Narcotic administration in cardiac surgery cases

Started by Drwine
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These replies always make me chuckle at how places can vary so widely across the country. I’m sure each person is convinced their way is best too!

Narcotic-free anesthesia is possible but also terrible for a lot of surgeries that aren’t of an extremity Try it sometime and see how your vitals widely vary (probably not properly anesthetized) and PACU pain scores are typically sky high… then treated with quick repeated narcotics anyway!
 
AdmiralChz said:
These replies always make me chuckle at how places can vary so widely across the country. I’m sure each person is convinced their way is best too!

Narcotic-free anesthesia is possible but also terrible for a lot of surgeries that aren’t of an extremity Try it sometime and see how your vitals widely vary (probably not properly anesthetized) and PACU pain scores are typically sky high… then treated with quick repeated narcotics anyway!
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But some people also give opioids for nonpainful cases where they are completely unnecessary, eg av fistulas, afib ablations, etc. These patients do very well with zero opioids in Cath lab/OR and PACU, yet some people insist on “working in” some fentanyl with no clear rationale.
 
The downsides of opioids are overblown. So someone got 100 mcg of fentanyl for an AV fistula they “didn’t need”. Who gives a ****.

It will make no difference to their outcome. Similarly, not that I personally do this, but a one time mammoth exposure to opioids for a big surgery is also not going to make a difference of any kind in the long run. It is meaningless to the outcome next to the skill of the surgeon, quality of the ICU care, and quality of the protoplasm.
 
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T-burglar said:
The downsides of opioids are overblown. So someone got 100 mcg of fentanyl for an AV fistula they “didn’t need”. Who gives a ****.

It will make no difference to their outcome. Similarly, not that I personally do this, but a one time mammoth exposure to opioids for a big surgery is also not going to make a difference of any kind in the long run. It is meaningless to the outcome next to the skill of the surgeon, quality of the ICU care, and quality of the protoplasm.
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If it makes no difference in outcome, there is no reason to give it. Why would you give something that makes no difference? Like fighting hypotension during prep? Habit?
 
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cittykat said:
That was my point. That’s why I don’t give opioids at induction for nonpainful procedures.
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Ok, I’ve reread your post. I think there are two ways of interpreting it.

I originally interpreted it as fighting hypotension during prep makes no difference in patient outcome.

But I think you meant it as you should only give opioids at induction if you like dealing with hypotension at prep.
 
Dantrolene FC said:
Ok, I’ve reread your post. I think there are two ways of interpreting it.

I originally interpreted it as fighting hypotension during prep makes no difference in patient outcome.

But I think you meant it as you should only give opioids at induction if you like dealing with hypotension at prep.
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Yes. Sorry my post wasn’t clear.
 
periopdoc said:
There is no pain under anesthesia, by definition.
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So youre giving fentanyl to someone for no reason then?

Be aware when you say ****ty things like this to colleagues, you open yourself to ridicule. So genius, why are you giving opiates needlessly?

If you have patients moving on cpb and you dont know why but you think iso is the cause and solution, your program is not great "by definition "
 
periopdoc said:
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.
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This is wierd, substandard care and when you have your case of awareness court case you will get destroyed.
Since eracs fent doses have reduced substantially but @ 100 for the whole case you are an extreme outlier. Most are under 1mg but none this low ive ever heard of. Tread carefully. Considering the average eracs patient gets around 20mg morphine in the 1st day of icu stay i dont know what your goal is. You're not including any adjunct or regional so
 
PpfSuxTube said:
What is a non painful procedure that requires a GA? Mri or something?

This is a cardiac thread btw.... do you do a lot of cardiac?
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I did cardiac (70-80 cases/year) for 20 years but I stopped 5 years ago. I trained when it was typical to give 2-3mg of fentanyl for a pump case. In practice I usually gave 200-250mcg for a pump case. I mentioned nonpainful procedures earlier in this thread, specifically afib ablations and av fistulas. They get zero opioids intraop or in PACU because they don’t need any. The rare exception is a EP lab patient with chronic low back pain who needs a small dose of fentanyl in pacu because they need to lie flat for 4 hours. For the record, I’m a big fan of opioids for analgesia in painful procedures. But I’m not a fan of overdosing.
 
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cittykat said:
I did cardiac (70-80 cases/year) for 20 years but I stopped 5 years ago. I trained when it was typical to give 2-3mg of fentanyl for a pump case. In practice I usually gave 200-250mcg for a pump case. I mentioned nonpainful procedures earlier in this thread, specifically afib ablations and av fistulas. They get zero opioids intraop or in PACU because they don’t need any. The rare exception is a patient with chronic low back pain who needs a small dose of fentanyl in pacu because they need to lie flat for 4 hours. For the record, I’m a big fan of opioids for analgesia in painful procedures. But I’m not a fan of overdosing.
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I find that even in non painful cases, opiate often helps smooth out an anesthetic and reduce requirements for other sedative/hypnotic agents. I don't see the advantage of giving zero opiates vs 100mcg of fentanyl or even 200 for a longer case even if non painful. Especially in a hospital setting with a long discharge process anyhow. Very often opiate is a pleasant experience for the patient. If I were a patient I would be happy to receive opiate.
 
Hoya11 said:
I find that even in non painful cases, opiate often helps smooth out an anesthetic and reduce requirements for other sedative/hypnotic agents. I don't see the advantage of giving zero opiates vs 100mcg of fentanyl or even 200 for a longer case even if non painful. Especially in a hospital setting with a long discharge process anyhow. Very often opiate is a pleasant experience for the patient. If I were a patient I would be happy to receive opiate.
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In my experience there is more intraop hypotension and higher vasopressor requirement when unnecessary opioids are given. They often make things less smooth not more. Patients also have better respiratory drive and are more clear headed in PACU. I trained in a very opioid heavy program where every patient had opioids titrated to a RR of 10-12 before extubation. Only after I finished training and started trying other things did I realize that opioids were not always desirable.
 
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While this is a very nice conversation it has absolutely nothing got to do with the subject matter so maybe start another thread for that? If anything this may be confusing for ppl, it may even be harmful for cardiac surgery patients.
cittykat said:
In my experience there is more intraop hypotension and higher vasopressor requirement when unnecessary opioids are given. They often make things less smooth not more. Patients also have better respiratory drive and are more clear headed in PACU. I trained in a very opioid heavy program where every patient patient had opioids titrated to a RR of 10-12 before extubation. Only after I finished training and started trying other things did I realize that opioids were not always desirable.
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PpfSuxTube said:
Im saying its wierd care when the average cardiac patient gets tonnes of opiod in icu.
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OK that's maybe fair but you said -

PpfSuxTube said:
substandard care and when you have your case of awareness court case you will get destroyed.
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Where are you seeing a risk of awareness? If anything a low-opioid anesthetic is likely to reduce risk of recall because you're going to have to be giving something else (e.g. volatile, benzo, ketamine) which have better-than-opioid benefits when it comes to recall.

It's the classic (archaic) practice of high-dose opioids for cardiac anesthesia that had a high recall risk.
 
pgg said:
OK that's maybe fair but you said -



Where are you seeing a risk of awareness? If anything a low-opioid anesthetic is likely to reduce risk of recall because you're going to have to be giving something else (e.g. volatile, benzo, ketamine) which have better-than-opioid benefits when it comes to recall.

It's the classic (archaic) practice of high-dose opioids for cardiac anesthesia that had a high recall risk.
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However the guy is obviously not giving enough of the what you call "better than opioids" meds pre sternotomy.
 
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