couple questions about CEAs and insulin...

[leaverus]

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1) What's everyone technique for BP control for CEA once the xclamp comes off? In residency, we'd have nicardipine hooked up, titrate in some metoprolol, and squirt lidocaine down the LITA tube - of course what really helped most was having the remifentanil going. Now, in PP i've got none of that stuff (NTG instead of the cardene) and almost invariably the BP shoots up as the patient starts emerging - and i'm pushing metoprolol, labetolol, NTG, and snakeoil boluses to get it under control. Any suggestions for a smoother emergence?

2) On on unrelated note, what you guys doing with people coming for surgery with an insulin pump hooked up? I never encountered any in residency. Do you generally leave them going or make the patient unhook, depending on case duration?

 

[Idiopathic]

its hard ill agree, lidocaine down the tube is nice and obv getting the tube out is helpful as well, esmolol is your friend as well.

re: insulin pumps ive treated them both ways. if its for a big case (whipple, AAA) then i will turn them off and hang my own insulin, but if its for a smaller case i will leave it on, since they should be able to sample and treat the patients blood glucose.

 

[proman]

Not in PP but

1) I used nitroprusside for BP control and really liked it. Also extubated deep (emerge in room). I have friends who use remi infusions and extubate on remi, but I've never done it that way.

2) We convert insulin pumps to insulin drips at the basal rate with hourly glucose checks. I wouldn't continue a device that I couldn't control.

 

[leaverus]

Not in PP but

1) I used nitroprusside for BP control and really liked it. Also extubated deep (emerge in room). I have friends who use remi infusions and extubate on remi, but I've never done it that way.

I've considered extubating deep - i think that would definitely help, but the surgeon likes to see them "moving everything" before i extubate.

 

[Idiopathic]

sure deep extubation is fine but i can definitely see the surgeons not being fans of that. however, an awake patient extubated is fine for neuro exam, i certainly dont get one before extubation

 

[jwk]

I've considered extubating deep - i think that would definitely help, but the surgeon likes to see them "moving everything" before i extubate.

Which is exactly why their BP goes way up. So glad I'm not in academia.

 

[fakin' the funk]

1) What's everyone technique for BP control for CEA once the xclamp comes off? In residency, we'd have nicardipine hooked up, titrate in some metoprolol, and squirt lidocaine down the LITA tube - of course what really helped most was having the remifentanil going. Now, in PP i've got none of that stuff (NTG instead of the cardene) and almost invariably the BP shoots up as the patient starts emerging - and i'm pushing metoprolol, labetolol, NTG, and snakeoil boluses to get it under control. Any suggestions for a smoother emergence?

For a little education for us young'uns out there...

Can you go into a little bit the goals/objectives for a wakeup after CEA, from the anesthesiologist and surgeon's perspectives?

 

[Ronin2258]

For a little education for us young'uns out there...

Can you go into a little bit the goals/objectives for a wakeup after CEA, from the anesthesiologist and surgeon's perspectives?

Seconded. I have only the surgical/post-op desires as quoted by a chief that would make House look well adjusted.

 

[Mman]

For a little education for us young'uns out there...

Can you go into a little bit the goals/objectives for a wakeup after CEA, from the anesthesiologist and surgeon's perspectives?

When doing an asleep CEA, the surgeon wants to see that the patient didn't have a massive stroke intraoperatively. They also appreciate it if the BP isn't 300/150 putting excessive tension on their suture lines.

From my perspective, I want a nice smooth wakeup that is pleasant for the patient and doesn't stress them hemodynamically. As far as I am concerned, doing a complete neuro exam prior to extubation is unnecessary. We can pull the tube deep (if it's appropriate) and then wait for them to wake up and start moving things before leaving the OR.

 

[Idiopathic]

the biggest problems ive ever had with carotids was during training when i had like three in a row who were all difficult airways and i had to have them wide awake to extubate. the first two went very badly, the third got cadillac treatment (lido, remi, precedex) and woke up great, but thats not always reasonable. for an easy airway carotid id be fine pulling deep

 

[sevoflurane]

When doing an asleep CEA, the surgeon wants to see that the patient didn't have a massive stroke intraoperatively. They also appreciate it if the BP isn't 300/150 putting excessive tension on their suture lines.

From my perspective, I want a nice smooth wakeup that is pleasant for the patient and doesn't stress them hemodynamically. As far as I am concerned, doing a complete neuro exam prior to extubation is unnecessary. We can pull the tube deep (if it's appropriate) and then wait for them to wake up and start moving things before leaving the OR.

Agree 100%. What is the point? You can do a complete neuro exam when they are extubated in the OR. If there is a deficit (I've actually never seen one in the OR), you just go back to sleep. Much more predictable hemodynamics IMO.

 

[sevoflurane]

Benefits>Risks, unless there is an AW issue.

 

[Mman]

Benefits>Risks, unless there is an AW issue.

Agreed, and how often would you have an unrecognized airway issue? I mean if the neck is flat, there probably isn't a significant hematoma. And you are probably far less likely to get a big hematoma if you can extubate them promptly and smoothly instead of watching them cough and gag and bust stitches on the carotid.

 

[Arch Guillotti]

Agreed, and how often would you have an unrecognized airway issue? I mean if the neck is flat, there probably isn't a significant hematoma. And you are probably far less likely to get a big hematoma if you can extubate them promptly and smoothly instead of watching them cough and gag and bust stitches on the carotid.

I thought he meant extubate deep unless there is a difficult airway that could go awry during emergence and not be easily controlled.

 

[sevoflurane]

Arch had me right and Mman makes a good point. 👍 Extubating deep certainly makes you less likely to blow stiches. Benefits>Risks.

 

[hoyden]

We do not have remifentanil as well and I am having SNP ready (diluted to 20 mcg per ml in a syringe - pumps are problematic in this place as well) plus I give lidocaine IV ( 1.5 mg/kg) prior to waking them up.
Anybody is using precedex for CEA - I mean specifically for emergence?

 

[Idiopathic]

split your lidocaine 50mg iv and 50 down the tube while they are closing

 

[Idiopathic]

i would also consider precedex boluses at emergence, not sure of the cost of 1mcg/kg though

 

[proman]

I've considered extubating deep - i think that would definitely help, but the surgeon likes to see them "moving everything" before i extubate.

The LTA is nice too, I think. In residency, the vascular surgeons were the ones who would ask for deep extubation. At first I was uneasy about it, but it works in the right patient.

I think emergence leads to a spike in BP whether or not it's rocky. An increase in BP will lead to bleeding, but only at a suture line that's inadequate.

 

[jwk]

The LTA is nice too, I think. In residency, the vascular surgeons were the ones who would ask for deep extubation. At first I was uneasy about it, but it works in the right patient.

I think emergence leads to a spike in BP whether or not it's rocky. An increase in BP will lead to bleeding, but only at a suture line that's inadequate.

You're not suggesting hemostasis is a surgical responsibility, are you? 😉