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Complete heart block

Discussion in 'Anesthesiology' started by anbuitachi, Oct 10, 2017.

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  1. anbuitachi

    anbuitachi ASA Member 7+ Year Member

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    For patients w lbbb that convert to complete heart block intra op. I read first thing to do is atropine, followed by epi/dopa infusions, or transcutaneous pacing. My question is in complete heart block, atropine shouldn't work since it targets SA node and SA node doesn't pass. But epi or isoproterenol should since it is direct acting. Is this correct?

    Also what would you guys do if patient with a LBBB went into complete heart block in the middle of a case?
     
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  3. gasdoc77

    gasdoc77 2+ Year Member

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    Tap scope vs pacing swan
     
  4. JobsFan

    JobsFan 10+ Year Member

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    that would be my expectation too.
    I would try to pharmacologically increase the heart rate ... i'd start an adrenaline infusion, and I'd then try pacing (transcutaneously if necessary while arranging transvenous).
     
  5. hudsontc

    hudsontc Attending 10+ Year Member

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    Correct—anticholinergics affect SA node only and have no effect on ventricular rate of 3rd degree block.

    Whether this is stable or unstable, I am consulting cardiology for direction...temporizing with epinephrine if unstable.
     
  6. pgg

    pgg Laugh at me, will they? Moderator 10+ Year Member

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    ACLS has been dumbed down so that followers of the protocol don’t have to distinguish between high and low grade blocks. The algorithm directs the administration of atropine for all causes of bradycardia as a first step. I guess too many EMTs and nurses thought the old ACLS was too hard.

    That doesn’t mean that those of us who know better should waste time with anticholinergics in patients who are obviously in complete heart block. Direct acting drugs (epi) and pacing are the right answers.
     
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  7. SaltyDog

    SaltyDog Keeping the Forces of Entropy at Bay 10+ Year Member

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    This. I had a lil' old lady go into complete hear block on me in PACU recently. It was hard to distinguish the exact rhythm on our crappy PACU monitor (aside from the obvious brady).

    Pushed glyco when she got into the 30's and called for 12 lead - no response.
    Pushed atroine when she hit 30 with marked hypotension and AMS, no response and still no 12 -lead
    At this point I'm convinced it's complete block - called for an epi stick
    Pushed 10mcg epi when she hit 27 which fixed her, had to repeat with one more 10mcg bump before the SA node woke back up
    12 lead finally shows up but is unimpressive at this point
    Cardiology comes by - takes a look at the strip and agrees complete block after studying it for a while - they don't wanna do anything about it since it's gone now unless it happens again - OK
     
  8. nimbus

    nimbus Member 10+ Year Member

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    Epi titrated in the right dose is almost always the right answer.
     
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  9. SaltyDog

    SaltyDog Keeping the Forces of Entropy at Bay 10+ Year Member

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    Any time someone is trying to die on you, almost regardless of etiology - Epi.
     
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  10. Psai

    Psai Account on Hold Physician 2+ Year Member

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    What if they have an irritable myocardium that's itching to go into vfib
     
  11. Noyac

    Noyac ASA Member SDN Advisor 10+ Year Member

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    Then you shock them when they go into it.
     
  12. SaltyDog

    SaltyDog Keeping the Forces of Entropy at Bay 10+ Year Member

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    A) I said almost regardless

    B) What drug are you gonna push when they do go into Vfib? ;)
     
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  13. Newtwo

    Newtwo 2+ Year Member

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    10mcg boluses fixed everything on the planet I used to think. Except for my last case last night...
     
  14. sethco

    sethco Senior Member 10+ Year Member

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    I can think of at least two situations where Epi is definitely not the answer and is more likely detrimental. Residents/Fellows, oral boards practice time, what are some examples of such?
     
  15. dchz

    dchz Avoiding the Dunning-Kruger 5+ Year Member

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    1)HOCM, IHSS, AS, and other stenotic lesions.

    2)coronary ischemic events

    3)type 1 hypersensitivity to epinephrine :)
     
  16. gasdoc77

    gasdoc77 2+ Year Member

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    IMG_2901.PNG
     
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  17. pgg

    pgg Laugh at me, will they? Moderator 10+ Year Member

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    Turn off the halothane, give epi. :)
     
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  18. pgg

    pgg Laugh at me, will they? Moderator 10+ Year Member

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    Details?
     
  19. SaltyDog

    SaltyDog Keeping the Forces of Entropy at Bay 10+ Year Member

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    He pushed roc - things went downhill from there. :D :poke:
     
  20. Crabbygas

    Crabbygas

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    I would add Tsako Tsubo cardiomyopathy to the list of things that might not do well with epi.
     
  21. Noyac

    Noyac ASA Member SDN Advisor 10+ Year Member

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    Ooh halothane.
    I used to love to use that in pedi hearts to slow them down.
     
  22. Newtwo

    Newtwo 2+ Year Member

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    You're gonna laugh but.... Lol

    It went really badly anyway. Still.trying to figure out why.
     
  23. algosdoc

    algosdoc algosdoc 10+ Year Member

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    During a trans-septal ablation of atrial and PV tracts in the EP lab today, the patient's ECG suddenly disappeared and the A-line went to zero for about 20 sec. The patient had atrial but not ventricular pacing leads in. The cardiologist asked for atropine, but slowly sinus bradycardia developed with maintenance of BP. Best drug for this situation?
     
  24. btbam

    btbam 5+ Year Member

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    I’m pretty sure no ECG or pulse for 20 seconds is called a code.
     
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  25. dchz

    dchz Avoiding the Dunning-Kruger 5+ Year Member

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    EPI?
     
  26. facted

    facted ASA Member 7+ Year Member

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    Most definitely. Atropine is no longer part of asystole algorithm in ACLS. If your in the OR and can give all sorts of stuff at once, don't think it would hurt, but would definitely go for epi first.
     
  27. jwk

    jwk CAA, ASA-PAC Contributor 10+ Year Member

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    Is anyone still using isoproterenol? I haven't used it in years but one of our vascular surgeons asked for it recently.
     
  28. Arch Guillotti

    Arch Guillotti Senior Member Administrator Physician Lifetime Donor Classifieds Approved 10+ Year Member

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    What was the indication?
     
  29. alternatecharacter

    alternatecharacter

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    The price is insane now. Some company did that thing where you buy up all the factories of everyone making the generic and raise the price. An EP doc wanted to try an experiment on a patient in the ICU (don't ask) and anyway ICU pharmacy was like this costs $8000 per vial and we have one in the hospital how valuable is whatever it is you are planning on doing. So no experiment.
     
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  30. Psai

    Psai Account on Hold Physician 2+ Year Member

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    Should sell that vial
     
  31. Ronin786

    Ronin786 ASA Member 5+ Year Member

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    I don't know how expensive it is but our EP docs use it for all their ablations to try and induce arrhythmia.
     
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  32. btbam

    btbam 5+ Year Member

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    Same. .01-.02 mcg/kg/min
     
  33. dhb

    dhb Member Lifetime Donor Classifieds Approved 10+ Year Member

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    I'm planning my next vacation, how many do you want?
     

    Attached Files:

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  34. drmwvr

    drmwvr 7+ Year Member

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    The capture charge and what the patient sees are two different things. What the third party pays, even more so. EP lab cost, anesthesia, PACU...isuprel is a drop in the bucket.
     
  35. hudsontc

    hudsontc Attending 10+ Year Member

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    I've been seeing epinephrine used more commonly in our peds EP lab the past several months in lieu of isoproteronol for arrhythmia induction...guess cost is probably why.
     
  36. AdmiralChz

    AdmiralChz ASA Member 7+ Year Member

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    https://www.eplabdigest.com/articles/Rising-Costs-Isoproterenol


    Disagree, the article above shows how much the price has gone up (and alternative drugs used along with their limitations). A mid-to-large center may be spending over $1-2 million on Isuprel where they used to spend $10K or the like.

    In residency we used to use it as a chronotropic agent post-Heart transplant, but it doesn’t work very well. Eventually the hospital convinced (forced) the surgeons to stop using it due to cost.
     
  37. anbuitachi

    anbuitachi ASA Member 7+ Year Member

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    Same our proceduralists use it all the time in EP
     
  38. drmwvr

    drmwvr 7+ Year Member

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    I'm kind of aghast reading that article. Hard to say what the regional differences are, but I can tell you that our 915 dollar, 1 mg amp can be made into 5 doses. Probably more if we wanted to, given the amount of time we have it infusing. 183 dollars a dose? Very probably among the least expensive elements of the entire procedure.
     
  39. BLADEMDA

    BLADEMDA ASA Member 10+ Year Member

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    [​IMG] Marathon Pharmaceuticals sold isoproterenol to Valeant Pharmaceuticals International Inc. in February 2015. Upon acquisition, Valeant Pharmaceuticals increased the price from $218.3/dose to $1,200/dose.” The United States Congress was trying to pass legislation to prohibit this type of behavior by the pharmaceutical industry, but to no avail. The cost of Isuprel continues to escalate, with its price now at $1,356 per vial.


    Valeant Pharmaceuticals Intl Inc (VRX) Stock Will Be Just Fine

    [​IMG]
     
  40. GA8314

    GA8314 Regaining my sanity 2+ Year Member

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    Our EP uses it for SVT ablations to attempt to induce the SVT after ablating.... I've run it for A-fib EP ablation cases for same reason. Really gets the heart racing without much change in BP.
     
  41. dhb

    dhb Member Lifetime Donor Classifieds Approved 10+ Year Member

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    Isuprel sol. perf. à diluer i.v. [amp.] 5 x 0,2 mg / 1 ml
    € 9,82
    So 2€/vial
     
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  42. nimbus

    nimbus Member 10+ Year Member

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    Wow! Too bad you can’t arbitrage the stuff. Ship over a few cases full.
     
    Last edited: Oct 20, 2017
  43. Psai

    Psai Account on Hold Physician 2+ Year Member

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    Let's go into business, I think we can make a lot of easy money together.
     
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  44. dhb

    dhb Member Lifetime Donor Classifieds Approved 10+ Year Member

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    I'll put up shop on the darknet :ninja:
     
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