How do you manage your cardiac meds: pump or freehand?

[ecCA1]

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What's the prevailing method of administration of vasoactive medications on this board? For a "typical" heart case, are you starting with neo, NTG/cardene in line? If so, do you titrate by hand or place on a pump? If not, are you giving small boluses of neo or NTG as needed for pressure control?

I run neo and NTG on pumps hooked into the central line prior to induction. Seems to work well for me, although every now and then I like to give 50 ug boluses of NTG to the more robust patients in need of transient pressure reduction (i.e. when the surgeon is about to cannulate aorta).

 

[Bertelman]

Typically thumb in neo as needed pre-pump. HTN = more anesthetic. Rarely hit the NTG. Certainly don't have it drawn up and ready to roll. No pressors in line until we come off.

 

[deleted162650]

At our place, we do it as follows:

For CABG: Dopa, Neo, NTG on pumps (>90% of CABG's are off pump)

For valves/PTE: Dopa, Neo, SNP on pumps

We run Amicar in the carrier for all pump cases except PTE's.

Pts usually go to sleep with just 1 or 2 PIV's, then get a RIJ/PAC after induction. Most of the time just Neo bolus via PIV if needed till central line in, then gtts hooked up to the PAC. Occasionally if the pt is really sick we'll have neo or dopa running through the PIV via the pump on induction.

For the OPCAB's some attendings like to have NTG running as BP tolerates throughout the case until revascularization complete.

 

[ProRealDoc]

SNP, amicar. NTG and insulin ready as per our protocol. Syringes with epi, neo, NTG and lidocaine ready at beginning of case. Inotropes and pressors may be needed prior to going on pump so it depends on the pt.

 

[ecCA1]

For those of you who have not specified, at times do you run your drips "by hand" (as in, not using a pump but cranking up/down on the drip control yourself) or are your neo/levo/NTG/cardene, etc. ALWAYS on a pump?

Thanks again!

 

[proman]

Always on pump. I won't post what I have to set up because it's embarrasing. I basically have a pole with every drug the ICU could possibly need.

 

[Bertelman]

For those of you who have not specified, at times do you run your drips "by hand" (as in, not using a pump but cranking up/down on the drip control yourself) or are your neo/levo/NTG/cardene, etc. ALWAYS on a pump?

Thanks again!

Always on a pump.

 

[periopdoc]

For those of you who have not specified, at times do you run your drips "by hand" (as in, not using a pump but cranking up/down on the drip control yourself) or are your neo/levo/NTG/cardene, etc. ALWAYS on a pump?

Thanks again!

Why is this even a question?

I don't see how titrating them with a roller clamp is a good practice. One needs to communicate dosages to the surgeons and ICU folks to give them a picture of how the patient did/ is doing. Also, there are too many things that can alter flow rates when your attention is distracted. Then it becomes a nightmare to sort out what has changed if you have two or three drips running. If you are running some background NEO during a ortho case then roller clamp is acceptable, but not in this scenario.

For me, drips are always on a pump. Epi, Neo, NTG. propofol, and a carrier fluid tied into a manifold. If the patient is sick, the manifold gets connected very proximally on the PIV prior to induction then switched to the IJ once it is placed. If the patient is reasonably healthy then I don't bother hooking the manifold up to the peripheral. I just tie into the IJ at some point before coming off pump or during LIMA harvesting for off-pump cases.

I also give occasional boluses to get levels up quickly if needed. I generally prefer to draw up and use what I need when I need rather than have a mess of syringes to sort through to find the drug I want.

- pod

 

[bullard]

What do you guys like to do for protamine? Syringe in a little at a time? Microdripper? or IV pump?

 

[ecCA1]

What do you guys like to do for protamine? Syringe in a little at a time? Microdripper? or IV pump?

I've seen protamine administered in different ways: pediatric burette/100 cc bag of NS or syringed in a bit at a time.

Some surgeons want to stop protamine at 75% of the full dose to pull the aortic cannula out before a clot forms on it. Others argue that the full dose must be given before withdrawing cannula to minimize bleeding.

I think that pulling it before full dose is given makes more sense.

As to "free style drips" vs. pumps, I think it's too easy to let a drip "get away from you" if it's not attached to a pump. However, there are people who never use pumps and somehow get neo/cardene (and in some rare cases, even levo(!)) to work fine. Prior to going upstairs to the ICU, they then switch over to a pump so the unit can manage the meds the "standard" way.

 

[proman]

I give protamine in a way that's counter to everyone else in my institution: Added to a 100cc back on a 15gtt set attached to a peripheral IV. I'll push it in peds due to a volume issue.

 

[periopdoc]

In fellowship I pushed it by hand. Here we put it in a buretrol with 1 amp of calcium and drip it in. I haven't decided which I like better.

- pod

 

[rsgillmd]

I haven't done cardiac in a while now. Where I trained our infusions were on pumps, including protamine.

Some would put Amicar on a pump also, but most just pushed it via syringe every hour.

If it's on a pump at a set rate you don't have to worry about the rate of delivery changing accidentally. Also it allows you to easily keep track of any changes you make and communicate those changes to the surgeon if necessary.

Vancomycin was an option -- you could put it on a microdrip (60 gtt) or put it on a pump. It was just easier to put it on a pump.

At my current institution the pumps are annoying to use and it's hard to find a pump that can handle multiple lines. Most are single pumps. So I tend to just use the roller clamp method. But I'm not doing cardiac anymore and rarely need to do this.

 

[proman]

Vancomycin was an option -- you could put it on a microdrip (60 gtt) or put it on a pump. It was just easier to put it on a pump.

That's the standard way here too (drip). I think it amounts to an assassination attempt. Multiple near-kills in the short time I've been here, and it rarely gets in before incision.

 

[seinfeld]

Where i work we do avg of 900 hearts a year. 80% of time come off on no drips. Few hand boluses of neo or Ephedrine here or there, generally if i have to use repeatedly push neo then I start something as a drip via PUMP OF COURSE. We have no predefined drips plugged in line. If i feel someone is likely to need a particular drug coming off ill make it up. Most of the time we merely come off pump and then see what is needed based on echo finding, BP, CO/CI and filling pressures. IN training we always did something in means of drugs coming off but what i have found in practice is that generally you chasing your tail if you make too many assumptions about what a patient may or may not need.

Ie Fxn is not normal so automatically give Milrinone, then you are on Norepi and maybe vasopressin, when what i have found in practice is that most dont even need the milrinone to start. Another example would be starting Epi then needing nitro to decrease SVR. I am not saying that drugs are not needed but sometimes we are our own worst enemies.

 

[Bertelman]

Where i work we do avg of 900 hearts a year. 80% of time come off on no drips. Few hand boluses of neo or Ephedrine here or there, generally if i have to use repeatedly push neo then I start something as a drip via PUMP OF COURSE. We have no predefined drips plugged in line. If i feel someone is likely to need a particular drug coming off ill make it up. Most of the time we merely come off pump and then see what is needed based on echo finding, BP, CO/CI and filling pressures. IN training we always did something in means of drugs coming off but what i have found in practice is that generally you chasing your tail if you make too many assumptions about what a patient may or may not need.

Ie Fxn is not normal so automatically give Milrinone, then you are on Norepi and maybe vasopressin, when what i have found in practice is that most dont even need the milrinone to start. Another example would be starting Epi then needing nitro to decrease SVR. I am not saying that drugs are not needed but sometimes we are our own worst enemies.

I'd never hear the end of it if I pushed ephedrine during a CABG.

As for your final point, might I suggest you have found a favorable group of surgeons and/or patient population, as well as a shorter pump run, such that you no longer rely on pressors to come off pump. As suggested in my earlier post, it is rare for me to use anything other than neo coming off pump. Hell, I can count on one hand the number of times I have dropped off in the ICU with anything else. But I don't actually believe it's because I am running a superior anesthetic, or because I have found some magic nirvana to cardiac anesthesia. I happen to believe it is because we have a fine group of surgeons.

That's gonna change drastically for me in a few months.

 

[ProRealDoc]

i give protamine in a way that's counter to everyone else in my institution: Added to a 100cc back on a 15gtt set attached to a peripheral iv. I'll push it in peds due to a volume issue.

+1

 

[12th man]

Mostly free hand neo or ephedrine. Ca2 to come off pump. If low EF "looks" like a problem post pump I load with milrinone, then levophed for back ground hypotension secondary to mili. If problems coming off with low EF then epi or dob/levophed. Try never to use dopamine. It was burned into my brain where I trained that dopamine is bad, yet I do use it to get heart rate up some times. To be honest most of our surgeons are rockstars and most patients do just fine. 👍

 

[nitroglycerine]

That's gonna change drastically for me in a few months.

What happened?

 

[Bertelman]

What happened?

Residency is done. Fellowship begins.