Epinephrine Post AV replacement

[ZA_Gasman]

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Was wondering what your thoughts were on using epinephrine to come off bypass post AVR for stenosis. Have been having spirited discussions with our surgical colleagues, who swear that it is the fruit of the devil and the patient will get a "suicidal LV" if we give so much as a sniff of epinephrine. While I concede that the majority of patients won't need it, we often find that they need a small dose at least initially, but that we can usually wean it off after 15-20min.

Bear in mind we don't have access to any inotropes other than Dobutamine and Epinephrine at our institution. Also to be considered is the fact that we typically have pump runs of 90 plus minutes for an AVR with clamp times in the region of 60min (plus), and our surgeons often wait more than 20min between cardioplegia doses.

Has anyone seen "suicidal LV" in this context? What do you think?

 

[Gator05]

Not too much epi used here for these shorter pump runs. We do give 5-10mg ephedrine fairly often coming off. I agree, sometimes they just need a little push for a few minutes.

 

[Planktonmd]

Was wondering what your thoughts were on using epinephrine to come off bypass post AVR for stenosis. Have been having spirited discussions with our surgical colleagues, who swear that it is the fruit of the devil and the patient will get a "suicidal LV" if we give so much as a sniff of epinephrine. While I concede that the majority of patients won't need it, we often find that they need a small dose at least initially, but that we can usually wean it off after 15-20min.

Bear in mind we don't have access to any inotropes other than Dobutamine and Epinephrine at our institution. Also to be considered is the fact that we typically have pump runs of 90 plus minutes for an AVR with clamp times in the region of 60min (plus), and our surgeons often wait more than 20min between cardioplegia doses.

Has anyone seen "suicidal LV" in this context? What do you think?

I think you can never go wrong with epi because think about it: when your heart needs to work harder your body responds by making Epinephrine not Dopmaine and not Mirlinon.

 

[Noyac]

I don't think I ever used it in an AVR. Mostly used dobutamine. Doesn't mean its not indicated from time to time. It depends on the pt, IMO. But theoretically it could be disastrous.

 

[proman]

I am just finishing up my month in our cardiac SICU and almost everyone comes out on epi, valve or no valve. The epi is titrated/weaned to a CI of 2.0 If they're hypertensive we use nicardipine to control pressures. Valves are normally kept a bit dry, if pressure tolerates it. There's no such thing as a short pump run here (or a fast track extubation for that matter).

 

[Noyac]

There's no such thing as a short pump run here (or a fast track extubation for that matter).

This is the difference. Long pump runs need big guns.

 

[ZA_Gasman]

There's no such thing as a short pump run here (or a fast track extubation for that matter).

You sure you don't work at my hospital?😀 I try to fast track my valves, and all of them snorkel overnight....
Glad to find some support on the epi though... Thanks for the input!

 

[urge]

But theoretically it could be disastrous.

Could you explain that to me? I'm a cardiac anesthesiologist and I don't see anything wrong with epi. I like levophed better but in my current job EVERYBODY gets epi, as the surgeons don't like levophed. In fact some of the people who trained me would argue that epi is the drug of choice for an AVR due to AS. And this is coming from one of the top cardiac places in the US.

What is a suicidal LV?

 

[ZA_Gasman]

Could you explain that to me? I'm a cardiac anesthesiologist and I don't see anything wrong with epi. I like levophed better but in my current job EVERYBODY gets epi, as the surgeons don't like levophed. In fact some of the people who trained me would argue that epi is the drug of choice for an AVR due to AS. And this is coming from one of the top cardiac places in the US.

What is a suicidal LV?

As I'm led to understand, suicidal LV occurs in patients with GOOD LV function who have AVR for AS. The theory is that if they get epinephrine, they go hypercontractile and don't relax. I believe it is also called "stone heart"

Some say that you can also cause this by giving big whacks of Calcium too early post clamp removal, causing high intracellular myocardial calcium and loss of relaxation. However, I ran this past one of our senior attendings, and his response was: "Horsesh it!"

I for one, have never seen it, and I believe it is as rare as rocking horse manure. But you know cardiac surgeons, always looking for someone to blame for whatever problem they may be having - marital, bad hair, rubbish car, lousy hands etc. (do you get the idea that we have a poor interdepartmental relationship?)

And I will remain an unrepentant epi giver post bypass (perhaps until we get norepi), until someone can show me hard evidence that it is bad.

 

[urge]

I agree with the calcium. Not with the epi.

There are top centers in the US, like Duke for example, where everybody comes off pump on epi. Their outcomes are not too shaby. I'll just say it's BS.

 

[ZA_Gasman]

Anyone know what they do at the Mayo Clinic? We have a certain surgeon who once spent a week or so at the Mayo, and continues to p*ss us off with comments that start along the lines of "Well, when I was at the Mayo they did X or Y"
I don't think quoting Urge's point about Duke is gonna cut it somehow🙄

 

[DET0897]

We routinely use epi coming off pump for AVR. WHile I agree its not the best for lusitropy, those pt's with good pre-op LV function on TEE tend to not be on epi for very long after the pump run. Otherwise, the benefit of improving RV function tend to offset the risk? of LV outflow obstruction in my opinion

 

[seinfeld]

Perhaps we would have better answers if cardiac sugery ever did any evidenced based studies😛

We use milrinone for lusitropy especially with significant LVH and then norepi to conteract the vasodilation. Used epi only once coming off pump and that was the 4th agent in line

 

[Gator05]

Stone heart, huh?

Your surgeon I think confused the order of things.

When you don't give good plegia or let that LV distend on CPB, you find yourself a stone heart, and you'll quickly find yourself on epi.

Remind said surgeon that association does not equal causation.

 

[Mac Six]

Our AVRs routinely come out on epi. Never had any issues with stone heart at our center.

 

[urge]

Anyone know what they do at the Mayo Clinic? We have a certain surgeon who once spent a week or so at the Mayo, and continues to p*ss us off with comments that start along the lines of "Well, when I was at the Mayo they did X or Y"
I don't think quoting Urge's point about Duke is gonna cut it somehow🙄

The only reasonable thing I can think of is to ask him to show you the papers saying epi is bad in this scenario. In the meantime you will keep using epi.

 

[ZA_Gasman]

The only reasonable thing I can think of is to ask him to show you the papers saying epi is bad in this scenario. In the meantime you will keep using epi.

I'll do that. It should be an interesting discussion. This is a guy who is on record as saying (on grand round in Cardiothoracic ICU) and I quote: "This evidence based medicine stuff is all well and good, but some of us surgeons have over 20years experience" - with a straight face.

😆
I'll invent a new sport:- CT Surgeon baiting.....

 

[militarymd]

When I was a resident, I rotated with Glenn Gravelee (cardiac guru)...all his hearts come off on epi.....

it's been more than 10 years though, so he may have changed his practice.

 

[Arch Guillotti]

Was wondering what your thoughts were on using epinephrine to come off bypass post AVR for stenosis. Have been having spirited discussions with our surgical colleagues, who swear that it is the fruit of the devil and the patient will get a "suicidal LV" if we give so much as a sniff of epinephrine. While I concede that the majority of patients won't need it, we often find that they need a small dose at least initially, but that we can usually wean it off after 15-20min.

Bear in mind we don't have access to any inotropes other than Dobutamine and Epinephrine at our institution. Also to be considered is the fact that we typically have pump runs of 90 plus minutes for an AVR with clamp times in the region of 60min (plus), and our surgeons often wait more than 20min between cardioplegia doses.

Has anyone seen "suicidal LV" in this context? What do you think?

I have never seen "suicidal" LV. We used epi if we needed it for these cases when coming off pump.

 

[jetproppilot]

Readying to come off bypass as you all know is a crucial time.....and its a time where your eyes should be looking over the drape at the heart.

Yes, our monitors are important...but you can quickly educate yourself on myocardial status by looking.

After you look at many you'll be able to quickly discern whether or not severe myocardial dysfunction is present.....many times you can anticipate what vasopressors/inotropes you'll need before this time as in a dude who gets on the table for his heart surgery with a bad heart to begin with.

Sometimes, though, long pump run, inadequate cardioplegia, etc, you won't anticipate it, you'll look over the drape, and see a poorly functioning myocardium. If this is the case I always ask the surgeon if he's happy with his graft placement, especially if theres significant, concominant ST issues.

If an inotrope is needed, I'm an epi fan....sometimes justa cuppla mikes per minute can make the difference....I'll usually start with 5ug/min and keep doubling it until adequate myocardial function is achieved.

If pulmonary pressures are very high I'll start witha phosphodiesterase inhibitor....milrinone....then add epi to that if more is needed. They're synergistic.

Yes, epi is a big gun...but you can start with a small dose...

I think its better to try and fly off bypass then limp off.....

 

[bulgethetwine]

Readying to come off bypass as you all know is a crucial time.....and its a time where your eyes should be looking over the drape at the heart.

Yes, our monitors are important...but you can quickly educate yourself on myocardial status by looking.QUOTE]

... or by TEE. Certainly an over the curtain gestalt never hurts. If you're getting skilled at TEE and correlate what you see over the drape WITH what you're seeing on the TEE, even better.

 

[ZA_Gasman]

Readying to come off bypass as you all know is a crucial time.....and its a time where your eyes should be looking over the drape at the heart.
......
If an inotrope is needed, I'm an epi fan....sometimes justa cuppla mikes per minute can make the difference....I'll usually start with 5ug/min and keep doubling it until adequate myocardial function is achieved.

.....

I think its better to try and fly off bypass then limp off.....

Readying to come off bypass as you all know is a crucial time.....and its a time where your eyes should be looking over the drape at the heart.

Yes, our monitors are important...but you can quickly educate yourself on myocardial status by looking.QUOTE]

... or by TEE. Certainly an over the curtain gestalt never hurts. If you're getting skilled at TEE and correlate what you see over the drape WITH what you're seeing on the TEE, even better.

Both points well made guys. I like to try and have at least one person (resident) looking over the drapes at the heart, and I do like to have the ME 4 chamber up on the TEE so I get a fair idea of what is cooking in the LV.
As for flying off bypass.... You chould meet our perfusionist Jet. Full bypass to off pump in 3-5min.... Can't get him to slow down. Having said that.... Most of the time they cope. I like to think it is my epi
I start at 0.05mcg/kg/min. We have no PDE3 inhib's so we tend to use TNT for afterload reduction and pulm press dropping - and yes, I know it is useless for that. Sometimes a bit of Dobs. (But not for the AVRs usually!!)

 

[jetproppilot]

Readying to come off bypass as you all know is a crucial time.....and its a time where your eyes should be looking over the drape at the heart.

Yes, our monitors are important...but you can quickly educate yourself on myocardial status by looking.QUOTE]

... or by TEE. Certainly an over the curtain gestalt never hurts. If you're getting skilled at TEE and correlate what you see over the drape WITH what you're seeing on the TEE, even better.

Good point.

 

[9french]

I think you can never go wrong with epi because think about it: when your heart needs to work harder your body responds by making Epinephrine not Dopmaine and not Mirlinon.

I think this logic is a bit spurious. Two of the most common complications post bypass are arrhythmias and renal failure. Both epinephrine and phenylephrine reduce both splanchnic and renal blood flow. Norepi does not seem to do so to as much of a degree.

As far as arrythmias are concerned, I believe that epi is more pro-arrhythmogenic then either dobutamine or milrinone. This is purely my opinion, and if there is any data counter to this, I will gladly admit that I am wrong.

I am not opposed to epi. I just don't think it should be a first line agent due to what I see as its downsides. I rarely have a problem getting someone off of a pump with levaphed and dobutamine. If I run into trouble, I may add milrinone. If my SVR is **** despite levaphed, I may start some low dose vasopressin.

Not to stray off topic, but anyone hear anything about levosemandin (sp?)? Supposedly it is an outstanding lusatrop, and not arrhythmogenic.

 

[militarymd]

I think this logic is a bit spurious. Two of the most common complications post bypass are arrhythmias and renal failure. Both epinephrine and phenylephrine reduce both splanchnic and renal blood flow. Norepi does not seem to do so to as much of a degree.

As far as arrythmias are concerned, I believe that epi is more pro-arrhythmogenic then either dobutamine or milrinone. This is purely my opinion, and if there is any data counter to this, I will gladly admit that I am wrong.

I am not opposed to epi. I just don't think it should be a first line agent due to what I see as its downsides. I rarely have a problem getting someone off of a pump with levaphed and dobutamine. If I run into trouble, I may add milrinone. If my SVR is **** despite levaphed, I may start some low dose vasopressin.

Not to stray off topic, but anyone hear anything about levosemandin (sp?)? Supposedly it is an outstanding lusatrop, and not arrhythmogenic.

yes , but never used it.

 

[urge]

Full bypass to off pump in 3-5min....

They just turn off the pump on the nl EF pts where I'm at. Full bypass to off pump in 3 seconds.