Sedation and anesthetic mgmt practices post-CPB?

[vector2]

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I was curious to see what kind of institutional and regional practice variations exist regarding this topic.

Personally, I start a precedex gtt at 0.4 - 0.6 for every cardiac case post-induction unless there is a specific contraindication and continue it into the ICU. The vast majority of the time, but especially in those with fragile suture lines or coagulopathies, I am titrating my volatile anesthetic down as the sternal wires are going in and titrating up the precedex (or sometimes propofol). My reasoning is that I would like to know in the room if the pt is going to need an antihypertensive gtt to control the SBP and then dial in that infusion rate since obviously they won't be on 1 MAC of iso in the ICU. Frequently I am leaving the room with precedex running at 0.8-1.2, ET iso concentration around 0.2-0.3, +- versed depending on the pt's age and baseline cognitive function. However, many of my colleagues frequently manipulate the vaporizer for BP control and might leave the room with a MAC of volatile still on board.

What's your guys' practice?

 

[DrZzZz]

We start precedex once on pump, 0.5-0.7. We usually give a little versed coming off pump. Volatile doesn't get turned back on unless they're hypertensive or have an elevated BIS (personally hate the BIS, but it's standard here). If it's on for HTN, we start an antihypertensive only if the SBP was >140. Otherwise, we only use the volatile to drop the BP for cannula removal and then shut it off once they're out. Volatile will be turned back off when the chest is closed to aid in further titrating any antihypertensive agents prior to leaving the OR.

 

[WholeLottaGame7]

Similar. Do mostly peds and we try to extubate the "straightforward" cases in the room. Precedex usually on at 0.3-0.5 after the central line gets hooked up. Usually do end up needing to turn gas back up during closure, but at a lower level. Get breathing spontaneously and reverse while dressings going on. Extubate on 0.5-0.7, usually. Sometimes have to pause it due to sleepiness, but more frequently upping it to ~1ish by the time we finish sign out in ICU.

Even for those we're not extubating, usually adjust precedex/volatile similarly, for reasons you mentioned. Want gas off before transport so not blowing off 1 MAC of iso during trip to PCICU and show up hypertensive. Most kids come out on low-dose epi and milrinone w/ nicardipine prn for BP control.

Still challenging sometimes to have tight BP control, as stimulation/transferring to bed, changing position/fluid shifts, oozing, etc, all play into BP. I've left the room cranking up the nicardipine only to turn it off in the ICU and vice versa. A little extra challenging in peds because of the lag time owing to the carrier rates being so low, even with minimizing tubing volume. Always trying to guess where we're going to be in 5-10min.

 

[abolt18]

I was curious to see what kind of institutional and regional practice variations exist regarding this topic.

Personally, I start a precedex gtt at 0.4 - 0.6 for every cardiac case post-induction unless there is a specific contraindication and continue it into the ICU. The vast majority of the time, but especially in those with fragile suture lines or coagulopathies, I am titrating my volatile anesthetic down as the sternal wires are going in and titrating up the precedex (or sometimes propofol). My reasoning is that I would like to know in the room if the pt is going to need an antihypertensive gtt to control the SBP and then dial in that infusion rate since obviously they won't be on 1 MAC of iso in the ICU. Frequently I am leaving the room with precedex running at 0.8-1.2, ET iso concentration around 0.2-0.3, +- versed depending on the pt's age and baseline cognitive function. However, many of my colleagues frequently manipulate the vaporizer for BP control and might leave the room with a MAC of volatile still on board.

What's your guys' practice?

I would say that there is some variability between attendings, but in general, precedex gets started on pump (sometimes before). Decrease volatile when they're starting chest closure and give fentanyl if pressure starts climbing. If patient is getting wiggly and is appropriate, we'll work in some midazolam. Volatile is usually turned off before moving over to the bed to ensure they don't get squirmy and we have less HD shifts during transport.

I'd say in general we are heavy handed with narcotic here so 1-2mg fentanyl by the end is about normal.

 

[bigdan]

Elective cases: do Iso pre-pump and then perfusionist runs ISO on pump during conduct of CPB.

Iso 0.4 (or so) alongside low dose Prop gtt until safely off pump (Prota complete, cannulae out, etc). Then Iso to 0.2 or off, leaning on Prop through hand-off in the unit.

Massive culture shift evolving to decrease Midaz and Fent dosing. Surgeons are pushing for “cardiac ERAS”, so we’ve (literally) just started doing Dex instead of Prop; ES blocks preop, +/- Scop patch, APAP, and/or Gabapentinoids before OR.

Our robotic mitrals are treated like general thoracic cases: Sevo during pre-CPB, Iso via perfusion on CPB, then Sevo until extubation. Generally no more than 2 mg Midaz, 250 mcg Fent, 50 mg Ketamine. It’s smooth enough to make you wonder if normal EF, surgically-smooth CABG or SAVR couldn’t just be done the same, but my vote doesn’t count.

Our EF 5%/LVAD/unplanned IABP/OHTxp/Type A/etc are handled case by case.

 

[Dexmetaketapropofol]

We're rolling out with our Cardiac ERAS as well. Mostly as above, Modified (medial PECS 2 block) with Exparel, Ketamine pre-sternotomy, Precedex after CPB, no Propofol, Fentanyl under 500 mcg, paralytic reversal and extubating in OR vs fast track in ICU for the appropriate candidates

 

[GassYous]

Elective cases: do Iso pre-pump and then perfusionist runs ISO on pump during conduct of CPB.

Iso 0.4 (or so) alongside low dose Prop gtt until safely off pump (Prota complete, cannulae out, etc). Then Iso to 0.2 or off, leaning on Prop through hand-off in the unit.

Massive culture shift evolving to decrease Midaz and Fent dosing. Surgeons are pushing for “cardiac ERAS”, so we’ve (literally) just started doing Dex instead of Prop; ES blocks preop, +/- Scop patch, APAP, and/or Gabapentinoids before OR.

Our robotic mitrals are treated like general thoracic cases: Sevo during pre-CPB, Iso via perfusion on CPB, then Sevo until extubation. Generally no more than 2 mg Midaz, 250 mcg Fent, 50 mg Ketamine. It’s smooth enough to make you wonder if normal EF, surgically-smooth CABG or SAVR couldn’t just be done the same, but my vote doesn’t count.

Our EF 5%/LVAD/unplanned IABP/OHTxp/Type A/etc are handled case by case.

Cabg can be done with midaz 2 and fent 500. But there's something fun about pushing a stick of fent

 

[dchz]

I start the precedex at 1 when we come off pump. Then keep the gas on full MAC.

Then treat the BP once we start rolling toward the ICU.

I also give about 200mg ketamine throughout the case because that the size of the bottle we have. In before the Elijah McClain jokes...

 

[pjl]

I was curious to see what kind of institutional and regional practice variations exist regarding this topic.

Personally, I start a precedex gtt at 0.4 - 0.6 for every cardiac case post-induction unless there is a specific contraindication and continue it into the ICU. The vast majority of the time, but especially in those with fragile suture lines or coagulopathies, I am titrating my volatile anesthetic down as the sternal wires are going in and titrating up the precedex (or sometimes propofol). My reasoning is that I would like to know in the room if the pt is going to need an antihypertensive gtt to control the SBP and then dial in that infusion rate since obviously they won't be on 1 MAC of iso in the ICU. Frequently I am leaving the room with precedex running at 0.8-1.2, ET iso concentration around 0.2-0.3, +- versed depending on the pt's age and baseline cognitive function. However, many of my colleagues frequently manipulate the vaporizer for BP control and might leave the room with a MAC of volatile still on board.

What's your guys' practice?

Precedex 0.7 after stable post coming off pump, or at sternal wire start. Wean Iso to <0.5 typically well before out of room (depends on patient). Most CABG get 2 versed, 500-750 or so of fent.

Extubate “easy” hearts in room when appropriate, minimal to no ongoing sedation.

 

[Arch Guillotti]

I also give about 200mg ketamine throughout the case because that the size of the bottle we have. In before the Elijah McClain jokes...

Nothing to joke about.

 

[OB1🤙]

I hate precedex.

That’s it. That’s the post.

 

[Drwine]

We start Precedex 0.7 when the wires are twisted and the patient isn't bleeding which gives enough time for a steady state of Precedex and decision to what else might be needed. IMHO isoflurane belongs on the same scrap heap as compact fluorescent light bulbs and 16 bit computers. Its only advantage that led to widespread adoption was the fact that surgeons had to take ownership of giving the patient hepatitis C from their liberal use of blood products in the day when they could blame us for halothane hepatitis. Isoflurane was introduced when I was finishing medical school and was in more widespread use by the time I was a resident. Once isoflurane was introduced the doses of narcotics and muscle relaxants during surgery increased exponentially. However in those days we pretty much used high dose narcotics with benzo and muscle relaxant. From morphine to fentanyl to sufentanil. Forty years ago the dogma was that inhalational agents were bad for the heart.

Once switching to sevo and putting vaporizers on the pump the need for adjunctive agents has become pretty minimal and the last 45 minutes to hour of the case is plenty of time to transition to a post op infusion that will control the hemodynamics and transition to a rapid recovery.

 

[GassYous]

We start Precedex 0.7 when the wires are twisted and the patient isn't bleeding which gives enough time for a steady state of Precedex and decision to what else might be needed. IMHO isoflurane belongs on the same scrap heap as compact fluorescent light bulbs and 16 bit computers. Its only advantage that led to widespread adoption was the fact that surgeons had to take ownership of giving the patient hepatitis C from their liberal use of blood products in the day when they could blame us for halothane hepatitis. Isoflurane was introduced when I was finishing medical school and was in more widespread use by the time I was a resident. Once isoflurane was introduced the doses of narcotics and muscle relaxants during surgery increased exponentially. However in those days we pretty much used high dose narcotics with benzo and muscle relaxant. From morphine to fentanyl to sufentanil. Forty years ago the dogma was that inhalational agents were bad for the heart.

Once switching to sevo and putting vaporizers on the pump the need for adjunctive agents has become pretty minimal and the last 45 minutes to hour of the case is plenty of time to transition to a post op infusion that will control the hemodynamics and transition to a rapid recovery.

wat

 

[deleted697535]

some of our more adventurous guys do ketamine/lidocaine throughout the case
Some use no midaz, some use all midaz
We all use suf infusions
No-one does precedex in the OR
All our MICS/SVST/robotics get a SAP catheter which works very rarely.

 

[dchz]

Nothing to joke about.

You'd think so but @nimbus made one in recent memory...

 

[OB1🤙]

This isn't rocket surgery.

Iso until they're closing skin. Then turn it off and turn on propofol. Run it till it's time to wake the patient up. Then turn it off. Then the patient wakes up.

KISS

 

[bigeyedfish]

Precedex .3-.5 started when I hook the lines up.
Usual total midaz for the case 5mg.
Usual fent 500.
Post cpb either iso .3-.4 or sevo .7 Use drips to control bp. Volatile off while sewing skin.
Err toward a lower bp for transport. Systolic of 80 will not kill a fresh heart, 180 might.

 

[ProRealDoc]

This isn't rocket surgery.

Iso until they're closing skin. Then turn it off and turn on propofol. Run it till it's time to wake the patient up. Then turn it off. Then the patient wakes up.

KISS

My approach exactly especially with a cost-conscious inpatient hospital pharmacy.

 

[vector2]

Iso 0.4 (or so) alongside low dose Prop gtt until safely off pump (Prota complete, cannulae out, etc). Then Iso to 0.2 or off, leaning on Prop through hand-off in the unit.

I start the precedex at 1 when we come off pump. Then keep the gas on full MAC.

This isn't rocket surgery.

Iso until they're closing skin. Then turn it off and turn on propofol. Run it till it's time to wake the patient up. Then turn it off. Then the patient wakes up.

KISS

You know the aphorism about many ways to skin a cat in anesthesia is true when so many heavy hitters can have 180 degree opposing techniques for the same thing. @sevoflurane what's your practice?

 

[pjl]

You know the aphorism about many ways to skin a cat in anesthesia is true when so many heavy hitters can have 180 degree opposing techniques for the same thing. @sevoflurane what's your practice?

He probably uses Iso.

 

[BLADEMDA]

I’ve seen all those techniques used for hearts. I don’t think there is any difference in outcomes. Within 30 minutes of arriving to the Cardiac ICU I doubt anyone could tell a difference between those anesthetics.

The only exception to my statement is the use of preop blocks. The verdict is still out whether they really do much to improve patient outcomes

 

[BLADEMDA]

Efficacy of Bilateral Pectoralis Nerve Block for Ultrafast Tracking and Postoperative Pain Management in Cardiac Surgery - PMC

Good postoperative analgesia in cardiac surgical patients helps in early recovery and ambulation. An alternative to parenteral, paravertebral, and thoracic epidural analgesia can be pectoralis nerve (Pecs) block, which is novel, less invasive ...

www.ncbi.nlm.nih.gov

 

[Dexmetaketapropofol]

Efficacy of Bilateral Pectoralis Nerve Block for Ultrafast Tracking and Postoperative Pain Management in Cardiac Surgery - PMC

Good postoperative analgesia in cardiac surgical patients helps in early recovery and ambulation. An alternative to parenteral, paravertebral, and thoracic epidural analgesia can be pectoralis nerve (Pecs) block, which is novel, less invasive ...

www.ncbi.nlm.nih.gov

I just started doing these within the last few months. I do believe the unit is able to shave a little time off extubation. They still complain of pleural pain and tube pain though. Opioid doses seem to be lower from what I can anecdotally see. Still needs more review and study though I agree. It's definitely not a silver bullet that makes it all rainbows.

We routinely switched to Dex instead of Prop as a hard change though: https://www.anesthesiologynews.com/...or-Timed-Outcomes-After-Cardiac-Surgery/59173

 

[deleted162650]

I'm not a cardiac guy, but at my shop routine cardiac cases all get IT duramorph pre-induction and extubated on the table.

 

[abolt18]

I'm not a cardiac guy, but at my shop routine cardiac cases all get IT duramorph pre-induction and extubated on the table.

Adults?

 

[deleted162650]

Adults?

Yes. No pedi cardiac here.

 

[drmwvr]

I'm not a cardiac guy, but at my shop routine cardiac cases all get IT duramorph pre-induction and extubated on the table.

what happens with the rare bloody tap?

 

[deleted162650]

what happens with the rare bloody tap?

Hasn’t been an issue

 

[Dexmetaketapropofol]

I'm not a cardiac guy, but at my shop routine cardiac cases all get IT duramorph pre-induction and extubated on the table.

Even the antiplatelet patients? Plavix, Effient?

 

[deleted162650]

Even the antiplatelet patients? Plavix, Effient?

No, not if they are actively anti-coagulated/anti-plateleted. Same ASRA guidelines apply, but these meds are usually held/bridged in anticipation of surgery anyways.

 

[nimbus]

I'm not a cardiac guy, but at my shop routine cardiac cases all get IT duramorph pre-induction and extubated on the table.

Many people seem surprised. We used ITMS for years at my place starting around 2000-2002 but we weren’t extubating in the OR. The issue was that it was associated with postpump vasoplegia and the patients who got ITMS typically needed more alpha agonists than those who didn’t. We all used 26 or 27g spinal needles and had no issues with bloody taps.

 

[vector2]

I’ve seen all those techniques used for hearts. I don’t think there is any difference in outcomes. Within 30 minutes of arriving to the Cardiac ICU I doubt anyone could tell a difference between those anesthetics.

The only exception to my statement is the use of preop blocks. The verdict is still out whether they really do much to improve patient outcomes

There are a couple more things that also need to be clarified when asking how people deal with sedation and BP control.

The first is how meticulous your surgeon is. If they are the obsessive kind who checks their suture lines and grafts 6 times before even beginning to close the chest, you're certainly going to be able to be more permissive with brief periods of hypertension than if you're working with a surgeon who starts closing while the chest is still filling up and just throws products at the problem when the pt really has prolene deficiency.

The second is your ICU pyxis availability of antihypertensives. At my shop there are no brand name premade Cardene bags in the ICU. Nicardipine gtt bags needs to come up from the pharmacy, and depending on the time of day that can take forever which means the pt might be sitting there for half an hour to an hour with a BP of 180. I suppose the ICU could just throw prop and dilaudid at the issue, but snowing out the pt instead of treating the problem doesn't seem ideal.

 

[sevoflurane]

You know the aphorism about many ways to skin a cat in anesthesia is true when so many heavy hitters can have 180 degree opposing techniques for the same thing. @sevoflurane what's your practice?

Precedex @ .5 started midway through pump run.

250 ish of fentanyl plus methadone usually all given prior to going on pump. I personally rarely give midazolam. If I do it’s only 2 mg.

Mag either in the pump or IV during the case.

Tight control of BP on all of our patients. Clevidipine started after protamine if BP stays above 130ish.

All go up to the unit with epi, norepi, insulin, precedex. A bit wasteful, but our goal has been to standardize our cases to streamline directed nursing interventions post op should there be a need.

Some of us do bilateral ESB on selective cases from time to time, but that is up to the particular anesthesiologist doing the case.

 

[McPoyle]

For most cases (OHT/LVAD and lung transplant may be different) I do ketamine on induction (0.5mg/kg) then ketamine and preceded drips once lines are in - ketamine stops prior to transfer to unit. Give a little fentanyl/esmolol for laryngoscopy and lines, some dilaudid on sternotomy then very little to no more narcotics until waking up (use anti-HTN and beta blocker instead). Isoflurane for volatile but once wires are in try and get this off and solely on precedex. Some narcotic may be worked in as they start over breathing and waking up. IV Tylenol on chest closure. NMB reversed in ICU prior to hand off.

Typically end up with with 50-100mg of ketamine, <500mcg fentanyl, and <2mg dilaudid. +\- 2-4mg if Midaz total. 600-900 of gabapentin and 1g APAP in preop and generally (if ~6hrs elapsed) 1g IV Tylenol.