How do you do your average cardiac case?

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Airlife91

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Just finished cardiac fellowship. I have the recipes of how I was trained to do the standard cardiac cases I was involved in. I’m talking mainly about the bread and butter type cases: CABGs, MVRs, AVRs, etc. Here is how we’d do them:
- In room. A-line before/after induction depending on case.
- Induce with heavy fentanyl/midaz, and maybe a bit of prop.
- Phenyl gtt in the background starting peri-induction and off/on till on pump. Maintain anesthesia with Iso
- Tube/TEE in.
- Central line +/- SWAN (our surgeons loved SWANs...some demanded them for every sternotomy case).
- start/run TXA gtt, give more fentanyl pre incision.
- prep/incision, TEE exam, pull off autologous blood.
- heparinize, cannulate, confirm placement on TEE. If placement good, RAP/VAP -> CPB
- during the pump run - hang drips for post CPB. Most often Norepi. Milrinone and/or epi if worried about fxn post/op. Start when clamp is off.
- Once stable off pump, give protamine via micro stripper over 5-8 min.
- if looking good and closing, hang prop or dex gtt. Give back autologous blood.
- if off pressors and the BP is inching up, give 50-100mcg hits of fentanyl. Sometimes give labetalol if persistently high.
- wrap up, go to ICU. Ideally extubated w/in 4hrs which was accomplished most of the time for straight forward cases that went ok.

Typically we’d give around 1000mcg of fentanyl, 5-10mg midaz for the whole case. Always came out on a sedating med even with goal of early extubation. Almost never extubated in the OR (old habits die hard). Usually never had to put on a gtt to lower BP (ie NTG, nicardipine, cleviprex) since we have so much narcotic.

Obviously some of the above would change as clinical scenario dictated, but that is the way a majority of our straight forward cases went and it was the way things worked there. I’d like to hear how people do it differently (or the same), since there are a “1000 ways to skin a cat.” I also realize a lot of that is ‘old school’...just the way it worked there.

Sorry for the length. Thanks for any input.
 
anybody out there adds 1g calcium chloride in their protamine drip?
 
Looks great in general. My one quibble would be that in 2018 the idea of a "cardiac induction" very heavy on fentanyl is a little antiquated.

But if it works for you and the patients are waking up on time, then it's all good.

I usually use a little ketamine on induction and on sternotomy, and most cases use 500mcg fent total, of which 350 is usually pre-bypass and 150 post.

I like the ANH and RAP action. Hopefully you're having them flush the circuit back before pulling the arterial cannula too.

Agree with pgg on the TXA, though it's pretty benign stuff.

I usually give a gram of calcium slowly with the protamine, but give both by hand rather than starting a drip.

I use norepi as first line pressor, I think it's a great drug. I only use inotropes if there's a real need. That is, just because the EF is a little depressed doesn't mean automatic inotrope.

Swans can be useful depending on the surgery and on the surgeon (that is, I'm more likely to put one in for surgeons known for more postop bleeding). Definitely not for "routine" cabgs or AVRs.

Good stuff.
 
Just started fellowship here and that's roughly how we do it.

here we don't start txa until the patient is on pump.

We do not give calcium with protamine. Though, in residency I had an attending who used to mix a bag of protamine, calcium, and phenyl and hang that on a mocrodripper.
 
Hawaiian Bruin said:
Looks great in general. My one quibble would be that in 2018 the idea of a "cardiac induction" very heavy on fentanyl is a little antiquated.

But if it works for you and the patients are waking up on time, then it's all good.

I usually use a little ketamine on induction and on sternotomy, and most cases use 500mcg fent total, of which 350 is usually pre-bypass and 150 post.
Click to expand...

So what is your typical cardiac induction?
 
Anyone have any papers on calcium + protamine? I usually avoid empiric calcium and treat any prot hypotension with vasopressors. Check ACT and ABG after prot is completed and only treat hypocalcemia (low ionized) at that point. I think there's pretty solid in vitro evidence that hypercalcemia worsens ischemic reperfusion injury without any substantial benefit.

Calcium-mediated cell death during myocardial reperfusion | Cardiovascular Research | Oxford Academic
Altered Calcium Handling in Reperfusion Injury. - PubMed - NCBI

In regard to TXA/Amicar, I personally give it around incision time because everyone is on ASA nowadays, but for those that are nervous I'd definitely recommend giving it before initiation of CPB. I believe it is more effective before significant contact activation with the circuit has taken place.
 
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Overall looks great. I don't do a heavy fent/midaz induction. Usually 2 mg midaz for the case. But my partners do, and I can't tell a difference in extubation times. I usually do 2 midaz, 100 fent (maybe 750-1000mcg for the case), 100 prop, 100 roc. For patients I'm particularly cautious about (e.g. critical left main) - I might do an inhaled induction + small doses of prop. It's a bit slower but so stable. Maybe do this twice a year.

Swans on almost all valves and low EFs.

Frequent ANH - try to be aggressive with this (most patients w/ starting Hct>35) bc I think it doesn't matter much unless a large volume (maybe 800-1200mL) is taken. There was a study supporting this, not entirely my own opinion.

Amicar on most. Less likely on bad CKD patients.

We don't RAP - but perfusionists have been proactive with shortening their lines, limiting prime volume, and making heavy use of the hemoconcentrator. I like it because we have a lot more BP stability in the peri-initiation period than at my previous institution where RAP was common. Typically euthermic bypass, infrequently drift.

Calcium in little aliquots to come off. Known concern for reperfusion injury, but unclear clinical relevance. At old institution, everyone would "recalcify" on pump w 1g calcium chloride after clamp removed. Protamine by hand, pretty quickly - slow down if PA pressures go up. Precedex once stable.

We don't extubate in OR, but have good rates of post-op extubation. >75% of isolated CABG extubated under 6 hrs.
 
For the fast track population, what are your thoughts on giving NMB reversal prior to extubation in the ICU? Where I was that's not even a thought that's entertained, I had the NP say "that's not what we do here" since they normally extubated when awake and minimal support. I just ask because I've noticed people tend to be a bit more heavy handed with redosing NMB for cardiac cases so shouldn't we be concerned about residual NMB blockade? I mean we reverse people who had a prolonged surgery who may not have needed any redosing of NMB since intubation, figured concept should apply to cardiac as well?
 
2Fast2Des said:
For the fast track population, what are your thoughts on giving NMB reversal prior to extubation in the ICU? Where I was that's not even a thought that's entertained, I had the NP say "that's not what we do here" since they normally extubated when awake and minimal support. I just ask because I've noticed people tend to be a bit more heavy handed with redosing NMB for cardiac cases so shouldn't we be concerned about residual NMB blockade? I mean we reverse people who had a prolonged surgery who may not have needed any redosing of NMB since intubation, figured concept should apply to cardiac as well?
Click to expand...

They dont extubate unless they have shown that the patient can breath well on spontaneous with minimal support for a while. So i dont think its needed to reverse
 
2Fast2Des said:
For the fast track population, what are your thoughts on giving NMB reversal prior to extubation in the ICU? Where I was that's not even a thought that's entertained, I had the NP say "that's not what we do here" since they normally extubated when awake and minimal support. I just ask because I've noticed people tend to be a bit more heavy handed with redosing NMB for cardiac cases so shouldn't we be concerned about residual NMB blockade? I mean we reverse people who had a prolonged surgery who may not have needed any redosing of NMB since intubation, figured concept should apply to cardiac as well?
Click to expand...
I don't routinely give it, but it's always a differential of mine in the cardiac ICU when somebody is a little weak waking up. Problem is most non-anesthesia intensivists and PAs/NPs don't consider it. I won't redose any NDMR after we're off pump though.
 
MoMoGesiologist said:
So what is your typical cardiac induction?
Click to expand...
A little midaz prior to a-line, 100 fent, usually 100 ketamine, 50-200 prop titrated to effect thereafter.

People are still being taught that ketamine is contraindicated in cabg, "to avoid tachycardia and hypertension". This is utter foolishness.

If you give nothing but ketamine to an awake volunteer, they will indeed get tachycardic and hypertensive. Because they'll be tripping balls.

As part of a "balanced" induction, the ketamine *prevents* tachycardia with laryngoscopy, and does the same pre-incision/sternotomy.

I suspect it reduces postop pain as well but the jury is out on that still.

Treats comorbid depression too... bonus!

Someone mentioned inhaled inductions- I do the same for the sickest of the sick. Nothing more stable.
 
All this sounds good, my “standard” management that has evolved in the one year post fellowship is only a little different;

I do all my lines awake, I don’t think a central line is required pre-induction if you have good PIV access but my work flow is such that I do place my lines awake. No PAC in general unless it’s a Lung tx, >2/3 systemic PAP, or failing RV.

I induce with a hybrid technique, meaning sort of a minimal old school cardiac induction (~500mcg Fentanyl, I try to minimize versed as most my pts are 70’s and 80’s and they typically get 1-2mg for lines) and I supplement with ~50mg of prop. But after about mid year the fellows are doing the inductions and I don’t micromanage too much.

We start the TXA around incision, I’m not aware of any clear reason not to. And I bet 75% of my patients get calcium but we wait till a bit after reperfusion and I don’t necessarily give with the protamine. I also favor NE as first line unless it’s severe AS, HOCM, or a bad RV.

We reverse NDMRs in the unit on dropoff.
 
Aline after induction unless depressed EF, hemodynamics, etc. 9 Fr MAC after sleep

Common Induction: Ketamine, Fent, Midaz, Vec (did Prop/Fent/Roc/Mid during fellowship)

NE, Nitro, TXA std drips (cardene for AVs, )

Rarely do PAC, unless definitely needed. Post pump Ca based on heart function or bleeding

Most pts extubated within 6 hrs. In fellowship not unusual to extubate in room.
 
Airlife91 said:
Just finished cardiac fellowship. I have the recipes of how I was trained to do the standard cardiac cases I was involved in. I’m talking mainly about the bread and butter type cases: CABGs, MVRs, AVRs, etc. Here is how we’d do them:
- In room. A-line before/after induction depending on case.
- Induce with heavy fentanyl/midaz, and maybe a bit of prop.
- Phenyl gtt in the background starting peri-induction and off/on till on pump. Maintain anesthesia with Iso
- Tube/TEE in.
- Central line +/- SWAN (our surgeons loved SWANs...some demanded them for every sternotomy case).
- start/run TXA gtt, give more fentanyl pre incision.
- prep/incision, TEE exam, pull off autologous blood.
- heparinize, cannulate, confirm placement on TEE. If placement good, RAP/VAP -> CPB
- during the pump run - hang drips for post CPB. Most often Norepi. Milrinone and/or epi if worried about fxn post/op. Start when clamp is off.
- Once stable off pump, give protamine via micro stripper over 5-8 min.
- if looking good and closing, hang prop or dex gtt. Give back autologous blood.
- if off pressors and the BP is inching up, give 50-100mcg hits of fentanyl. Sometimes give labetalol if persistently high.
- wrap up, go to ICU. Ideally extubated w/in 4hrs which was accomplished most of the time for straight forward cases that went ok.

Typically we’d give around 1000mcg of fentanyl, 5-10mg midaz for the whole case. Always came out on a sedating med even with goal of early extubation. Almost never extubated in the OR (old habits die hard). Usually never had to put on a gtt to lower BP (ie NTG, nicardipine, cleviprex) since we have so much narcotic.

Obviously some of the above would change as clinical scenario dictated, but that is the way a majority of our straight forward cases went and it was the way things worked there. I’d like to hear how people do it differently (or the same), since there are a “1000 ways to skin a cat.” I also realize a lot of that is ‘old school’...just the way it worked there.

Sorry for the length. Thanks for any input.
Click to expand...
Pent Sux Tube
 
Don’t bother trying to extubate in the OR. People don’t wake up from cold non pulsatile perfusion and severe chest trauma like they do from a lap chole. Unless you’re willing to wait a long time in the OR it’s just a waste to try to “force it” before leaving for the ICU
 
T-burglar said:
Don’t bother trying to extubate in the OR. People don’t wake up from cold non pulsatile perfusion and severe chest trauma like they do from a lap chole. Unless you’re willing to wait a long time in the OR it’s just a waste to try to “force it” before leaving for the ICU
Click to expand...

I agree with this. It’s a parlor trick. And one that inevitably will lead to having to re-induce an urgent bring back. The 4-6 hours saved from the vent isn’t worth the risk, let them show they aren’t bleeding for an hour or two at least.

In my residency and fellowship we extubated on the table about half the time, and the times we had to come back with a hemodynamically fragile Pt without an ETT was not 0.
 
Hawaiian Bruin said:
Looks great in general. My one quibble would be that in 2018 the idea of a "cardiac induction" very heavy on fentanyl is a little antiquated.

But if it works for you and the patients are waking up on time, then it's all good.

I usually use a little ketamine on induction and on sternotomy, and most cases use 500mcg fent total, of which 350 is usually pre-bypass and 150 post.

I like the ANH and RAP action. Hopefully you're having them flush the circuit back before pulling the arterial cannula too.

Agree with pgg on the TXA, though it's pretty benign stuff.

I usually give a gram of calcium slowly with the protamine, but give both by hand rather than starting a drip.

I use norepi as first line pressor, I think it's a great drug. I only use inotropes if there's a real need. That is, just because the EF is a little depressed doesn't mean automatic inotrope.

Swans can be useful depending on the surgery and on the surgeon (that is, I'm more likely to put one in for surgeons known for more postop bleeding). Definitely not for "routine" cabgs or AVRs.

Good stuff.
Click to expand...
I usually end up using 25mcg of sufenta for the case and 2mg of midaz if i placed the a-line pre-induction.
Never crossed my mind to withhold txa until heparinized.
No swan unless pHTN
 
Hawaiian Bruin said:
If you give nothing but ketamine to an awake volunteer, they will indeed get tachycardic and hypertensive. Because they'll be tripping balls.
Click to expand...
Depends how much: i've never seen that effect when i give 15-20mg to sit a lol for a hip nail.
Otoh i talked to a patient to whom EMT gave 400mg for a shoulder fracture 😀😱
 
Hawaiian Bruin said:
A little midaz prior to a-line, 100 fent, usually 100 ketamine, 50-200 prop titrated to effect thereafter.

People are still being taught that ketamine is contraindicated in cabg, "to avoid tachycardia and hypertension". This is utter foolishness.

If you give nothing but ketamine to an awake volunteer, they will indeed get tachycardic and hypertensive. Because they'll be tripping balls.

As part of a "balanced" induction, the ketamine *prevents* tachycardia with laryngoscopy, and does the same pre-incision/sternotomy.

I suspect it reduces postop pain as well but the jury is out on that still.

Treats comorbid depression too... bonus!

Someone mentioned inhaled inductions- I do the same for the sickest of the sick. Nothing more stable.
Click to expand...
The only patients I have seen bounce back from the floor to the icu due to delirium had ketamine on induction.
 
dhb said:
Never crossed my mind to withhold txa until heparinized.
Click to expand...

It always makes me wonder what really went on with Patient 0 that lead to this practice without clear evidence.
 
Average cardiac case: prop roc tube. Pre induction a line unless healthy mitral flail or something similar like ASD closure.

People say hypotension on induction is worse than hypertension but neither is really that life threatening in the vast majority of cases. There are exceptions where tight hemodynamics matter.

There’s no recipe really. Cardiac boils down to knowing what the surgeon is doing down to the last detail and being able to anticipate the problems he/she may run into because they are your problems too. I spent a lot of time reading Kirklin Barat Boyes and “safeguards and pitfalls in cardiac surgery” which are both Cardaic surgery textbooks.
 
urge said:
The only patients I have seen bounce back from the floor to the icu due to delirium had ketamine on induction.
Click to expand...
You're saying these are patients who had a cardiac case, went to the ICU, then a couple days later went to the floor, then came back to the unit?

Or noncardiac patients who went to the floor then had to go to the Unit for delirium?

I've never seen an ICU admission solely for delirium, and I've never had a cardiac patient with postop cognitive weirdness or hallucinations from ketamine on induction/incision in my n of many thousands.
 
Hawaiian Bruin said:
You're saying these are patients who had a cardiac case, went to the ICU, then a couple days later went to the floor, then came back to the unit?

Or noncardiac patients who went to the floor then had to go to the Unit for delirium?

I've never seen an ICU admission solely for delirium, and I've never had a cardiac patient with postop cognitive weirdness or hallucinations from ketamine on induction/incision in my n of many thousands.
Click to expand...
Cardiac patients. CABGs, mostly off pump, valves and aortas. Mild delirium in icu. Unmanageable delirium on floor.

I used to work with a guy who did inductions like yours: midaz, ketamine, propofol and very little fentanyl. Delirium was very common.

When you say you have never seen "delirum from ketamine", makes me think you have seen plenty of delirium and all your patients get ketamine but somehow the two are not related in your mind.
 
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urge said:
Cardiac patients. Mild delirium in icu. Unmanageable delirium on floor.

I used to work with a guy who did inductions like yours: midaz, ketamine, propofol and very little fentanyl. Delirium was very common.

When you say you have never seen "delirum from ketamine", makes me think you have seen plenty of delirium and all your patients get ketamine but somehow the two are not related in your mind.
Click to expand...
Hate to burst your bubble, but we've actually studied the postop delirium in our shop and looked at it critically and closely. My rates are no different than my colleagues' who don't use ketamine.
 
Hawaiian Bruin said:
Hate to burst your bubble, but we've actually studied the postop delirium in our shop and looked at it critically and closely. My rates are no different than my colleagues' who don't use ketamine.
Click to expand...
Delirium must be quite a problem in your shop to merit such close scrutiny.
 
urge said:
Delirium must be quite a problem in your shop to merit such close scrutiny.
Click to expand...
We looked at it because someone wanted to see whether this business of precedex instead of propofol postop had any meaningful impact on delirium. Cliff's notes: rates were very low with both, for all anesthesiologists. So no, we don't have a delirium problem.

Appreciate your interest in our humble workplace!

I'm gonna go crack a beer and sear a slab of cow over fire now. Good day to you, sir.
 
dhb said:
Never crossed my mind to withhold txa until heparinized.
Click to expand...

holding txa/amicar is an old chestnut that persists from a single case report of an LM occlusion after amicar and before heparin that has become legend. I'm sure you can find it if you are of a mind...the 'younger' set love citing that possibility. I start it as soon as the pharmacist can send it up.
 
Thanks for all the responses. Good to see how others do things. I have come to love the high dose fentanyl route, but the group I’m joining doesn’t like this method, so I’ll be adopting a few of the methods mentioned here to cut the narcs down. I like the ketamine addition.

I’ve heard the guys in the group I’m joining like to use ~250mcg of fent or less for the case. Do you guys that run it lean on the narcs find you have to run antihypertensive gtt’s as the case is winding down? NTG/nicardipine/etc? I can see the ketamine helping to replace the analgesia lost by the reduced fentanyl early in the case...but at the end it seems like you’d frequently be leaving a patient in the ICU with high BPs (in the more robust patients at least)...
 
Airlife91 said:
Thanks for all the responses. Good to see how others do things. I have come to love the high dose fentanyl route, but the group I’m joining doesn’t like this method, so I’ll be adopting a few of the methods mentioned here to cut the narcs down. I like the ketamine addition.

I’ve heard the guys in the group I’m joining like to use ~250mcg of fent or less for the case. Do you guys that run it lean on the narcs find you have to run antihypertensive gtt’s as the case is winding down? NTG/nicardipine/etc? I can see the ketamine helping to replace the analgesia lost by the reduced fentanyl early in the case...but at the end it seems like you’d frequently be leaving a patient in the ICU with high BPs (in the more robust patients at least)...
Click to expand...

I usually will have low dose precedex running through the entire case then bump it up towards closure if pt is a little hypertensive. If it's refractory then I'll get some cardene going. I'd rather have a short acting vasoactive infusion hanging that can continue in the ICU prn rather than try to treat the high pressure with another 1mg of fent that's going to snow the pt for hours.
 
Good discussion all around. I agree that using such high doses of fent is pretty antiquated - if you are having to routinely start neo or norepi then you might be a little heavy handed with it. That being said if you know it’s coming and works for you then go for it. For sickly patients (emergent CABG for ruptured LM or Impella in place) I’ll often induce with no fentanyl and make them earn it after induction. You stay remarkably stable during maintenance which allows you to do a complete echo exam, if indicated (often omitted for straightforward, normal EF CABG).

I’m also not shy about etomidate. We used a LOT of it in fellowship and we didn’t have fast-trackers puking their guts out, or developing adrenal insufficiency. You often need to have that esmolol with you during induction, though,

Some of this subtle induction stuff I learned in fellowship and it markedly improved my skills as an anesthesiologist.
 
2Fast2Des said:
For the fast track population, what are your thoughts on giving NMB reversal prior to extubation in the ICU? Where I was that's not even a thought that's entertained, I had the NP say "that's not what we do here" since they normally extubated when awake and minimal support. I just ask because I've noticed people tend to be a bit more heavy handed with redosing NMB for cardiac cases so shouldn't we be concerned about residual NMB blockade? I mean we reverse people who had a prolonged surgery who may not have needed any redosing of NMB since intubation, figured concept should apply to cardiac as well?
Click to expand...

Never saw it done in fellowship, but we reversed a couple times in residency. Why subject the patient to hemodynamic alterations associated with glyco/ neo? I usually give an extra 30 mg roc hit coming off pump and that usually carries me through the end of the case. If you need more, just don’t diss crazy amounts. It should wear off within an hour or two, for sure. If not - check twitches, sugammadex. Just haven’t seen a necessity for it on the reg - you don’t need to be deeply relaxed to close the chest.
 
nimbus said:
Did you read your reference? It actually supports HB. The authors were looking to see if ketamine reduced delirium. There was no difference in delirium between ketamine and placebo. I have also found no difference in delirium.
Click to expand...
Did you read it?

Here is the conclusion:
A single subanaesthetic dose of ketamine did not decrease delirium in older adults after major surgery, and might cause harm by inducing negative experiences.
Click to expand...

In my hospital a pt that is screaming at night with hallucinations gets labeled as delirium. That is what they described in the paper as “negative experiences.”

Whatever you choose to label as delirium, they concluded ketamine causes harm.

Thus, unless your intent is to harm patients, you are better off staying away from ketamine.
 
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urge said:
Did you read it?

Here is the conclusion:


In my hospital a pt that is screaming at night with hallucinations gets labeled as delirium. That is what they described in the paper as “negative experiences.”

Whatever you choose to label as delirium, they concluded ketamine causes harm.

Thus, unless your intent is to harm patients, you are better off staying away from ketamine.
Click to expand...


You extrapolated and extended their conclusion. They said “might” which is different than “they concluded ketamine causes harm”. Earlier smaller trials showed a benefit which is why this study was conducted in the first place. Regardless, seems like ketamine didn’t do much postoperatively in this larger study. Intraoperatively ketamine has a large opioid and MAC sparing effect.
 
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Airlife91 said:
Thanks for all the responses. Good to see how others do things. I have come to love the high dose fentanyl route, but the group I’m joining doesn’t like this method, so I’ll be adopting a few of the methods mentioned here to cut the narcs down. I like the ketamine addition.

I’ve heard the guys in the group I’m joining like to use ~250mcg of fent or less for the case. Do you guys that run it lean on the narcs find you have to run antihypertensive gtt’s as the case is winding down? NTG/nicardipine/etc? I can see the ketamine helping to replace the analgesia lost by the reduced fentanyl early in the case...but at the end it seems like you’d frequently be leaving a patient in the ICU with high BPs (in the more robust patients at least)...
Click to expand...


A lot depends on your patient population. For my patients in their 70s and 80s I will often do the case with 250mcg of fentanyl. For younger more robust patients in their 50s and 60s I’ll use 500-750mcg. Usually I transport with propofol 15-50mcg/kg/min. I deal with hypotension more often than hypertension.
 
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Airlife91 said:
Just finished cardiac fellowship. I have the recipes of how I was trained to do the standard cardiac cases I was involved in. I’m talking mainly about the bread and butter type cases: CABGs, MVRs, AVRs, etc. Here is how we’d do them:
- In room. A-line before/after induction depending on case.
- Induce with heavy fentanyl/midaz, and maybe a bit of prop.
- Phenyl gtt in the background starting peri-induction and off/on till on pump. Maintain anesthesia with Iso
- Tube/TEE in.
- Central line +/- SWAN (our surgeons loved SWANs...some demanded them for every sternotomy case).
- start/run TXA gtt, give more fentanyl pre incision.
- prep/incision, TEE exam, pull off autologous blood.
- heparinize, cannulate, confirm placement on TEE. If placement good, RAP/VAP -> CPB
- during the pump run - hang drips for post CPB. Most often Norepi. Milrinone and/or epi if worried about fxn post/op. Start when clamp is off.
- Once stable off pump, give protamine via micro stripper over 5-8 min.
- if looking good and closing, hang prop or dex gtt. Give back autologous blood.
- if off pressors and the BP is inching up, give 50-100mcg hits of fentanyl. Sometimes give labetalol if persistently high.
- wrap up, go to ICU. Ideally extubated w/in 4hrs which was accomplished most of the time for straight forward cases that went ok.

Typically we’d give around 1000mcg of fentanyl, 5-10mg midaz for the whole case. Always came out on a sedating med even with goal of early extubation. Almost never extubated in the OR (old habits die hard). Usually never had to put on a gtt to lower BP (ie NTG, nicardipine, cleviprex) since we have so much narcotic.

Obviously some of the above would change as clinical scenario dictated, but that is the way a majority of our straight forward cases went and it was the way things worked there. I’d like to hear how people do it differently (or the same), since there are a “1000 ways to skin a cat.” I also realize a lot of that is ‘old school’...just the way it worked there.

Sorry for the length. Thanks for any input.
Click to expand...

Solid plan
 
Airlife91 said:
Thanks for all the responses. Good to see how others do things. I have come to love the high dose fentanyl route, but the group I’m joining doesn’t like this method, so I’ll be adopting a few of the methods mentioned here to cut the narcs down. I like the ketamine addition.

I’ve heard the guys in the group I’m joining like to use ~250mcg of fent or less for the case. Do you guys that run it lean on the narcs find you have to run antihypertensive gtt’s as the case is winding down? NTG/nicardipine/etc? I can see the ketamine helping to replace the analgesia lost by the reduced fentanyl early in the case...but at the end it seems like you’d frequently be leaving a patient in the ICU with high BPs (in the more robust patients at least)...
Click to expand...
No i deal with hypotension much more than hypertension even with a very little narcs.

Urge: no blocks & no K your SO must have a pain practice 😛
 
nimbus said:
You extrapolated and extended their conclusion. They said “might” which is different than “they concluded ketamine causes harm”. Earlier smaller trials showed a benefit which is why this study was conducted in the first place. Regardless, seems like ketamine didn’t do much postoperatively in this larger study. Intraoperatively ketamine has a large opioid and MAC sparing effect.
Click to expand...
I knew that was coming. Look at the p values for causing harm. They are all statistically significant. They just wanted to soften it, my guess is, so the people who routinely give ketamine don't get into legal issues.
 
urge said:
I knew that was coming. Look at the p values for causing harm. They are all statistically significant. They just wanted to soften it, my guess is, so the people who routinely give ketamine don't get into legal issues.
Click to expand...

+1 to anti-ketamine except in a few situations (awake intubation, very sick sedation case) . Of course it reduces intra-op MAC and opioids.. its a HYPNOTIC, adding another agent to your anesthetic is going to deepen the plane, and less HD response to stimulation is the result.. i really do believe ketamine is a hypnotic and not a pain medication and is just being purported to be more than it is due to the opioid epidemic and need to find alternatives
 
No offense to OP, and it seems like some other posters briefly touched on this, but 5-10mg Versed seems like A LOT, especially if that’s routine even for 70+yr olds. I’d be much more concerned about post-op delirium from that amount of benzos than 50mg ketamine with induction.
 
NightNight said:
No offense to OP, and it seems like some other posters briefly touched on this, but 5-10mg Versed seems like A LOT, especially if that’s routine even for 70+yr olds. I’d be much more concerned about post-op delirium from that amount of benzos than 50mg ketamine with induction.
Click to expand...

Fair point. This seemed to be a dogma of where I trained. Usually up to 0.1mg/kg midaz during induction. Some old school guys would often advocate to just give the whole 10mg stick. Isn’t necessarily what I plan on doing now that I’m done...and it is one reason I appreciate the input from others on this thread.
 
Preinduction Aline except for regurgitate

Post induction central line except for bad rv😛a htn : pembolectomy pt

No pa cath unless similar to above or surgeon really wants it for post op

Cerebral sat only for circ arrest

Bis if pt is a maniac or unstable and I wanna run lighter side

70-80yo Midaz 1mg max if needs it
80+ no midaz

400 - 500 fent / .5mg/kg ketamine sometimes / titrate prop / epi or neo or levo bolus available pending underlying pathology - crashing patient with full stomach gets etomidate

Amicar prior to incision (lower dose)

Perfusion minimizes prime with small bucket and hoses

Less frail maybe some dialudid with rewarming

Check twitches and titrate a little more pralytic if needed , no spont breathing coming off pump

calcium ok if 15 min since clamp off and you need some bp help

Ddavp after protamine (slow)

Pressors/ tropes are completely driven by by the patient , the run , and what the tee shows

Anticipate though and have stuff ready ...

For example I’ll empirically start some epi if the ventricle looked poopy with the severe mr

Anticipating needing nitric or an iabp has helped

Don’t like milrinone till I feel like pt can handle it and needs it


Labs and product selection driven by patient / pump run / field at the time...platelet function testing is a new lab for me since fellowship (never had it before and never had teg either)....I will draw fibrinogen and platelet count close to end of run if I think it’s going to be super low (somewhat controversial), but it’s help pull trigger on other products if field is a mess and I’m still waiting on labs

Don’t drop the ball post pump - manage the lytes, don’t flog with ns, glucose <180, make sure temp is good , optimize volume/cardiac index/ tone , don’t just push an extra stick of vec because it’s already drawn up

Precedex if Younger side and once I feel like we are stable

Suggamadex in ctu for those planning <4-6 hr extinction
 
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