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oh good...I've been working on being more direct.
Narcotic administration in cardiac surgery cases
Started by Drwine
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Cool to see all the different practices.
Personally I run precedex 0.3 mcgs/kg from the start, increasing to 1 when wires go in. Only give midaz to young patients (55 and younger), or whos anxiety is cranking up the catecholamines. 250 of fent on induction, 250 on sternotomy, 500 on transport.
Personally I run precedex 0.3 mcgs/kg from the start, increasing to 1 when wires go in. Only give midaz to young patients (55 and younger), or whos anxiety is cranking up the catecholamines. 250 of fent on induction, 250 on sternotomy, 500 on transport.
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If I haven’t given 1000 fent by the end, I feel a little incomplete.
I waste narcotics in the patient.
Joking aside, it’s for the ICU nurses. Provides a good 45-hour of sedation; nurses can get the patient “tucked in” without worrying about them flailing around.
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Honestly if we had to wait for a patient to obey as well as some cardiac icu nurses pre extubation there wouldn't be more than 1 case done in any OR in the entire world. Some of em want the patients to bloody write a novel while calmly intubated...
There’s a predictable and transient bump on the levophed during transport, no doubt. If I were practicing in a vacuum, most would go up on a prop gtt.
I agree, unfortunately the CT ICUs at these shops have poor/no intensivist involvement. As I’m sure many have seen, you need to treat the nurse / surgeon at times.
As an intensivist, that's quite frustrating. When I came to my current shop, I was quite aggressive, and able to get nursing buy-in (by being very involved in all aspects of care, and charming when doing what I wanted, rather than be an dingus). As a result, our average time to extubation was reduced by about two hours.
So the transient need for inopressor from the universally described MAP dump on going from the table to the ICU bed (@ nimbus) or from the narcotic hit? Or both? That universal fall in blood pressure is well anticipated and has been postulated as being 2/2 release of sequestered acidotic blood on the move off of the table. Pure speculation, never seen a paper on it, but it's a thing. Can imagine how a whack of fentanyl would exaggerate it.
Nah. Sometimes I bolus a smidge of prop on the walk to the until. Icu nurse has prop drip waiting on arrival
I am resurrecting this thread to see if people have changed their fentanyl usage in the last 2 years. How many are doing blocks? Anyone using fentanyl infusions?
I went backwards. Used to do (relatively low volume) TTP blocks. Old surgeons would complain it made their LIMA harvest like “dialysis tissue”. Stopped doing them. They’ve never asked me to do them again. Whatever. They did work though.
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At a new place this year, but still mostly the same regarding narcotic dosing. I could probably be more heavy handed, as the ICU staff here don't know how to wean in a timely fashion, and always go up on my sedation after I leave, rather than work on getting the tube out.
No infusions. No blocks. But I've definitely decreased my opioid use for hearts. Used to be 500-750 for most hearts. Now usually more like 250-500 (closer to 250). Seen no major difference. I rely a little more heavily on sevo earlier in the case. Turn the gas off when they start closing subq layer and work in more fentanyl 50mcg at a time as BP or HR rise (precedex already running). Makes the transition to ICU smooth, as they don't suddenly get hypertensive due to blowing all the gas off on the way to the ICU.
I’m in a new spot this year. Added ESP blocks to my routine before induction, it can be tricky if BMI > 40 and don’t do it for all (not for emergencies). It works great and a good block is obvious due to lack of BP spike with incision, often I’ve given under 100-200 mcg fentanyl the whole case. I don’t use a fentanyl infusion (and already barely have enough pumps to do my work), just check out the context-sensitive half-life graph for an explanation. I seldom use more than 250 mcg fentanyl for the whole case.
I haven’t been as impressed with TTP (aka PIF) blocks, seems like those patients still have a good deal of pain post-extubation. Also the last thing I want to do at the end of a long cardiac case is a block.
Our ICU is in no rush to extubate people either.
I think part of that is the PIF often isn’t covering the chest tube sites
Damn, are you not using local for your a-lines?
Who out there is using methadone for cardiac cases? What doses are you giving? When are you giving? Are you giving any additional narcotics? Are you doing any blocks in addition (especially for minis)? Are you extubating on table after methadone? And finally…if needed, is ICU giving additional methadone or their usual postop pain meds
I've seen a variation of rectus sheath, TAP, or external oblique blocks for chest tubes.
What is your go-to for covering chest tube pain?
In my practice, heavy sedation before allows it to set in for the couple minutes it takes for the a-line, then your induction dose can be really very small and hemodynamically well tolerated.
Can also do this before the ESP block at the start of the case, same effect and then a-line post-induction if that’s your fancy.
Are you doing these a lines in the OR just before induction?
We do them in preop, no sedation, just local.
I've added it now that I work somewhere that has methadone on formulary and reliably available. Almost everyone gets 20mg worked in about 5 min before incision. Works well, and no need to re-dose. If I use methadone, I don't need any additional narcs during the case, and the ICU typically will use fentanyl or dilaudid afterwards.
Surgeons I worked with previously would perseverate endlessly about narcotics, blaming postop ileus on as little as 300mcg of fent for a CABG. I ended up using a fair amount of ketamine and ESP blocks, and would end up giving 100-200mcg for a typical cabg.
Current regimen is ESP blocks prior to induction, 20mg methadone, precedex 0.4-0.6mcg/kg/hr, plus sevo. I do typically give 20-50 ketamine on induction, but I think it's got a negligible analgesic effect post-bypass. If I didn't have methadone, I'd usually end up using about 250 of fent or 50 of sufent.
Interesting
We do all of ours in preop. I don't think I've ever sedated anyone for an arterial line. Ultrasound for everyone. If the vessel doesn't look great I'll just go brachial with a micropuncture kit from the start. Even that isn't a miserable experience. I leave a lot of radial arteries unmolested based on an ultrasound look. Generous local.
I'm not sure if I'd actually prefer to do them in preop or in the OR. I guess doing them in the OR would spare us the very (very) rare metric hit on anesthesia-faulted delays, if it's an exceptionally difficult line to get in.
I heard (2nd or 3rd hand) that a new surgeon here floated the idea of asking everyone to do them in the OR, supposedly to track some time-to-place metric. But it wasn't clear to me why anyone cares about that, especially since the current standard is to put the line in before they get to the OR. Maybe they just favor the sterile OR environment - but it's just an art line.
Reduced by 2 hours to how many hours?
To a little over two hours. The norm used to be in the four to six range, with a handful getting extubated just past the six hour mark and messing up the metrics.
Were averaging 4hrs for suitable patients. Some of my colleagues do OR extubations but ive no interest in that
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Neat
I just got risk reported by an ICU nurse because I reversed a post-CABG patient upon arrival in the ICU, the patient passed a spont breathing trial 15 minutes later, and got uneventfully extubated.
We're meeting on Thursday so all stakeholders can synergize their feelings and leverage their core competencies concerning sedation and paralytic use.
I thought about being a little more passive aggressive and extubating the next one in the OR, but that might've been a step too far. The hell of it is, I'm totally happy to use whatever sedation +/- paralytic regimen they prefer, but their preferred form of communication seems to be risk reports. Hopefully the new ICU scheme and regime will make everyone happy.
I've been told that in-OR extubations are undesirable, because it removes the lowest risk and lowest-hanging fruit from the <6hr extubation metric, and risks making those numbers look bad. I wish I was making that up.
Meanwhile, in residency my attending had me wake up and extubate a heart transplant recipient in the OR. After the fact I realized why they had me do it: the ICU would have kept the patient intubated and sedated for days.
Literally the only issue that patient had was a genetic conduction system issue with their native heart that had declared itself less than 6 months prior.
Wow thats some crazy stat altering stuff. I dont like it cause it adds maybe 30 mins to my day but we never let anyone leave icu on pod0 so theres no real system benefit. If we do get to simple cases leaving icu pod0, then if may consider it again...
Im not sure the nurses like it either really cause they dont have time to do their charting etc. Plus its a huge new development they have minimal experience with. The rts aren't around, there overall slightly less support
Apart from our CTICU, our other ICUs object to accepting patients direct from the OR if they've been extubated, instead insisting they go to PACU first. So we can take an ICU patient direct to the OR, do a case, extubate them, and need to stop off in PACU first.
This is because they don't have staff to be 1:1 for phase 1 recovery, so all arrivals need to be either intubated or already meeting phase 2 criteria. This does make a certain level of sense to me, but it still seems weird. I would have thought there was always enough staff flex for an ICU RN to be 1:1 with a patient for at least a little while.
Not a hill to die on, in any case. Truth be told, it's a lot easier for us to drop off patients in PACU than the ICU.
LOL
One of the few times I think a meeting might actually be useful. 🙂 I'm not sure why the post CT surgery Precedex infusion +/- some residual roc that's been fine for the last 4 years is suddenly a problem. But I guess that's why we're meeting.
Overall, the program is making a turn for the better. The new CT surgeon who was hired to be the new program director is excellent. We've all been very impressed. The consultants rebuilding the program seem calmly competent in every way, and administration is even listening to them.
Yeah local becomes optional. Another benefit .
We are in the operating room before any lines are placed also, if that wasn’t obvious.
Another person said then induction can be smaller doses of everything because they’ve had a few minutes to let the line sedation reach peak effect. Which is why I like this sequence for a standard heart case.
Again, there do exist cases where I think it’s unsafe to provide much sedation before I can see continuous blood pressure but they are few and far between.
Post-induction lines on everyone except the absolute sickest, think tamponade. 100 mcg fent for the case. Esmolol and nitroglycerin boluses for the sternotomy, with glyco drawn up for frequent peri-sternotomy and peri-pericardiotomy bradycardia. Propofol infusion plus 5 of midaz plus 50 of roc on initiation of CPB (we've had a couple of patients move 5-20 min after being placed on bypass, which I suspect was due to the switchover from Sevo on the anesthesia machine to Iso on the CBP machine, we use all Iso now). Continue Prop infusion to ICU.
Double stick neck with CCO Swan for all (surgeon and ICU request), though it seems we've finally convinced the ICU to go with the single stick MAC.
Rarely need pacing for more than 20 min post bypass.
Great program overall
Double stick neck with CCO Swan for all (surgeon and ICU request), though it seems we've finally convinced the ICU to go with the single stick MAC.
Rarely need pacing for more than 20 min post bypass.
Great program overall
Normal physiologic reaction to slicing through the chest and triggering a bunch of pain receptors is hypotension & bradycardia, right?
I mean I never see patients have increases in HR or BP with painful stimuli. <end sarcasm>
I suggest they submit a paper for the high incidence of Bezold-Jarisch reflex of their patient population. 🙄
I’ve seen it three times in the past few years (one with transient asystole). Stretch from sternal retraction (not sternotomy) stimulating vagus nerve in parasympathetic predominant patients (young, active guys with bad CAD). It happens. Usually not a big deal with cessation of retraction.
I’ve seen the reflex too. (Which is why I mentioned it.)
Clearly you missed the point of the overall sarcastic reply.
I see good old SDN hasn’t changed much.
Neither have I.
I never particularly cared about how “normal people” were doing it, which is why I was maxing out at 250 mcg of fentanyl when I finished fellowship, and everyone around me was still using old-school 2,500 mcg doses as their starting point. Now, no one I know is using more than 250. 🤔
Opiates are still way overdosed in anesthesia, and hyperalgesia is a class effect, with sufenta probably having the least. I disagree with my peers who claim that asleep patients don’t benefit from small doses. Ok. I don’t necessarily disagree with the concept, I just find that a small, 25-50 mcg dose of fentanyl up front does make my job way easier.
I’m not surprised that you haven’t encountered the bradycardia that can come from sternotomy and pericardiotomy (and yes sternal stretching) if you’re obliterating parasympathetic reflexes with opiates. (Yes it blunts both sympathetic and parasympathetic, no matter what the book might say).
And, since I wait to see how the patient is going to respond to the various stimuli before administering meds, no it’s not coming from the esmolol and/or nitro.
Neither have I.
I never particularly cared about how “normal people” were doing it, which is why I was maxing out at 250 mcg of fentanyl when I finished fellowship, and everyone around me was still using old-school 2,500 mcg doses as their starting point. Now, no one I know is using more than 250. 🤔
Opiates are still way overdosed in anesthesia, and hyperalgesia is a class effect, with sufenta probably having the least. I disagree with my peers who claim that asleep patients don’t benefit from small doses. Ok. I don’t necessarily disagree with the concept, I just find that a small, 25-50 mcg dose of fentanyl up front does make my job way easier.
I’m not surprised that you haven’t encountered the bradycardia that can come from sternotomy and pericardiotomy (and yes sternal stretching) if you’re obliterating parasympathetic reflexes with opiates. (Yes it blunts both sympathetic and parasympathetic, no matter what the book might say).
And, since I wait to see how the patient is going to respond to the various stimuli before administering meds, no it’s not coming from the esmolol and/or nitro.
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There is no pain under anesthesia, by definition.
Follow the history of intraoperative opiates in anesthesia. Early cardiac anesthesia favored high-dose opiates because the prevailing wisdom was that halothane was bad for the cardiovascular system, and it also sensitized the heart to arrhythmias when catecholamines were given. Isoflurane replaced halothane in adults because surgeons couldn't accuse us of halothane hepatitis when they gave blood products liberally before hepatitis C testing. Look at the exponential increase in fentanyl use that accompanied the transition to isoflurane because it is a mediocre anesthetic to titrate to varying levels of surgical stimulus. We now have sevoflurane, which is much more rapidly titratable and can allow for much less need for narcotics. I compare the evolution from halothane to isoflurane to sevoflurane to the evolution from incandescent light bulbs to fluorescent to LED.
Very possible today with the agents and techniques we have today, but it is much easier to make it smoother with judicious administration of small doses of narcotics. Opioid-free anesthesia has become a religious cult.
