norepi plus phentolamine

[ryanjmy]

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Just joined a practice where the ct surgeions insist that we add 20 mcg/cc phentolamine to our norepi drips. They say its renal protective. Cant find anything in my anesthesia text about this. Are other places doing this? Is there literature to support what these guys are saying?

 

[Bostonredsox]

Not anesthesia but if memory serves me right it can be added to norepinephrine to help prevent exstravisation necrosis. This is a mute point though if given through a central line, as it always should be.

Not sure how a pure alpha antagonist would protect the beans though. Seems counterintuitive to me.

 

[urge]

Just joined a practice where the ct surgeions insist that we add 20 mcg/cc phentolamine to our norepi drips. They say its renal protective. Cant find anything in my anesthesia text about this. Are other places doing this? Is there literature to support what these guys are saying?

Never heard of it. There is a reason for it, it is insane.

 

[periopdoc]

That was pretty cutting edge, in 1976.

Some animal studies suggest an improvement in renal blood flow over a straight norepi infusion. I understand the technique was to use norepi to bring the pressure up to 20% higher than preop then infuse phentolamine to bring it back down to the preop level.

You could probably achieve the same result with lower norepi dosing plus some dobutamine. It would be cheaper too.

Even better norepi plus milrinone. Great combo.

- pod

 

[Colbare]

Is this common for surgeons to intervene with crappy physiology advice? Is it acceptable to respectfully disagree and continue with your own plan or do they have ultimate say since they are technically the surgeons patient?

 

[Mman]

Is this common for surgeons to intervene with crappy physiology advice? Is it acceptable to respectfully disagree and continue with your own plan or do they have ultimate say since they are technically the surgeons patient?

one consideration is that 5 minutes after they are out of the OR they are going to order whatever they damn well please. It's usually better to have a rational discussion about what is best for the patient (and why) preferably with evidence to back it up.

But you can do whatever you damn well please in the OR. They aren't scrubbing out and even if they did they'd probably be incapable of programming the pump to run whatever they want to run. It's just equal poor form on your part to tell them to F' off while they are operating since for the patient's sake you'd like their A game and full attention on the patient.

 

[Consigliere]

Just joined a practice where the ct surgeions insist that we add 20 mcg/cc phentolamine to our norepi drips. They say its renal protective. Cant find anything in my anesthesia text about this. Are other places doing this? Is there literature to support what these guys are saying?

Just do what the surgeon tells you like a good little b*tch. You will NEVER win this argument, and, if you insist, you will be unemployed. There are a dozen other -ologists waiting to replace you.

 

[Colbare]

one consideration is that 5 minutes after they are out of the OR they are going to order whatever they damn well please. It's usually better to have a rational discussion about what is best for the patient (and why) preferably with evidence to back it up.

But you can do whatever you damn well please in the OR. They aren't scrubbing out and even if they did they'd probably be incapable of programming the pump to run whatever they want to run. It's just equal poor form on your part to tell them to F' off while they are operating since for the patient's sake you'd like their A game and full attention on the patient.

Makes sense it sounds like you really have to be good at making everyone happy while maintaining a high level of safety for the patient. I can see why they look for team players and diplomats during interviews

 

[Colbare]

Just do what the surgeon tells you like a good little b*tch. You will NEVER win this argument, and, if you insist, you will be unemployed. There are a dozen other -ologists waiting to replace you.

So if a verbal order from a surgeon is implemented against your best logic because they insist on it even after you tried reasoning with them and something bad happens, does it get messy to sort out or are they willing to accept some responsibility?

 

[MTGas2B]

Sounds like the epinephrine calcium drip I found on our ICU med list.

 

[pgg]

So if a verbal order from a surgeon is implemented against your best logic because they insist on it even after you tried reasoning with them and something bad happens, does it get messy to sort out or are they willing to accept some responsibility?

Take Consigliere's posts with a grain of salt, he seems to work in a pretty toxic place.


You're responsible for what you do. There's no mess. You manage the patient in the OR, and the surgeon manages the patient postop, unless there's some other arrangement in the ICU. Ideally there's a consistent plan and no major changes made during the postop handoff.

Most places, everyone is rational, and this simply isn't an issue. For simplicity and continuity, it's often best to just do things the way the surgeon wants them done, if it's reasonable. A lot of what we and they do is personal preference and habit without a lot of science proving one way is clearly better than the other. Usually, the surgeon's preferences are reasonable. It's not like they're going to ask you to start an IV infusion of Mountain Dew to ward off evil spirits.

Most of this stuff is not worth arguing over. Arguing with a surgeon over minutia (and most of this stuff IS minutia) during a case is rarely the right thing to do. Do the case safely, don't let your ego get wrapped up in who thinks who is the real captain of the ship, and get on with your life.

 

[sevoflurane]

Being a team player, especially in the CT OR, is very important. Honest discussions and reviews of protocols are equally important.

To the OP, we're 3 months into using fenoldopam for our high risk renal patients that are undergoing pump runs. Cr> 1.5 with recent dye load or single kidney. We use a low dose and hypotension is not a problem.

I understand the fear of renal damage during pump runs. It is a significant and independent risk factor for major morbidity/mortality.

 

[sevoflurane]

There is another study out there that looks at fenoldopam and perioperative renal blood flow via doppler ultrasound. I can't find it right now. It's a recent paper in annals of cardiothoracic surgery. The one below also looks at renal blood flow via doppler, but it's underpowered. They do seem to quantify changes in renal perfusion resistance and blood flow (particularly important when patients get dropped off in the ICU with significant pressors which tend to insult renal perfusion).


http://www.ncbi.nlm.nih.gov/pubmed/19553140

Doppler measurements of renal blood flow and echocardiographic hemodynamic determinations after Doppler echocardiography measured flux velocities of the main, segmental, and interlobar and interlobular right renal arteries. The authors calculated the resistive index of all the renal segments studied. Moreover, the authors measured the flux of the main renal artery and its diameter as well as the main hemodynamic variables. All the measurements were performed in the intensive care unit setting at baseline and 20 minutes after the infusion of 0.1 microg/kg/min of fenoldopam mesylate. Fenoldopam mesylate infusion significantly increased blood flow in all renal compartments, thus improving the resistive index. The study showed that fenoldopam mesylate infusion does not induce any significant change of the heart rate or arterial pressure, cardiac output, preload, or wall stress.

CONCLUSIONS: In hemodynamically stable cardiac surgery patients with preserved renal function, an infusion of 0.1 microg/kg/min of fenoldopam mesylate has no influence on systemic hemodynamics while increasing renal blood flow.

Here is another one:

http://www.ncbi.nlm.nih.gov/pubmed/20332738

Conclusions: Fenoldopam improves the quality of perfusion during CPB. In patients receiving catecholamines to treat a postoperative low cardiac output state, fenoldopam significantly improves renal function and prevents AKI and major morbidity.

There are also some older studies out there that say it makes no difference. The protocols and dosage are different however. Many papers looking at this in the pediatric heart population.



We are hoping we are catching a subgroup of patients from going into renal failure post-op (some patients are just high risk and post-op dialysis is expected... but not all). Hard to tell, but using our fenoldopam protocol, we've seen patients walk in with a Cr of 1.6 or higher (after a dye load) and end up post-op day 1 with a Cr of 1.5 and post-op day 2 with a Cr of 1.4. We would like to think that our maneuvers are helpful, but we need more numbers in order to see weather it is making a difference or not. It could be that some patients are just recovering in the face of a recent pump run. In our minds however, it is not harming anybody, and may be helping a subgroup of patients. The waters are still a bit murky to make any definitive statements.

We run our fenoldopam via the PA once it is placed, and then keep it going for 24 hrs.

 

[Gern Blansten]

Phentolamine is an old drug, but very effective (if you can find it) for treating short term hypertensive crisis.

In the dental world, it got a little more attention as a local anesthetic reversal agent. I heard about this use a couple years ago. I have not looked into it too much, but I think it just increases blood flow and washout of the local anesthetic, the opposite of adding epi to your local. The company that marketed the drug touted it as a way to terminate the local effects after the dental procedure was done.

What's new with phentolamine mesylate: a reversal agent for local anaesthesia?
Yagiela JA.
Source

Division of Diagnostic and Surgical Sciences, UCLA School of Dentistry, Los Angeles, CA 90095, USA. [email protected]
Abstract

Phentolamine mesylate (OraVerse), a nonselective a-adrenergic blocking drug, is the first therapeutic agent marketed for the reversal of soft-tissue anaesthesia and the associated functional deficits resulting from an intraoral submucosal injection of a local anaesthetic containing a vasoconstrictor. In clinical trials, phentolamine injected in doses of 0.2 to 0.8 mg (0.5 to 2 cartridges), as determined by patient age and volume of local anaesthetic administered, significantly hastened the return of normal soft-tissue sensation in adults and children 6 years of age and older. Median lip recovery times were reduced by 75 to 85 minutes. Functional deficits, such as drooling and difficulty in drinking, smiling, or talking--and subjects' perception of altered function or appearance--were consistently resolved by the time sensation to touch had returned to normal. Adverse effects of phentolamine injected in approved doses for reversal of local anaesthesia in patients ranging in age from 4 to 92 years were similar in incidence to those of sham injections, and no serious adverse events caused by such use were reported. The clinical use of phentolamine is viewed favorably by dentists who have administered the drug and by patients who have received it. Optimal use may require some modifications of the technique described in the package insert; cost of the agent may be influencing its widespread adoption into clinical practice. Phentolamine mesylate, in the form of OraVerse (Novalar Pharmaceuticals, San Diego, USA) represents a new therapeutic class of drugs in dentistry intended to reverse soft-tissue anaesthesia after nonsurgical dental procedures (e.g., restorative or deep scaling/root planing procedures). As shown in Figure 1, OraVerse is manufactured in 1.7 mL dental cartridges, each of which contains 0.4 mg active drug. This review describes the development of phentolamine as a dental drug, its pharmacologic characteristics, and how it may be used in clinical practice to improve patient care.

 

[countingdays]

Just do what the surgeon tells you like a good little b*tch. You will NEVER win this argument, and, if you insist, you will be unemployed. There are a dozen other -ologists waiting to replace you.

Take it with a grain of salt if you want, but it's also completely true. There is nothing a surgeon could want that is too stupid for administration to take their side about. Administrators don't have the knowledge to know and don't care who's right or wrong.

If it's harmless, then who cares? Don't sacrifice yourself over nothing.

If it's harmful, then look for another job. A great anesthesiologist is worth much less than a terrible surgeon as far as hospital administrators are concerned.

 

[urge]

Take it with a grain of salt if you want, but it's also completely true. There is nothing a surgeon could want that is too stupid for administration to take their side about. Administrators don't have the knowledge to know and don't care who's right or wrong.

If it's harmless, then who cares? Don't sacrifice yourself over nothing.

If it's harmful, then look for another job. A great anesthesiologist is worth much less than a terrible surgeon as far as hospital administrators are concerned.

This.

The only way you could make a change is if it is pushed forward by senior, well respected, anesthesiologists at your institution.

Things to consider:
What are the other anesthesiologists in the group doing about the phentolamine?
What is the reputation of said surgeons?
How old are the surgeons?

At the end of the day you have to realize that you are spinning your wheels with this concoction. Might have to run 0.1mcg/kg/min instead of 0.05mcg/kg/min of norepi. It is silly but I don't think it is dangerous.

I would not alienate your self from the team for this reason.

 

[shopsteward]

Either you go with what the surgeons want, until they have retired or you have moved on, or -

1. Research what's best for best/newest/cheapest for renal protection.
2. Present your findings to the anesthiologists in your practice.
3. If they agree, you/the practice presents the findings to the CT surgeons.

As you have just joined the practice, go carefully, take your time and gather allies about you if you are going to suggest changes.