Etomidate for craniotomy

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climbingdocs

climbingdocs

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I can't figure out why would one use etomidate/propofol mix for induction for crani for tumor resection vs. just propofol. Patient was stable, BP was ok.
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CPP and transmural pressure. Not saying that you couldn't go slow with just propofol.
 
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climbingdocs said:
I can't figure out why would one use etomidate/propofol mix for induction for crani for tumor resection vs. just propofol. Patient was stable, BP was ok.
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they got trained by someone about the "myths" of anesthesia, so now they perpetuate it.
 
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THE drug of choice here is thiopental. Isn't anyone using thiopental anymore? (SHEESH!)

-copro
 
So the deal is that I am doing a presentation on this case, and I want to be able to explain why certain drugs were given etc. Should I just say that etomidate was not necessary? Are there any studies done on that or its just your experience?
Also what is your guys' experience on precordial doppler? Ever came handy?
 
climbingdocs said:
So the deal is that I am doing a presentation on this case, and I want to be able to explain why certain drugs were given etc. Should I just say that etomidate was not necessary? Are there any studies done on that or its just your experience?
Also what is your guys' experience on precordial doppler? Ever came handy?
Click to expand...

Are you doing a sitting crani?

Otherwise no real benefit, and TEE is even better but I've never seen anyone use TEE for a crani. And if you are going to do a precordial doppler are you also going to place a central line appropriately for VAE?
 
The crani was not sitting, but head was up some. They didn't have central line but had precordial doppler, and their reasoning was that if there was VAE they'd just put head down and pour saline into surgical field. Some attending told me also that if there was VAE central line wouldn't help and you just treat symptoms.
 
climbingdocs said:
The crani was not sitting, but head was up some. They didn't have central line but had precordial doppler, and their reasoning was that if there was VAE they'd just put head down and pour saline into surgical field. Some attending told me also that if there was VAE central line wouldn't help and you just treat symptoms.
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Your attending is probably right but if you were to get a large VAE and an airlock in the RA then central line is probably your only chance. I have seen one in 10 yrs for a sitting shoulder case. The guy died. It was a very good anesthesiologist and a poor surgeon with bad judgement.
 
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climbingdocs said:
So the deal is that I am doing a presentation on this case, and I want to be able to explain why certain drugs were given etc. Should I just say that etomidate was not necessary? Are there any studies done on that or its just your experience?
Also what is your guys' experience on precordial doppler? Ever came handy?
Click to expand...
Mixing Etomidate and Propofol is not based on any scientific evidence and it has never been studied pharmacologically to my knowledge.
What is the induction dose of a Propofol + Etomidate mixture?
How do they interact?
Is there a real brain protective effect?
No one really knows.
So this practice is at best experimental and anecdotal.
 
Noyac said:
No

i asked for some from pharmacy the other day and they sent me penicillin:eek:
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Dude, you win a huge :thumbup::thumbup::thumbup: for even asking for it.

This is a great induction agent that has been squeezed outta the market by propofol and etomidate, and not necessarily rightfully so. If you've got a good, well-functioning, patent IV line, there's no reason not to use it. The problem with it is that it has been around since the 1940's, has a much-maligned and undeserved reputation of being a "dangerous" drug (e.g. extravasation issues, hemodynamic instability, etc.), and is not routinely stocked at many pharmacies.

I don't think the benefits in head trauma/surgery are theoretical. It has an excellent side-effect profile, it almost immediately drastically reduces the CMRO2 and does it better than propofol and etomidate, and also provides better cerebral protection than most other agents.

We, in this era of cost containment, should be thinking about equally effective and less costly alternatives. Droperidol is another one that comes to mind (unless your patient is going home the same day). But, we are compelled by those that purchase the drugs - and the pharmaceutical companies marketing them - that somehow certain meds (ondansetron, propofol, etc.) are somehow inherently better than other meds. We never stop to fully question why we believe this; we just believe it.

I'm not at all suggesting that you use thiopental for every case. But, in certain select cases, especially those where there is some sort of space occupying lesion inside the calvarium, you should give it a try. You don't slam it in like I see a lot of my resident and physician colleauges do with other meds, and probably the standard 5mg/kg induction dose is WAY too liberal and unnecessary. But, have a good fast-flowing IV, use it, push it slow, be patient, and watch how smooth you can induce someone with it.

I'm grateful that I have had at least one attending who lets me use this drug in crani's, and I feel like I'm pretty damn good with it and have a good feel for what it can do. I've never had a surgeon complain, and my brains are always soft when it comes time to do some whackin'. Does it make a huge difference in the longterm outcome? Probably not. But, you can do cookie-cutter anesthesia or you can actually try to have a few more guns in your arsenal. I choose the latter.

-copro
 
Planktonmd said:
Mixing Etomidate and Propofol is not based on any scientific evidence and it has never been studied pharmacologically to my knowledge.
What is the induction dose of a Propofol + Etomidate mixture?
How do they interact?
Is there a real brain protective effect?
No one really knows.
So this practice is at best experimental and anecdotal.
Click to expand...

Excellent, excellent points.

-copro
 
coprolalia said:
Dude, you win a huge :thumbup::thumbup::thumbup: for even asking for it.

This is a great induction agent that has been squeezed outta the market by propofol and etomidate, and not necessarily rightfully so. If you've got a good, well-functioning, patent IV line, there's no reason not to use it. The problem with it is that it has been around since the 1940's, has a much-maligned and undeserved reputation of being a "dangerous" drug (e.g. extravasation issues, hemodynamic instability, etc.), and is not routinely stocked at many pharmacies.

I don't think the benefits in head trauma/surgery are theoretical. It has an excellent side-effect profile, it almost immediately drastically reduces the CMRO2 and does it better than propofol and etomidate, and also provides better cerebral protection than most other agents.

We, in this era of cost containment, should be thinking about equally effective and less costly alternatives. Droperidol is another one that comes to mind (unless your patient is going home the same day). But, we are compelled by those that purchase the drugs - and the pharmaceutical companies marketing them - that somehow certain meds (ondansetron, propofol, etc.) are somehow inherently better than other meds. We never stop to fully question why we believe this; we just believe it.

I'm not at all suggesting that you use thiopental for every case. But, in certain select cases, especially those where there is some sort of space occupying lesion inside the calvarium, you should give it a try. You don't slam it in like I see a lot of my resident and physician colleauges do with other meds, and probably the standard 5mg/kg induction dose is WAY too liberal and unnecessary. But, have a good fast-flowing IV, use it, push it slow, be patient, and watch how smooth you can induce someone with it.

I'm grateful that I have had at least one attending who lets me use this drug in crani's, and I feel like I'm pretty damn good with it and have a good feel for what it can do. I've never had a surgeon complain, and my brains are always soft when it comes time to do some whackin'. Does it make a huge difference in the longterm outcome? Probably not. But, you can do cookie-cutter anesthesia or you can actually try to have a few more guns in your arsenal. I choose the latter.

-copro
Click to expand...
OK, I trained at a time when thiopental was still a main stream induction agent and I probably induced more people with thiopental than you induced with propofol or any induction agent combined, and I can tell you with certainty that it's not as great as you might think, it is less flexible and it causes slower emergence and it is not as easy to titrate as Propofol.
It also (as you obviously know) doesn't mix well with many drugs in the IV line.
So, in short: It's not very good.
 
Planktonmd said:
OK, I trained at a time when thiopental was still a main stream induction agent and I probably induced more people with thiopental than you induced with propofol or any induction agent combined, and I can tell you with certainty that it's not as great as you might think, it is less flexible and it causes slower emergence and it is not as easy to titrate as Propofol.
It also (as you obviously know) doesn't mix well with many drugs in the IV line.
So, in short: It's not very good.
Click to expand...

Did you skim my post?

Crani's.... say it with me "CRANI'S"...

I'm not saying use it every time. You need a good-flowing IV (already said that) and you need to pick the right patient (already said that). And, do not use it if you have a bicarb drip going.

-copro
 
coprolalia said:
I'm not at all suggesting that you use thiopental for every case. But, in certain select cases, especially those where there is some sort of space occupying lesion inside the calvarium, you should give it a try. You don't slam it in like I see a lot of my resident and physician colleauges do with other meds, and probably the standard 5mg/kg induction dose is WAY too liberal and unnecessary. But, have a good fast-flowing IV, use it, push it slow, be patient, and watch how smooth you can induce someone with it.

I'm grateful that I have had at least one attending who lets me use this drug in crani's, and I feel like I'm pretty damn good with it and have a good feel for what it can do. I've never had a surgeon complain, and my brains are always soft when it comes time to do some whackin'. Does it make a huge difference in the longterm outcome? Probably not. But, you can do cookie-cutter anesthesia or you can actually try to have a few more guns in your arsenal. I choose the latter.
Click to expand...

Just a little additional clarification for "those" who skimmed...

-copro

P.S. More than occassionally when I ready your posts, Plankton, I'm reminded how grateful I am that (A) my residency is coming to an end soon, and (B) I have some great attendings who actually allow people the leeway to try different things barring their own personal experience (dare I say "baggage") with particular techniques.
 
Noyac said:
No

i asked for some from pharmacy the other day and they sent me penicillin:eek:
Click to expand...

not from my pharmacy.


we actually send our friends in the OR a good amount of it. come to NY.
 
Used thiopental just the other day since my pharmacy box didn't have any propofol and I was too lazy to go get another one.. Not a bad idea to use it for fun so you know how to mix it up in an emergency (i.e. OB)



coprolalia said:
Dude, you win a huge :thumbup::thumbup::thumbup: for even asking for it.

I don't think the benefits in head trauma/surgery are theoretical. It has an excellent side-effect profile, it almost immediately drastically reduces the CMRO2 and does it better than propofol and etomidate, and also provides better cerebral protection than most other agents.



-copro
Click to expand...

Speaking of myths, the concept that protection of neurons by anesthetics during an ischemic event is explained by a reduction in cell metabolism is among my favorites.

Not saying that these agents cant provide neuroprotection, just that decreasing CMRO2 doesn't correlate well with neuronal protection during ischemia.
 
We stock propofol and STP concurrently here.

STP advantages:

Takes a lot more to knock-down airway reflexes, along with respiratory drive, compared with propofol (also a disadvantage depending on the case). Preserves the baroreceptor reflex. Not as much of a problem with hypotension, especially if pt on ACEi/ARB. If pt with high ICPs needing a procedure, a good slug can keep you out of trouble. If brain is swollen, slug/infusion of STP can help too.

Det: mind sending some articles re:

"Speaking of myths, the concept that protection of neurons by anesthetics during an ischemic event is explained by a reduction in cell metabolism is among my favorites.

Not saying that these agents cant provide neuroprotection, just that decreasing CMRO2 doesn't correlate well with neuronal protection during ischemia."

?

I think this is a true statement, just wanted to see your literature.

Finally....it's not what you use, it's how you use it.

Of note! Etomidate could be the choice if you're doing EEG/SSEP.
 
coprolalia said:
Just a little additional clarification for "those" who skimmed...

-copro

P.S. More than occassionally when I ready your posts, Plankton, I'm reminded how grateful I am that (A) my residency is coming to an end soon, and (B) I have some great attendings who actually allow people the leeway to try different things barring their own personal experience (dare I say "baggage") with particular techniques.
Click to expand...

:laugh:
Yes, I actually skimmed through your post because it was too long.
I was just trying to point out that, crani or no crani, thiopental is not the greatest induction agent but that doesn't mean you should not try it as a resident.
You will eventually reach the conclusion that it's not the greatest agent.
I was just trying to give you the bottom line, so don't get offended.
When you have something to say you should be happy when someone offers the opposite point of view because this means your opinion has some value.
 
We still stock and use pentothal for some crani's and for general C/S.
 
Gator05 said:
We stock propofol and STP concurrently here.

STP advantages:

Takes a lot more to knock-down airway reflexes,
Click to expand...
Who told you that?

Gator05 said:
along with respiratory drive, compared with propofol.
Click to expand...
Again where did you get that information from?

Gator05 said:
Preserves the baroreceptor reflex. Not as much of a problem with hypotension, especially if pt on ACEi/ARB..
Click to expand...
Absolutely incorrect.
Do you know that STP killed as many soldiers as the Vietcong in Vietnam because of hypotension?

Gator05 said:
If pt with high ICPs needing a procedure, a good slug can keep you out of trouble. If brain is swollen, slug/infusion of STP can help too. .
Click to expand...
And this can not be done with Propofol?
 
climbingdocs said:
I can't figure out why would one use etomidate/propofol mix for induction for crani for tumor resection vs. just propofol. Patient was stable, BP was ok.
Click to expand...

As usual, I won't make you wait:

THATS SOME STUPIDA SS ACADEMIC ANESTHESIA STUFF.

UNPROVEN.

Waste of time.

OMFG, are there REALLY attendings out there that mix etomidate and propofol thinking they're making a DIFFERENCE in PATIENT OUTCOME?

HAHAHAHAHAHAHAHAHHAHA
 
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coprolalia said:
[Thiopental] is a great induction agent
Click to expand...

We have thiopental stocked in our anesthesia carts, which is odd since it's a controlled substance. I'm not sure how we get around the lack of accounting. I think that because it's right there, lots of us use it more than we might otherwise.

I use it often for cranis. As CA-2s, We do an out rotation at the Univ of VA for some extra neuro cases - the brain case pickings being slim around here. I drew up thiopental my first day there and my attending looked at me like I'd grown an extra head. He let me use it - just made the claim that propofol probably accomplishes everything thiopental does.

I also like to use thiopental for the occasional pediatric IV induction because it doesn't sting like propofol.
 
COP'S QUESTION IS A GOOD ONE.

"Why are we using a non-thiopental induction agent?"

Has the NEW WAVE INDUCTION DRUG been SO GOOD that theres really no question between

STP AND PROPOFOL?

I gotta be honest with you (readers).

I've always considered propofol superior to sodium thiopental.

For several reasons.

Propofol has a shorter halflife, which translates into less PACU sedation issues.

Propofol has a superior profile concerning post-op N/V compared to STP...

Propofol is here today, Gone Tomorrow, whereas STP may be hanging around for a while.....

STP may lead to increased nausea and vomiting, and increased post-op sedation compared to propofol.

BUT I'LL COME CLEAN WITH YOU HERE.

And I've used a tonna STP....

I REALLY DON'T KNOW WHICH IS TRUE.

Does propofol really have less N/V.../sedation-in-the-PACU than STP?

Are the "literature-proven" studies saying STP makes a patient stay longer in the PACU than propofol really mean ANYTHING?

"I hope theres alotta more listeners out there than there are critics....I'm not monetarily reimbursed for my opinion...

"I think Cop's opinion that STP, an induction agent from the 1940s, be BETTER LOOKED AT is a strong opinion. A good one.

Sometimes we're swayed by marketing.....even when it doesnt make a difference in patient care....

SO OK, ITS ME, JET....

and I think propofol, of course titrated to situation, is better for the patient than sodium thiopenthal.

AM I A VICTIM OF THE BUSINESS MAJORS THAT SAT BY THE POOL WHILE I WAS IN ORGANIC CHEM LAB AS AN UNDERGRAD?

DID ONE OF THOSE TANNED MO-FO BUSINESS MAJORS GO TO WORK FOR A DRUG COMPANY AND CONVINCE ME PROPOFOL IS BETTER THAN SODIUM PENTOTHAL?

Or is it really true that inducing with propofol affords less peri-anesthesia side effects than inducing with STP?

I think I'm informed.

But maybe I'm a victim of the NATIONWIDE MEDIA WAGON
 
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Gator05 said:
We stock propofol and STP concurrently here.


Det: mind sending some articles re:

"Speaking of myths, the concept that protection of neurons by anesthetics during an ischemic event is explained by a reduction in cell metabolism is among my favorites.

Not saying that these agents cant provide neuroprotection, just that decreasing CMRO2 doesn't correlate well with neuronal protection during ischemia."


I think this is a true statement, just wanted to see your literature.

.
Click to expand...

Sure Gator. Of course these studies are all rat models of ischemia since no anesthestic has reliably shown neuroprotection when used in humans.

1)`poor correlation between decreased CMRO2 as measured by EEG burst suppression and the prevention of neuronal injury

http://www.ncbi.nlm.nih.gov/pubmed/...ez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

http://www.ncbi.nlm.nih.gov/pubmed/...ez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

2) selectivity between various barbiturates, all of which can produce burst suppression on EEG, has been observed in the ability of these agents to protect the brain

http://www.ncbi.nlm.nih.gov/sites/entrez
 
We use STP for ECT's at my new gig. Why? 'Cuz that's how they do it I guess. In residency we routinely used etomidate or brevital.
 
2ndyear said:
We use STP for ECT's at my new gig. Why? 'Cuz that's how they do it I guess. In residency we routinely used etomidate or brevital.
Click to expand...

STP increases the seizure threshold, are you still getting a good seizure activity?
This is why people always advocated Methohexital for this use but I guess you can use anything.
 
Planktonmd said:
STP increases the seizure threshold, are you still getting a good seizure activity?
This is why people always advocated Methohexital for this use but I guess you can use anything.
Click to expand...

Yeah, I'm still too new to rock the boat on this one. Seizure times seem to be OK. I know we don't have Methohexital on formulary. I guess it's not enough of a big deal to pull a 'new guy won't do it this way' thing on. Perhaps when I get a little more experience I will. One thing I don't do is put tetracaine in my peripheral nerve blocks. There are some older guys using up to 60 mg of tetracaine, even in the brachial plexus, along with 30 mL 0.5% bupiv. Umm, OK. No good for me. Neurotoxic.
 
jetproppilot said:
As usual, I won't make you wait:

THATS SOME STUPIDA SS ACADEMIC ANESTHESIA S HIT.

UNPROVEN.

Waste of time.

OMFG, are there REALLY attendings out there that mix etomidate and propofol thinking they're making a DIFFERENCE in PATIENT OUTCOME?

HAHAHAHAHAHAHAHAHHAHA
Click to expand...

wow your response has such a great educational value!! Thanks!! :thumbup:
 
2ndyear said:
We use STP for ECT's at my new gig. Why? 'Cuz that's how they do it I guess. In residency we routinely used etomidate or brevital.
Click to expand...

You used etomidate for ECTs? I don't think I'd want to give someone an induction dose of etomidate every day for a month, or longer. We use methohexital.
 
Noyac said:
Are you doing a sitting crani?

Otherwise no real benefit, and TEE is even better but I've never seen anyone use TEE for a crani. And if you are going to do a precordial doppler are you also going to place a central line appropriately for VAE?
Click to expand...

I'd much rather have TEE than precordial. Just as sensitive, but gives you a ton more information--ventricular and valvular function, volume status, cardiac output, etc. The problem with TEE in a sitting crani is that the head is frequently flexed, and that can lead to mucosal damage from pressure from the probe. I haven't seen it, but my colleagues have. That sitting position makes it a little more difficult to manipulate the probe.
 
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