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- Feb 5, 2010
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Middle aged male for enucleation of prostate. Has non-compaction cardiomyopathy with EF of 15% and an LVAD.
I'm not a cardiac guy so always treat these with kid gloves. Pre-induction art line and 16 g PIV placed in the forearm under ultrasound for vasoactives should I need them.
I've had similar patients crump before just by cracking a vial of propofol across the room, so after hooking up monitors and placing a Sedline I started with 0.5mg midaz and 10 mg prop. Waited thirty seconds, nothing happened, BP stable, great, another 10 mg of prop. Waited a minute, guy still responsive, gave him another 20mg, rinse and repeat.
By the time I almost got to the end of my first stick, and the guy would still open his eyes and give me a thumbs up, and his Sedline spectral edge was essentially unchanged, I started to sweat a little bit. Could the IV not be working? Skin felt great, carrier flew like a champ, he never complained once with the pushes, and I had been giving small bumps of phenylephrine throughout which would immediately bump his pressure.
Still, I went to the other arm and placed a new IV and started stick of propofol number 2. By the time 400 mg of propofol was in, he was sleepy and hypopneic, but still opening his eyes to his name. At this point I didn't really know what to think. Hemodynamics were fine, LVAD function great, he was clearly sleepier and there was a slow trend of the spectral edge downward. I thought about breathing him down on vapor but at this point we're literally like 25 minutes into the induction and I didn't want to go down the inhalation route if I didn't have to. I switched over to etomidate 2mg at a time, and it seemed like it was having a more pronounced effect on his mental status, so gave a total of 10mg at which point he became unresponsive.
I've never given this much for any patient, let alone one with severe LV dysfunction. I still don't really understand what happened. Maybe I was going so slow that I didn't even really build up a plasma concentration of propofol? The entire process from start to intubation was literally like 40 minutes. Totally crazy stuff.
I'm not a cardiac guy so always treat these with kid gloves. Pre-induction art line and 16 g PIV placed in the forearm under ultrasound for vasoactives should I need them.
I've had similar patients crump before just by cracking a vial of propofol across the room, so after hooking up monitors and placing a Sedline I started with 0.5mg midaz and 10 mg prop. Waited thirty seconds, nothing happened, BP stable, great, another 10 mg of prop. Waited a minute, guy still responsive, gave him another 20mg, rinse and repeat.
By the time I almost got to the end of my first stick, and the guy would still open his eyes and give me a thumbs up, and his Sedline spectral edge was essentially unchanged, I started to sweat a little bit. Could the IV not be working? Skin felt great, carrier flew like a champ, he never complained once with the pushes, and I had been giving small bumps of phenylephrine throughout which would immediately bump his pressure.
Still, I went to the other arm and placed a new IV and started stick of propofol number 2. By the time 400 mg of propofol was in, he was sleepy and hypopneic, but still opening his eyes to his name. At this point I didn't really know what to think. Hemodynamics were fine, LVAD function great, he was clearly sleepier and there was a slow trend of the spectral edge downward. I thought about breathing him down on vapor but at this point we're literally like 25 minutes into the induction and I didn't want to go down the inhalation route if I didn't have to. I switched over to etomidate 2mg at a time, and it seemed like it was having a more pronounced effect on his mental status, so gave a total of 10mg at which point he became unresponsive.
I've never given this much for any patient, let alone one with severe LV dysfunction. I still don't really understand what happened. Maybe I was going so slow that I didn't even really build up a plasma concentration of propofol? The entire process from start to intubation was literally like 40 minutes. Totally crazy stuff.