That's the whole idea. One gets both the advantages of an infusion and of a long context-sensitive half-time (i.e. as if giving dilaudid, but without the bolus effects). So, tram-track during the case and no need for separate long-acting opiates for the end.
I know correlation does not equal causation, but when the fentanyl is there, the patients are more hypotensive compared to the patients who don’t get it. Outside of the fentanyl infusion, there is nothing else apparently obvious that this particular attending does compared to others that would be notable for hypotension. This attending always seems to have his patient on inotropes/pressors a few clicks higher than other attendings. We are taught to be observant, this is just what I have observed. So it’s either the fentanyl infusion, of this attending is exuding something that is causing hypotension.
Your patients are hypotensive also because you are growing up in a culture that is obsessed about IV fluids, and runs everybody on pressor infusions.
What's the standard tiva mix for this guy vs the other docs?
Your patients are hypotensive also because you are growing up in a culture that is obsessed about IV fluids, and runs everybody on pressor infusions.
First thing we used to do, back in residency, was to give the patient up to 2 liters of IV crystalloid (for having been NPO). The number of cases that needed a pressor infusion was minuscule, when compared to nowadays. I am an intensivist, and still I will give those first 2 liters without blinking, if my non-septic patient needs a lot of pressors in the OR.
On the other hand, if my patient is hypotensive on a fentanyl infusion, I will probably drop the main agent. The main reason that patient is hypotensive is not just vasodilation, or loss of sympathetic response, it's the imbalance between the surgical stimulus and anesthesia. So the problem is probably not your attending; the problem is you not adjusting your anesthesia to having a good amount of fentanyl on board.
Btw, that fentanyl infusion is probably not much different than when an attending pushes 2 mg of dilaudid at the beginning of the case.
So usually propofol+dexmedetomidine infusion +/- ketamine infusions on one hand; prop+dex+fentanyl Infusions (+fentanyl blouses) on the other.
How about rates? Does this attending run things higher than other attendings? I'm asking cause I'm curious really. It really shouldn't be the fentanyl causing hypotension, but you never know. As far as the difference between icu and the OR, the fentanyl infusions in icu are generally lower rates and the sedation infusions in the icu are as well, generally titrated to a specific rass score whereas us providing general anesthesia is a MUCH deeper plane requiring higher doses. Can guarantee, if the icon's ran anesthetics at our rates they'd have very significant hypotension.
Ahhh got it. That used to frustrate me as a resident. Remember, this is not your case. This is your attendings case. His/her name is on the chart. You are just a body there to do as they say, and learn as much as you can without ruffling feathers. There will be other attendings, people you will like much better, with which you can practice being a physician. This is not that attending. Goal of residency is to keep your head down and get through it while learning as much as you can. Good luck.
DO NOT EXTUBATE ALONE, unless explicitly permitted. If the patient gets into trouble, and you can't fix it, or your attending walks in on that, you will be in trouble. I rarely if ever write up residents, but, if you extubated in my absence and something happened, I would make a fuss. Cockiness in the OR is dangerous (and also the main reason we have oral boards).
I feel your pain and frustration. You had me at propofol + precedex.
Perhaps the environment is just very different at my institution. I have never been greeted with anything but "oh cool, you already extubated. They look good. Nice job." If anything, when I have waited a long time and the patient was clearly ready, I've been told things like "what are you waiting for? take that tube out"
Your patients are hypotensive also because you are growing up in a culture that is obsessed about IV fluids, and runs everybody on pressor infusions.
First thing we used to do, back in residency, was to give the patient up to 2 liters of IV crystalloid (for having been NPO). The number of cases that needed a pressor infusion was minuscule, when compared to nowadays. I am an intensivist, and still I will give those first 2 liters without blinking, if my non-septic patient needs a lot of pressors in the OR.
On the other hand, if my patient is hypotensive on a fentanyl infusion, I will probably drop the main agent. The main reason that patient is hypotensive is not just vasodilation, or loss of sympathetic response, it's the imbalance between the surgical stimulus and anesthesia. So the problem is probably not your attending; the problem is you not adjusting your anesthesia to having a good amount of fentanyl on board.
Btw, that fentanyl infusion is probably not much different than when an attending pushes 2 mg of dilaudid at the beginning of the case.
What do you give for surgical stimulation then, and for immediate postop pain?
I totally don't know jack about Eurohumor. I see though that OP doesn't do both Ketamine and Fentanyl.
To address a few questions, the reason these cases are done under TIVA is that we are utilizing an ICU ventilator for these cases either for their specialized vent settings or nebulization of epoprostenol (for some reason we don’t have the equipment to administer epoprostenol with the OR ventilator.)
