another free flap

[urge]

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This time around no paralysis, no pressors as usual.

Pt is hypotensive (80/55) on 0.8 mac yet moving/bucking on stimulation. Remi drip sent the BP down the crapper so it had to be stopped.

How would you deal with this?

 

[seinfeld]

How much fluid has the patient had? Whats the HR? Can i increase CO and subsequent bp by mild hypervolemia or by increasing HR?

In these cases i usually just talk (argue) with the surgeon about whats more important for him to have. The ability for nerve monitoring or non moving target under the scope ? Sometimes maintaing the TOF to 1 you can accomplish both.

IN general i hate these cases

 

[Planktonmd]

This time around no paralysis, no pressors as usual.

Pt is hypotensive (80/55) on 0.8 mac yet moving/bucking on stimulation. Remi drip sent the BP down the crapper so it had to be stopped.

How would you deal with this?

Start a neo drip but don't tell anybody.

 

[Noyac]

What gas are you running?

 

[urge]

Des, hr 90's, albumin dripping, htc 30, ionized ca normal.

I hate these cases too.

 

[ucsfgaspain]

Urge,

So I'm fortunate enough to be really good friends with our guy who does free flaps. I talked to him about this very issue and just laid it out to him this way. Would you want me to put your patient into pulmonary edema by blasting him with volume in an attempt to bring his pressure up or would you rather me run a pressor? His answer: he'd take pulmonary edema.

Luckily, I've never had to actually put this to the test. But it's interesting his take. I asked if he felt that with the patient so hypervolemic would it threaten the flap from inhibiting venous outflow and he stated nope.

 

[proman]

Why no paralysis?

 

[Planktonmd]

Urge,

So I'm fortunate enough to be really good friends with our guy who does free flaps. I talked to him about this very issue and just laid it out to him this way. Would you want me to put your patient into pulmonary edema by blasting him with volume in an attempt to bring his pressure up or would you rather me run a pressor? His answer: he'd take pulmonary edema.

Luckily, I've never had to actually put this to the test. But it's interesting his take. I asked if he felt that with the patient so hypervolemic would it threaten the flap from inhibiting venous outflow and he stated nope.

Your good friend doesn't seem to be taking your opinions too seriously.
With many of these guys it is really a waste of time and effort to even try to explain why it is ok to give a pressor to treat the unopposed vasodilation caused by anesthetics when the painful stimulus is not sufficient to keep the BP where you want it.
One thing you could do is use Ketamine/Propofol instead of inhaled anesthesia.
I know the "minimally invasive anesthesia" guy would love that.

 

[Jeff05]

agree completely with ketamine/prop, or just straight ketamine infusion.
will keep the BP up and provide excellent analgesia + pt will not move.

 

[Jalopycat]

I hate free flaps. The ones where I'm training have been known to run 24+hours. Absolutely ridiculous.

 

[urge]

Why no paralysis?

Nerve monitoring.

I did a ketamine drip and versed drip, along with des. Worked more or less ok. Pt tried to sit up during the case, though.

 

[proman]

What kind of free flap was it? What nerves were they concerned about? Were they also doing nerve re-attachment? We do a ton of flaps and none that I've seen have nerve monitoring.

 

[urge]

What kind of free flap was it? What nerves were they concerned about? Were they also doing nerve re-attachment? We do a ton of flaps and none that I've seen have nerve monitoring.

Facial nerve. They were digging on the cheeks. Remember the movie Face/off? Looked kind of like that.

 

[bostonblaz]

50 mg im ephedrine

 

[MTGas2B]

Dopamine or dobutamine? In our institution those are the agreed upon agents of BP really does become a problem in these cases.

 

[Planktonmd]

Dopamine or dobutamine? In our institution those are the agreed upon agents of BP really does become a problem in these cases.

I am not sure that Dobutamine would help you improve the pressure of a patient who is hypotensive because of vasodilation.

 

[coprolalia]

Start a neo drip but don't tell anybody.

EXACTLY! (Friggin' plastics guys...)

-copro

 

[coprolalia]

I am not sure that Dobutamine would help you improve the pressure of a patient who is hypotensive because of vasodilation.

Again, EXACTLY! Dobutamine might (and likely will) make the BP lower. Many people don't realize that dobutamine, while a great inotrope, actually causes dilatation of vessels and drops the SVR. That's why it works particularly well in CHF.

You're on a roll, Plank.

-copro

 

[jetproppilot]

Pt tried to sit up during the case, though.