? for Jet re: myths perpetuated in academia

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joshmir

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o great mythbuster Jet-

many moons ago you dropped knowledge about the classic myths that academia perpetuates, and that we should be cognisent(sp?) of in the real world. I found it very useful

I looked back through your posts, but was unable to find a clear listing...can you drop that payload on us again? the newbies will certainly benefit from it.....as I recall, there was someting re: misconceptions of aspiration (both LMA related, and related to innefective ways to prevent the resultant pneumonitis/pneumonia), something about albuterol administration in pts who have asthma but are not weezing, etc

sincerely appreciated

would also love to hear similar thoughts from others too. (btw, welcome back mil! you were thoroughly missed...and your time is really appreciated...)
 
joshmir said:
o great mythbuster Jet-

many moons ago you dropped knowledge about the classic myths that academia perpetuates, and that we should be cognisent(sp?) of in the real world. I found it very useful

I looked back through your posts, but was unable to find a clear listing...can you drop that payload on us again? the newbies will certainly benefit from it.....as I recall, there was someting re: misconceptions of aspiration (both LMA related, and related to innefective ways to prevent the resultant pneumonitis/pneumonia), something about albuterol administration in pts who have asthma but are not weezing, etc

sincerely appreciated

would also love to hear similar thoughts from others too. (btw, welcome back mil! you were thoroughly missed...and your time is really appreciated...)
Click to expand...

Lemme first see if I can locate that post somehow then have one of the computer studs post a link to it cuz it was a pretty lengthy deal.
 
You're not thinking of this post, are you?

jetproppilot said:
Theres alotta stuff clinicians do every day thinking they are accomplishing something by instituting it, when in fact there is little to no evidence supporting these actions. Like:

Pre-op reglan/pepcid before inducing a full stomach

Ruling out an LMA for diabetics/GERD patients....I'll use an LMA as long as the GERD pt doesnt have postural symptoms.

Being scared sh*tless to put a parturient to sleep for a C section because of "increased risk"

Pre-op albuterolol tx for an asymptomatic asthmatic/COPDer

Too many pre-op labs/ekgs/cxrs

SWANs

too many A lines/TLCs.....not every ELAP, back, thoracotomy, vascular case needs them

huge thiopental dose in carotids

shunts in carotids...although thats the surgeons call, not ours

avoidance of lmas for all laparoscopic cases.....yes, you can use them sometimes.

too many awake intubations

too many awake extubations

waiting to start a c section because the lady ate a few hours ago

waiting to start an urgent but not emergent case because the pt ate a few hours ago....(closed but serious fractures, appendix, etc)

Intubating every D & C

Starting an IV on a kid having ear tubes put in

Using muscle relaxant on pedi tonsils....yes, you can mask'em down, start the IV, and use volatile agent only. Will save yourself tons of time. Give a little opiod after youve extubated on your way to the recovery room if you want. No more reversal/risk of wasting time for prolonged neuromuscular blockade.


I'm sure we'll add to this list but its a good start.
Click to expand...
 
jetproppilot said:
There was one before that....had some comments after each one.....but thats a pretty good summary.

If you find the other post please put a link up.
Click to expand...

Here's another...I don't think it's the right one, but we're getting there:

jetproppilot said:
Review my posts on the plethora of academic teachings that I don't think hold water, Volatile.

I remember a lengthy post I wrote about putting a woman to sleep for a C section when necessary....and how residents are taught the "dangers" of doing this, to the point where their fear of same could affect their performance....

Risks of certain clinical situations should be taught in academia, I agree.

But academia fails in conveying that the risks are VERY LOW if you are a deft clinician.

And yes, volatile, there are many anesthesia myths perpetuated by academia.

I've never used less than a 7.0 tube for a C-section requiring GA.

C-sections requiring GA are just like any other RSI GA, except they desaturate like a morbidly obese person so you have to be quick. And if there is difficulty intubating, a little reverse T-berg and appropriate (read non gastric-insufflating) mask ventilation can be done until you get the tube in. Academia's over-emphasis on parturient aspiration risk is overblown. Pure and simple. To the point of needlessly placing overblown fear in new clinicians...to the point of potentially affecting your performance. Soooo, have you ever heard an academic dude give you an explanation like that for intubating a parturient? I'll bet not. I'll bet they placed fear in your head.

I've yet to figure out why it is taught that an RSI must be done on someone with non-postural GERD.

I've yet to figure out why many clinicians give a pre-op albuterol treatment to an asymptomatic asthmatic.

I think our NPO guidelines need to be modified.

I could go on and on.

Not blindly agreeing.

Just calling it like I see it after ten years making my living in this biz.
Click to expand...

Also:
jetproppilot said:
They pounded in your head a totally overblown risk. Which is commensurate with academic medicine.

Dude, with all due respect, I dont make this s hit up.

Since I'm still just a working class dude, I live this stuff every day I go to work.

And come the end of June, it'll be ten years in the biz.

Not bragging. BELIEVE me, nothing to brag about.

Once I become a stay-at-home-dad I'll start bragging.

Just pointing out that there are what I consider anesthesia myths.

I certainly wouldnt profess on a situation I wasnt familiar with.

Believe me.

I've pulled a zillion LMAs in my ten year career.

And it can be done without deleterious sequelae.

Patient breathing good tidal volumes?

Sevo at end-tidal .2%?

No problem.

Rip it out.

On just about every patient, I do an aggressive jaw lift, at least initially. Birdie fingers buried behind the mandibular ridges, pushing-to-the-ceiling.

Thumbs on top of the mask, pushing to-the-floor.

With APL open, looking at the bag for movement.

Works, dude. And sometimes its not even needed. Upon removing the LMA, if the pt starts breathing, just place mask on face, APL open, call for stretcher.

You are conveying a fear that does not need to be conveyed.

No matter what extubation criteria you abide by (with ETT and LMA), you are still gonna see a (rare) laryngospasm.

No big deal.

Apply a big-time seal with the mask, pull up on the mandible with your left hand, apply positive pressure with your right hand on the bag.

Most of the time this is all it takes.

If it doesnt work (RARE), give 20-40 mg sux. Enough to address the problem without stranding you in the OR for 20 minutes.

Dont be fooled, folks, by posters that tell you THIS IS THE WAY IT HAS TO BE DONE.

In anesthesia, and probably every other specialty,

yes, there are a few scenerios that require adherence to a certain protocol.

This isn't one of them.l
Click to expand...

This was an awesome one (from a thread asking suggestions on a topic for a paper the OP had to write):

jetproppilot said:
Malignant hyperthermia/does nitrous oxide really cause post op nausea-vomiting?/intraoperative awareness and sound ways to prevention/MilMD....Man or Myth??? /best cocktail for preventing post op nausea-vomiting/regional anesthesia for joint replacement/utilization of femoral nerve catheter for post-op total knee analgesia/how a volatile agent works/relevant anatomy for subclavian central line placement/amicar vs aprotinin/DDAVP utilization in cardiac surgery/heparin utilization in cardiac surgery/combined spinal-epidural (da-bomb) for labor analgesia/anatomy of an ankle block/anaphylaxis management/body temperature management during surgery and the relevance of same/transfusion guidelines/preoperative workups:are we ordering too much stuff?/2-6-di-isopropylphenol....an induction revolution/benzodiazepines:can their routine use help our quest of reducing intraoperative awareness?/what is a surrogate endpoint and how does following them skew our clinical care?/why is everyone scared to put a pregnant woman to sleep?/LMA and it's impact on day surgery/anesthesia for the post-op tonsil bleed/post dural puncture headache management in the parturient following epidural labor analgesia/fiberoptic intubation in the known difficult airway patient/laryngoscopy blade selection among anesthesiologists/reperfusion injury after intravenous calcium administration...fact or myth?/anatomy of a cricothyrotomy...and how a clinician prepares for one/incidence of pruritus after neuraxial Duramorph administration (100%)/the George Foreman Grill of anesthesia....ropivicaine and sufentanil for labor analgesia/what is a high spinal?/.................................................. .................................................. ............ok thats enough.............
Click to expand...

Damn, I wish I could do literature searches for EBM stuff this well. Anyway, I'm turning off my JPP stalker-mode now. Jet, you can do an search of your posts on the advanced search by entering your username and a keyword that you think might find that post you're thinking of.
 
you posted earlier that in academics they make you think you need to be scared s@$tless when doing GA for OB. Today actually had an attending tell me that they would never do a GA alone in OB. Correct me if i am ignorant but i assume that in private practice you don't call in a colleague or CRNA to help you do a GA in OB.
 
seinfeld said:
you posted earlier that in academics they make you think you need to be scared s@$tless when doing GA for OB. Today actually had an attending tell me that they would never do a GA alone in OB. Correct me if i am ignorant but i assume that in private practice you don't call in a colleague or CRNA to help you do a GA in OB.
Click to expand...
C sections under GA are almost always unexpected, and almost always urgent so if you are not at the big university hospital where there are residents and other attendings sitting around all day you are on your own.
 
sphincter tone in OB GA situations may change as the glidescope becomes more universal
 
seinfeld said:
you posted earlier that in academics they make you think you need to be scared s@$tless when doing GA for OB. Today actually had an attending tell me that they would never do a GA alone in OB. Correct me if i am ignorant but i assume that in private practice you don't call in a colleague or CRNA to help you do a GA in OB.
Click to expand...

I don't know why your staff feels that way.

Don't take my comments wrong. I am not underestimating what is at stake.

We are all aware of the physiologic changes in a parturient and the concominant considerations that must take place in a clinicians mind before induction.....the most important being

1) Low FRC with resultant quick desaturation.

2) Treated as a full stomach.

3) Potential upper airway edema....this one is way overplayed. 99.9% of parturient airways look normal. I've had to use a tube smaller than a 7.0 less than a handful of times in 11 years of practice.

But why the fear of God is placed in residents minds for this I really dont know. GA for C section is part of every private practice. Not often, but frequent enough that you accept it as part of your practice.

Nothing special happens when a lady needs to be put to sleep for a C section. No extra people are called. Whats the difference between this and an obese emergent appendix?

Bring her in the room, monitors on, preoxygenate.

A little reverse trendelenberg.

Dont induce until prep/drape/surgeon scalpel ready.

Propofol, sux. No prefasic needed.

Put the tube in with the skill you've worked so hard for.

Tell the dude to cut.

Failed regional (rare) and emergent C sections make this part of everyday practice.

Usually 1-2 per month in my 15 doctor, busy OB part of our practice.
 
Obstetric general anesthesia deaths occur from loss of ability to VENTILATE. Not from aspiration pneumonitis (maybe a few do but its the MINORITY).

LMA should ALWAYS be available! This device will save your A$$. Proseal around? Great, use it. Fastrach around? Great, use it.
 
jetproppilot said:
I don't know why your staff feels that way.

Don't take my comments wrong. I am not underestimating what is at stake.

We are all aware of the physiologic changes in a parturient and the concominant considerations that must take place in a clinicians mind before induction.....the most important being

1) Low FRC with resultant quick desaturation.

2) Treated as a full stomach.

3) Potential upper airway edema....this one is way overplayed. 99.9% of parturient airways look normal. I've had to use a tube smaller than a 7.0 less than a handful of times in 11 years of practice.

But why the fear of God is placed in residents minds for this I really dont know. GA for C section is part of every private practice. Not often, but frequent enough that you accept it as part of your practice.

Nothing special happens when a lady needs to be put to sleep for a C section. No extra people are called. Whats the difference between this and an obese emergent appendix?

Bring her in the room, monitors on, preoxygenate.

A little reverse trendelenberg.

Dont induce until prep/drape/surgeon scalpel ready.

Propofol, sux. No prefasic needed.

Put the tube in with the skill you've worked so hard for.

Tell the dude to cut.

Failed regional (rare) and emergent C sections make this part of everyday practice.

Usually 1-2 per month in my 15 doctor, busy OB part of our practice.
Click to expand...
last month I did 3 C sections under GA in one day!
 
Let's not forget that maternal deaths dropped considerably once anesthesiologists accepted the "regional only" dogma.
 
urge said:
Let's not forget that maternal deaths dropped considerably once anesthesiologists accepted the "regional only" dogma.
Click to expand...

We've spoken about this very important issue that is great conversation, namely: does the literature support decreased maternal mortality as a direct result of less general anesthetics and more regional anesthetics?


And just as important: How reliable is the literature we site? Old study vs new? Single study vs multicenter? One study vs many?

I hope Mil chimes in because he was involved in our conversation before and if my 43 year old mind isnt failing me, I'd swear that after the thread I wasnt convinced.

Additionally, other countries practice more GA than we do for C sections with similar morbidity/mortality numbers as us.

Nice, important discussion.

Hey Mil, where are you with your keen literature brain?
 
Jet

those pearls are exactly what we resident need!

-How are your NPO decisions different from the dogma?

-which laparoscopy cases do you use LMAs on?

thanks again, man
 
I bet much of the literature was pre-fast trach...maybe some was pre-LMA...
 
I believe that in Germany, the majority of their C-sections are done under GA.

Maternal deaths dropped because we figured out how to manage the airway...not because of regional.

If you look at closed claims for ob deaths....the majority is from GA....but the GA's were done under emergent conditions.

If you look at non OB closed claims....when do the complications occur???? when it is under emergent conditions.

OB gurus will always spout the safety of regional over GA...but I'm not convinced.

I see no difference between the obstetric airway from the 400 lb heffer who has an appendix that needs to come out.
 
joshmir said:
Jet

those pearls are exactly what we resident need!

-How are your NPO decisions different from the dogma?

-which laparoscopy cases do you use LMAs on?

thanks again, man
Click to expand...

These are personal decisions I've made, Josh. Decisions I'm comfortable with. I want to inspire residents to think about the information you are being fed.

It took a few years for me to figure out that alotta stuff I was taught in residency, just like in every other residency was either 1)overkill or 2)a benefit wasn't resoundingly reflected in the literature.

Theres alotta gray in medicine. But when you are new to your craft you stick to what you are taught. After you are out a while in a busy private practice you start to think...........hmmmmmm......this dude has a closed tib fib that the ortho dude wants to do ASAP, but right before dude attempted a fakie off a ramp on his Suzuki RM 250 he ate a Whopper with cheese.....now its 6pm. Suzuki dude has been writhing in pain since the accident, which was four hours ago.

So heres the difference between academia and a non-obstructionalist private practice physician.

I aint waiting 2-4 more hours to put this guy to sleep. Why? Because I know waiting 2-4 more hours is not gonna affect (effect?) his outcome. He is in pain, which deleteriously affects gastric emptying, as you know, so waiting longer wont make much difference. And I'm confident in my ability with rapid sequence inductions.

Same with a C section. Lady ate 3 hours ago, is contracting, needs a C section. I'm not gonna wait. She's gonna have a gag reflex so if she vomits, which about a third of them do anyway, its all good. What about a high level? High levels are rare in experienced hands. And if it happens I'll have her intubated in 30 seconds without ventilating her.

If a 20 year old ASA 1 dude took a few sips of coffee on the way to the hospital for his knee scope, I'm gonna do the case. He'll get a tube instead of a LMA #4.

I've done LAVHs on skinny ladies with an LMA with a surgeon that routinely took 30 minutes skin to skin.

I'll push on somebodies neck during an RSI if the CRNA I'm working with asks me too. Otherwise I dont worry about it.

Beta agonist respiratory treatments are rescue medicines for bronchoconstriction. There is no protective effect, like with a MAST cell inhibiting med. If you have a staff that orders a breathing treatment on a non wheezing asthmatic/COPDer pre-op, ask them why.

I don't consider diabetes, obesity, or GERD a contraindication to an LMA. If someone takes a daily PPI for GERD and they are asymptomatic thats good enough for me. What concerns me is postural symptoms. Dudes chest burns when he goes to sleep or lays back in his recliner.

I dont order reglan/pepcid preop unless the patient has postural GERD symptomatology.

WHEW..... thats alotta s h it....but thats my comfort zone, and the comfort zone of many more busy private practice dudes out there, I'm sure.

We all have our quirps and I respect that. UT gets pissed off when anything but a needle goes in the sharp box. Wanna piss off UT? Throw your empty Copenhagen can in there. :laugh:

Mine is tape the eyes ASAP!! I hate seeing the syringe dangling off the ETT flipping all over the place with untaped eyes.

Whats more important, though, at least for me, is to provide a different, albeit just as effective, point of view on anesthesia for you resident studs out there.

Life is different out here in the trenches. And it is important for residents to know that alotta the stuff you are doing now is done quite differently out here.
 
jetproppilot said:
I don't know why your staff feels that way.

Don't take my comments wrong. I am not underestimating what is at stake.

We are all aware of the physiologic changes in a parturient and the concominant considerations that must take place in a clinicians mind before induction.....the most important being

1) Low FRC with resultant quick desaturation.

2) Treated as a full stomach.

3) Potential upper airway edema....this one is way overplayed. 99.9% of parturient airways look normal. I've had to use a tube smaller than a 7.0 less than a handful of times in 11 years of practice.

But why the fear of God is placed in residents minds for this I really dont know. GA for C section is part of every private practice. Not often, but frequent enough that you accept it as part of your practice.

Nothing special happens when a lady needs to be put to sleep for a C section. No extra people are called. Whats the difference between this and an obese emergent appendix?

Bring her in the room, monitors on, preoxygenate.

A little reverse trendelenberg.

Dont induce until prep/drape/surgeon scalpel ready.

Propofol, sux. No prefasic needed.

Put the tube in with the skill you've worked so hard for.

Tell the dude to cut.

Failed regional (rare) and emergent C sections make this part of everyday practice.

Usually 1-2 per month in my 15 doctor, busy OB part of our practice.
Click to expand...

The OB Gurus at my institution agree wholeheartedly with you, and they say that ppl make mountains out of molehills when it comes to GAs in obstetric patients.
 
I misspoke when I said nothing special happens at my gig when a lady goes to sleep for a C section. Something special DOES occur, and here it is.....actual conversation in doctors lounge:

Charles: "Dude, that laboring lady upstairs? Had to put her to sleep for that C section."

Jet: "Bummer. Hey, ya using your Saints tickets on Sunday?"
 
Whats more important, though, at least for me, is to provide a different, albeit just as effective, point of view on anesthesia for you resident studs out there.


i'd say you're doing a great job of that, amigo

was curious on one further point....what laparoscopic cases do you throw an LMA in for? do you use pressure support w/ spont ventilation?

thanks again man. you can have my Pats tix anytime. it's not even fun anymore...it's like watching a movie when you already know the ending :hardy:
 
joshmir said:
Whats more important, though, at least for me, is to provide a different, albeit just as effective, point of view on anesthesia for you resident studs out there.


i'd say you're doing a great job of that, amigo

was curious on one further point....what laparoscopic cases do you throw an LMA in for? do you use pressure support w/ spont ventilation?

thanks again man. you can have my Pats tix anytime. it's not even fun anymore...it's like watching a movie when you already know the ending :hardy:
Click to expand...

Used it on certain LAVHs with fast surgeon. He used no trendelenberg and took 30-40 minutes. Controlled ventilation since thats the only option on the machines at that gig. Dont think SV would work with all the pressure in the belly, but not saying that for sure....just never tried it.
 
jetproppilot said:
Beta agonist respiratory treatments are rescue medicines for bronchoconstriction. There is no protective effect, like with a MAST cell inhibiting med. If you have a staff that orders a breathing treatment on a non wheezing asthmatic/COPDer pre-op, ask them why.
Click to expand...


I agree with your point, but not with your statement. I never give "prophylactic" albuterol, but there is established data for beta agonists preventing bronchospasm-- particularly long acting beta agonists (salmeterol) for chronic asthma, copd, and exercise induced asthma. They also may increase mortality overall, but do seem to prevent episodes of bronchospasm. I doubt this has been studied perioperatively.
 
How about..."you'll never get him extubated if you put him to sleep because his lungs are so bad"

that is such a load
 
His heart is too sick to tolerate a general anesthetic....so you have to do this (fill in the blank ) case under LOCAL or SPINAL or some other regional technique....

a CROCK full of it monkey dung.
 
the patient has been NPO for 10 hours...soooo his deficit must be 1 liter of some isotonic crystalloid....

maintenance during a bowel case is.....10 cc/kg/hr from "third spacing"....

garbage can full of rotten fish.
 
replace blood loss with 3 to 1 ns....but 1 to 1 with albumin or hespan.....

I don't know what that is a crock of?
 
jetproppilot said:
I don't know why your staff feels that way.

3) Potential upper airway edema....this one is way overplayed. 99.9% of parturient airways look normal. I've had to use a tube smaller than a 7.0 less than a handful of times in 11 years of practice.
Click to expand...

Hmm. As a resident I have been involved in 3 or 4 crash c sections requiring GA. I distinctly remember one of the them having the most edematous swollen airways I have ever seen. All the tubes were easy though and I used a 7.0 each time. We do see a lot of high risk OB patients, many of whom are preeclamptic.
 
Arch Guillotti said:
Hmm. As a resident I have been involved in 3 or 4 crash c sections requiring GA. I distinctly remember one of the them having the most edematous swollen airways I have ever seen. All the tubes were easy though and I used a 7.0 each time. We do see a lot of high risk OB patients, many of whom are preeclamptic.
Click to expand...

Yep, you'll see it, Arch.

Just not as much as you are lead to believe you'll see.

Overplayed. Not nonexistent.
 
Arch Guillotti said:
This sounds kind of corny but on my first crash section it was an enormous rush to throw the tube and holler "cut" to the OB. There must of been twenty people in the damn room.
Click to expand...

Those memorable experiences contribute to your confidence as a clinician.

You da man, EZ E!
 
There are three F's in medicine: Fact, Fiction, and Fetish. There is a whole lot more of the last two than you realize.

I remember one of our more mature attendings tell me how they used to work the labor floor many years ago.

Wait until the patient labors until fully dilated. Bring back to delivery room.
Induce GA by mask. After patient is asleep (but still being masked) the OB would slap on the salad tongs and do a forceps delivery.

I honestly thought he was f-ing with me until I asked others in his cohort.

For a few years, everybody was delivered this way. I'm sure it's not as safe as avoiding GA, but you shouldn't **** a pickle when you have to do it.
 
to speak to jets statements, I think we RSI most full stomachs, etc. in academia because there are so many multiple attempt intubations and quite a bit of manipulating the airway in substandard conditions. i dont think all my patients are quite as induced as I would like (i.e. many attendings prefer less narcotic than i would like to give) and coupled with two or three attempts, maybe the possibility for vomiting/aspiration is higher? I havent seen data on complications of resident-run anesthetic vs. PP anesthetics, but this would be interesting.
 
jetproppilot said:
Additionally, other countries practice more GA than we do for C sections with similar morbidity/mortality numbers as us.
Click to expand...
Just wondering, do you remember if the comparison between US and "other country" morbidity and mortality rates controlled for just how god awful sickeningly F A T so many pregnant Americans are?

Just thinking that maybe if their patient population was full of mumu-wearing monstrosities to the degree ours is, maybe their bad outcome numbers wouldn't be so great.
 
swpm said:
Just wondering, do you remember if the comparison between US and "other country" morbidity and mortality rates controlled for just how god awful sickeningly F A T so many pregnant Americans are?

Just thinking that maybe if their patient population was full of mumu-wearing monstrosities to the degree ours is, maybe their bad outcome numbers wouldn't be so great.
Click to expand...

:laugh:

The F A T description goes for the USs general population as well.
 
DrDre' said:
You always say this. From my experience, I don't necessarily disagree. THat said, show me the money. What do you have for articles on this?
Click to expand...

I didn't say "from my experience"....

Look at the SAFE trial publishyed in NEJM a few years back...

Look at the data....not the conclusion.
 
militarymd said:
well accepted, but wrong....and a myth.
Click to expand...

Whats your fluid replacement strategy for SDA bowel cases?

I go by a few things and have ditched that 10ml/kg/hr for large open bowel cases.

1)preop CVP and correlating HR/BP. Lots of confounding factors but thats what I got.

2) run replacement at 4-5ml/kg/hr. Follow UOP and BP and bolus fluids to see if there is a response.

3)after several liters of crystalloid a 5% albumin finds its way in there. Following hemodynamics, uop, blood gas.

4)run balanced anesthetic at about .5 mac of volatile, 1:1 air oxygen, and plenty of narcs. Our GS dudes don't like the thoracic epidural. SO whatever.

Last 1.5 weeks I did 5 whipples following above protocol and extubated em all. All very very comfortable.

Target HB's (please don't rail me for this). DM, CAD, PVD goal Hb 10. Everyone else >7. This is the most SIMPLISTIC view.
 
VentdependenT said:
Whats your fluid replacement strategy for SDA bowel cases?

I go by a few things and have ditched that 10ml/kg/hr for large open bowel cases.

1)preop CVP and correlating HR/BP. Lots of confounding factors but thats what I got.

2) run replacement at 4-5ml/kg/hr. Follow UOP and BP and bolus fluids to see if there is a response.

3)after several liters of crystalloid a 5% albumin finds its way in there. Following hemodynamics, uop, blood gas.

4)run balanced anesthetic at about .5 mac of volatile, 1:1 air oxygen, and plenty of narcs. Our GS dudes don't like the thoracic epidural. SO whatever.

Last 1.5 weeks I did 5 whipples following above protocol and extubated em all. All very very comfortable.

Target HB's (please don't rail me for this). DM, CAD, PVD goal Hb 10. Everyone else >7. This is the most SIMPLISTIC view.
Click to expand...

I'm still trying to figure it out.
 
Why do you need a central line for a Whipple? We do 250+ a year here, and very few get central lines. The ones that do get it for comorbidities more than the procedure. Surgical time ranges from 4-7 hours.
 
proman said:
Why do you need a central line for a Whipple? We do 250+ a year here, and very few get central lines. The ones that do get it for comorbidities more than the procedure. Surgical time ranges from 4-7 hours.
Click to expand...

Although it is not unreasonable to not place lines, most of these patients will benefit from them:

These patients usually stay in the hospital for many days with multiple blood draws during their stay. A central line will prevent multple sticks for them.

These patients will likely be NPO for more than just 24 hours, so they require relatively long term IV access with possible need for TPN, etc...central lines prevent multiple sticks as PIVs infiltrate or get pulled out.

Should a need for vasoactive drugs develop..you're ready.
 
proman said:
Why do you need a central line for a Whipple?
Click to expand...

There is no real "need" for anything. But they are nice to have. Can you do a whipple without a central line? Sure. Can you do it without an a-line? Sure. The only reason we put them in is because it makes management so much easier.
 
proman said:
Why do you need a central line for a Whipple? We do 250+ a year here, and very few get central lines. The ones that do get it for comorbidities more than the procedure. Surgical time ranges from 4-7 hours.
Click to expand...

To echo what MMD and Urge said above:

Our surgeons usually want them for post op management anyways.

Blood draws, CVP, and a stable source for access/ability to run vasopressors on 75y/o grandma with CAD are added benefits.

You don't need a tripple lumen for these cases. A 16 gauge IV will get you there.

Plus I'm a resident and I like doing procedures....
 
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