Narcotic administration in cardiac surgery cases

[Drwine]

I am curious what everyone is doing currently for narcotic administration in cardiac surgery cases? Are people using infusions or just giving boluses before times of stimulation?

Unfortunately sufantanil has been available for a long period of time. When I was a medical student and starting residency some attendings were still giving 2mg/kg of morphine. That later evolved to giving 5000-6000 ug fentanyl and later 1000-1500 mg sufentanil. When ERAS and early extubation became popular and sevoflurane the doses plummeted. Forty years ago the dogma was that inhalation anesthesia was to be avoided/minimalized in patients with critical heart disease and hospital stays were long.

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[PpfSuxTube]

50 suf for induction, 50 for sternotomy and about 200 to 250 total suf for almost every case.
Ppf infusion at 50
Sevo 1%
For off pumps I just bolus, on pumps I infuse cause I need to infuse txa anyways
We do a parasternal block at the end
We do eracs and extubate most inside about 5 hours. The goal is obviously 4 hours bit that mostly icu nursing driven and they need constant reminders... they often could extubate earlier just don't care to...

They always need the patient fully cooperative etc, I don't think I've ever had a patient in an OR meet the strict criteria they use prior to extubation... the icu nurses often do the precedex dance pre extubate, it makes them feel happy but just seems to waste 2 or 3 hours

I give 5 midaz the second they enter the OR. No particular reason other than, we get 10mg vials and I do 2 cases and don't wanna have to account for discarded MG... so everyone gets 5mg... I might start to cut it down... I kind of like the reassurance that I can cut down on my ppf a bit with the 5 midaz and still not have awareness... ive not noticed incr time to extubation or delirium with 5 midaz... some of my partners give 10 to 15

 

[psychbender]

Fentanyl usually 250mcg for the whole case. Maybe a little more for younger patients, those with chronic opioid use, or if they seem to need it. If I go through the whole 250mcg before bypass, may get another 100mcg fentanyl or 1mg dilaudid during rewarming. I have partners that still do 1000mcg fentanyl, plus 5mg versed routinely. Post-op pain seems no different between our two cohorts.

 

[kb1900]

Fentanyl usually 250mcg for the whole case. Maybe a little more for younger patients, those with chronic opioid use, or if they seem to need it. If I go through the whole 250mcg before bypass, may get another 100mcg fentanyl or 1mg dilaudid during rewarming. I have partners that still do 1000mcg fentanyl, plus 5mg versed routinely. Post-op pain seems no different between our two cohorts.

I have colleagues that give more than this for a 3 hour robot belly case routinely.

 

[vector2]

I'm usually giving about 150-250 mcg of fent earlier in the case, and depending on the patient 1-2 mg of dilaudid toward the end. I also routinely run precedex and very often give ketamine as an adjunct.

 

[Beeftenderloin]

I use methadone 0.3mg/kg (max dose 30mg). Half with induction, half before sternotomy. If patient looks a little more robust or acts a little more robust under anesthesia I may also give 100-250mcg fentanyl early on. No more than 2mg midaz, unless it’s a circ arrest, then ~5mg.

 

[abolt18]

My hearts usually get 500-750 fentanyl. 250 at incision, some upon rewarming and work some more in post bypass. Occasionally more prior to bypass. Where I trained, nearly everyone got a minimum of 1000mcg.

 

[anaesthetic]

Usually 250 mcg fentanyl +/- 2-5 mg midazolam depending on age. More fentanyl if they have room for it at the end. Multimodal stuff (acetaminophen, methocarbamol), blocks if mini, etc. Rarely need above 500 mcg of fentanyl but the occasional young, obese, hypertensive drug user with a type A dissection will get more. Usually reserve dilaudid for the ICU folks to figure out. Haven’t really used ketamine much outside of fellowship but probably not a bad adjunct.

I also trained where 5-10 mg midazolam/1000 mcg fentanyl for most patients was standard which I’ve found to be unnecessary in practice, but to each their own. Haven’t read the data on methadone but would be open to it. Used sufenta during fellowship which went okay. Just trying to avoid headaches from pharmacy currently.

 

[Iso4ane]

3mcg/kg rounded to nearest 50mcg on induction. Usually 0.1-0.2mg/kg methadone depending on robustness. Try to do blocks pre-incision. Maybe small doses of fentanyl if they respond to incision or sternotomy (max of 500mcg , because that how big my vials of fentanyl are).

 

[jwk]

I'll be the first to admit I don't do hearts, but I remember checking out 100ml of fentanyl during cardiac rotations. Funny how things have swung so far in the other direction. What we used to call "balanced anesthesia" is now "multi-modal". We throw everything at many of our patients - except narcotics. Blocks, NSAIDs, ketamine, steroids, propofol and lidocaine drips, methocarbamol, acetazolamide, etc. It's surprising what can be done without the use of any narcotics.

 

[pgg]

Typically around 250 mcg at induction, maybe 250 more around incision and sternotomy.

Typically finish the case somewhere in the neighborhood of 500-750 mcg.

Less if I'm also using ketamine.

 

[GassYous]

Where's my 10 of versed, 20 of fentanyl crew at

 

[coffeebythelake]

What blocks are u guys doing?

 

[pgg]

What blocks are u guys doing?

Nope

 

[Iso4ane]

What blocks are u guys doing?

PIF/TTP blocks. The PIF is no too dissimilar from like a PECS 2, just done parasternally.

 

[T-burglar]

Sedation for a line: 25 ketamine, 50 fent, 30 propofol

200 ish fent prior to CPB

Coming off another 25 ketamine, 100 fent, 2 midaz

Astronomical opioid doses are stupid

 

[brominator]

Pediatric cardiac: infants can get anywhere from 25 to 75 mcg per kg

 

[gunnershow]

Sedation for a line: 25 ketamine, 50 fent, 30 propofol

200 ish fent prior to CPB

Coming off another 25 ketamine, 100 fent, 2 midaz

Astronomical opioid doses are stupid

Why do you need sedation for a-lines? Those are induction doses for most cardiac patients.

 

[Arch Guillotti]

Sedation for a line: 25 ketamine, 50 fent, 30 propofol

 

[pgg]

Sedation for a line: 25 ketamine, 50 fent, 30 propofol

200 ish fent prior to CPB

Coming off another 25 ketamine, 100 fent, 2 midaz

Astronomical opioid doses are stupid

Why on earth are you sedating people to put in an IV (art line)?

Why give fentanyl prior to going on CPB? It's not a painful event.

 

[DesiredMemberName?]

I don’t need a GA for the a line, but if I’m about to have heart surgery, please don’t make me lie there sober while you place it. It’s not for the line itself, it’s for the fear of the surgery.

I’ll give 1-2mg versed for the a line. Then maybe another 1-2mg for CPB/rewarming.

Usually 250-500mcg fentanyl for the case. More in select cases if they’re really asking for it.

 

[T-burglar]

I never said I was very smart

 

[psychbender]

In the days at my old shop, we sedated for the CVC/PAC (on the table in the OR), and used similar doses. I'm also assuming that the 200mcg fentanyl prior to bypass means the total dose of fentanyl pre-bypass (induction, pre-sternotomy, etc), rather than given as a bolus just before going on pump.

 

[T-burglar]

In the days at my old shop, we sedated for the CVC/PAC (on the table in the OR), and used similar doses. I'm also assuming that the 200mcg fentanyl prior to bypass means the total dose of fentanyl pre-bypass (induction, pre-sternotomy, etc), rather than given as a bolus just before going on pump.

Bingo.

And why sedate for the a line? Why NOT sedate for the a line. Jesus . What are you accomplishing by doing it with some Xanax . Just knock them out ffs

 

[T-burglar]

Are your patients getting unstable and arresting all the time with some sedation?? What are you scared of

 

[Beeftenderloin]

Seriously. 4 people descend on them and place 20+ large, cold stickers on their naked body then I poke them, in a relatively sensitive area, with needles all the while they are laying their pondering their mortality for this (relatively) high risk surgery. As long as PA pressures aren’t starting 2/3 systemic, they can have (deserve) some sedation.

 

[DirtDocMD]

Fentanyl from 250ug up to 1000ug (250-500 most of time).

Versed usually approx 10mg. 2-3 to start, 2 to go on pump, 2 when warming, 2-3 for trip to ICU.

My CT surgeons are NOT fast, can’t always count on perfusion to run enough iso when on the pump, and ICU are more interested in charting than other issues.

Not trying to be overly critical of surgeons/staff/etc, but since fast wake-up is not a priority at my facility, I concentrate more on making sure pt doesn’t have recall during the case or upon arrival to ICU. Not really an issue for a 75-80y/o, but we’re doing enough 50-60 y/o’s, that it’s a concern. Horses for courses….

 

[IMGASMD]

I have colleagues that give more than this for a 3 hour robot belly case routinely.

I must be doing something wrong. 1g of fent for robotic belly?! They wake up?

 

[IMGASMD]

I use methadone 0.3mg/kg (max dose 30mg). Half with induction, half before sternotomy. If patient looks a little more robust or acts a little more robust under anesthesia I may also give 100-250mcg fentanyl early on. No more than 2mg midaz, unless it’s a circ arrest, then ~5mg.

That’s what I heard recently. Methadone really makes the wake up a smooth process. Never tried it, but by the way some of my older partners describing it, they are also convinced.

 

[PpfSuxTube]

Fentanyl from 250ug up to 1000ug (250-500 most of time).

Versed usually approx 10mg. 2-3 to start, 2 to go on pump, 2 when warming, 2-3 for trip to ICU.

My CT surgeons are NOT fast, can’t always count on perfusion to run enough iso when on the pump, and ICU are more interested in charting than other issues.

Not trying to be overly critical of surgeons/staff/etc, but since fast wake-up is not a priority at my facility, I concentrate more on making sure pt doesn’t have recall during the case or upon arrival to ICU. Not really an issue for a 75-80y/o, but we’re doing enough 50-60 y/o’s, that it’s a concern. Horses for courses….

That sounds brutal. How long does your day run?

 

[PpfSuxTube]

That’s what I heard recently. Methadone really makes the wake up a smooth process. Never tried it, but by the way some of my older partners describing it, they are also convinced.

We're thinking about trying it but we just rolled out eracs last yr and anything new in the mix might blow the icu nurses heads off... it's tough for them to change... theyre all still dying to start fent infusions the second they hit the icu... some won't attempt extubation for min 6 hrs... it's very annoying but some just won't change

 

[drmwvr]

Between the vaporizer on the pump and my propofol infusion, 2 mg of versed is all they need for recall....and they (can) get extubated in an hour or 2. And demonstrably less POCD in the populations most vulnerable to it.

 

[Bertelman]

We're thinking about trying it but we just rolled out eracs last yr and anything new in the mix might blow the icu nurses heads off... it's tough for them to change... theyre all still dying to start fent infusions the second they hit the icu... some won't attempt extubation for min 6 hrs... it's very annoying but some just won't change

Does no one care about STS metrics, early extubation?

 

[DirtDocMD]

That sounds brutal. How long does your day run?

Often takes 6-8 hours for a “straightforward” CABG. These ought to be 4-hour cases.

NOT a busy heart center, so luckily only doing 2-3 of these per month (150 hearts a year, divided between 8 Docs)

Yes, I would certainly cut back on the benzos, and likely the narcs, if these guys could do their work in a more timely fashion…

 

[Potatoman1800]

2 of versed before going to the OR - that's usually enough for art line placement (+/- 50 fentanyl). Once we get started I like to work in dilaudid - no more than 2mg and finish off the rest of the fentanyl. Precedex infusion. Extubate >90% on the table unless on lots of stuff and needing more resuscitation in ICU. Surgeons love it.

 

[Twiggidy]

1000mcg fentanyl and 5 of versed at most for most patients. People with “social habits” might get more and obviously little frail patients or super sick unstable patients get less

Since I work alone and have quite a bit experience I have no problem just sleeping someone for their a line unless again, super sick. I can use an ultrasound and get it in with them asleep probably a lot faster than fighting with them “sedated”

 

[Twiggidy]

Fentanyl from 250ug up to 1000ug (250-500 most of time).

Versed usually approx 10mg. 2-3 to start, 2 to go on pump, 2 when warming, 2-3 for trip to ICU.

My CT surgeons are NOT fast, can’t always count on perfusion to run enough iso when on the pump, and ICU are more interested in charting than other issues.

Not trying to be overly critical of surgeons/staff/etc, but since fast wake-up is not a priority at my facility, I concentrate more on making sure pt doesn’t have recall during the case or upon arrival to ICU. Not really an issue for a 75-80y/o, but we’re doing enough 50-60 y/o’s, that it’s a concern. Horses for courses….

This makes sense. You certainly have to compensate for a slow surgeon and if there’s cooling and warming.

 

[PpfSuxTube]

Often takes 6-8 hours for a “straightforward” CABG. These ought to be 4-hour cases.

NOT a busy heart center, so luckily only doing 2-3 of these per month (150 hearts a year, divided between 8 Docs)

Yes, I would certainly cut back on the benzos, and likely the narcs, if these guys could do their work in a more timely fashion…

It's a different topic but at such low volumes you would have to question these guys competence.

 

[PpfSuxTube]

Does no one care about STS metrics, early extubation?

I mean we do as the anesthesia and icu folk in charge but the rns certainly don't. Especially not the locum nurses we've had to rely on recently. And the locum nurses always get the easy straightforward cabgs that should be extubated inside 4 hrs... you couldn't trust them with the complex cases obviously

 

[pgg]

Seriously. 4 people descend on them and place 20+ large, cold stickers on their naked body then I poke them, in a relatively sensitive area, with needles all the while they are laying their pondering their mortality for this (relatively) high risk surgery. As long as PA pressures aren’t starting 2/3 systemic, they can have (deserve) some sedation.

OK

Not to be too argumentative ... but arguing is what I do, so what the hell

4 people aren't descending on my patients in preop and putting stickers on their naked bodies while I poke them. They're not even present because we're not even in the operating room. I talk to them about the anesthesia in preop, get consent, and then, with ultrasound and generous local, put an arterial line in. It's honestly less traumatic and bloody and unpleasant than some of the IVs some preop RNs put in.

It's also an opportunity to use my soothing voice and pleasant personality and finely honed motor skills to demonstrate my competence and confidence and put them at ease about the whole thing.

These fentanyl midazolam ketamine cocktails for an art line are just weird. I'm not saying it's unsafe or wrong, but it's just weird.

Central line goes in after they're asleep in the OR. I think an awake central line for heart patients is dumb and unnecessary 97%+ of the time.

I give most of them some midazolam either on the way to the OR, or shortly after arriving. I'm not a complete barbarian.

 

[PpfSuxTube]

1 These fentanyl midazolam ketamine cocktails for an art line are just weird.

2 I'm not saying it's unsafe or wrong, but it's just weird.

3 Central line goes in after they're asleep in the OR.

4 I think an awake central line for heart patients is dumb and unnecessary 97%+ of the time.

Agreed on 3 of 4 points.

I disagree re 2. It is unsafe... if one does enough of that nonsense for essentially a 20g IV, a patient will crump...
Ive seen it a couple times a year...
Hypoxia, and worse hypercabia in a bad heart and they can fall apart in front of you...

For anyone interested in some of our Tavis the co2 can climb to 70s, and PAs can jump to 70 80s too with that...

 

[Beeftenderloin]

OK

Not to be too argumentative ... but arguing is what I do, so what the hell

4 people aren't descending on my patients in preop and putting stickers on their naked bodies while I poke them. They're not even present because we're not even in the operating room. I talk to them about the anesthesia in preop, get consent, and then, with ultrasound and generous local, put an arterial line in. It's honestly less traumatic and bloody and unpleasant than some of the IVs some preop RNs put in.

It's also an opportunity to use my soothing voice and pleasant personality and finely honed motor skills to demonstrate my competence and confidence and put them at ease about the whole thing.

These fentanyl midazolam ketamine cocktails for an art line are just weird. I'm not saying it's unsafe or wrong, but it's just weird.

Central line goes in after they're asleep in the OR. I think an awake central line for heart patients is dumb and unnecessary 97%+ of the time.

I give most of them some midazolam either on the way to the OR, or shortly after arriving. I'm not a complete barbarian.

Unfortunately you won’t find too much disagreement here. My work-flow is just different. Patient gets all their stickers and pre-induction art line on OR table with a circuit mask on their face so I can induce as soon as the art line is in. Intro+swan always after asleep. I’m typically giving 1-2mg midaz on arrival to OR, +/- 50mcg of fentanyl if they’re being a big baby or won’t stop talking. And this is with a fully monitored patient in OR with supplemental O2 via circuit mask and ETCO2.

I disagree re 2. It is unsafe... if one does enough of that nonsense for essentially a 20g IV, a patient will crump...
Ive seen it a couple times a year...
Hypoxia, and worse hypercabia in a bad heart and they can fall apart in front of you...

Patient selection is key. Not everyone gets sedation. Someone with near systemic PAPs or high baseline supplemental O2 requirements gets their line wide awake. The vast majority of my patient population has no trouble tolerating a few minutes of mild-moderate sedation before going to sleep and having their (typically mild) hypercarbia corrected on the vent.

 

[pgg]

There's also a difference between sedating a person for lines when they're in the OR on the table with a circuit mask on their faces, and doing it in some preop bay - and then the patient sits there for 10 or 20 minutes while the OR gets ready for them.

I disagree re 2. It is unsafe... if one does enough of that nonsense for essentially a 20g IV, a patient will crump...

As he says, you've got to choose wisely.

I choose not to do it.

I do most of my blocks without sedation too. Some places / people do their pre-TKA adductor canal blocks with a midaz/fent/ketamine cocktail. I don't see the point.

I think midazolam is the most overused drug we have. Except maybe dexmedetomidine.

 

[kb1900]

Only a trainee but yeah I have never gotten more complements on a-line from patients than my 0-2 midaz pre-induction a-line with generous local and US guidance. I mean some of the patients are so sick they should walk around with an art line and anesthesiologist. I love pre-induction Alines. Probably the most satisfying procedure for me. And I think it’s great as it allows the attending to be comfortable with me inducing as a trainee in these cardiac cripples.


My cardiac attendings definitely are 50/50. Most will induce as soon as they walk into the room and see the monitors or expect me to push induction meds and soon as tegederm goes on. It’s maybe 5 minutes from in the room to tubed here if we have nurses that help with getting on the bed and stickers/monitors. I definitely have attendings that are annoyed I don’t give more for my art lines but most don’t care because it’s literally a 15 second procedure. The meds are for the environment and stress more than anything else which is why, if it’s safe and planned, I give midaz as we’re rolling back. I would never give fentanyl. Makes no sense to me


I’m sure my practice will change with time

 

[abolt18]

Only a trainee but yeah I have never gotten more complements on a-line from patients than my 0-2 midaz pre-induction a-line with generous local and US guidance. I mean some of the patients are so sick they should walk around with an art line and anesthesiologist. I love pre-induction Alines. Probably the most satisfying procedure for me. And I think it’s great as it allows the attending to be comfortable with me inducing as a trainee in these cardiac cripples.


My cardiac attendings definitely are 50/50. Most will induce as soon as they walk into the room and see the monitors or expect me to push induction meds and soon as tegederm goes on. It’s maybe 5 minutes from in the room to tubed here if we have nurses that help with getting on the bed and stickers/monitors. I definitely have attendings that are annoyed I don’t give more for my art lines but most don’t care because it’s literally a 15 second procedure. The meds are for the environment and stress more than anything else which is why, if it’s safe and planned, I give midaz as we’re rolling back. I would never give fentanyl. Makes no sense to me


I’m sure my practice will change with time

Never say never!

 

[Arch Guillotti]

pre-induction art line on OR table with a circuit mask on their face so I can induce as soon as the art line is in.

This sounds terribly inefficient.

 

[sevoflurane]

2mg versed/50mcg fentanyl for aline/around induction.
0-100 mcgs right before sternotomy.
10-20 mg of Methadone before bypass.
Precedex started 10 min before AoCx removed.
+/- 0-100 mcgs of fent once Mac is below .5 and we’re about to head to ICU.

*All patient age/history/comorbidity dependent. I am more conservative on big cases. (ie. double valve low EF on a 70+ y/o patient)

 

[Bertelman]

This sounds terribly inefficient.

Explain, please

 

[sevoflurane]

I will never again do lines in pre-op on awake patients.
Patients hate it, i hate it… little to gain.
Mount Sinai in Florida used to do that.
Not a fan. Little upside, lots of downsides.

 

[abolt18]

2mg versed/50mcg fentanyl for aline/around induction.
0-100 mcgs right before sternotomy.
10-20 mg of Methadone before bypass.
Precedex started 10 min before AoCx removed.
+/- 0-100 mcgs of fent once Mac is below .5 and we’re about to head to ICU.

*All patient age/history/comorbidity dependent. I am more conservative on big cases. (ie. double valve low EF on a 70+ y/o patient)

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