inotropes/CVP trending/good access.

See: cardiac induction, pacemaker management, SSEP/MEP/blah blah in some texts and do whatever floats your boat there. Nothing fancy there. Use magnet.

Counsel patient extensively.

Ask the surgeon why his referral base sucks so bad.

I think that covers it for now. Let's see what train wreck awaits.
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I hope this and the simplification "Use magnet" is a joke
 
VickInABox said:
I hope this and the simplification "Use magnet" is a joke
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Not really. What's the issue?

AICDs and PMs are two of the most overblown instances in anesthesia.

Yeah, if pacer dependent go ahead and program to asynchronous. If not, proceed with magnet.
 
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Ignatius J said:
Not really. What's the issue?

AICDs and PMs are two of the most overblown instances in anesthesia.
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I have an older partner who thinks the same way and never places a magnet no matter what so that he doesn't have to call the rep to interrogate it afterward. His belief is that even if the rep says its okay to put a magnet on it, they still have to come in and intterogate it prior to patient leaving the hospital.

I'm not sure how I feel about it because on one hand, every book and articles I've read say that in this situation with an AICD pacemaker, I should have the rep switch the pacer to DOO mode, deactivate aicd, and put pads on patient. On the other hand, I've never heard of a case in real life where the aicd or pacemaker malfunctioned from abberant currents.
 
PainDrain said:
While I commend Noyac on his care and the other posters here, I am still at a loss that some merely consider themselves to be cogs in the wheel who must do as the surgeon requests. If you ask me, it is this that should separate us from nurses.
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I don't disagree with PainDrain. I think we are the ones that should be the gate keepers to the OR in some form. But if we refuse cases more and more then they will just switch to using nurses more and more because the nurses won't say no.
The pts may not do as well but the surgeons will get their cases done.
 
jason46242003 said:
I have an older partner who thinks the same way and never places a magnet no matter what so that he doesn't have to call the rep to interrogate it afterward. His belief is that even if the rep says its okay to put a magnet on it, they still have to come in and intterogate it prior to patient leaving the hospital.

I'm not sure how I feel about it because on one hand, every book and articles I've read say that in this situation with an AICD pacemaker, I should have the rep switch the pacer to DOO mode, deactivate aicd, and put pads on patient. On the other hand, I've never heard of a case in real life where the aicd or pacemaker malfunctioned from abberant currents.
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Nor have I.
 
Noyac said:
So you would cancel the case, right?
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How is this patient a candidate for elective lower back surgery? Cardiomyopathy, respiratory insufficiency requiring home oxygen. Less than 4 METs. What is his functional status? I'm guessing he doesn't even get out of a wheelchair. After the "twinge" in his lower back is fixed, is he going to be able to participate in aggressive physical therapy?

The rub is that this case would never be done at my hospital. And I frequently see ASA 3's and 4's for outpatient surgery. But I don't think the spine surgeons here would accept this patient for elective surgery. They know (we both know) that this patient has an astronomically high chance of perioperative complications. I have the skills to keep the patient alive intraoperatively, but after that, I'm not sure what good is done. First, do no harm. I'm probably biased, because my father-in-law fit this exact description and 2 years ago went in for elective lower back surgery and died of a massive PE.
 
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inflamesdjk02 said:
How is this patient a candidate for elective lower back surgery? Cardiomyopathy, respiratory insufficiency requiring home oxygen. Less than 4 METs. What is his functional status? I'm guessing he doesn't even get out of a wheelchair. After the "twinge" in his lower back is fixed, is he going to be able to participate in aggressive physical therapy?

The rub is that this case would never be done at my hospital. And I frequently see ASA 3's and 4's for outpatient surgery. But I don't think the spine surgeons here would accept this patient for elective surgery. They know (we both know) that this patient has an astronomically high chance of perioperative complications. I have the skills to keep the patient alive intraoperatively, but after that, I'm not sure what good is done. First, do no harm. I'm probably biased, because my father-in-law fit this exact description and 2 years ago went in for elective lower back surgery and died of a massive PE.
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He has a penile implant. Does that count for a couple mets?
 
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Colba55o said:
Jack Kevorkian had extensive discussions with patients about risks benefits and alternatives before he euthanized people, didn't he still wind up in jail?
Do some of you people really do any case as long as the patient wants it, surgeon wants it and they both understand the risks? The thing is when there is a bad outcome it wont be easy to parse out whether it was poor anesthesia or surgical management. This is a cool thread for academic purposes but the cowboys here shouldn't blather on about how its our job to safely do every **** case that is thrown in front of us.
No one should be faulted for refusing to do this case; if you are 20 yrs into practice have a nice financial cushion and plenty of contacts all over yeah do the case. For those of us who are a few years out of residency, have student loans, families to feed, etc...I'm not willing to have a potential stain on my career this early just to win a who has bigger balls contest.
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Excellent point.

Just because the patient is at deaths door doesnt give me permission to push him through that door. I'll let someone else do it.
 
IlDestriero said:
What annoys me is when the schedulers shield them from many of the complex cases, which just compounds the problem.
.
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oh god dammit do i hate doing all the **** cases, cases most likely to have a bad outcome because other people dont want to and they manipulate the schedule. Manipulating the schedule is a fukking art to lazy anesthesiologists. BUt nothing amuses me more than when the schedule backfires on the schedule triagers.
 
Noyac said:
He has a penile implant. Does that count for a couple mets?
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Sexual activity preorgasm is 2-3 mets, during orgasm, it is about 4 mets. So instead of asking patients if they can climb stairs, which varies a lot in how steep, how high, and how many steps, I just ask if they can acheive orgasm.
 
Noyac said:
He has a penile implant. Does that count for a couple mets?
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To answer your question, if this case presented at my community hospital, I would cancel. And I can count on one hand the number of cases that I've cancelled in the past year.
 
So I obviously don't know everyone's level of experience and years out of training here but I'm getting the impression that the older more experienced (Cowboys if you wish) would do the case and the younger green (obstructionist) would not.
Guys and gals. This pt is optimized!
This pt has been extremely well informed of his risks!
This pt has already been through the first half of his planned surgery and did well!
We have a very good plan in place.
He is not DNR or even in a wheelchair.
His cardiac status has not changed in well over a year. Except for recent Afib after the last case which has no bearing here since he is BiV paced and there are no needs for medication changes.
He has made great strides with regards to his DM management achieving a HgA1c of 7.2.
What more do you want? A heart transplant?
 
Noyac said:
So I obviously don't know everyone's level of experience and years out of training here but I'm getting the impression that the older more experienced (Cowboys if you wish) would do the case and the younger green (obstructionist) would not.
Guys and gals. This pt is optimized!
This pt has been extremely well informed of his risks!
This pt has already been through the first half of his planned surgery and did well!
We have a very good plan in place.
He is not DNR or even in a wheelchair.
His cardiac status has not changed in well over a year. Except for recent Afib after the last case which has no bearing here since he is BiV paced and there are no needs for medication changes.
He has made great strides with regards to his DM management achieving a HgA1c of 7.2.
What more do you want? A heart transplant?
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We all know that this case could have gone very differently. He could have wound up with a prolonged ICU stay, worsening respiratory status, requiring muscle relaxant infusion leading to ICU myopathy and an overall poor outcome. If that had happened the OP would never have posted this case for discussion. People here only like to put on display their successes, their 100% block success rates. Everyone here passed their orals on the 1st try without using a course right?

This is a good teaching case, but also a platform for someone to grandstand. Younger yes, but obstructionist I am not.
 
Noyac, nice case and nice work getting that guy through his procedure. I'm just over a year out of residency. I agree with you, he's optimized. Do the case. I just have a comment based on what some people have said regarding using phenylephrine/vaso/norepinephrine. This guys contractile function sucks. EF= 25%. Increasing his after load without helping contractility is a recipe for disaster. Epi, dobutamine, whatever. Something that helps contractility not just after load. Might help your numbers look ok, but probably not the right thing to do.
 
ColBa55o: Wrong! When your pt is as I presented this one, well informed and optimized, then "you" walking in the day of surgery and canceling the case because "you" think it "may" not go well then you have missed the boat. If you can't do the case then pass it on to someone who can.
 
It's palliative surgery.

It's high risk. He wants it. He's of sound mind. Document the hell out of the risks, including handwritten annotations to the consent, and get on with it.

It'd be a shame to have to tell this guy to live with the pain or chase escalating narcotic doses for the rest of his life.


Agreeing to do this case is NOT the same as just being a blind cog in a do-whatever-the-surgeon-wants machine. This isn't a TKA in a bedridden demented 97 year old paraplegic. It's a frail old guy in pain who found a surgeon who agrees the procedure might improve his quality of life.
 
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The takeaway from this is that anesthesiologists should be able to do any case, but they shouldn't do every case, ethically-speaking.

You got lucky. The patient got lucky. The surgeon got lucky. The patient's family got lucky.

How many countless others similar to the above case have died in the OR, died in the ICU, died on the surgical floor, died in rehab, or died at home post-operatively. Their deaths were brought about by the surgery itself.

I wouldn't cancel the case though.
 
DrBeaker said:
Noyac, nice case and nice work getting that guy through his procedure. I'm just over a year out of residency. I agree with you, he's optimized. Do the case. I just have a comment based on what some people have said regarding using phenylephrine/vaso/norepinephrine. This guys contractile function sucks. EF= 25%. Increasing his after load without helping contractility is a recipe for disaster. Epi, dobutamine, whatever. Something that helps contractility not just after load. Might help your numbers look ok, but probably not the right thing to do.
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Yes you are thinking correctly. In a sense you are increasing the workload of a sick heart by increasing afterload (phenylephrine) which may worsen the output. But one thing to think about with phenylephrine is that the afterload increase along with the resultant slowing of HR (not in this case since the pt is paced at 80) give the myocardium increased perfusion pressure. I witnessed this first hand when I did a lot of off-pump CABG cases. You would just see the heart muscle wake up with small doses. I didn't use vasopressin in these cases so I can't comment on its effect. I like that it "may" have less pulmonary impact but I've not noticed a difference clinically. Doesn't mean that it isn't there.
So essentially, phenylephrine does help contractility by increasing flow to the myocardium.
My drug of choice had this gone bad wou,d have been dobutamine before norepi since I want increase contractility more than increased SVR. Norepi is ideal in low SVR states like sepsis. But I prefer to treat the issue and in this case it's contractility.
Does that answer your question?
 
I have no problems doing this case.
TEE in the prone position... has anyone done this?
 
Colba55o said:
If that had happened the OP would never have posted this case for discussion. People here only like to put on display their successes, their 100% block success rates.
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Carastrophes don't get posted for a couple reasons -

One, it's the nature of anesthesia that avoidable catastrophes are rare. Even for cowboys.

Two, it'd be stupid to discuss a case you might get sued over on a public forum.

The most you're going to see posted in that direction are near misses. I've posted a couple of mine, including the errors I made leading up to them.
 
chfo said:
How many countless others similar to the above case have died in the OR, died in the ICU, died on the surgical floor, died in rehab, or died at home post-operatively. Their deaths were brought about by the surgery itself.
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That risk is nonzero, but the patient has chosen to accept that risk, and that makes all the difference in the world.

(Assuming he was counseled appropriately and consented properly.)
 
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chfo said:
The takeaway from this is that anesthesiologists should be able to do any case, but they shouldn't do every case, ethically-speaking.

You got lucky. The patient got lucky. The surgeon got lucky. The patient's family got lucky.

How many countless others similar to the above case have died in the OR, died in the ICU, died on the surgical floor, died in rehab, or died at home post-operatively. Their deaths were brought about by the surgery itself.

I wouldn't cancel the case though.
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Wrong again. I've been doing cases like this for over 10yrs. That's not luck my friend. And as arrogant as it may sound to some here, it's about knowing the terms and your ability to handle situations. It's about have the experience to see how things will go and how to adjust as issues arise.
Any pt that comes to the OR under "our" care should be assumed to not get any worse unless there is a surgical mishap. Now if I didn't trust my surgeon then I might not have done this case. But I have worked with this guy long enough to know every step of this case. And this is also why he asked me to do the case. Why in the world would this guy be any different then the ones before him? And if he is different, the plan is in place to get him through it safely.

Anesthesia is not the place for chicken**** personalities. There are too many people watching out for their own interests and not considering the pts we are assigned to care for.
 
sevoflurane said:
I have no problems doing this case.
TEE in the prone position... has anyone done this?
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Finally, someone asks a real question.
Sevo, you know I haven't done a TEE prone. But was wondering if you had.

An interesting part of this case is that I placed the central line supine and the CVP was 9. Then we rolled the pt prone and it was immediately 20.

I have seen this many times. But who here wants to explain it?
 
Noyac, I like your reasoning. As I said, just a comment.

In regards to increasing CVP prone, they chest padding for the prone OR table will increase intrathoracic pressure and hence CVP. If you adjusted your peep that will affect it as well.

I have not done a TEE prone, but I think it could be done.
 
Noyac said:
Finally, someone asks a real question.
Sevo, you know I haven't done a TEE prone. But was wondering if you had.

An interesting part of this case is that I placed the central line supine and the CVP was 9. Then we rolled the pt prone and it was immediately 20.

I have seen this many times. But who here wants to explain it?
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transducer position, or line partially kinked
 
WTF is a "cardiac induction"?
180/90 is a pretty good pulse pressure for someone with EF of 25%.
Is PASP 50 or mPAP 50? How bad is PH--remember BP is 180/90.
TEE should be more than just "checking volume status". Never mentioned anything about the RV size and function. Trying to fill an empty LV when RV is full will be counter-productive. Rather have CVP/PAC.
Finally, most anesthesiologists can get this guy out of the OR alive. But what is his chances throwing a PE or having a MI postop? Does that still count against you? Funny that someone mentioned if you cancelled the case, you need to find an academic job. Guess where the PP guys send these patients to? You trust someone in your own ICU to manage him postop?
 
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Noyac said:
Finally, someone asks a real question.
Sevo, you know I haven't done a TEE prone. But was wondering if you had.

An interesting part of this case is that I placed the central line supine and the CVP was 9. Then we rolled the pt prone and it was immediately 20.

I have seen this many times. But who here wants to explain it?
Click to expand...

Pressure on the abdomen transmitted to the right atrium.
 
Noyac said:
An interesting part of this case is that I placed the central line supine and the CVP was 9. Then we rolled the pt prone and it was immediately 20.

I have seen this many times. But who here wants to explain it?
Click to expand...

This is one reason why I wouldn't put much faith in CVP for this case (or, really ever). CVP has time and again been shown to be unable to predict either fluid responsiveness or intravscular volume status. A CVP shows the pressure of the blood in the thoracic vena cava, and that is it. In this case, the pressure in the thoracic vena cava changed because of the change in intrathoracic pressure due to prone positioning and pressure along the chest wall. A direct measurement of pulse-pressure variation would be the most accurate method of assessing volume status and fluid responsiveness, followed by pulse-contour analysis-derived stroke volume variation (although, as HB rightly said, pressors alter the contour of the pulse wave, thus changing stroke volume estimates and decreasing accuracy). From there, delta-IVC, TEE measurements, CO by PAC and esophageal doppler are fairly accurate, and nearly everything else is guesswork. In the first stage of the case, I would have used a TEE for both assessment of volume status, and to assess his cardiac function (there you go, DrN2O) in real-time under changing loading conditions, blood loss, etc. For the second, prone, stage, I would not use it, but rather plan to use esophageal doppler (although, honestly, I don't have that here) and/or PPV (if I had a device that could directly measure it, otherwise use SVV, realizing that pressor use will make it less reliable). Based on reading the changes in cardiac monitoring in the CCM literature, these would still be more accurate than using CVP or PCWP to indirectly assess volume.

As for pressors in this gentleman, part of the rationale of using pressors is to increase to baseline the SVR that is decreased by volatile anesthetics. As such, the use of low-dose pressors is reasonable, as the goal is to maintain afterload near his functional baseline and maintain perfusion pressure, rather than to jack the afterload up in excess, thus putting undue strain on his already stressed LV. I would prefer to do this with vasopressin (no increase in PVR) or norepinephrine (increase in both PVR and SVR, but slight increase in inotropy should improve right heart function enough to partially to offset the increase in PVR), rather than just phenylephrine (no positive inotropic effect to offset increased PVR). Either which way, if confronted with increasing pressor requirements, there should be a very low threshold to initiate or increase an inotrope, to improve contractility to offset the increased afterload.

I know most of the people participating in this thread already know this information, but it bears mentioning for the lurking med students and junior residents.

Also, for transparency sake, I am only two-years out of residency, and I doubt my spine surgeon's ability to do this case reasonably well, or my ICUs ability to care for him afterward, so would likely not do the case in reality, at my current institution.
 
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DrN2O said:
WTF is a "cardiac induction"?
180/90 is a pretty good pulse pressure for someone with EF of 25%.
Is PASP 50 or mPAP 50? How bad is PH--remember BP is 180/90.
TEE should be more than just "checking volume status". Never mentioned anything about the RV size and function. Trying to fill an empty LV when RV is full will be counter-productive. Rather have CVP/PAC.
Finally, most anesthesiologists can get this guy out of the OR alive. But what is his chances throwing a PE or having a MI postop? Does that still count against you? Funny that someone mentioned if you cancelled the case, you need to find an academic job. Guess where the PP guys send these patients to? You trust someone in your own ICU to manage him postop?
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Nice post, now someone is talking about the case instead the knee jerk cancel comment.
I made the academic comment and while it may have been a bit unfair it is the mindset I see when people who are more academically driven come to PP. They want all kinds of useless tests like PFT's etc that don't change the plan whatsoever and then cancel last minute after weeks and months of preparation on others part. Also, if someone is sent to an academic facility for surgery it is for surgical reasons not anesthesia. I don't ever recall in any of my practices someone being sent somewhere else because the anesthesia was too complicated. That's not why they go to other facilities.
The PHTN was 50mmhg systolic during a BP of around 150/90, his baseline. So it's legit PHTN but not scary.
TEE would be nice but not in this case since it's the prone position. I don't remember the RV siE but it wasn't bad. Good fxn also.
Yes, chances of post op events are present and moderately high. This has all been addressed with the pt. he wants to continue as does his wife.
 
Noyac said:
Finally, someone asks a real question.
Sevo, you know I haven't done a TEE prone. But was wondering if you had.
Click to expand...

I have not. But this thread did get me a bit curious. It seems like some people have.

I think it would be a PITA. And forget it if you have a mirror- not going to risk damaging a 100K probe. I would have to have easy access to the face. Maintaining the probe in place without causing any traction on the esophagus may also be a challenge. The information obtained would be extremely useful, but not necessary. I would be curious as to what others have experienced if they have done this.

http://www.ncbi.nlm.nih.gov/pubmed/21203747
 
DrBeaker said:
Noyac, nice case and nice work getting that guy through his procedure. I'm just over a year out of residency. I agree with you, he's optimized. Do the case. I just have a comment based on what some people have said regarding using phenylephrine/vaso/norepinephrine. This guys contractile function sucks. EF= 25%. Increasing his after load without helping contractility is a recipe for disaster. Epi, dobutamine, whatever. Something that helps contractility not just after load. Might help your numbers look ok, but probably not the right thing to do.
Click to expand...
Careful use of phenylephrine is not always as bad as you think in this patient population, it improves the coronary perfusion by increasing the diastolic pressure and as a result improves contractility.
 
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Newly minted CA-1 here...why is everyone so down on etomidate? I understand the risk of adrenal suppression as well as potential for myoclonus. Is there another reason people are avoiding it? We use it at my institution quite a bit, especially in our trauma/ED cases when little info is known about the patient
 
d9sccr said:
Newly minted CA-1 here...why is everyone so down on etomidate? I understand the risk of adrenal suppression as well as potential for myoclonus. Is there another reason people are avoiding it? We use it at my institution quite a bit, especially in our trauma/ED cases when little info is known about the patient
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I think there was a retrospective study published in Anesthesiology not to long ago showing that even a single induction dose of etomidate was associated with increased mortality compared to propofol even after accounting for comorbidities. Its a single retrospective article so take it with a spoon of salt.
 
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Job Hunting While Employed
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