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Phenylephrine vs. Norepi in CHF Pt

Discussion in 'Anesthesiology' started by wolfpackMD, Jan 11, 2019.

  1. wolfpackMD

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    Hi all, CA-1 here.

    Had a discussion with a neurosurgery resident and thought I'd get some feedback here.

    60 year old pt with CHF (EF 30%), HTN (baseline MAPs 130s), severe cervical spinal stenosis, coming in for c-spine decompression. We do a pre-induction a-line and induce with etomidate. Pressures are stable. Intra-op monitoring so we're running TIVA (propofol, remifentanil, ketamine (b/c of history of chronic pain). I run a phenylephrine infusion to keep her around her baseline MAP (per neurosurgery attending request) and neurosurgery resident says I should be using norepi because that's what they use in the ICU.

    His argument is that norepi will increase contractility in this patient with low EF while phenylephrine is only increasing afterload - which makes sense. However, my argument back to him was that I'm keeping her MAP at baseline and that norepi will also increase heart rate via stimulation of beta-1 receptors and that will contribute more to myocardial oxygen demand than just some increased afterload to overcome the vasodilation from prop and remi infusions (which is the real cause of her hypotension and not a further reduction in EF).

    I could be wrong though!

    I kept the phenylephrine infusion and patient did well.

    What are your thoughts? Do you feel strongly one way or another in this patient with an EF of 30%?
     
    #1 wolfpackMD, Jan 11, 2019
    Last edited: Jan 11, 2019
  2. Urzuz

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    My thoughts are you should never, ever waste your time discussing physiology and pharmacology with a surgical resident.

    And stop wasting money by running remifentanil infusions for spine cases. Completely unnecessary.
     
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  3. FFP

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    Phenylephrine does increase afterload, and can produce a decrease in cardiac output in CHF patients. It will also increase myocardial oxygen consumption, by increasing transmural myocardial pressures (higher BP means more cardiac work to eject blood). But what matters the most is the balance between supply and demand (not just one of them), and increasing the (D)BP can increase coronary circulation, hence supply.

    However, in real life (and this is where most surgical residents and attendings are greenhorns), the effect on CO is not significant except in patients with low EF (definitely not around 30%), and it's very easy to notice because the BP tends to drop despite/because of the phenylephrine. In THOSE situations, norepi IS better. I've only seen it once, in a post-CABG patient who was going into pulmonary edema because of poor contractility. Also, it's a bad idea to run norepi on a peripheral line when there is a safer alternative. Last, but not least, you don't tell the surgeon what sutures to use, he doesn't get to tell you what pressors.

    Btw, the etomidate induction and pre-induction a-line were not really needed in this patient.

    Pulmcrit - An alternative viewpoint on phenylephrine infusions
     
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    #3 FFP, Jan 11, 2019
    Last edited: Jan 11, 2019
  4. Ezekiel2517

    Ezekiel2517 Anesthesiologist
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    There are levels to this. You will encounter patients with severe heart failure who will not only not respond to phenylephrine, they will actually get worse hemodynamically. Gotta be prepared with other agents. These patients can surprise you. EF doesn't give you the whole picture
     
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  5. vector2

    vector2 ASA Member
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    E: beaten by a mile
     
  6. DM27

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    I second that it is an overall irrelevant discussion. In theory the Norepinephrine will have a slight CO increase in addition to its more dominant alpha activity compared to Phenylephrine. However, I have never seen a heart rate increase that I could attribute to a Norepinephrine bolus or infusion, the most I can say about Norepinephrine increasing the heart rate is you rarely see a heart rate drop as you see with the pure alpha of Phenylephrine.
     
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  7. hankbb02

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    You will not see increased heart rate with norepinephrine. The beta agonsim is balanced by the reflex bradycardia of alpha agaonism and the heart rate really doesn't change. You can run norepinephrine temporarily through a PIV as long as you placed it and trust it. Frequent extremity checks should be performed if you are doing this. Also pre-induction a-line is a good idea. Induction is the period of time in which hypotension is most likely to be encountered and you already know what hypotension does to patients with CAD/CHF. In my opinion if you are placing an a-line for the case there is no reason not to do it awake.

    As mentioned above what you need to worry about when running remi, and phenylephrine together is bradycardia which decreases CO which can cause acidosis which can cause decreased contractility and further hypotension. The choice of pressor doesn't matter. What matters is that you know that if you choose phenylephrine and experience increasing hypotension despite increasing dose of phenylephrine you should add beta agonism.
     
  8. MoMoGesiologist

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    If the BP is dropping because of too much anesthesia, use less anesthesia. If you're uncomfortable with using less, then add phenyl.

    If BP is dropping due to decreased EF, use NE or epi. Not sure why you would need it for a neuro case. I usually think of that for post CPB or reperfusion of something.
     
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  9. SaltyDog

    SaltyDog Homey O'Stasis
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    That should be a sticky.
     
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  10. SaltyDog

    SaltyDog Homey O'Stasis
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    My opinion is that your opinion is ridiculous.
     
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  11. FFP

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    Anybody who can't induce/intubate almost all patients without an a-line... should do more GI (solo), with ASA 4 patients. ;)

    It's like a cook who cannot add salt to the food without weighing it.

    Disclaimer: every attending is free to practice anesthesiology the way they want, and it never hurts going the safer way, even if some cowboys would argue against it. However, one should also prepare one's residents for the real world, where there is a shortage of equipment (e.g. ultrasound or glidescope), drugs (e.g. remi, precedex, suggamadex), and ESPECIALLY time. It drives me nuts when I see CA-3s who are scared to induce without an awake a-line.
     
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    #11 FFP, Jan 11, 2019
    Last edited: Jan 11, 2019
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  12. AdmiralChz

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    My first reaction to this:

    upload_2019-1-11_14-17-8.jpeg

    FFP in the OR (probably)
     
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  13. SaltyDog

    SaltyDog Homey O'Stasis
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    @FFP, please pleaseplease make that your avatar.
     
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  14. T-burglar

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    It drives me equally crazy to see anesthesiologists, masters of patient comfort, scared to quickly place a lightly sedated a-line before inducing and intubating. Then struggling to get the ****ing line in and when they finally do the pressure has either been through the roof or through the floor for 10 minutes. Sedate the patient, numb the wrist, place the line with ultrasound. The whole thing should take 120 seconds. Stay in practice with this in case you have to do it when seconds count.
     
  15. Newtwo

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    Lol
    Make a profound ballsy statement then utterly climb down with your disclaimer...

    Sure why not turn off the pulse oximeter too and if your patient looks a bit blue give them more oxygen?
     
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  16. GravelRider

    GravelRider SDN Lifetime Donor
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    I vote for that as well.

    Is it really time for an awake vs asleep a-line debate again? File the results of this one under “who cares.”
     
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  17. woopedazz

    woopedazz Baby anaesthetist
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    You guys sedate for A-Lines in the US?
     
  18. TimesNewRoman

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    Like a boss.

    All joking aside, it’s not horribly rare when I have to intubate someone (or have my fellow intubate someone) in the icu without a waveform.....that’s one of the few things that still gives me sweaty palms.
     
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  19. Psai

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    Just put hfnc on everyone prior to intubation and get those big boy pants on
     
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  20. anbuitachi

    anbuitachi ASA Member
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    Like most said, EF of 30% is too high to matter. and like you said phenylephrine counteracts some of the vasodilation from anesthesia. it's a common difference and i see this get talked about occasionally in ICUs. Patients on pressors in the ICU are not vasodilated significantly from medications. ive had one ICU attending (non anesthesia trained), tell us when we rotated in ICU that phenylephrine is very bad pressor and anesthesiologists should not be using it as their go to pressor. clearly he doesn't get what happens in the OR.

    And agree with above poster. dont bother arguing w surgery resident about that stuff.
     
  21. Psai

    Psai Snitches get zero vicryl
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    Most intensivists have zero idea about what goes on in the or. One person was scandalized by our use of lidocaine and thought the patient could have had last and I'm like no
     
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  22. Newtwo

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    Yeah I don't really understand why ppl try to extrapolate ICU evidence into the OR. Sometimes it would make sense but a lot of times no they're not the same
     
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  23. AdmiralChz

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    For sure! I’ve also run into some MICU docs freaking out about our use of phenylephrine citing X study about poor outcomes with unopposed alpha as a single pressor... but the two environments are so very different it’s not an equivalent situation.
     
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  24. drmwvr

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    this is why surgeons should stick with surgery...pressors/inopressors in the OR in the context of an anesthetic is not in the same zip code as in the ICU. Getting closer to baseline vasomotor tone lost from an anesthetic is all you're doing. That said, you probably didn't need much, and at the end of the day, either one is fine...but he didn't know that...
     
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  25. FFP

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    The disclaimer is there because I don't want to be like the cowboys who think everybody who plays safe is an idiot.

    On the other hand, it's not OK to play it supersafe on a regular basis when teaching residents, especially in a good program. Inducing more complicated patients without an a-line is something every graduate should know (aka "slow controlled induction"). Same goes for intubating them. It's not rocket science; it's anesthesia 201 or 301.
     
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  26. FFP

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    So which one is it? Is it an easy a-line or a complicated one? If it's easy, then it will take 120 seconds after the patient is (semi)asleep. If it's complicated, then why torture the patient with it. Sometimes, numbing up the wrist take so much local that the a-line placement becomes difficult; people have different pain thresholds.

    I will do an awake arterial line if:
    1. the patient is the stoic kind who doesn't really care, and
    2. it would seriously benefit him during induction/intubation, and
    3. I have a good superficial pulse, or an easy access under ultrasound.
    Generally, I will do one if my patient is like the typical cardiac surgical patient.

    Otherwise, I can just put that cuff at q2-2.5 min and do a nice, slightly slower than usual, induction. Especially if there are 2 anesthesia providers, one can ventilate while the other places the A-line. Now maybe I am just a more experienced guy who knows how to dose his induction agents so that the patients don't go rollercoaster; I sincerely doubt that. I think I may be just more patient.

    I don't think most patients need a pre-induction a-line for stuff like: moderate AS, 70% carotid stenosis with good collateral circulation, EF of 30% etc. We do upper endoscopies without an A-line on these folks, so why can't we induce and/or intubate them without one? I did an EGD on a critical AS with AVA of 0.6 cm2 (and low CO) just a couple of weeks ago (his lowest MAP was 20% less than baseline and he didn't remember squat). Would you guys have put in an awake a-line for that 10 minute procedure? It's no different than an intubation. Why is it so hard to maintain somebody's resting MAP plus/minus 20%?

    Anyway, I am not here to argue about awake vs asleep a-lines. That's why I wrote that disclaimer.
     
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    #26 FFP, Jan 12, 2019
    Last edited: Jan 12, 2019
  27. anbuitachi

    anbuitachi ASA Member
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    how much prop did you push
     
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  28. MoMoGesiologist

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    Severe AS AND low CO!? That would be something I would be wary of inducing.
     
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  29. FFP

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    On the AS? I think it ended up at around 1 mg/kg for the entire procedure, in 10-20 mg doses at a time. Had it been a colonoscopy, I would have set up a pump and just induced with a continuous infusion, at around 10-20 mg/min, and then run it as low as possible for maintenance. The most important part is waiting between doses, allowing the medications to circulate and kick in.
     
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  30. anbuitachi

    anbuitachi ASA Member
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    i think it also depends a lot on proceduralist. they pretty much expect general without a tube for EGDs here. patients dont remember anything even with low dose prop but they probably will still move. though with severe AS/ low CO.. how long did that induction take to get in 1 mg/kg? it'll probably take a while just for it to circulate
     
  31. FFP

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    It actually took less than 2 minutes for the proceduralist to be able to start. We were in the CCU and we had discussed the risks for (and WITH) the patient. The patient was moving slowly (humans have reflexes), but he did not remember anything, and my role was to reassure the GI doc and keep the patient safe.
     
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  32. FFP

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    His baseline BP was around 120/70, not on any pressors. He didn't look in any distress; actually he looked quite well. He was able to lie completely flat. He did not have any signs of acute HF or any history of syncope. His AS had been pretty asymptomatic (except for DOE) until it got decompensated by anemia. I didn't even have to use pressors.
     
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    #32 FFP, Jan 12, 2019
    Last edited: Jan 12, 2019
  33. hankbb02

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    That's probably because you are not very good at a-lines.
     
  34. MoMoGesiologist

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    *grabs popcorn :corny:
     
  35. hankbb02

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    I place the a-line preinduction if there is time in any case i'm going to use one unless the patient is crazy and I don't feel like dealing with them. It's no different for patient comfort than placing an IV if you know what you are doing. It's also one less thing to do in the OR. It's just as important that resident's learn how to place an a-line without a struggle in an awake patient.
     
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  36. hankbb02

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    This sounds like a long justification for bad a-lines skills
     
  37. nimbus

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    Vast majority of coronary angio’s are done through the radial artery on awake patients. Awake Aline is not a big deal. I do preinduction Aline on all hearts and any patient I expect to be unstable during induction. Also I have a very low threshold to go brachial if I don’t see a good radial target on ultrasound.
     
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  38. anbuitachi

    anbuitachi ASA Member
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    it's also funny because in IR when they do angios and give patient local in the groin or whatever. they use 18G needles!
     
  39. SaltyDog

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    It’s probably because you are not very good at inductions.
     
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  40. sigrhoillusion

    sigrhoillusion ASA Member
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    Can we all agree that the only real issue with this scenario was the use of Etomidate... :shrug:
     
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  41. Monty Python

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    Truer words have never been spoken.
     
  42. dannyboy1

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    This is silly. If you are going to place an a-line anyways for the case and the guy has CHF why would you not do it awake? Why not have the benefit of the line during the (possibly) hemodynamically unstable induction. Side benefit is that some surgeons decide that the patient is ready for positioning the moment that the tube is in. If you have the a-line in already then that is one less fight that you need to have. For the record, I’m not sure this case needs an a-line but if you are going to do it Pre-induction is the way to go.
     
  43. T-burglar

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    If your arterial lines ever become torture for the patient then you need to take a step back and analyze your technique. Most likely your sedation isn’t quite right for the patient. Sedation does the leg work for most procedures done under local. At my shop we frequently do both the a line and the swan sedated while we wait for the surgeon to become available from his previous case.

    I’m not saying most of these patients “need” the a line before going to sleep. But it’s literlaly like placing an IV so why not do it awake. Also “true” severe aortic stenosis is not a lesion to **** around with. We get lulled a little bit about AS because in reality a lot of people presenting for AVR don’t have truly precarious AS but if it’s bad enough it’s an arrest on induction waiting to happen that cannot be resuscitated. Just put the a line in awake.
     
    #43 T-burglar, Jan 13, 2019 at 5:09 PM
    Last edited: Jan 13, 2019 at 5:16 PM
  44. drmwvr

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    A lines in the holding area with appropriate sedation simply moves things along more smoothly. It's nothing to have one in by the time the circulator has turned the room and is ready to get the patient....it's far less about need for induction v. moving the room.

    Critical AS/severe left main dz need pre-induction a lines because there are cooler, more rational ways to demonstrate that you're a huge swinging d***.
     
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  45. fakin' the funk

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    This.
     
  46. fakin' the funk

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    Arguing hemodynamic theory with a neurosurgery resident is hilarious.

    Keep in mind, it's just theory. We have no idea what's going on in your patient's circulation.

    Take heart in the fact that nearly all surgical patients have lots of extra global (whole-body) flow to draw from. Reserve. Let's say your colleague is right and the CO goes down 20%. Who cares. No one's even measuring.
     
  47. Psai

    Psai Snitches get zero vicryl
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    Thats probably within error for those measurement tools as it is
     
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