BP management during Gastric Bypass

[seinfeld]

New surgeon comes to town to do Roux-en-Y gastric bypass. First time i talk to him is as i am inducing his patient. We exchange cordial hello's then he tells me that no matter what the BP has to be around 100 systolic. I look at him perplexed and ask Why? He tells me is to decrease bleeding from the anastomosis. He goes as far as to tell me to keep it down even in PACU. I ask about perfusion of the anastomosis and his response is that Beta Blockers are good. To which i go into the poise trial and the recent onslaught of editorials about using beta blockers without need. I know there is good literature on low volume fluid resuscitation for GI surgery and better outcomes but not aware of hypotensive technique improving outcomes.

Is this a common thing asked by all the Gastric Bypass surgeons. In my training strict bp control to that degree was never asked for these cases.

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[Planktonmd]

Just say: "yes, you are right", and then do whatever you want.

 

[pgy13]

Been doing bariatric anesthesia for years, have never heard that one.

 

[Chloroform4Life]

How common is it for surgeons to tell anesthesiologists how to do their jobs? Because that is totally unacceptable.

 

[urge]

New surgeon comes to town to do Roux-en-Y gastric bypass. First time i talk to him is as i am inducing his patient. We exchange cordial hello's then he tells me that no matter what the BP has to be around 100 systolic. I look at him perplexed and ask Why? He tells me is to decrease bleeding from the anastomosis. He goes as far as to tell me to keep it down even in PACU. I ask about perfusion of the anastomosis and his response is that Beta Blockers are good. To which i go into the poise trial and the recent onslaught of editorials about using beta blockers without need. I know there is good literature on low volume fluid resuscitation for GI surgery and better outcomes but not aware of hypotensive technique improving outcomes.

Is this a common thing asked by all the Gastric Bypass surgeons. In my training strict bp control to that degree was never asked for these cases.

Never heard of it and I have been in 2 programs with nationally recognized fatologists who do a boatload. I hope he is doing them laparoscopic, right?

Care to ask him for some papers on that?

Be careful with that. A good part of the case is done in extreme reverse trendelenburg. You don't want the noggin hypoperfused.

Glad it is you and not me, btw.

 

[Planktonmd]

How common is it for surgeons to tell anesthesiologists how to do their jobs? Because that is totally unacceptable.

Very common, actually in this business not only the surgeons tell you what to do but also the nurses, the cardiologists, the internists, the hosptalists, the cleaning people...
Everyone seems to know more about anesthesia than you, and if you can't live with that then this specialty is not for you.

 

[aredoubleyou]

How common is it for surgeons to tell anesthesiologists how to do their jobs? Because that is totally unacceptable.

Not uncommon at all. On one hand, they do the surgery every day while you do a far more wide range of cases, so never discount their input just because they're "telling you what to do." Most of the time it seems to be BS like this case.

Either way, Plank gave you the answer

 

[urge]

How common is it for surgeons to tell anesthesiologists how to do their jobs? Because that is totally unacceptable.

I don't think it is like that. Do you have a chip on your shoulder?

He believes, right or wrong, hypotension is a good thing and is asking for you to help him with that.

Sometimes we tell surgeons open procedure is a bad idea for so and so, laparoscopic is bad..... robotic would be better.... yada yada yada. You try to do whatever you think is best for the patient.

 

[seinfeld]

Thanks, i told the CRNA to ignore him and not give any more beta blocker, went out to my partners asked them about it and they all were dumb founded. It became an issue later in the PACU and the Head of PACU got into it with him. Then came back to me asking my opinion and i told her to request evidence from him before changing PACU practice to which he answered i dont need evidence this is how i do it.

Needless to say the guy is quickly getting the reputation for being a tool. Besides all of this he gave one of his 1 week out pts who came into the ED with BRBPR factor VII (PTT/PT were nl)

 

[Arch Guillotti]

Besides all of this he gave one of his 1 week out pts who came into the ED with BRBPR factor VII (PTT/PT were nl)

 

[IlDestriero]

How common is it for surgeons to tell anesthesiologists how to do their jobs? Because that is totally unacceptable.

It's pretty common to discuss the anesthesia plan with the surgeon. We have a huddle in the morning before the first case where we discuss all the cases for the day, including surgical and anesthetic concerns, required equipment, expected blood loss, etc. They may have requests that we can accommodate. Things like nasal intubation, paralysis vs not (for neuro monitoring, etc), intrathecal opioids, blocks, quick wake for neuro check at conclusion prior to ICU transport, etc. Relative hypotension to decrease blood loss is not an unreasonable request, though I have never heard of it for gastric bypass. We try to work as a team. For the most part, I don't care what they ask for, but they are very reasonable. The only time I really don't comply is if they say something about not needing invasive BP monitoring or a central line. If I think I need it, I do it.

 

[sevoflurane]

Thanks, i told the CRNA to ignore him and not give any more beta blocker, went out to my partners asked them about it and they all were dumb founded. It became an issue later in the PACU and the Head of PACU got into it with him. Then came back to me asking my opinion and i told her to request evidence from him before changing PACU practice to which he answered i dont need evidence this is how i do it.

Needless to say the guy is quickly getting the reputation for being a tool. Besides all of this he gave one of his 1 week out pts who came into the ED with BRBPR factor VII (PTT/PT were nl)

Ummmm.......

 

[HalO'Thane]

In regards to Ildestriero's situation...it seems like the anesthesiologist and surgeon actually have a logical, well thought out discussion about the periop management of their patients for the day and both physicians seem to value each other's input. I have no problem with that and actually hope I can have that kind rapport with the surgeons in my practice next year. What I have more of an issue with is the first post where the surgeon is dictating how to manage his patient's anesthetic without any science behind it or allowance for flexibility. To me, that is complete crap. I suppose that is the nature of our speciality. You have to be okay with navigating that type of situation. You may even be lucky enough to join an anesthesia group with a backbone that doesn't allow other health care providers to tell them how to do their job

 

[Sergio99]

Never heard of it and I have been in 2 programs with nationally recognized fatologists who do a boatload. I hope he is doing them laparoscopic, right?

Care to ask him for some papers on that?

Be careful with that. A good part of the case is done in extreme reverse trendelenburg. You don't want the noggin hypoperfused.

Glad it is you and not me, btw.

Hello,

I agree with everyone. I have never seen it either.

And as Urge says, a good part of the case is done in reverse Trendelenburg, so whatever you do, make sure you keep the transducer at brain level at all times.

Obese people sometimes have all the weight of their fat pressing on their organs, on their aorta and on their vena cava, and get hypotensive when lying fat. They need to have pressors just because they are lying supine. You will give these people hypotensive drugs and kill them.

Besides, sometimes there are patients where you just cannot lower the pressure, because you start lowering it and it goes well to a certain point and then it falls precipitously to near zero. Then you have to start giving pressors. It becomes a see-saw tracing, very difficult to control. We don't want the patient to have a stroke or an MI.

 

[NotAMD]

control the pressure with more gas as opposed to meds, keep sbp 110ish, have neo in line, and just keep quiet and dont engage this surgeon unless you have to ...