Narcotic administration in cardiac surgery cases

[drmwvr]

That's a pretty judgey tone there

oh good...I've been working on being more direct.

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[D4C]

Cool to see all the different practices.

Personally I run precedex 0.3 mcgs/kg from the start, increasing to 1 when wires go in. Only give midaz to young patients (55 and younger), or whos anxiety is cranking up the catecholamines. 250 of fent on induction, 250 on sternotomy, 500 on transport.

 

[T-burglar]

I’m judging all of you

 

[Bertelman]

If I haven’t given 1000 fent by the end, I feel a little incomplete.

 

[medicine2wallstreet]

Cool to see all the different practices.

Personally I run precedex 0.3 mcgs/kg from the start, increasing to 1 when wires go in. Only give midaz to young patients (55 and younger), or whos anxiety is cranking up the catecholamines. 250 of fent on induction, 250 on sternotomy, 500 on transport.

I don't really care about varying styles and think it's interesting but 500 on transport??? For what?

 

[D4C]

I don't really care about varying styles and think it's interesting but 500 on transport??? For what?

I waste narcotics in the patient.

Joking aside, it’s for the ICU nurses. Provides a good 45-hour of sedation; nurses can get the patient “tucked in” without worrying about them flailing around.

 

[nimbus]

I waste narcotics in the patient.

Joking aside, it’s for the ICU nurses. Provides a good 45-hour of sedation; nurses can get the patient “tucked in” without worrying about them flailing around.

Usually we get some hypotension on transferring the patient from the OR table to the ICU bed. Do you have issues with hypotension during transport after giving 500mcg of fentanyl for transport? I typically used 250mcg for a routine case and transported with propofol 30mg/kg/min.

 

[psychbender]

I waste narcotics in the patient.

Joking aside, it’s for the ICU nurses. Provides a good 45-hour of sedation; nurses can get the patient “tucked in” without worrying about them flailing around.

Ooooor, they could just get the patient breathing and extubated that much sooner. Often, if patients are getting a little fidgety, flipping them to PSV gets them to calm back down, so the nurse can finish the initial charting.

 

[PpfSuxTube]

Honestly if we had to wait for a patient to obey as well as some cardiac icu nurses pre extubation there wouldn't be more than 1 case done in any OR in the entire world. Some of em want the patients to bloody write a novel while calmly intubated...

 

[D4C]

Usually we get some hypotension on transferring the patient from the OR table to the ICU bed. Do you have issues with hypotension during transport after giving 500mcg of fentanyl for transport? I typically used 250mcg for a routine case and transported with propofol 30mg/kg/min.

There’s a predictable and transient bump on the levophed during transport, no doubt. If I were practicing in a vacuum, most would go up on a prop gtt.

Ooooor, they could just get the patient breathing and extubated that much sooner. Often, if patients are getting a little fidgety, flipping them to PSV gets them to calm back down, so the nurse can finish the initial charting.

I agree, unfortunately the CT ICUs at these shops have poor/no intensivist involvement. As I’m sure many have seen, you need to treat the nurse / surgeon at times.

 

[psychbender]

There’s a predictable and transient bump on the levophed during transport, no doubt. If I were practicing in a vacuum, most would go up on a prop gtt.


I agree, unfortunately the CT ICUs at these shops have poor/no intensivist involvement. As I’m sure many have seen, you need to treat the nurse / surgeon at times.

As an intensivist, that's quite frustrating. When I came to my current shop, I was quite aggressive, and able to get nursing buy-in (by being very involved in all aspects of care, and charming when doing what I wanted, rather than be an dingus). As a result, our average time to extubation was reduced by about two hours.

 

[drmwvr]

There’s a predictable and transient bump on the levophed during transport, no doubt. If I were practicing in a vacuum, most would go up on a prop gtt.

So the transient need for inopressor from the universally described MAP dump on going from the table to the ICU bed (@ nimbus) or from the narcotic hit? Or both? That universal fall in blood pressure is well anticipated and has been postulated as being 2/2 release of sequestered acidotic blood on the move off of the table. Pure speculation, never seen a paper on it, but it's a thing. Can imagine how a whack of fentanyl would exaggerate it.

 

[castafari]

For folks that give more than 2-4 versed, are you infusing sedation as well? There is a culture in some places of giving 2-3 anesthetics per case (over doses of fentanyl and versed + volatile agent + propofol +/- precedex, the main objective being amnesia apparently...

Nah. Sometimes I bolus a smidge of prop on the walk to the until. Icu nurse has prop drip waiting on arrival