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I'm set in my ways. They can deal with my anesthetic.
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I'm set in my ways. They can deal with my anesthetic.
what specifically are you concerned about with their ventilation? why does the lvad make you concerned about ventilation? real question not pimping..
I have found that the less you do for these frail ones the better...
Intubating and extubating in 5 minutes is doing too much .. youve got the hemodynamic changes that come with induction/intubation/ppv, weaning from ppv, etc... also your taking forever and slowing down a room
I have always found that with these cases the best anesthetic is: "a little of this, a little of that" - meaning a little versed, fentanyl, ketamine, etomidate, small little doses that produce reliable temporary amnesia and sedation and stable BP. 2 of versed, 50 of fent, 30 of ketamine, 4 of etomidate boluses prn - almost anyone can survive that
Agree in principle but I had a cardiac patient go apneic from 2 of versed while I was placing preinduction a line.
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Yup, I've seen this too. I also had a bad cardiac patient arrest after 40 of prop. I have placed art lines for EGD's a few times in the past on sick cardiac patients. Don't get what the big deal is, it takes 5 min. To this day I have yet to regret any art line I have ever placed.
Well a 5 minute a line would double the procedure time so...
Oh I understand, I don't take it as pimping. I appreciate your reply. I have always thought low and slow as well. Why put a sick patient through induction/extubation of course. But my attending got me thinking that for these LVADs that are already in the ICU full monitors, it doesn't add much time to intubate in order to minimize the spiral of RV dysfunction from hypoxia/hyperacrbia as the LVAD patients fully depend on RV function. As said above, airway/ventilation is inevitably the crux of GI. It was just another perspective that I hadn't appreciated before. Like I said, the other half of attendings do low and slow too. It's case by case for sure.
Doesn't cut into time or delay anything at all. This isn't like some of the outpatient GI's I work with where we routinely do 30-45+ cases a day. These patients are in hospitals. The turnovers are slow, the staff is not in a big rush, and typically they are inefficient with GI cases. I can simply plan ahead and place the line early or while they're still getting set up or do it during the turnover.
To the trainees - in PP you’re going to get called to ICU for scopes. I don’t deal with quite as bad cardiac cripples as some people on this board but get my fair share of frailness. Regardless of what the patient looks like on paper, they’re in the ICU for a reason -ie. 60 year old with a GI bleed but otherwise fairly healthy - I always cut my dose of propofol in half. You’re outside the OR and alone. It’s better to apologize to the patient later for being aware than code them now.
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Depends on local culture. The ones I work with don't want them done in the ICU except under duress.
"The delivery of good medical care is to do as much nothing as possible." -Law 13
I'm amazed that y'all have contracts where you're able to get in 30-45 cases in a day - is that personally performed anesthetics? We get 15 and think we've won the lottery.
Wow. Seems like I missed a good popcorn moment. I will have to look up previous posts. LOL
+1 for low and slow propofol. Have done many cases w/ 20-40 mg of propofol and wishing they would wake up quicker (and that I had given 10mg less). Don't like versed hanging around either. I wouldn't worry about awareness in these. If they are that sick they have never griped about it. If I have an irate patient b/c of awareness afterwards, I would question my original assessment skills.
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Or "White Lightning" as one of my attendings likes to call it
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Seriously you’ve given 20mg of propofol and wished you had given less?
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I find that low propofol for endoscopies almost always makes things worse rather than better. The coughing and gagging inevitably leads to desats. Supplementing with versed will also just make them apneic and again, desats. My go to for cardiac cripples and morbid obesity is almost always ketofol . The other option is to topicalize the hell out of them and give them a whiff of versed/fentanyl but I would only do this if they are in the ICU on multiple pressors already and don't need to be intubated.
I feel very lucky to be in a PP setting now where the endoscopists and anesthesiologists have a very cordial relationship and respect one another. I never feel rushed or scoffed for deciding to put in an aline or GA. I remember in residency where the GI docs didn't even know the names of the anesthesiologists and are sitting there holding the scope and tapping their foot as you are still in the process of connecting monitors. That type of environment is never safe.
I feel very lucky to be in a PP setting now where the endoscopists and anesthesiologists have a very cordial relationship and respect one another. I never feel rushed or scoffed for deciding to put in an aline or GA. I remember in residency where the GI docs didn't even know the names of the anesthesiologists and are sitting there holding the scope and tapping their foot as you are still in the process of connecting monitors. That type of environment is never safe.
I just tell them they are always welcome to do versed and fentanyl without me. They usually b*tch a little less after that.
