Noyac said:
Ok, so you guys like the stuff. But why? I know that you can decrease the amount of narcotics, gas, etc. But for fast track hearts I didn't see the real benefits. I did probably around 100-150 hearts last year and if it was just a single LIMA I could would extubate on the table pain free (sufenta 20-50 mcg per case) and transport to the ICU A&Ox3. So what I am getting at is why use something so expensive if you can get the job done as well without it? Are you seeing less postop complications? I'll agree that there may less intraop hemodynamic changes but are those really all that difficult? I'm just trying to get an idea. I don't discredit the benefits in the ICU however. They breath easier with less narcotics and are easier to ween from the vent, among other benefits.
PS: when I would bring a case to the PACU (extubated), I would keep it running until in the PACU. Is this how you guys are using it?
Thanks in advance
Yeah, you bring up a good point, Noyac: is it really worth using considering its cost, and does it provide any benefit. I've got pretty extensive experience with dex, so I'll give you my history of use and opinion.
Let me say before going into detail that this is ONE way to do a CABG. It is not the right way or the wrong way, nor am I claiming this is best or worst.
OK, into more detail....
We initially started using dex in CABGs, then branched out to CEAs and back cases. Some CRNAs (namely Thomas M.) started using it instead of midaz/propofol sedation during an epidural anesthetic for joint replacement.
Prior to dex, we would line the CABGs in holding before the case using midazolam/fentanyl for sedation. This was laborious for the holding room RN since finding the "window" between apnea- and-reaching-up-during-the-IJ/subclav placement is sometimes difficult.
Then to the OR...typical induction was more midazolam if the pt wasnt sleepy enough from line placement, more fentanyl, etomidate if necessary, and pancuronium. So total for pre-op plus induction meds would be midaz 5-10 mg (again depending on where the pt is on the dose response curve), fentanyl around 500ug (typically 50-150ug in holding then the rest at induction), then if pt shows any sign of breathing/moving after all the midaz/fentanyl, etomidate 10-20mg, then pancuronium 10mg. Of course sux was used when the airway was an issue, cis-atracurium was used if kidneys were an issue, etc.
Typically over the course of the case another 500ug fentanyl and 2-4 mg midaz was used. We used des for volatile agent of choice.
SO, total midaz/fentanyl for line placement and CABG was typically 6-10 mg midaz and 500-1000ug fentanyl.
Many cases using this technique require some intervention for hemodynamic lability using NTG/increased volatile agent/bumps of neo/ephedrine.
Contrast this to a dex CABG. Holding room RN starts dex bolus then infusion...usually pt gets somnulent just from the dex and requires no other meds in holding for line placement. If they werent sleepy enough, which was uncommon, midaz 2mg would usually do the trick. Whats funny is UT mentioned seeing hypertension during the bolus of dex...I think I saw this once with all the cases I did...we saw hypotension, not hypertension. Hypotension was usually incidental with no sequelae, easily fixed by a cuppla ephedrine bumps or hespan during line placement..
Now back to the OR...midaz 2mg if pt didnt get any in preop (for amnestic purposes), fentanyl 50-150ug, then pancuronium 10mg. Volatile agent requirements were DRASTICALLY reduced (as was benzo/opiod requirements). Not uncommon to have des around 3% ET for the whole case.
The kicker to me was the ease of the case...usually no BP lability...I did an emergency CABG one night without dex and was constantly adjusting the des, using NTG, etc...really showed me the benefits of dex concerning ease of case.
To answer your question about when to turn it off, for CABGs we left it running and it was turned off when pt was deemed ready for extubation (if they werent extubated already), hence using the dex for in-icu-sedation.
For CEAs, we turned it off 30 minutes or so before expected end-of-case time since the surgeons wanted to see the pt move, stick out their tongue, squeeze your hand, etc. Lack of hemodynamic lability during a CEA with dex made the cases easier, since its common to see a CEAs BP all over the place during the case.
SO, the answer to your question is that dex, at least for us, made the cases easier. Whether or not there is a clinical advantage will be panned out by the academic dudes.
