Deliberate hypotension

[jennyboo]

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When deliberate hypotension is asked for, what do you like to use?

I've been slapping on the remifentanil and can't remember the last time I used nitroprusside, nitroglycerin or labetalol.

 

[dfk]

precedex and remi

 

[Planktonmd]

When deliberate hypotension is asked for, what do you like to use?

I've been slapping on the remifentanil and can't remember the last time I used nitroprusside, nitroglycerin or labetalol.

Give more anesthesia.

 

[jwk]

When deliberate hypotension is asked for, what do you like to use?

I've been slapping on the remifentanil and can't remember the last time I used nitroprusside, nitroglycerin or labetalol.

Deliberate hypotension is becoming a thing of the past in many practices, particularly with the highly publicized risks of POVL. For what kinds of cases do you still use it?

 

[huktonfonix]

i like to raise the transducer.....😀

 

[Noyac]

Absolutely a thing of the past. Don't do it unless the bleeding is too much for the surgeon to find the problem and then only do it for a brief period. Usually when this is the case the BP is low anyhow. Don't do it in the prone position, steep T-berg or for long periods of time.

You may think huktonfonix is kidding but this is the best and safest way to perform deliberate hypotension.

 

[Broken Ankles]

Absolutely a thing of the past. Don't do it unless the bleeding is too much for the surgeon to find the problem and then only do it for a brief period. Usually when this is the case the BP is low anyhow. Don't do it in the prone position, steep T-berg or for long periods of time.

You may think huktonfonix is kidding but this is the best and safest way to perform deliberate hypotension.

then what do you tell the surgeon when they ask for it?

had a lefort I osteotomy recently, and omfs began to cry when the BP was 135/80. they remarked the patient would bleed out in a few minutes at that pressure, so i gave some labetalol and titrated anesthetic to MAP 60.

i understand where huktonfonix is coming from, but isn't there something more upfront that can be said to the surgeon? if deliberate hypotension is really a thing of the past, then would it be out of line to say, "if you can't normally control the bleeding at the patient's physiologic BP, then you shouldn't be doing the procedure"?

 

[goodoc]

1. place your monitors where only YOU see the vitals
2. When they ask for hypotension drop the pressure a little rustle your hands and ask better?
That should solve the problem, who gives a f*ck if they think BP should be 80 over whatever, the result is what matters, remember you dictate what is safe and what not just work with them within YOUR parameters, not thiers. If they do not like it let them do the anesthesia.

 

[huktonfonix]

The thing is some surgeons either dont care or dont get certain concepts. When the surgeon requests hypotension, I look or ask to see what the issue is. If its say...a ruptured aneurysm, then Im getting that BP down temporarily so they can clip it. If its a surgeon doing a total hip and basically whining about blood loss then I will accomodate as best as I can. Now on a young healthy person that means I may choose to drop the MAP to 50-55 depending on circumstance. On an older patient, especially with comorbidities (CAD, etc..) I am keeping the blood pressure within 20% of baseline. This also depends on the procedure, patient position, etc.... If the patient needs blood I'll transfuse. I tried to explain this earlier in my career, but a lot of surgeons didnt care or got offended. Basically I do whatever is best for the patient in the particular situation and sometimes its just moving the transducer to keep everyone happy. Oh, and if you do it always document "at surgeons request".

 

[Noyac]

I think we are confusing the issues. Deliberate hypotension to me means prolonged hypotension as in the spine surgeries of the past. Some of you guys are talking about dropping the BP somewhat to assist the surgeon with the ongoing bleeding. These are two different points.

Here's how you handle the surgeon that asks for you to decrease the BP. Ask him/her what BP they would like (ie: 90/50). Take a piece of tape and write that BP on it and stick it on the monitor covering the real BP.

Actually, the circumstance dictates the action. Is it safe to do for a short period? If yes then do it.

 

[jwk]

then what do you tell the surgeon when they ask for it?

had a lefort I osteotomy recently, and omfs began to cry when the BP was 135/80. they remarked the patient would bleed out in a few minutes at that pressure, so i gave some labetalol and titrated anesthetic to MAP 60.

i understand where huktonfonix is coming from, but isn't there something more upfront that can be said to the surgeon? if deliberate hypotension is really a thing of the past, then would it be out of line to say, "if you can't normally control the bleeding at the patient's physiologic BP, then you shouldn't be doing the procedure"?

Better surgeons understand the risks of deliberate hypotension far outweigh the benefits. If they don't, you should explain it to them. Give them copies of the last few editions of the APSF Newsletter, including the one that just came out.

If a patient is going to "bleed out in a few minutes" from a Lefort I with a pressure of 135/80, your surgeons need to work on their hemostasis skills. or speed or both.

 

[Idiopathic]

Our ortho guys are notorious for demanding SBP < 90. Obviously it can work in some, but we see so many ASA 3/4 with hip fractures, etc. in whom a MAP < 60 wont always fly.

I just tell them right off the bat. "i know you want no twitches and SBP < 90. Ill help you as much as i can."

I usually am able to titrate with volatile

 

[SleepIsGood]

To the original poster...

All I ever use is increased GAS.