PACU hypotension and acute AV graft failure

[FiO2@21]

We had a patient at the VA last week for a new LUE AV graft. Had access on the contralateral side that failed. Pre-op systolic 120s.

Gave 1 mg versed, blocked him, gave him ~40 mcg precedex during the case (130ish kg I think). The surgeon didn’t need to supplement and pt was comfortable during the case.

I had something come up and had to leave before case end, but apparently pt had hypotension in PACU (SBP 80s - 90s) for an hour or so. Asymptomatic, awake according to the attending who finished the case.

The graft thrombosed and the surgeon is attributing this to the hypotension in PACU. I tried to look this up, found one reference to low pressures during dialysis being associated with thrombosis.

Anyway, I feel that we were pretty light handed. Maybe I could have skipped the precedex since he was pretty happy with the 1 mg versed. Was curious if anyone else has experienced this issue. Is there a role for pressor infusion in PACU to maintain a certain hemodynamic goal? Can’t find much evidence to support it.

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[coffeebythelake]

We had a patient at the VA last week for a new LUE AV graft. Had access on the contralateral side that failed. Pre-op systolic 120s.

Gave 1 mg versed, blocked him, gave him ~40 mcg precedex during the case (130ish kg I think). The surgeon didn’t need to supplement and pt was comfortable during the case.

I had something come up and had to leave before case end, but apparently pt had hypotension in PACU (SBP 80s - 90s) for an hour or so. Asymptomatic, awake according to the attending who finished the case.

The graft thrombosed and the surgeon is attributing this to the hypotension in PACU. I tried to look this up, found one reference to low pressures during dialysis being associated with thrombosis.

Anyway, I feel that we were pretty light handed. Maybe I could have skipped the precedex since he was pretty happy with the 1 mg versed. Was curious if anyone else has experienced this issue. Is there a role for pressor infusion in PACU to maintain a certain hemodynamic goal? Can’t find much evidence to support it.

Tbh I think this is just surgeon blaming anesthesia whenever there is a complication. For your reference:

 

[GassYous]

Hypotension probably related to precedex. Noticed a lot of pacu hypotension when I was putting precedex in taps. Could be related to the thrombosis but probably not. The patient already had a graft failed, probably has bad protoplasm.

 

[FiO2@21]

Personally doubt such transient hypotension could have caused a complication that’s typically due to surgical factors. Agree that the precedex contributed to the hypotension.

Given that he was happy with just the 1 mg versed I could have left it alone. As I’m starting my CA-3 year I’m trying to tighten things up and develop “complaint-proof” anesthetics. Maybe next time I’ll push them to give me parameters and just leave them on a phenylephrine drip in PACU. But the pressures we encountered are likely the pressures he gets during dialysis.

As an aside, noticing a lot more “constructive feedback” from surgeons here at the VA compared to our typical hospitals at our community-setting program.

 

[coffeebythelake]

Personally doubt such transient hypotension could have caused a complication that’s typically due to surgical factors. Agree that the precedex contributed to the hypotension.

Given that he was happy with just the 1 mg versed I could have left it alone. As I’m starting my CA-3 year I’m trying to tighten things up and develop “complaint-proof” anesthetics. Maybe next time I’ll push them to give me parameters and just leave them on a phenylephrine drip in PACU. But the pressures we encountered are likely the pressures he gets during dialysis.

As an aside, noticing a lot more “constructive feedback” from surgeons here at the VA compared to our typical hospitals at our community-setting program.

There are only so many things you can control. Bad things happen even when everything is done right.

And you will inevitably have surgeons lay their own mistakes on you. (Had a patient tell me he ended up in the ICU after a previous surgery because his blood pressure was low due to anesthesia. Some digging revealed the patient had unanticipated several liters of surgical blood loss which is the real reason.)

 

[vector2]

A 130kg dude who could tolerate a block and AVF with 1 mg of versed and 40 mcg of precedex is a dude who could tolerate those things with no sedation at all.

 

[GassYous]

A 130kg dude who could tolerate a block and AVF with 1 mg of versed and 40 mcg of precedex is a dude who could tolerate those things with no sedation at all.

I think the versed helped. I don't think the precedex did. Nowadays I give as little medication as I think I can get away with

 

[Blockit]

I am not aware of any formal guidelines regarding blood pressure goals immediately post AVF creation. And I think that blaming PACU hypotension for your AV graft failing is a little bit childish. I mean this individual already has thrombosed at least one graft in the past, and on top of that the immediate postoperative inflammatory state may make him more likely to clot things period.
Don’t sweat it.

 

[ethilo]

There's no anesthesia like no anesthesia!

 

[DrOwnage]

Seems weird to me the patient was hypotensive in PACU and not during the procedure as you gave the precedex and midaz for your anesthestic. Maybe I'm missing something? Was he on prop infusion during the case and precedex was bolused at the end? That's a pretty low preop systolic for a patient with ESRD, I feel like all my patients have BPs in the 160's-180s (in fact I can't even remember the last time I've had an ESRD patient in the 120s). Was this guy volume down?

 

[coffeebythelake]

Seems weird to me the patient was hypotensive in PACU and not during the procedure as you gave the precedex and midaz for your anesthestic. Maybe I'm missing something? Was he on prop infusion during the case and precedex was bolused at the end? That's a pretty low preop systolic for a patient with ESRD, I feel like all my patients have BPs in the 160's-180s (in fact I can't even remember the last time I've had an ESRD patient in the 120s). Was this guy volume down?

It is very common to see postop hypotension from precedex. I am curious to know the dose used for sedation in this particular case , whether any boluses were given, and when it was turned off.

 

[nimbus]

Ive

It is very common to see postop hypotension from precedex. I am curious to know the dose used for sedation in this particular case , whether any boluses were given, and when it was turned off.

Agree. In my experience, patients are commonly very comfortable, clear headed and hypotensive in PACU after intraoperative precedex.

 

[FiO2@21]

Seems weird to me the patient was hypotensive in PACU and not during the procedure as you gave the precedex and midaz for your anesthestic. Maybe I'm missing something? Was he on prop infusion during the case and precedex was bolused at the end? That's a pretty low preop systolic for a patient with ESRD, I feel like all my patients have BPs in the 160's-180s (in fact I can't even remember the last time I've had an ESRD patient in the 120s). Was this guy volume down?

No the only drugs I gave were the ones listed above.

I’ve seen the gamut with ESRD personally. Some live in the 80s - 90s, some live in the 190s SBP.

 

[coffeebythelake]

I’ve seen the gamut with ESRD personally. Some live in the 80s - 90s, some live in the 190s SBP.

Some patients with EDRD can be quite labile. I'm sure we've all seen midodrine in the med lists of such patients who get really lightheaded and hypotensive especially with their HD sessions.

 

[FiO2@21]

They went back again this afternoon. I did the blocks again while waiting on my scheduled case to start.

Only gave 0.5 mg versed and the attending in that room is going to just chat with the patient and pray my blocks cover that nearly axilla incision.

 

[GassYous]

They went back again this afternoon. I did the blocks again while waiting on my scheduled case to start.

Only gave 0.5 mg versed and the attending in that room is going to just chat with the patient and pray my blocks cover that nearly axilla incision.

Interscalene/pecs 2 or supraclav

can also just infiltrate with intercostobrachial

 

[FiO2@21]

Interscalene/pecs 2 or supraclav

can also just infiltrate with intercostobrachial

We did interscalene + supraclav + intercostobrachial.

A brachial plexus block technique for upper arm AV Fistula

To the Editor:

academic.oup.com

Described above. Except we used ropi instead of lido for the intercostobrachial.

 

[Twiggidy]

I think the versed helped. I don't think the precedex did. Nowadays I give as little medication as I think I can get away with

This is the gospel and the takeaway for OP. "Less Is More" Especially in these types of patients.

 

[GassYous]

Why would you do interscalene and supraclav? Makes no sense

 

[FiO2@21]

Why would you do interscalene and supraclav? Makes no sense

Had multiple surgeons end up making incisions that extended above mid humerus flirting with interscalene territory.

But I think 99% of the time supraclav + intercostobrachial should be sufficient.

But to be honest once I’m back to community hospitals would rather just LMA and call it a day.

 

[GassYous]

Had multiple surgeons end up making incisions that extended above mid humerus flirting with interscalene territory.

But I think 99% of the time supraclav + intercostobrachial should be sufficient.

But to be honest once I’m back to community hospitals would rather just LMA and call it a day.

Why would you do supraclav and intercostobrachial?

 

[FiO2@21]

Why would you do supraclav and intercostobrachial?

T2 isn’t covered by supraclav and they almost always dig around there.

 

[sevo00]

precedex is renal elimination. I see post op hypotension frequently when using it.

 

[deleted875186]

Block, low dose prop infusion if needed.

why anyone chooses anything but propofol for sedation is beyond me. Fast one and off, predictable, effects are almost always off before leaving the Or and patient is back to their crappy hypertensive everyday life in PACU.

 

[DocMcCoy]

total garbage to put the blame on hypotension and anesthesia and I’m guessing MAPs were still pretty good. We have one guy who’s grafts go down all the time. Same guy that takes 2+ hrs to put a graft in. Funny his colleagues don’t have the same problem.

That being said, I loved precedex as a resident. BUT, I’ve used it exactly twice since then because of bradycardia and hypotension. Not really a role for it in my PP job. Many other ways to get the job done.

Sounds like if you should be documenting everything with this guy…

 

[ProwlerturnGas]

I do these with infraclav (occasionally supraclav), intercostobrachial and propofol infusion. No precedex. No issues at all. Grafts, fistulas, anywhere in the arm.

 

[GassYous]

You can do these cases with versed and surgeon local only

 

[Arch Guillotti]

You can do these cases with versed and surgeon local only

You can but if the surgeon isn't good with it then you can't.

 

[Arch Guillotti]

I do these with infraclav (occasionally supraclav), intercostobrachial and propofol infusion. No precedex. No issues at all. Grafts, fistulas, anywhere in the arm.

This.

 

[Airway]

You can but if the surgeon isn't good with it then you can't.

Didn't know it was possible to do a graft without a block or ga until my current job. Academics...

 

[Greenbayslacker]

Given that he was happy with just the 1 mg versed I could have left it alone. As I’m starting my CA-3 year I’m trying to tighten things up and develop “complaint-proof” anesthet

it’s easy when the patient is happy with no sedation. It becomes difficult when the patient is uncomfortable, moaning, moving around even with additional local. Goes do you safely sedate a patient that crumped from precedex?

 

[woopedazz]

Why we all using multiple GABA/alpha for this? Why not just alfentanil +/- miniscule dose of propofol if your block is a fail?

 

[deleted697127]

Some patients with EDRD can be quite labile. I'm sure we've all seen midodrine in the med lists of such patients who get really lightheaded and hypotensive especially with their HD sessions.

Was wondering if someone was going to bring this up. Being on midodrine has been implicated in graft failure in AV fistulas. It (or maybe the orthostatic hypotension it’s prescribed for) is definitively a risk factor for poor outcomes after kidney transplant. This isn’t surprising as we know hypotension isn’t great for any organ system and in this case is a surrogate of low blood flow. Remember the whole virchow’s triad of hypercoaguability (surgery induced), stasis/turbulence (hypotension in this case), and endothelial dysfunction (ERSD and a vascular case).

Sorry OP, I’m going to have to take the surgeons side here in that it’s at least plausible hypotension may have contributed. You know hypotension is a risk of using precedex. It’s your responsibility to prevent or quickly recognize and treat post op hypotension. Give some ephedrine on the way out or at least communicate parameters with PACU. It’s not unfair for the surgeon to expect SBP and MAP to be maintained > 90 and 65. Sure maybe a little hypotension doesn’t matter in some patients but these patients are inherently high risk. I’ve definitely witnessed MAPs 40s and and systolics low 70s in an awake patient chilling in pacu after precedex. I have a hard time believing this is a good thing.

 

[Twiggidy]

Didn't know it was possible to do a graft without a block or ga until my current job. Academics...

It's interesting. Is your surgeon on the younger side. Ours are dinosaurs and they want everyone asleep for just about everything despite literature that supports that Regional has longer term graft patency. Having said that we do a ton of declots and redos here as well.

At the expense of the reduction of my own personal skills, it is much easier for me to just slam and LMA in and titrate with opioid.

 

[FiO2@21]

I do these with infraclav (occasionally supraclav), intercostobrachial and propofol infusion. No precedex. No issues at all. Grafts, fistulas, anywhere in the arm.

Why infra vs Supra? For coverage reasons or to avoid phrenic nerve?

 

[deleted875186]

Was wondering if someone was going to bring this up. Being on midodrine has been implicated in graft failure in AV fistulas. It (or maybe the orthostatic hypotension it’s prescribed for) is definitively a risk factor for poor outcomes after kidney transplant. This isn’t surprising as we know hypotension isn’t great for any organ system and in this case is a surrogate of low blood flow. Remember the whole virchow’s triad of hypercoaguability (surgery induced), stasis/turbulence (hypotension in this case), and endothelial dysfunction (ERSD and a vascular case).

Sorry OP, I’m going to have to take the surgeons side here in that it’s at least plausible hypotension may have contributed. You know hypotension is a risk of using precedex. It’s your responsibility to prevent or quickly recognize and treat post op hypotension. Give some ephedrine on the way out or at least communicate parameters with PACU. It’s not unfair for the surgeon to expect SBP and MAP to be maintained > 90 and 65. Sure maybe a little hypotension doesn’t matter in some patients but these patients are inherently high risk. I’ve definitely witnessed MAPs 40s and and systolics low 70s in an awake patient chilling in pacu after precedex. I have a hard time believing this is a good thing.

I would say it’s plausible the hypotension contributed, but highly unlikely.

I agree with this overall though. Precedex causes hypotension and bradycardia, CO is greatly reduced, for this reason I dislike it except in the rare circumstance.

 

[GassYous]

Why infra vs Supra? For coverage reasons or to avoid phrenic nerve?

Yea infra sucks it's just a harder supra

Blocks are better because the blood vessel dilates and blood flow is improved so less chance of clot

 

[FiO2@21]

I would say it’s plausible the hypotension contributed, but highly unlikely.

I agree with this overall though. Precedex causes hypotension and bradycardia, CO is greatly reduced, for this reason I dislike it except in the rare circumstance.

I have some attendings at the VA who give it out like candy because of the much higher incidence of PTSD/anxiety manifesting on wake up. I skipped it on a patient for a thyroid and regretted it.

But I think I’m done using it for MAC. The super long washout is pretty unappealing. Low dose prop seems better for longer MAC cases.

I think I’ll reserve precedex for longer general cases on very anxious patients, heavy MJ users, and peds.

 

[FiO2@21]

Was wondering if someone was going to bring this up. Being on midodrine has been implicated in graft failure in AV fistulas. It (or maybe the orthostatic hypotension it’s prescribed for) is definitively a risk factor for poor outcomes after kidney transplant. This isn’t surprising as we know hypotension isn’t great for any organ system and in this case is a surrogate of low blood flow. Remember the whole virchow’s triad of hypercoaguability (surgery induced), stasis/turbulence (hypotension in this case), and endothelial dysfunction (ERSD and a vascular case).

Sorry OP, I’m going to have to take the surgeons side here in that it’s at least plausible hypotension may have contributed. You know hypotension is a risk of using precedex. It’s your responsibility to prevent or quickly recognize and treat post op hypotension. Give some ephedrine on the way out or at least communicate parameters with PACU. It’s not unfair for the surgeon to expect SBP and MAP to be maintained > 90 and 65. Sure maybe a little hypotension doesn’t matter in some patients but these patients are inherently high risk. I’ve definitely witnessed MAPs 40s and and systolics low 70s in an awake patient chilling in pacu after precedex. I have a hard time believing this is a good thing.

I don’t disagree. The hypotension certainly didn’t make things better, even if I’m not sure it was the primary cause of the graft failure.

I learned a few good lessons from all this, I’ll be modifying my practice. My love affair with precedex might be over outside of peds.

 

[GassYous]

I have some attendings at the VA who give it out like candy because of the much higher incidence of PTSD/anxiety manifesting on wake up. I skipped it on a patient for a thyroid and regretted it.

But I think I’m done using it for MAC. The super long washout is pretty unappealing. Low dose prop seems better for longer MAC cases.

I think I’ll reserve precedex for longer general cases on very anxious patients, heavy MJ users, and peds.

I had a va attending who ran remi on every case. Lap chole? Remi. Spine? Remi. ENT? Remi. Nowadays all the cases I gave remi for I just give 100 of fentanyl and it's totally fine 99% of the time. Remi sucks.

 

[FiO2@21]

I had a va attending who ran remi on every case. Lap chole? Remi. Spine? Remi. ENT? Remi. Nowadays all the cases I gave remi for I just give 100 of fentanyl and it's totally fine 99% of the time. Remi sucks.

I like remi for thyroids or for chronic opioid cranis. That’s about it.

 

[Arch Guillotti]

I like remi for thyroids or for chronic opioid cranis. That’s about it.

Chronic opioid user and remi?

 

[GassYous]

I like remi for thyroids or for chronic opioid cranis. That’s about it.

I don't use for thyroids anymore. Fent 100 dilaudid 1 roughly.

Cranis I just use fentanyl maybe 250 or so and nothing after the skull is open

 

[deleted875186]

I like remi for thyroids or for chronic opioid cranis. That’s about it.

Chronic opioids need long acting opioids, the PACU will thank you. You achieve the same effect with hydromorphone or morphine for wake up in sufficient doses. But you have to look at their PMP and see how much they take, Yoj almost always need more than the standard 2 mg hydromorphone IV. Last craniotomy I did for a guy on COT, gave 4 or 5 mg hydromorphone I think, woke up great, just like a Remi wake up, no delayed emergence or anything. It’s actually very easy for COT patients because they are so tolerant, very difficult to overdose the narcs.

 

[FiO2@21]

Chronic opioid user and remi?

For cranis I normally give 200-400 mcg fentanyl before induction, a fraction of that for pinning, and be done with it.

Problem with the bad chronic opioid patients, I would get behind on their baseline opioid requirements and the pressure would start trending up.

I could add dilaudid to the above but then I’m a bit lost. I’ve been burned and had to give narcan.

I’d rather just keep them dialed in during the case and give them fentanyl/hydromorphone after. They’re going to be hyperalgesic no matter what I do. It’s a crani not a spine, not that painful anyway.

 

[deleted697127]

I don't use for thyroids anymore. Fent 100 dilaudid 1 roughly.

Cranis I just use fentanyl maybe 250 or so and nothing after the skull is open

Hm seems like a lot of dilaudid for a thyroid. Rarely seem to have pain in recovery with local. I usually use 50 fent for induction. The other 50 for wake up so they don’t buck on the tube which probably isn’t even necessary. I’m not worried about hyperalgesia when they’re not in pain in recovery but I’ll concede maybe yours do better when the local wears off.

If plan A of fentanyl/dilaudid doesn’t work, it ends up being a hassle to set up remi while the surgeons complaining. If i have remi available from the start, it just seems to go smoother, set it and forget it.

 

[coffeebythelake]

I had a va attending who ran remi on every case. Lap chole? Remi. Spine? Remi. ENT? Remi. Nowadays all the cases I gave remi for I just give 100 of fentanyl and it's totally fine 99% of the time. Remi sucks.

That's a very expensive anesthetic.

 

[GassYous]

Hm seems like a lot of dilaudid for a thyroid. Rarely seem to have pain in recovery with local. I usually use 50 fent for induction. The other 50 for wake up so they don’t buck on the tube which probably isn’t even necessary. I’m not worried about hyperalgesia when they’re not in pain in recovery but I’ll concede maybe yours do better when the local wears off.

If plan A of fentanyl/dilaudid doesn’t work, it ends up being a hassle to set up remi while the surgeons complaining. If i have remi available from the start, it just seems to go smoother, set it and forget it.

It's not about pain but bucking. A lot of my thyroids are fat anxious ladies who buck on incision or even head movement. Surgeons hate that. So I just load em up with opioids.

 

[ProwlerturnGas]

Infra harder than supra clav??? Lol, more like hardly. I like performing the block, spares phrenic and it’s just so satisfying seeing all three cords bathed in local! I personally think it’s a safer block.

 

[FiO2@21]

Infra harder than supra clav??? Lol, more like hardly. I like performing the block, spares phrenic and it’s just so satisfying seeing all three cords bathed in local! I personally think it’s a safer block.

I’ll need to practice it more