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fakin' the funk said:
Blade's dim view of this operation as high-risk, high-mortality is correct...but the fatalism?

This kind of high-risk patient is exactly the kind of scenario where you, the anesthesiologist, can make some high-benefit interventions.

The mortality data are scary. But those outcome data are based on how the patient leaves the OR, not how they enter it.

In between, you help decide their outcome, not chance.
Click to expand...



I don't like this guy.

And for the record, he doesn't like me.

BUT FAKE NAILED THIS POST.

THIS IS (one of the many reasons)

WE MAKE THE BIG BUCKS.
 
redy said:
I thought the whole idea of low dose dopamine increasing renal perfusion has gone out of favour, no?
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dopamine increases renal blood flow and hence, UOP. it also helps the kidney become more ischemic, increasing the risk of renal injury. it is a fantastic DIURETIC. it has no place in renal protection.

with that said, lasix is also a fantastic DIURETIC that does nothing to protect the kidneys (in fact, it harms them as well) except in the patient who cant perfuse them because of LV failure
 
How is the patient doing now?
 
Couldn't find anything good on the fly, but they were talking about it in the last couple of meetings I've been to... one being the SCA.

Have you read anything recent in regard to it's use for sepsis? Seems like it is the least ugly of the renal protection bastard childs.
 
http://www.ncbi.nlm.nih.gov/pubmed/20332738


Fenoldopam improves the quality of perfusion during CPB. In patients receiving catecholamines to treat a postoperative low cardiac output state, fenoldopam significantly improves renal function and prevents AKI and major morbidity.


N=80

I'm not saying I'm for it or against it. Just saying there is some backgound noise that might be worth listening to.

I thought of it recently on a patient that had a pre-CABG high CR... we ended up cancelling the case because of high likelyhood of post-op dialysis. Worth thinking about... I guess.

Urge and Pod may have better insight into this.
 
seinfeld said:
ON call last night get the call I dream of, ruptured AAA coming to the OR. Run into Vascular surgeon, 60 something year old,review CT scan with him and it shows 11cm suprarenal AAA with rupture. Patient arrives in OR, quick hx reveals she doesnt see doctor regularly, she is barley responsive. Move to OR table, nurses prep belly, surgeon scrubbed and ready as I place left SC MAC cordis, CRNA puts in R radial aline and BP reads 45/20. Uncrossed PRBC flying in. Drapes up, small dose of versed, 100mg zemuron, Tube in easily, surgeon in belly immediately, BP drops to nothing, 50MCG epi, vasopressin chasers, Supraceliac clamp is on and bp up to 160 nicely, start NITRO drip and crank the gas. HCT 10 and pH 7.1 on first gas. VFIB then ensues x2 with ultimate successful cardioversions. I place TEE probe and see good function with no RWMA's valves all are good, no LV overdistention from high cross clamp. Float PA cath, Resuscitation in the usual manner for 3 hours, patient leaves OR with normal ABG no base excess, nl elctrolytes and HCT 30, INR 1.1. Post op requires diuresis for oxygenation and high filling pressures.

This is why is went into anesthesia. Love what you do and you wont work a day in your life!!!
Click to expand...


Well done dude. And totally agree with that last sentence. We've had 2 type A's recently. One being a redo sternotomy. Tough cases. Those supraceliac AAA's are tough and you abosolutely need to bring your game.

Well done sir. Well done. 👍
 
seinfeld said:
ON call last night get the call I dream of, ruptured AAA coming to the OR. Run into Vascular surgeon, 60 something year old,review CT scan with him and it shows 11cm suprarenal AAA with rupture. Patient arrives in OR, quick hx reveals she doesnt see doctor regularly, she is barley responsive. Move to OR table, nurses prep belly, surgeon scrubbed and ready as I place left SC MAC cordis, CRNA puts in R radial aline and BP reads 45/20. Uncrossed PRBC flying in. Drapes up, small dose of versed, 100mg zemuron, Tube in easily, surgeon in belly immediately, BP drops to nothing, 50MCG epi, vasopressin chasers, Supraceliac clamp is on and bp up to 160 nicely, start NITRO drip and crank the gas. HCT 10 and pH 7.1 on first gas. VFIB then ensues x2 with ultimate successful cardioversions. I place TEE probe and see good function with no RWMA's valves all are good, no LV overdistention from high cross clamp. Float PA cath, Resuscitation in the usual manner for 3 hours, patient leaves OR with normal ABG no base excess, nl elctrolytes and HCT 30, INR 1.1. Post op requires diuresis for oxygenation and high filling pressures.

This is why is went into anesthesia. Love what you do and you wont work a day in your life!!!
Click to expand...
I can't wait man. I got chills reading your narrative. Haters gonna hate.
 
Doing Ok, was extubated by colleague in ICU POD#2 but then pulm edema on top of COPD got the best of her and was reintubated for a couple more days. Extubated for past 3 days and doing well. No current infections, renal failure, no post hemorrhage issues/DIC. Some delirium issues which appear to be resolving. Will likely need Cardiac Cath in future as post op TTE showed some inferior ischemia and a drop in EF compared to my intraop TEE.
 
Not bad.

I did a similar case some time ago. 87 yo lady with leaking AAA. Came delirious to holding on 100% non rebreather mask but with reasonable vitals. Surgeon wanted to do a hybrid repair, tevar plus debranching of aorta, since the gut was involved. Aline, tube, central line, spinal drain, tee, all done carefully making sure not to pop her AAA .... The debranching took forever. She left the room 8 hrs later looking good. Then she failed exubation twice and ended with a trach. She left the hosp after a month. She has been back to some follow up appointments and is doing well. Trach was closed.

It always amazes me what old people tolerate.
 
sevoflurane said:
http://www.ncbi.nlm.nih.gov/pubmed/20332738


Fenoldopam improves the quality of perfusion during CPB. In patients receiving catecholamines to treat a postoperative low cardiac output state, fenoldopam significantly improves renal function and prevents AKI and major morbidity.


N=80

I'm not saying I'm for it or against it. Just saying there is some backgound noise that might be worth listening to.

I thought of it recently on a patient that had a pre-CABG high CR... we ended up cancelling the case because of high likelyhood of post-op dialysis. Worth thinking about... I guess.

Urge and Pod may have better insight into this.
Click to expand...

I played with fenoldopam a few years ago based on its renal protection literature but lost interest since I have not seen an elective straightforward case end up on dialysis. In fact the creatinine drops the first few days up until they get a bunch of diuretics prior to discharge.

The pts that get dialysis are the ones that come in shock.

So what happens to the pt if he doesn't get a cabg? I guess he didn't qualify for stents to begin with. Medical management?
 
urge said:
Not bad.

I did a similar case some time ago. 87 yo lady with leaking AAA. Came delirious to holding on 100% non rebreather mask but with reasonable vitals. Surgeon wanted to do a hybrid repair, tevar plus debranching of aorta, since the gut was involved. Aline, tube, central line, spinal drain, tee, all done carefully making sure not to pop her AAA .... The debranching took forever. She left the room 8 hrs later looking good. Then she failed exubation twice and ended with a trach. She left the hosp after a month. She has been back to some follow up appointments and is doing well. Trach was closed.

It always amazes me what old people tolerate.
Click to expand...

As the fatman said.....rule #1.....
 
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