Robotic AVRs

[Iso4ane]

This feels like something good to know. My sedation for TAVRs is usually a little fentanyl and a little precedex. Maybe 1-2mg midazolam added if they're squirmy.

I have found that a slightly heavier hand on opiates in the right patient, will make them tolerate a lot more, and require a lot less propofol.

A remifentail infusion is nice, they will still feel the pokes, but it’s a lot less painful, and God knows, a lot of these patient have back problems and have trouble lying still, a little remi takes care of that too.

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[anaesthetic]

I have found that a slightly heavier hand on opiates in the right patient, will make them tolerate a lot more, and require a lot less propofol.

A remifentail infusion is nice, they will still feel the pokes, but it’s a lot less painful, and God knows, a lot of these patient have back problems and have trouble lying still, a little remi takes care of that too.

Agreed. Our interventional folks want “conscious sedation” yet don’t want the patients to move or talk at all (i.e., general without an airway). Low-dose remi is very nice especially for the TAVR sheath insertion and patients with chronic back pain. I run all three at varying doses (cost is not really a problem here). Almost never any issues except the occasional apneic episode (easy fix with remi).

 

[Drwine]

This feels like something good to know. My sedation for TAVRs is usually a little fentanyl and a little precedex. Maybe 1-2mg midazolam added if they're squirmy.

We have evolved our TAVR sedation to Precedex baseline when they enter the room and titrate remifentanil to desired level of comfort. They tolerate discomfort and they are fully recovered shortly after the procedure. Propoful is only good for painful procedures when you are turning the sedation into a general anesthetic. We are up to 4000 TAVRs.

 

[DrN2O]

We have evolved our TAVR sedation to Precedex baseline when they enter the room and titrate remifentanil to desired level of comfort. They tolerate discomfort and they are fully recovered shortly after the procedure. Propoful is only good for painful procedures when you are turning the sedation into a general anesthetic. We are up to 4000 TAVRs

I used to worry about bradycardia needing postop pacing, but I don't think that's actually thing. I see more postop hypotension with high dose dex. I've seen every combination with pro, dex, remi and ketamine even. My favorite is iGel 😂

 

[2buckchuck]

I like to keep it simple for myself. Our cardiologists aren’t accustomed to us piggy-backing art pressure off an arterial sheath so we place art lines. Fentanyl +/- versed for art line (with local), then prop at deep sedation level + norepi gtt to maintain MAP mid 80s (usually put an OPA in). Once they get a wire into the LV the MAP will usually go into mid 60s with PVCs etc. They rapid pace, deploy. Usually it’s fine, sometimes gotta balloon again for a PVL. One they get their big sheaths out and use whatever perclose device and the cardiologist breaks scrub (leaving the tech to hold groin pressure for a few minutes) I turn the prop and NE off. I like it like that bc by the time we hit recovery the patient is awake and off o2, and nothing I gave is still lingering.

 

[PpfSuxTube]

We do prop, preecedex, remi infusion for 95%, no levo, slave off the cards aline and central line.
In room to out of room time is averaging 90 mins or less these days. Sometimes 70 mins... Doing 5 a day, 2 days a week... It's sweet day

 

[GassYous]

We do prop, preecedex, remi infusion for 95%, no levo, slave off the cards aline and central line.
In room to out of room time is averaging 90 mins or less these days. Sometimes 70 mins... Doing 5 a day, 2 days a week... It's sweet day

In residency we used to do precedex at 1.2 for a few minutes as soon as they come in the room and titrate down while prop is at 25-50.

 

[OB1🤙]

Colonoscopy and TAVR are the same anesthetic for me. KISS.

 

[deleted545787]

We perform RAVRs at our institute pretty regularly through a small R thoracotomy incision, high success rate, extubation in OR with reduced pacemaker placement in comparison to TAVRs.

 

[abolt18]

We perform RAVRs at our institute pretty regularly through a small R thoracotomy incision, high success rate, extubation in OR with reduced pacemaker placement in comparison to TAVRs.

RAVR?

 

[PpfSuxTube]

RAVR?

Robotic avr. Sounds awful. Hard to believe there's any actual real world benefit other stoking some surgeons ego...

Modern day savr is like 1-2 percent mortality.
How do you improve on that?

 

[deleted545787]

Robotic avr. Sounds awful. Hard to believe there's any actual real world benefit other stoking some surgeons ego...

Modern day savr is like 1-2 percent mortality.
How do you improve on that?

lol I know but these guys do pretty well, some are discharged home after 3-5 days on average.

 

[Drwine]

We have done over 4000 TAVRs with every imaginable approach. We have evolved to starting 0.7 ug/kg/hr of precedex when we hit the table and gradually titrate remifentanil to the desired level of sedation/comfort. For young patients who decline SAVR but were otherwise would have had that procedure will get 1 or 2 mg of midazolam in the mix. Whenever I am assigned to TAVR or other structural heart cases I become the "Walmart greeter" in admissions and I am very observant of the functional status of the patients coming in. Not nearly the same information when they are in the holding area on a cart.