Case discussion

[anbuitachi]

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the CV pressure alone is not nearly as useful as a study of both the pressure and the waveform morphology.

central venous pressures and waveforms are very useful but EVERYONE in our specialty forgets the information gained from analyzing the waveform.

Our systems generally have fidelity similar to those cardiologists use so there is no excuse to disregard it. And you should troubleshoot poor fidelity so you can have the information from a clear waveform.

how often do you put in central lines in the OR just to look at waveforms?

i like numbers too. and also i like BIS. it helps me realize when the IV on the tucked arm gets infiltrated before the patient jumps off the table

 

[nimbus]

i recently tried to intubate someone without paralytic (unrelated to this topic), bolused some midaz and ketamine... and then could not open his mouth at ALL. Fully clenched. super fail

2 midaz and some ketamine..

Sounds like you skipped the step where you ask the patient to open their mouth real wide.

 

[deleted59964]

PVP is actually a much better trend monitor than CVP - but whatever. Also, have we really decided CVP trends aren't correct? We can see consistent cases where CVP numbers drop over time but actual venous pressures rise over time - or the converse? I don't care about an absolute number - I would agree that is not very helpful. If you never use it - it's fine. It's not like you can't get the info in other ways.

Regarding your comment about anesthesia depth monitor. Show me a single study that shows the BIS doesn't trend well to anesthesia depth (careful now...I'm not talking about recall...I'm talking about anesthesia depth trends).

This topic has been discussed lots of times on here so we don't need to rehash -

But I will just say this.

If I am using BIS - and I give a propofol bolus, the number seems to ALWAYS decrease. But I'd like you to prove me wrong. Show me a good example over 20 patients where you give a propofol bolus and the BIS increases. Also, it seems to ALWAYS INCREASE when I decrease my anesthetic depth. Prove me wrong though. Show me a case where in 20 patients, you significantly decrease anesthetic depth (and without doing anything else), the BIS drops. It is in no way - a random number generator. You know why? Because it's science. That number changes based on EEG - and EEG absolutely changes with anesthetic depth (so the BIS number will absolutely change).

Now before you say anything, I know you could come up with examples in your own experience where the BIS didn't work correctly and the numbers were funny. But let me ask you this...has that ever happened to your A-Line? Has your pulse ox ever given funny numbers? did you then immediately dismiss the value of A-Lines in ALL CASES or the value of the pulse-ox because in this patient the monitor was not being reliable? Not at all..and the reason is - because you are astute enough to know when your monitor was not acting like it should.

So all I ask is that you NOT be hypocritical. Fine if you don't like the BIS because this one time you found it gave funny numbers. Okay. But you then HAVE to apply that to all the monitors you use. And basically you will then hate ETCO2 monitoring, pulse ox, BP cuffs, A-lines, and Tidal Volume reports, and many other things. Good luck with that.

(oh and by the way - the study with awake patients giving each other Sux doesn't count. That doesn't change what I am saying. Do other things affect the number? Yep...but again...remember, you are astute and paying attention to stuff and the info that the monitor is giving you).

 

[anbuitachi]

she let herself be suxxed awake? what a champ. but a part of bis is EMG activity. always aim for 00 on the bis

 

[epidural man]

I tried to publish a case report when I was a resident - it was fascinating.

It was our hospitals first TAVR. The guy had HORRIBLE lungs so we didn’t want to intubate and ask IR/Vasc if it was okay. They said yeah of course (******s). Because right in the middle they said “okay. Hold respirations now”. As a resident I was like ”uhh....”.

Anyway, I could bolus opioids, some prop, or sux. I chose sux and used maybe 20mg. They asked for it 3 times. I was running the BIS around 65-70. Anyway, each time I bolused sux, the BIS took a huge dive -one time down to 19 (without any other anesthetic changes). That was interesting but also timing was interesting. It almost always took the dive right when the patient started breathing again.

Anyway, I was asked to revise the first draft and the journal wanted Aspect Medical to respond, but I was a resident and never got around to revising the thing.

 

[epidural man]

I think we pretty much all agree with good evidence that the pericardial fluids should be drained. So I consider the main point of the thread to be over. So let's let the derailing begin.

Disclaimer: None of what i'm saying is meant to be an ad hominem attack on @epidural man . He is not the first one that's made these arguments and definitely won't be the last. So it's definitely worth while to discuss the topic. I do agree that no monitor is better than an astute clinician and the tool is only as good as the tool using it.

Claim: The monitor sucks and doesn't tell you what you need to know, but it is a better monitor as a trend.

E.g. CVP does not give you a good assessment of LV preload, but it will tell you which way the LV preload is going if you simply trend it. If the CVP went from 10 to 15, the LV preload must be higher at the CVP 15 compared to the CVP 10.

I find this idea not logically sound. If the initial data correlates poorly with the true quantity, then there should be no reason that the trend of the initial data would follow the changes in the true quantity except for random chance. Therefore, the reliability of the trend is then dependent on the % of the time that they move in the same direction.

In our example, the % of time they move in the same direction isn't overwhelming; there are 3 valves and lungs in the way between the RA and the LV. Imagine if the PVR increased and all else equal, the CVP would increase by the LV preload would actually decrease. There is a specific time in which they will trend the same direction: there are no valvular pathology and the PVR moves the same way as the CVP. How often can you claim that is the case?? How easily identifiable is that clinical situation ??? If you can't claim the case a huge % of the time and you can't clearly identify the situation which CVP and PVR decreases simultaneously, then CVP is worthless as a LV preload predictor.

The counter argument often goes. Of course you can't rely on a monitor 100% of the time, you have to use your clinical assessment along with the CVP. E.g. If CVP is high and there is decrease skin turgor then obviously the patient is dehydrated. I always wondered: If you can rely on skin turgor and the decrease of skin turgor completely invalidates CVP, why not just go pinch the skin rather than sticking an invasive line????!?!

end of rant, i'm tired and going to bed.

This feels like an ad hominem attack on me.

To that I say “Your mother was a hamster, and your father smelled of elderberries!”

jk....good points.

 

[anbuitachi]

I tried to publish a case report when I was a resident - it was fascinating.

It was our hospitals first TAVR. The guy had HORRIBLE lungs so we didn’t want to intubate and ask IR/Vasc if it was okay. They said yeah of course (******s). Because right in the middle they said “okay. Hold respirations now”. As a resident I was like ”uhh....”.

Anyway, I could bolus opioids, some prop, or sux. I chose sux and used maybe 20mg. They asked for it 3 times. I was running the BIS around 65-70. Anyway, each time I bolused sux, the BIS took a huge dive -one time down to 19 (without any other anesthetic changes). That was interesting but also timing was interesting. It almost always took the dive right when the patient started breathing again.

Anyway, I was asked to revise the first draft and the journal wanted Aspect Medical to respond, but I was a resident and never got around to revising the thing.

you shouldve just repeated what they said. tell patient to hold breath

 

[deleted697535]

2 midaz and some ketamine..

Idk man it's hard to know. I've had reasonable luck with it but I use plenty of lidcaine too and Emla and all sorts...
It doesn't seem to matter so much which drug people use as long as the plane of sedation is right.
My test for that is when I shove them roughly on the shoulder do they open their eyes slowly...
I also trial it all by inserting an oral airway slathered in Emla first. If they tolerate that were golden