Meds where infusion rate matters

[Iso4ane]

That’s when the scorpion and the chicken foot are your friends.

View attachment 361457

But Scorpions have eights legs...either way new favorite name for these things. I've also heard them called Beetles.

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[anbuitachi]

txa we routinely bolus, undiluted, for total joints. no infusions needed. usually 1g.
magnesium 2mg bolus, not really a problem, torsades, eclampsia

 

[woopedazz]

txa we routinely bolus, undiluted, for total joints. no infusions needed. usually 1g.

Vomiting an issue?

 

[Beach bum]

Phenytoin is funny, it should go in by itself in its own IV. It'll precipitate and turn the IV tubing into concrete when mixed with lots of other drugs. Mostly acidic ones, IIRC.

When was the last time you gave Dilantin iv in the OR??? Maybe for dig toxicity?? Kind of surprised have a young cardiologist at my shop using dig. Before that it only the old guys…. Seems like Keira has replaced except for maybe some off label use??

 

[pgg]

When was the last time you gave Dilantin iv in the OR??? Maybe for dig toxicity?? Kind of surprised have a young cardiologist at my shop using dig. Before that it only the old guys…. Seems like Keira has replaced except for maybe some off label use??

I was a resident. Maybe 2008 or 2009?

 

[PpfSuxTube]

What in the world are you pushing ephedrine (aka levo flavored La Croix) for in a CV case? You’ve got levo hanging. Just pull some off the bag and dilute to push dose.

Sure i could but the tech draws up ephedrine and it works fine so theres that..

We dont hang any vasoactive meds for a lot of our cabg/opcab cases... probably only 10-20%

 

[anaesthetic]

Sure i could but the tech draws up ephedrine and it works fine so theres that..

We dont hang any vasoactive meds for a lot of our cabg/opcab cases... probably only 10-20%

I don’t use ephedrine or phenylephrine on any hearts, but that’s just my preference. I think the indirect agonist activity/response is too unpredictable and pure alpha-1 agonism increases (in theory) LV afterload which is the opposite of what you want in a sick heart trying to come back to life. That being said, I’ve used both throughout training, and it goes okay.

I hang epi/norepi for every single heart because I don’t want to be scrambling in a pinch if the RCA takes some air or if we run into sudden bleeding. Also, I think our ICU would flip out if I came up with no drips ready to go. The nurses there are greener than grass and would take 10x longer to grab vasoactives from whatever Omnicell/Pyxis they have which always happens to be too far away and with one too many barcodes to scan.

 

[Beeftenderloin]

Sure i could but the tech draws up ephedrine and it works fine so theres that..

We dont hang any vasoactive meds for a lot of our cabg/opcab cases... probably only 10-20%

Interesting. I’ve seen/done hearts at 5 different hospitals and with rare exception there is virtually always at least a bag of levo hanging (among other things). Maybe a few young, otherwise healthy HOCM patients coming for septal myectomy that I just had some phenylephrine hanging.

At my current institution I don’t even get asked. It’s protocolized. Levo, insulin, prop, precedex, amicar hanging for everyone, every time.

 

[anbuitachi]

Vomiting an issue?

nope

 

[anbuitachi]

When was the last time you gave Dilantin iv in the OR??? Maybe for dig toxicity?? Kind of surprised have a young cardiologist at my shop using dig. Before that it only the old guys…. Seems like Keira has replaced except for maybe some off label use??

some neurosurgeons request it so ive given not that long ago

 

[deleted1147063]

Whenever in doubt, whenever it's not a medication I know well, I just give it over 5-10-30 minutes from the syringe, with carrier fluid slowly running (pseudoinfusion). Even something like 200 mg sugammadex can give near-code bradycardia when bolused, in some patients.

I seldom see side effects. Why be a cowboy if one doesn't have to? Also, giving a medication in fractional doses decreases the chances of a bad outcome if one administers the wrong medication (to err is human).

I even give phenylephrine as 50 mcg, at first, especially in elderly or ASA 4. One can always give more, but one cannot take it back. If OK, I'll give the other 50 after a minute or two. Some patients like 50-100, some patients 200, and I like my coronaries.

 

[Ezekiel2517]

Not sure if it was mentioned already but, Pitocin

 

[Beeftenderloin]

This is exactly what I was looking for. Thanks!

What about in OB patients? We give TXA for C/S occasionally. Most of those patients haven't had any midaz/prop. Would you drip it in slowly for them?
I know seizures is the known side effect from TXA, but what's less clear is whether that is from a bolus load to the CNS or whether it has more to do with the long term effects of the meds. There's plenty of data showing increased ICU seizure rates in post-bypass patients who got TXA, and obviously those patients are asleep when they get TXA.

This is a fair point. My group uses amicar exclusively in open hearts for this reason. Supposedly fewer seizures in ICU, no accumulation in renal failure, etc. Which is sort of ironic because some data show worse renal function post-op with amicar relative to TXA.

For the bleeding parturient: if I’m giving TXA it’s because they are hemorrhaging. In that moment the TXA induced seizure is theoretical, the blood pooring out of her uterus is real. I just hang it to gravity.

 

[anbuitachi]

Not sure if it was mentioned already but, Pitocin

its always wide open after delivery in or for us. thru 18g iv. plus IM pit

 

[deleted1147063]

its always wide open after delivery in or for us. thru 18g iv. plus IM pit

But it's pre-diluted by the pharmacy.

 

[Ezekiel2517]

its always wide open after delivery in or for us. thru 18g iv. plus IM pit

Yah but there are folks who put 20 in the bag or 30 or 40, etc. There's also folks who don't do any drip and just use straight boluses. There's also stuff like this "rule of 3's" for pitocin: Randomized, Double-blinded Trial of a “Rule of Threes” Algorithm versus Continuous Infusion of Oxytocin during Elective Cesarean Delivery

 

[Radar26]

I’ve definitely seen nausea and even vomiting when slamming in ancef during MAC cases, especially in the neuro patient population. I’ll push it slow if I’m reconstitute it into a syringe…

 

[PpfSuxTube]

I don’t use ephedrine or phenylephrine on any hearts, but that’s just my preference. I think the indirect agonist activity/response is too unpredictable and pure alpha-1 agonism increases (in theory) LV afterload which is the opposite of what you want in a sick heart trying to come back to life. That being said, I’ve used both throughout training, and it goes okay.

I hang epi/norepi for every single heart because I don’t want to be scrambling in a pinch if the RCA takes some air or if we run into sudden bleeding. Also, I think our ICU would flip out if I came up with no drips ready to go. The nurses there are greener than grass and would take 10x longer to grab vasoactives from whatever Omnicell/Pyxis they have which always happens to be too far away and with one too many barcodes to scan.

We have very experienced nurses, mostly great surgeons that are fast and a good supply of normal ventricles with severe 3vd.

I used to work at ivory tower with all that stuff but happier with my current set up