CEA- What's your recepie

[snowman8]

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How do you do your CEA? monitors, induction technique, antihypertensive of choice, deep/awake extubation

 

[drmwvr]

How do you do your CEA? monitors, induction technique, antihypertensive of choice, deep/awake extubation

Recipe? Iddm or not? "Urgent" CEA or not? Hypertensive or not? CVA recently? Sick or healty? Smoker? Still smoking? Most everyone shunts and patches. Does your surgeon? Getting the picture? The more ill patient gets SNP plugged in-line and at the ready. If he's better off, labetalol works pretty well. Some would use hydralazine. Do you keep the patient well paralyzed? Titrating vol. agent for low bp is an option. If not, deeper anesthesia with a modest phenylepherine infusion may be the way to go. Deep extubations work well if there are no reflux concerns and if the surgeon is happy with the patient coming to in recovery room or on the way to RR. When the stakes are higher, awake and talking on the table may be asked of you. One absolute I do live by is little to no narcotic. 100 ug max for some pre-op sedation with versed... And keep it simple .

 

[drccw]

Propofol sux tube....
seriously...
lots of local by the surgeon
one dose of phenylephrine while they are clamped to make myself feel better.
Normal extubation.
usualy skin to skin time is 25-35 mins. avg clamp time is 6-10 mins.

No shunts, no monitoring. Routine ASA monitors.
Nothing fancy... we knock out 4 of theses by noon....

 

[thegasman]

Propofol sux tube....
seriously...
lots of local by the surgeon
one dose of phenylephrine while they are clamped to make myself feel better.
Normal extubation.
usualy skin to skin time is 25-35 mins. avg clamp time is 6-10 mins.

No shunts, no monitoring. Routine ASA monitors.
Nothing fancy... we knock out 4 of theses by noon....

The one issue I have is my surgeon. He is slow,and he wants the patients awake and following commands with all extremities(wiggle your toes, squeeze my hand)prior to extubation. This can be a pain and eliminates deep extubation. The BP can be HIGH during this, so several techniques can be effective. Remifentanyl works well but is costly. Same for nicardipine. I usually just give a crapload of esmolol and maybe a little hydralazine too. Propofol bumps to get the gas off. I always wish this joker would just let us pull the tube when we are ready, instead of standing over the crna doing a neuro exam while the patient is still intubated. WTF?

 

[Noyac]

The one issue I have is my surgeon. He is slow,and he wants the patients awake and following commands with all extremities(wiggle your toes, squeeze my hand)prior to extubation. This can be a pain and eliminates deep extubation. The BP can be HIGH during this, so several techniques can be effective. Remifentanyl works well but is costly. Same for nicardipine. I usually just give a crapload of esmolol and maybe a little hydralazine too. Propofol bumps to get the gas off. I always wish this joker would just let us pull the tube when we are ready, instead of standing over the crna doing a neuro exam while the patient is still intubated. WTF?

I never understood this wake them up and have them move b/4 pulling the tube. If it was a difficult intubation then maybe but do your usual extubation and if things are not right gently put the tube back in. I think this may have originated back when just putting a tube in a pt was a challenging experience.

 

[Noyac]

My recipe is nothing special for 90% of them. 2 IV's one for BP up and one for BP down, an A-line and a Sheridan endotracheal tube. I have a syringe of neo and a syringe of NTG ready. I rarely ever use the NTG. Induction is propofol, fentanyl, and roc.

 

[maceo]

Propofol sux tube....
seriously...
lots of local by the surgeon
one dose of phenylephrine while they are clamped to make myself feel better.
Normal extubation.
usualy skin to skin time is 25-35 mins. avg clamp time is 6-10 mins.

No shunts, no monitoring. Routine ASA monitors.
Nothing fancy... we knock out 4 of theses by noon....

propofol sux tube huh?
sounds good.. but how do you blunt the HD response to intubation that these guys will invariably have.

 

[Planktonmd]

propofol sux tube huh?
sounds good.. but how do you blunt the HD response to intubation that these guys will invariably have.

You give enough anesthesia? 😎

 

[bubalus]

Remifentanil may not be as cheap as it could be, but compared to the cost of the operation, it's a drop in the bucket.

 

[dfk]

here at home, all the surgeons like awake carotids. all get SCP block, and only a few get DCP block. for all, we double transduce the aline and have them squeeze every 1-2 minutes when clamped. unfortunately the surgeons are on the slower end of not-so-quick. it is a little more of a pain though.

 

[Planktonmd]

here at home, all the surgeons like awake carotids. all get SCP block, and only a few get DCP block. for all, we double transduce the aline and have them squeeze every 1-2 minutes when clamped. unfortunately the surgeons are on the slower end of not-so-quick. it is a little more of a pain though.

Here is the problem:
The reason why someone might want to do a CEA awake is usually because they want to monitor the neurological function because they are clamping without shunting. This requires a fast surgeon to be done safely.
If you are slow and you clamp the carotid for a long time there will be some patients who will get restless, agitated and stop cooperating in the middle of the surgery (because of ischemia) and this is never a pleasant situation ( I have seen it twice and this is why I don't do these cases awake anymore).
So, a slow surgeon should be encouraged to forget about awake carotids and just learn how to shunt and do surgery.

 

[urge]

Prop, sux, tube, gas, remi. We do eeg monitoring, that's my reason for the remi. That's a drop in the sea compared to the neurophysiologist's cost.

 

[USAnesthesiaDoc]

Anyone using ultrasound guided block for carotids?

 

[Bertelman]

Prop, sux, tube, gas, remi. We do eeg monitoring, that's my reason for the remi. That's a drop in the sea compared to the neurophysiologist's cost.

ditto.

 

[Frank Rizzo]

Prop, sux, tube, gas, remi. We do eeg monitoring, that's my reason for the remi. That's a drop in the sea compared to the neurophysiologist's cost.

about the same, +/- a dilute neosynephrine gtt in line also

 

[dhb]

Piv, A-line, SCB, prop roc tube minimal opiods. Hypotension is generally more of a concern than hypertension.

 

[dfk]

Prop, sux, tube, gas, remi. We do eeg monitoring, that's my reason for the remi. That's a drop in the sea compared to the neurophysiologist's cost.

hey urge, you think there's any way of convincing surgeons that "the way" you word above would be beneficia. beyond what "they" propose? i understand it's an individual thing with the surgeons, but it would be nice to not suffer the patients in said situations. merely for example, i did a carotid where a patient had a deep and superficial CPB, and was uncomfortable the whole way thru. the surgeon "seemed" to get annoyed when i asked for more local to the site. granted they (plexus blox) don't work 100% all the time, but man... i said to myself i would never go "here" for a carotid. however, this is my opinion.

 

[Noyac]

hey urge, you think there's any way of convincing surgeons that "the way" you word above would be beneficia. beyond what "they" propose? i understand it's an individual thing with the surgeons, but it would be nice to not suffer the patients in said situations. merely for example, i did a carotid where a patient had a deep and superficial CPB, and was uncomfortable the whole way thru. the surgeon "seemed" to get annoyed when i asked for more local to the site. granted they (plexus blox) don't work 100% all the time, but man... i said to myself i would never go "here" for a carotid. however, this is my opinion.

Excuse me but what the F*ck are you talking about?

Seriously dude, are you even in the medical field?

 

[dhb]

Propofol sux tube....
seriously...
lots of local by the surgeon
one dose of phenylephrine while they are clamped to make myself feel better.
Normal extubation.
usualy skin to skin time is 25-35 mins. avg clamp time is 6-10 mins.

No shunts, no monitoring. Routine ASA monitors.
Nothing fancy... we knock out 4 of theses by noon....

WOW that's CDAZY FAST

 

[dfk]

Excuse me but what the F*ck are you talking about?

Seriously dude, are you even in the medical field?

hey dude, my inquiry revolved around urge's response. i was merely wondering if there was much leg work involved in having surgeons believe one technique is superior over another.

p.s. read it slower and take it easy

 

[jetproppilot]

Excuse me but what the F*ck are you talking about?

Seriously dude, are you even in the medical field?

HAHAHAHAHAHAHAHAHAHAHAHAHAHAHA

(jet clears throat)

"EHHHEMMMM."

Scuse me.

Carry on.😏😏

 

[urge]

hey urge, you think there's any way of convincing surgeons that "the way" you word above would be beneficia. beyond what "they" propose? i understand it's an individual thing with the surgeons, but it would be nice to not suffer the patients in said situations. merely for example, i did a carotid where a patient had a deep and superficial CPB, and was uncomfortable the whole way thru. the surgeon "seemed" to get annoyed when i asked for more local to the site. granted they (plexus blox) don't work 100% all the time, but man... i said to myself i would never go "here" for a carotid. however, this is my opinion.

All the sturgeons I have known have been very stubborn. I wouldn't have my hopes high. You can remind them awake cea suck every time a pt misbehaves (in a good way, ie: "God F-ing Damn it, I Hate this F-ing thing, and I Hate You too Fukr!..." Don't forget to throw stuff on the floor and make a lot of noise while you are at it!) and hope one day they listen to you.

Sorry, I know I'm not much help.

 

[pgg]

hey urge, you think there's any way of convincing surgeons that "the way" you word above would be beneficia. beyond what "they" propose? i understand it's an individual thing with the surgeons, but it would be nice to not suffer the patients in said situations. merely for example, i did a carotid where a patient had a deep and superficial CPB, and was uncomfortable the whole way thru. the surgeon "seemed" to get annoyed when i asked for more local to the site. granted they (plexus blox) don't work 100% all the time, but man... i said to myself i would never go "here" for a carotid. however, this is my opinion.

Excuse me but what the F*ck are you talking about?

Seriously dude, are you even in the medical field?

He's a nurse, which I imagine is the source of both his inability to convince the surgeon to alter his technique, and the surgeon's annoyance when he tries.

Hell, surgeon's aren't always the most cooperative or reasonable when it's a doctor driving the Drager.

 

[achieman]

depends on whether the surgery is awake or asleep.

Either way, A line, 2 IV, 1 drip for HTN, 1 for hypotension, plus 1 syringe of each of the above.

There are good evidence that superficial block is safer and more effective than deep blocks if regional is what you want. Also, recent GALA (general vs local) showed little difference in death, stroke, MI, but may show improvement when there's bilateral disease.

if regional, as little sedation as possible for premed, propofol or remi or dex infusion.

If GA, narc, lido, prop, sux, tube, deep extubation if easy to mask and reintubate.