How much fentanyl and midaz for a routine CABG

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Say... 65 y/o, 75 kg individual for a 6 hour CABG (from in the room time until you leave them in the ICU)
 
varies widely with me per pt. Some of my partners have a certain cocktail they give everyone... I'm not in that camp.

midaz: 5-20 mg
fent: 750-2000 mcg
 
sevoflurane said:
My practice has changed tremendously since residency... Just wondering what others are doing.
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Largely depends on aim: is this pt to be fast-tracked? Are your surgeons really taking 6 hrs for a standard CABG?! Why so damn long? Our guys take about 2.5-3 hrs for a std CABG (3-4 vessels). Similar times to 1 valve + CABG. Anyhow, to get to your initial question: it all varies.... But on average, 10-15mg of versed and 1-1.5mg of fent. Lower doses for smaller patients and those who will get fast-tracked, i.e., extubated within 1-2 hours from SICU arrival. 25mcg/kg/min propofol running on rewarm for all patients.
 
For a garden-variety CABG, it has varied. Where I trained, they routinely use about 20mg of Versed and 1mg of fentanyl. Where I do them now in practice, it's usually about 10mg of Versed and 500mcg-1mg of fentanyl.
 
IN2B8R said:
Largely depends on aim: is this pt to be fast-tracked? Are your surgeons really taking 6 hrs for a standard CABG?! Why so damn long? Our guys take about 2.5-3 hrs for a std CABG (3-4 vessels). Similar times to 1 valve + CABG. Anyhow, to get to your initial question: it all varies.... But on average, 10-15mg of versed and 1-1.5mg of fent. Lower doses for smaller patients and those who will get fast-tracked, i.e., extubated within 1-2 hours from SICU arrival. 25mcg/kg/min propofol running on rewarm for all patients.
Click to expand...

Sounds like you haven't changed your formula much since residency. 🙄

In the room time (6:00 am) to the time I walk out of the ICU is 6hrs on average- I usually hang around for about 15 minutes. I'm on my second CABG by 12:15pm. I don't think this is particularly long... most get 3-4 vessels... but it seems faster than where we trained. Our surgeons are very anal about bleeding, and they take their sweet time closing. Last year we had 3 bring backs and did 300 hearts.

I've cut down on my benzo's and narcs quite a bit. Whereas 10-15mg of Versed + 2000mcg was the norm for most routine cases, I now use 5-7 mg and 750 mcgs of fentanyl- on average. Extubated within 3 hours of CVICU arrival. I don't use propofol gtt on the way to ICU anymore. They turn it off as soon as they get there anyways to expedite extubation and I usually have .4 Mac on board when leaving the OR.

What about MAC values? Routinely used .5 mac of ISO during residency... now I run MAC values of .8-1.0 of DES.
 
When i started in PP i was amazed at how much Opioid the senior partners were giving during a case, some still give scopolamine 😕. I generally dont go over 10mg versed or 1000mcg of fent, all prior to CPB. I try to use gas when i can as it continues to show benefit on ischemic preconditioning.
 
Still in academia, but usually 0-2 mg versed unless a heavy drinker. 1-2 mg fent. 2-4 mg hydromorphone. Isoflurane at 1ish MAC. Usually have the first CABG in the ICU by 11:30 to noonish. Propofol drip at 50 mcg/kg/min as they cough on 25 (no loading dose). Exubate within 1 hour of arrival unless contraindications.

-pod
 
My in-room time is 7:15 am, I'm outa room about 10:30-11:00 at the latest. We have excellent surgeons around here, they have been "outa of the house" for a while.... Bring-backs are a rare thing around here. Believe me, much has changed since training days; my previous description, as I have mentioned, was prototypical: I have used all sorts of **** to put plain CABG's to sleep.... 25mcg/kg/min of propofol (x1-2hrs) in SICU still allows pt to breath easily and will not hinder faster awakening. Mac values depend on what I use. Also depends on what stage of the surgery I'm in. For maintenace purposes, I never use more than 1/2 mac of des or sevo. No Iso since the partners around here do not use it. Best thing about a solid CT team? Good team approach: you gotta have excellent nurse practioners/PA's who will scrub in and expedite the surgery. If you do not have that, that will always add .5-1 hour to your day--regardless of how fast you get the case started.




sevoflurane said:
Sounds like you haven't changed your formula much since residency. 🙄

In the room time (6:00 am) to the time I walk out of the ICU is 6hrs on average- I usually hang around for about 15 minutes. I'm on my second CABG by 12:15pm. I don't think this is particularly long... most get 3-4 vessels... but it seems faster than where we trained. Our surgeons are very anal about bleeding, and they take their sweet time closing. Last year we had 3 bring backs and did 300 hearts.

I've cut down on my benzo's and narcs quite a bit. Whereas 10-15mg of Versed + 2000mcg was the norm for most routine cases, I now use 5-7 mg and 750 mcgs of fentanyl- on average. Extubated within 3 hours of CVICU arrival. I don't use propofol gtt on the way to ICU anymore. They turn it off as soon as they get there anyways to expedite extubation and I usually have .4 Mac on board when leaving the OR.

What about MAC values? Routinely used .5 mac of ISO during residency... now I run MAC values of .8-1.0 of DES.
Click to expand...
 
IN2B8R said:
My in-room time is 7:15 am, I'm outa room about 10:30-11:00 at the latest. We have excellent surgeons around here, they have been "outa of the house" for a while.... Bring-backs are a rare thing around here. Believe me, much has changed since training days; my previous description, as I have mentioned, was prototypical: I have used all sorts of **** to put plain CABG's to sleep.... 25mcg/kg/min of propofol (x1-2hrs) in SICU still allows pt to breath easily and will not hinder faster awakening. Mac values depend on what I use. Also depends on what stage of the surgery I'm in. For maintenace purposes, I never use more than 1/2 mac of des or sevo. No Iso since the partners around here do not use it. Best thing about a solid CT team? Good team approach: you gotta have excellent nurse practioners/PA's who will scrub in and expedite the surgery. If you do not have that, that will always add .5-1 hour to your day--regardless of how fast you get the case started.
Click to expand...

Dang... out at 10:30am. that's nice...👍 You could be outta the hospital by 2:00pm and have done 2 hearts. That's really good from where I am standing.

Earliest I've been out has been 9:30am... but that was off-pump/single vessel... so that doesn't count.
 
IN2B8R said:
Good team approach: you gotta have excellent nurse practioners/PA's who will scrub in and expedite the surgery. If you do not have that, that will always add .5-1 hour to your day--regardless of how fast you get the case started.
Click to expand...

Agreed.

IMHO it tends to be the ancillary staff that make or break us. The other day I did a solo case (no resident, attending standing in the hallway drinking coffee). I had my favorite anesthesia tech with me. 0730 through the door. By 0745 had done my a-line, monitors, pre-ox, induced/ intubated, CVP, PAC, 2nd PIV, TEE in and major findings ready for the surgeon who didn't show up for another 15 minutes cause he is not used to <30 min starts. I owe that start to my tech cause the other techs slow me down.

If we are doing a AVR, and we have a good PA, we are usually out of the room by 11-1130. If we don't have a good PA it takes 30 min to an hour longer, like you said.

- pod
 
ProRealDoc said:
2mg versed with 1mg fent, +/- sufenta/lidocaine infusions depending on the attending.
Click to expand...

(heavy sigh) Gone are the days of 100cc of fentanyl.
 
sevoflurane said:
My practice has changed tremendously since residency... Just wondering what others are doing.
Click to expand...

Precedex infusion begun in holding room. Ten minutes later line the patient and to the OR, with precedex going all the way to delivery to ICU.

One or two ccs fentanyl with induction. Maybe one more cc before sternotomy. Rarely check out more than a five cc vial.

In comparison my mother in law had a routine on-pump three vessel CABG at the Houston mecca by Denton Cooley's group a few years ago. Her pre-op on the ward was 10 mg morphine and some scope.
 
trinityalumnus said:
Precedex infusion begun in holding room. Ten minutes later line the patient and to the OR, with precedex going all the way to delivery to ICU.

One or two ccs fentanyl with induction. Maybe one more cc before sternotomy. Rarely check out more than a five cc vial.

In comparison my mother in law had a routine on-pump three vessel CABG at the Houston mecca by Denton Cooley's group a few years ago. Her pre-op on the ward was 10 mg morphine and some scope.
Click to expand...

👍

Cuts down on your narcs significantly... and can use it in the ICU before the ETT comes out.

10mg of morphine and scop?.... related to this guy I wonder?

caveman.jpg


Just kidding....
 
Last edited:
trinityalumnus said:
Precedex infusion begun in holding room. Ten minutes later line the patient and to the OR, with precedex going all the way to delivery to ICU.

One or two ccs fentanyl with induction. Maybe one more cc before sternotomy. Rarely check out more than a five cc vial.

In comparison my mother in law had a routine on-pump three vessel CABG at the Houston mecca by Denton Cooley's group a few years ago. Her pre-op on the ward was 10 mg morphine and some scope.
Click to expand...

Seems like you would need more narcotic to blunt the response to sternotomy. Are you running higher amounts of volatile or is the precedex really helping that much? Seems like you would need to load the precedex up pretty good to blunt response to sternotomy.
 
Arch Guillotti said:
Seems like you would need more narcotic to blunt the response to sternotomy. Are you running higher amounts of volatile or is the precedex really helping that much? Seems like you would need to load the precedex up pretty good to blunt response to sternotomy.
Click to expand...

I have to agree... 250mcgs for a cabg does seem a bit low.... but I don't use it much. I've done a handful of TIVA's for cabg's where I used it, but I'm pretty sure I used more fentanyl. Intriguing.
 
Arch Guillotti said:
Seems like you would need more narcotic to blunt the response to sternotomy. Are you running higher amounts of volatile or is the precedex really helping that much? Seems like you would need to load the precedex up pretty good to blunt response to sternotomy.
Click to expand...

Sorry the first posting about the precedex was done too quickly.

In the holding room the pt gets the precedex loading dose over ten minutes, with perhaps 1-2 mg versed. (from that point the precedex usually remains at maintenance dose all the way to the ICU). Lines in. To OR. Usual induction is 50-100 mics fentanyl, paralytic, and lower amount of propofol or etomidate. Run on low-ish amounts of des.

Working with the same CT surgeons, and knowing their times, helps quite a bit. Usually just 50 additional mics of fentanyl a minute or two before sternotomy does the trick. If anything when coming off pump it's another cc of fentanyl and/or low dose NTG. On rare occasion the perfusionist will ask us to lower the precedex rate or turn it off.

The precedex (and the sub-q Pain Ball by the surgeon) really smooths things out and allows for earlier extubation.

The drug is not cheap.
 
periopdoc said:
Agreed.

IMHO it tends to be the ancillary staff that make or break us. The other day I did a solo case (no resident, attending standing in the hallway drinking coffee). I had my favorite anesthesia tech with me. 0730 through the door. By 0745 had done my a-line, monitors, pre-ox, induced/ intubated, CVP, PAC, 2nd PIV, TEE in and major findings ready for the surgeon who didn't show up for another 15 minutes cause he is not used to <30 min starts. I owe that start to my tech cause the other techs slow me down.

If we are doing a AVR, and we have a good PA, we are usually out of the room by 11-1130. If we don't have a good PA it takes 30 min to an hour longer, like you said.

- pod
Click to expand...

That tech is worth his/her weight in gold.
 
DreamMachine said:
During residency, I had an attending that used dex and minimal narcotics for CABGs. Basically, what you describe here. Had to set up an extra drip. The patients woke up in more pain. The only real advantage over using large amounts of narcotics that I noticed is the early extubation. So I use sufentanil now and the patients get extubated early. I never appreciated that technique much, but I've done it only 3 times.
Click to expand...

Sufent drips are the bomb, I try to use em whenever I can. Once you get good at titrating them you can time it so they wake up just when you want them to. I love using them in the neuro room w/crani's. We have one attending who loves to use them w/hearts so I'm looking foward to working with him next month
 
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