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Noyac

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So are many of you guys using it and what are the pros and cons? I have used it for hearts and I gotta say, It ain't impressive enough to warrant the cost yet. But it does seem to work well in the ICU. What are your thoughts?
 

UTSouthwestern

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I've used it pretty extensively for hearts, difficult airway patients, MAC sedation, bariatric surgery, and other types of cases with great results. The only side effects I've seen are hypertension with bolusing (just bolus slower to prevent crossover from alpha 2 stimulation to alpha 1). I have gone as high as 1 mcg/kg/hr without significant hypotension.

For cardiac cases, we have used it for fastracking patients and in conjunction with injection of local anesthetic at all incision sites, it seems to work quite well, typically allowing us to extubate on the table. I prefer to keep them intubated for at least an hour after completion of the surgery in case the patient needs to be brought back.
 

militarymd

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I love the stuff, although I don't have it where I am now.

The quality of the sedation is definitely different from versed.
 

jetproppilot

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Noyac said:
So are many of you guys using it and what are the pros and cons? I have used it for hearts and I gotta say, It ain't impressive enough to warrant the cost yet. But it does seem to work well in the ICU. What are your thoughts?

Used it routinely on CABGs at my previous gig (over 400 pump cases a year)..love it...minimal hemodynamic lability, routinely used 250ug or less of fentanyl for the WHOLE case.
 

Noyac

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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
 

Idiopathic

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What Ive noticed in my short time is that docs like it because they can cut the pain meds. Some see themselves as purveyors of a new opiate-free, but pain-free, anesthesia. I had a 30 minute or so dissertation from one of UT-Southwestern's former attendings just the other day. If it holds up, it is certainly fascinating.
 

jetproppilot

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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.
 

Noyac

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Thanks guys. Thats more what I was after. I won't discount its benefits but again I would like to the cost remedied. I guess time will tell how big of a part dex will play in our practice.
 

jetproppilot

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Noyac said:
Thanks guys. Thats more what I was after. I won't discount its benefits but again I would like to the cost remedied. I guess time will tell how big of a part dex will play in our practice.

Don't lose sight of the cost "big picture", that is, using a little more money in the OR and significantly reducing post-CABG ventilator times and ICU stay because of low intr-op opiods.
Similar to the cost justification of pre/intra op anti-emetic utilization to shorten the very expensive PACU time.
 

UTSouthwestern

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Hey Jet,

On CEA's, we actually left it running and the patient's remained very cooperative, but sedated enough to be completely relaxed and comfortable.

Also, for you guys just starting to use it, it is a gem for difficult airways as it keeps the patients exceptionally calm, yet still with full respiratory function. I have intubated patients without topicalization with local anesthetic, using a Miller blade who gag, choke, spit, etc., yet when you ask them the next day about the experience of being intubated, they say it was a very mild or even pleasant experience. BTW, that was not my choice of techniques. An attending wanted to show me the euphoriant effects of dex in this setting.
 

jetproppilot

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UTSouthwestern said:
Hey Jet,

On CEA's, we actually left it running and the patient's remained very cooperative, but sedated enough to be completely relaxed and comfortable.

Also, for you guys just starting to use it, it is a gem for difficult airways as it keeps the patients exceptionally calm, yet still with full respiratory function. I have intubated patients without topicalization with local anesthetic, using a Miller blade who gag, choke, spit, etc., yet when you ask them the next day about the experience of being intubated, they say it was a very mild or even pleasant experience. BTW, that was not my choice of techniques. An attending wanted to show me the euphoriant effects of dex in this setting.

Yeah, UT,
I can see leaving it running..we seemed to have problems having them lucid enough at the end for the surgeon's request to be able to have them follow commands as soon as the tube comes out.
I concur with dex utilization for awake intubation. Have used it myself. Agree that its alot easier when the pt continues to breathe well.
An alternative technique which I almost prefer since its easier is to do a mask induction with sevo, let the pt breathe themselves deep enough, yet still breathing on their own, then take the mask off and do your thing with the bronchoscope. The downside is you are time limited so you've gotta be deft with the scope.
BTW, sevo mask inductions are cool, fast, and easy for adult LMA cases like knee scopes, hysteroscopies, etc. Have done many with sevo only...no propofol, no fentanyl.
 

2Deep

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I too have used dex for cardiac cases and agree with the above postings. I have another anecdotal observation as well...I noticed that even with diabetic patients, I rarely needed much more than 2units/hour of insulin to control blood glucose while on bypass. Typically, without dex, even many non-diabetics have very insulin resistant spikes in glucose concetrations while on CPB. I am hypothesizing that dex's ability to modulate sympathetic outflox is at least partially responsible for this. Has anyone else observed this effect while using dex in cardiac cases?
 

jetproppilot

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2Deep said:
I too have used dex for cardiac cases and agree with the above postings. I have another anecdotal observation as well...I noticed that even with diabetic patients, I rarely needed much more than 2units/hour of insulin to control blood glucose while on bypass. Typically, without dex, even many non-diabetics have very insulin resistant spikes in glucose concetrations while on CPB. I am hypothesizing that dex's ability to modulate sympathetic outflox is at least partially responsible for this. Has anyone else observed this effect while using dex in cardiac cases?

hmmm...very interesting. Didnt notice, but only started to worry about glucose control about 2 years ago so thats a pretty cool observation and hypothesis.
When I did my cardiac rotation at Texas Heart circa 1995 the pumps were primed with alot of D5 and we purposely had high sugars for the post operative diuretic effect it induced. So when one of the heart surgeons started ranting and raving about the glucose I was like..."Well Dude, thats not the way Denton Cooley does it..." :laugh: :laugh:
Military, is there really credence to this new tight-glucose-control stuff? Its in stark disagreement with the way I was trained. I've heard about the infection studies etc but havent personally reviewed them. Are they legit studies? Randomized, prospective? n= a high number? Low p value?
 

militarymd

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Here is the data that got the tight glucose control thing going:

NEJM article

The patient population was 70% post CABG patients. Now on the face of it, it sounds very intriguing, but when you look a little more carefully, you realize that you are dealing with a patient population who stayed in the ICU for > 5 days and had an overall mortality of between 10% and 20%...which is pretty damn high...or what it means is that the patient population was pretty sick, or the surgeons sucked.

So, if you practice at a place where you have a relatively high mortality, it would be a good idea to have tight glucose control while in the ICU. Otherwise, the data probably does not support it, but it makes sense.
 

jetproppilot

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militarymd said:
Here is the data that got the tight glucose control thing going:

NEJM article

The patient population was 70% post CABG patients. Now on the face of it, it sounds very intriguing, but when you look a little more carefully, you realize that you are dealing with a patient population who stayed in the ICU for > 5 days and had an overall mortality of between 10% and 20%...which is pretty damn high...or what it means is that the patient population was pretty sick, or the surgeons sucked.

So, if you practice at a place where you have a relatively high mortality, it would be a good idea to have tight glucose control while in the ICU. Otherwise, the data probably does not support it, but it makes sense.

Thanx a mil for the reference.
But what about the new rave of insulin infusions during a CABG? Is it really necessary for a 3 hour case when the glucose is 250mg%?
 

militarymd

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jetproppilot said:
Thanx a mil for the reference.
But what about the new rave of insulin infusions during a CABG? Is it really necessary for a 3 hour case when the glucose is 250mg%?


Tight glucose control during CABG stems from that study....I'm pretty sure. If anyone knows any better, please let me know.

Because the majority of the patients in that study was post CABG, all the editorials extrapolated the study to care during surgery....does it make a difference? Probably.....Number needed to treat .....probably hundreds if not thousands.
 

Disse

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I've used it pretty extensively for hearts, difficult airway patients, MAC sedation, bariatric surgery, and other types of cases with great results. The only side effects I've seen are hypertension with bolusing (just bolus slower to prevent crossover from alpha 2 stimulation to alpha 1). I have gone as high as 1 mcg/kg/hr without significant hypotension.

Never used precedex for hearts (but would love to try it after reading these posts) but have used it extensively for almost everything else.

Favorites: Bariatric, MAC, and awake intubations.
Bariatric patients--low levels of inhalaled anesthetic, less gas to fill up the fat, much faster wake ups (I generally leave the precedex running until extubation whatever the case...very smooth extubation, patient looks at you with the tube down their throat completely comfortable before you pull it).
MAC--works great!!!!
Awake intubations--just make sure you start it early (usually preop).

Fantastic drug.
 

UTSouthwestern

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Idiopathic said:
What Ive noticed in my short time is that docs like it because they can cut the pain meds. Some see themselves as purveyors of a new opiate-free, but pain-free, anesthesia. I had a 30 minute or so dissertation from one of UT-Southwestern's former attendings just the other day. If it holds up, it is certainly fascinating.

Id, who was the attending just out of curiosity? Mike Ramsay?
 
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