Share your very low EF induction

[JWebar]

Hey guys!

Just curious. What would be your induction for a 50–60 yo 70 kg patient with severely depress EF (lets say 15%). Let's just skip all the other considerations say she is not decompensated and has optimal medical management on board. Just focus on the induction for a GA with intubation. Pre–induction arterial line for sure.

And what about if its ischemic CM?

Would you start with vasopressors on board?

Thanks in advance for sharing!

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[NICMAN]

Methohexital on a micro dripper infusion along with titrated phenylephrine, lidocaine, and alfentanyl +\- roc depending on how the airway looks once the patient is comfortably sedated.

 

[D P356]

For what procedure?
Only induction this patient would be having is for a multi-vessel Cabg Or R and/or LVAD. Lots of unknowns. And this isn’t the type of pt to “skip all the other considerations.” Baseline EKG, echo. Right heart function? Pulmonary pressures, valvlopathy? AICD/pacer settings? If they don’t have one, why not?

On a pump case we’ve done albumin 250-500cc for preload deficit optimization. etomidate, fentanyl succ depending on airway as mentioned above. Low dose Epi gtt on before induction. Calcium, epi and neo in line for a bolus. EF was roughly 21%. That was just their cardiovascular problems...

 

[Mman]

For what procedure?
Only induction this patient would be having is for a multi-vessel Cabg Or R and/or LVAD. Lots of unknowns.

Really? These patients get GAs all the time for all sorts of procedures.

 

[deleted171991]

Hey guys!

Just curious. What would be your induction for a 50–60 yo 70 kg patient with severely depress EF (lets say 15%). Let's just skip all the other considerations say she is not decompensated and has optimal medical management on board. Just focus on the induction for a GA with intubation. Pre–induction arterial line for sure.

And what about if its ischemic CM?

Would you start with vasopressors on board?

Thanks in advance for sharing!

Bring up pressure and heart rate with a bit of epi, if needed. (The goal is not to drop cardiac output and coronary perfusion, but also not to increase the double product too much.) 20 of propofol. Wait, wait, wait more, go from there. Another 10-20. Wait, wait... then push roc etc.

Another option is doing it by pump, at 25-50 mcg/kg/min. Or you can do an inhalational induction, while treating hypotension. Or you can use a touch of etomidate, instead of propofol. Or you can use just versed (about 5 mg, titrated in, followed by roc when consciousness is lost), with a touch of esmolol for tachycardia etc.

Induction is like doing a TEE or EGD or similar. If you can do those on a patient, you can also induce and intubate them. The keyword is PATIENCE. As long as you maintain HR, BP and CO, and you go slow, there is no wrong way of doing it.

 

[D P356]

Really? These patients get GAs all the time for all sorts of procedures.

You’re experience is likely way beyond mine. I’ve got a lot to learn.

 

[Mman]

You’re experience is likely way beyond mine. I’ve got a lot to learn.

old person fall and break hip and not candidate for spinal = GA

 

[Shimmy8]

Touch of neo. Touch of prop, squirt of ketamine. Wait a few minutes. Sux/Tube.

 

[Mman]

I almost always do a preinduction art line. That's the extent of my recipe for these cases. Have induced with etomidate, ketamine, propofol, sevoflurane, etc. Just need to be prepared for vasodilation on top of the already low EF and have meds to support inotropy as well as vasopressor as needed.

 

[Silo004]

Methohexital on a micro dripper infusion along with titrated phenylephrine, lidocaine, and alfentanyl +\- roc depending on how the airway looks once the patient is comfortably sedated.

I have never seen methohexital used. Would love to have it in my toolbox.

 

[sevoflurane]

EF was roughly 21%...

 

[deleted59964]

What you do << important than how you do it.

S l o w is good

 

[ethilo]

I saw a guy code on 20mg propofol for induction given by my cardiac anesthesia attending. Severe left main disease and severe depressed EF. I could hardly believe it but I was up there doing compressions when that A-Line flattened!

 

[Mman]

I have never seen methohexital used. Would love to have it in my toolbox.

most commonly used for ECT

 

[p30doc]

I did robotic inguinal hernia repair on EF 5-10%, cardiology said low risk for surgery! Preinduction a-line with flotrac, phenylephrine gtt connected but not started then etomidate, roc, tube. Uneventful anesthetic in the end.

 

[Ezekiel2517]

Inhalation induction works nicely on these types of patients

 

[Twiggidy]

Hey guys!

Just curious. What would be your induction for a 50–60 yo 70 kg patient with severely depress EF (lets say 15%). Let's just skip all the other considerations say she is not decompensated and has optimal medical management on board. Just focus on the induction for a GA with intubation. Pre–induction arterial line for sure.

And what about if its ischemic CM?

Would you start with vasopressors on board?

Thanks in advance for sharing!

You induce them like they're Kansas City BBQ......slow and low. The actual agent you use doesn't even really matter so long as you give a little ( and I mean like 1 cc of whatever you've chosen ) and see what happens. Rinse and repeat. Go almost painfully slow for everyone in the room including yourself. Of course, I'd have my pressors (neo vs vaso, epi) ATR. Yes pre induction A line, but actually depends on how long a procedure.

Give a bit.
"hey sir how you doing?"
"Im good"
Give a bit
"How you doing?"
"I'm gooo...."
Give a bit
"a blad blah"
Give a bit
"Hows that?"
*crickets* or snoring
Give a bit and relaxant and DL/Video whatever (I'm making airway assumptions) The DL will bring your pressure up. Also this is assuming a procedure that requires a GA.

Slow and low....that is the tempo.

 

[deleted171991]

I did robotic inguinal hernia repair on EF 5-10%, cardiology said low risk for surgery! Preinduction a-line with flotrac, phenylephrine gtt connected but not started then etomidate, roc, tube. Uneventful anesthetic in the end.

Holy cow! EF 5-10% with a robotic procedure (for a freakin' hernia)?! Tempting the gods much in your practice???

The cardiologist was a *****.

 

[Mman]

Holy cow! EF 5-10% with a robotic procedure (for a freakin' hernia)?! Tempting the gods much in your practice???

The cardiologist was a *****.

I kinda question the math when the EF reads out that low on somebody that is appears to be alive. I mean that's a stroke volume of what, 10-20mls at most?

 

[T-burglar]

If the heart is very dilated then an EF of 10% can be a suprisingly large stroke volume. It's obviously not 10 - 20 mLs if the patient is in pre-op holding and sitting upright talking to you. Ejection fractions that appear the same by echocardiography can have different calculated stroke volumes, the echo doesn't tell the whole story. Our understanding of the circulation continues to evolve - when you dig into the bleeding edge imaging literature on aortic stenosis for example, we still don't really understand it as well as you might think.

Anyway, no need to go slow, just have norepinephrine available as a push and infusion. Pre-induction arterial line.

 

[Mikkel]

If the patient is alive without infusions running, before coming into the operating room, then you'll be fine.

Run low dose phenylephrine from microdripper, titrate. Give small amounts of propofol over a long time. I like to avoid art line preinduction in favor of the cuff because waiting for the cuff to cycle every 2.5 minutes is a better cadence for your dosing, and the instantaneous art line pressure can give you a false confidence to accelerate and increase dosing before the body has enough time to recirculate already given meds.

All you need is time, propofol, and phenylephrine. When asleep, add your roc.

 

[deleted875186]

Great advice.

Personally I think inhalation induction with pressers runnin works great. Or 2-3 mcg/kg fentanyl, pressers, and a very small amount of hypnotic. Epinephrine ready and in line, if you were really concerned you could start the epi low before induction and see if the patient is able to increase their BP and CO.

Anyone ever do an old school scopolamine and opioid induction? Over only heard of it, never seen anyone do it.

 

[Mikkel]

Anyone ever do an old school scopolamine and opioid induction? Over only heard of it, never seen anyone do it.

I haven't done narcotic inductions since residency. They're old school, in a bad way.

 

[deleted59964]

Personally I think inhalation induction with pressers runnin works grea

Me too, as does a tiny dose of propofol and then a low dose of gas - an each way bet.

 

[pgg]

It depends on the case too. Duration, plan for extubation vs ICU vent. Benzo and opioid inductions can be super smooth but they have a relatively longer tail.

Small, incremental doses of midazolam, ketamine, fentanyl, propofol, sevoflurane. Time.

Be mindful that PPV may harm cardiac output.

Arterial line up front, of course. Appropriate IV access, vasoactive infusion set up and in-line. I use a lot of phenylephrine infusions in older people, but for those with really poor cardiac function I lean toward starting epi early, sometimes pre induction. Better to stay ahead than catch up.

 

[Hork Bajir]

As others have suggested, many approaches are safe as long as you go slow. What I find much more challenging (and what you’ll get on the oral boards) is the situation where you’re forced to choose between slow induction for hemodynamic control, or RSI for aspiration risk.

For example last month on call I had the following case: dude with an SBO who was nauseous and vomiting, surgical intern tried to place an NGT but caused a nosebleed (INR 2+ on Coumadin for AF), so aborted the placement. EF 15-20%, now w/ worsening belly pain and concern for ischemic bowel/abdominal sepsis, comes to OR for urgent ex-lap. This kind of case is (unfortunately) routine at my gig- can’t do a slow induction, or homeboy might aspirate. Induce too hard, you’ll dump his myocardial perfusion pressure and risk a death spiral. OTOH if you dont get him deep enough before you start doing mean things like sticking a laryngoscope in his airway, he gets tachy/hypertensive and either gets ischemic or gets flash pulmonary edema (I’ve seen both on more than one occasion in this circumstance).

What do you do? Take your best guess for dosing, decide if risk of aspiration outweighs risk of hemodynamic embarrassment or vice versa, and be prepared to correct course quickly if need be. An extra set of experienced hands is an asset for this type of induction, no matter how long you’ve been doing this... but this is why they pay us the big buck$

 

[Mikkel]

Be mindful that PPV may harm cardiac output.

Good point. In really old patients with bad hearts, a desflurane+nitrous induction works miracles. Keeping patients spontaneously breathing can help quite a bit with preserving cardiac output.

 

[Mikkel]

What do you do? Take your best guess for dosing, decide if risk of aspiration outweighs risk of hemodynamic embarrassment or vice versa, and be prepared to correct course quickly if need be. $

Just give a paralytic and put the tube in.

If you're concerned about recall, give some versed.

It's not rocket scientology.

 

[DM27]

You can do this however you want as long as you are cautious. In reference to this patient would only have a cardiac procedure, that is unfortunately VERY far from the truth.

It ultimately depends on the case what I would do for induction (longer case is easier because I don't need to worry about a snappy emergence in <1 hour). Typically my move is I would do a pre-induction a-line, start an epinephrine infusion to get what little reserve I can out of that heart, and then do a slow induction likely with a combination of midaz + ketamine + fentanyl. If I was feeling lazy or extra spooked, I would just go to etomidate and ketamine. The clinically relevant myocardial depression you see from ketamine is at closer to true induction doses (~100mg +), so you can give 50mg without significant concern.

You could also topicalize to need even less to tolerate laryngoscopy.

 

[pgg]

Just give a paralytic and put the tube in.

If you're concerned about recall, give some versed.

It's not rocket scientology.

Snarky, condescending, AND missing the point ("give some versed" IS an induction in some of these people). You're fitting right in on SDN.

 

[dannyboy1]

As others have suggested, many approaches are safe as long as you go slow. What I find much more challenging (and what you’ll get on the oral boards) is the situation where you’re forced to choose between slow induction for hemodynamic control, or RSI for aspiration risk.

For example last month on call I had the following case: dude with an SBO who was nauseous and vomiting, surgical intern tried to place an NGT but caused a nosebleed (INR 2+ on Coumadin for AF), so aborted the placement. EF 15-20%, now w/ worsening belly pain and concern for ischemic bowel/abdominal sepsis, comes to OR for urgent ex-lap. This kind of case is (unfortunately) routine at my gig- can’t do a slow induction, or homeboy might aspirate. Induce too hard, you’ll dump his myocardial perfusion pressure and risk a death spiral. OTOH if you dont get him deep enough before you start doing mean things like sticking a laryngoscope in his airway, he gets tachy/hypertensive and either gets ischemic or gets flash pulmonary edema (I’ve seen both on more than one occasion in this circumstance).

What do you do? Take your best guess for dosing, decide if risk of aspiration outweighs risk of hemodynamic embarrassment or vice versa, and be prepared to correct course quickly if need be. An extra set of experienced hands is an asset for this type of induction, no matter how long you’ve been doing this... but this is why they pay us the big buck$

Pre induction art line, phenylephrine running, etomidate, lido, sux in a 20 cc syringe and push. Esmolol drawn up. Would use video scope as it seems to cause less stimulation/tachycardia.....

 

[MoMoGesiologist]

If the case is going to be quick, let’s say EGD needing GA, or maybe like a ortho pinning <30min, do y’all still place an art line preinduction?

I kind of liked what @Mikkel said about not placing aline to force you to slow down and wait for NIBP

 

[AdmiralChz]

Anyone ever do an old school scopolamine and opioid induction? Over only heard of it, never seen anyone do it.

I haven’t given a huge slug of narcotic (>250mcg fentanyl) since the big opiate shortage a couple of years ago and even then I found while it can be stable for induction they tend to became fairly hypotensive and have high pressor requirements when the effect peaked at 5ish minutes. For some of our emergent, sick CABGs I often give zero narcotic and make them earn it.

I last saw IV scopolamine as an intern in 2013 and we promptly used the last of it in a trauma case. The pharmacists told us at the time it wasn’t manufactured anymore...

 

[Twiggidy]

If the case is going to be quick, let’s say EGD needing GA, or maybe like a ortho pinning <30min, do y’all still place an art line preinduction?

I kind of liked what @Mikkel said about not placing aline to force you to slow down and wait for NIBP

I don’t. I evaluate the case first and then decide. If it’s a short case I’ll just repeat the BP every 2 min and be slightly more aggressive with pressors

 

[psychbender]

For what procedure?
Only induction this patient would be having is for a multi-vessel Cabg Or R and/or LVAD.

The other week, I did an ERCP on a guy with LVEF 10-20% and severe AS. A day later, one of my colleagues did him again for his lap chole. We each just induced him really slowly, usually with a little hit of phenylephrine with each little hit of prop, then sux and tube. As others have said, we do all kinds of non-cardiac cases on patients with piss-poor cardiac function all the time now.

 

[MoMoGesiologist]

The other week, I did an ERCP on a guy with LVEF 10-20% and severe AS. A day later, one of my colleagues did him again for his lap chole. We each just induced him really slowly, usually with a little hit of phenylephrine with each little hit of prop, then sux and tube. As others have said, we do all kinds of non-cardiac cases on patients with piss-poor cardiac function all the time now.

Geez. Just curious, how much propofol and phenyl did you end up giving for induction (if you remember)?

 

[AdmiralChz]

The other week, I did an ERCP on a guy with LVEF 10-20% and severe AS. A day later, one of my colleagues did him again for his lap chole. We each just induced him really slowly, usually with a little hit of phenylephrine with each little hit of prop, then sux and tube. As others have said, we do all kinds of non-cardiac cases on patients with piss-poor cardiac function all the time now.

We do cases like this all the time. Some of these folks actually have reasonable functional status and do well. Very important to ask what they can do at home, will give you hints to how they will do during during an anesthetic.

 

[psychbender]

Geez. Just curious, how much propofol and phenyl did you end up giving for induction (if you remember)?

Not a lot. I think it was only about 60mg, given in 10-20mg boluses every two minutes (cuff cycling q2), with about 25mcg fentanyl given as I was getting him on monitors. Gave one mL phenylephrine with each bolus. His PPM kept his heart rate constant. He was remarkably stable throughout, and did just fine for both of us.

 

[Twiggidy]

I think the effect of poly-pharmacy on the hemodynamics is something that isn't really stress. Sure, propofol alone can cause vasodilation and some cardiac depression, but I feel the real problems with propofol AND midazolam AND versed one after the other. Elderly or cardiac depressed patients I'm almost never including versed as part of their induction or even after intubation and I'm light with the narcotics until I see how they tolerate stimulation, whether its from DL or the incision. I'm sure study has been done to prove this right or wrong but I just don't feel like looking.

I think that if you just take your time and choose which agent and which combo of agent, if any combo at all, is appropriate for induction then you'll be fine in most of these cases.

 

[nimbus]

If the case is going to be quick, let’s say EGD needing GA, or maybe like a ortho pinning <30min, do y’all still place an art line preinduction?

I kind of liked what @Mikkel said about not placing aline to force you to slow down and wait for NIBP

I do because they’re much easier to place while they still have a pulse.

 

[nimbus]

I think the effect of poly-pharmacy on the hemodynamics is something that isn't really stress. Sure, propofol alone can cause vasodilation and some cardiac depression, but I feel the real problems with propofol AND midazolam AND versed one after the other. Elderly or cardiac depressed patients I'm almost never including versed as part of their induction or even after intubation and I'm light with the narcotics until I see how they tolerate stimulation, whether its from DL or the incision. I'm sure study has been done to prove this right or wrong but I just don't feel like looking.

I think that if you just take your time and choose which agent and which combo of agent, if any combo at all, is appropriate for induction then you'll be fine in most of these cases.

I agree. My usual recipe is preinduction Aline, little epi or phenylephrine, just enough propofol slowly until they don’t respond to my voice (typically 30-50mg), roc and tube. No opioids until incision time and no opioids at all for nonpainful procedures. Almost never versed.

 

[Mman]

I think the effect of poly-pharmacy on the hemodynamics is something that isn't really stress. Sure, propofol alone can cause vasodilation and some cardiac depression, but I feel the real problems with propofol AND midazolam AND versed one after the other.

I prefer to chase the first few molecules of midazolam with some versed for synergy

 

[DM27]

You give the generic vial and then just try to give as little as possible to conserve the top shelf brand name.

 

[Mikkel]

I think the effect of poly-pharmacy on the hemodynamics is something that isn't really stress. Sure, propofol alone can cause vasodilation and some cardiac depression, but I feel the real problems with propofol AND midazolam AND versed one after the other. Elderly or cardiac depressed patients I'm almost never including versed as part of their induction or even after intubation and I'm light with the narcotics until I see how they tolerate stimulation, whether its from DL or the incision. I'm sure study has been done to prove this right or wrong but I just don't feel like looking.

I think that if you just take your time and choose which agent and which combo of agent, if any combo at all, is appropriate for induction then you'll be fine in most of these cases.

Agree 100%.

They teach synergism, but it's always taught as a "good thing". They never tell you that not only do you have synergism for higher levels of hypnosis/analgesia for given medication doses, you also have synergism with hemodynamics, i.e. more hypotension with combo.

I've switched to prop for induction, gas+nitrous for maintenance, and PACU for analgesia (assuming adequate local given by surgeons or block performed).

No more problems with anesthesia-related hypotension, surprise surprise.

 

[Mikkel]

If the case is going to be quick, let’s say EGD needing GA, or maybe like a ortho pinning <30min, do y’all still place an art line preinduction?

I kind of liked what @Mikkel said about not placing aline to force you to slow down and wait for NIBP

I would put it in if it's a longer case or if I expect hemodynamic instability from the surgery/procedure itself. If you're careful enough, your anesthetic shouldn't be the problem.

I wouldn't put one in for any GI cases. Maybe for a pinning if patient will lose a high percentage of blood (90 year old woman with 45kg weight) and I want to stay on top of hemoglobin and pH.

 

[Twiggidy]

I prefer to chase the first few molecules of midazolam with some versed for synergy

My bad....meant fentanyl

 

[dchz]

I haven't done narcotic inductions since residency. They're old school, in a bad way.

What do you mean in a bad way? humor me and explain to me what's wrong with a narcotic induction.

 

[deleted875186]

What do you mean in a bad way? humor me and explain to me what's wrong with a narcotic induction.

Agreed, I’m not talking about 1-2 mg of fentanyl or a buttload of morphine, maybe just 2-3 mcg/kg of fentanyl.

 

[Mikkel]

What do you mean in a bad way? humor me and explain to me what's wrong with a narcotic induction.

Agreed, I’m not talking about 1-2 mg of fentanyl or a buttload of morphine, maybe just 2-3 mcg/kg of fentanyl.

Opioid-induced hyperalgesia

Slow-track recovery (opposite of fast track)

Chest wall rigidity

Inability to use pressure support due to decreased respiratory drive, when you could have used patient-driven ventilation to decrease transmural pressure and auto-recruit atelectatic lung (i.e. yawning)

Increased risk of post-op mechanical ventilation and concomitant morbidity and increase in costs

Increase in intraoperative and post-op hypotension and associated increased use of vasopressors and inotropes

Decreased ability to use volatile agents due to profound hypotension from synergy; volatile agents would help precondition the heart to minimize the effects of ischemia

Increased risk of use of narcotic reversal and concomitant morbidity

 

[bcat85]

What do you mean in a bad way? humor me and explain to me what's wrong with a narcotic induction.

I agree with this. Every code I’ve ever seen in a cardiac patient prior to incision was in a patient who received a “narcotic induction.”

I use a pretty simple recipe: arterial line, push norepinephrine or epi until the pressure rises, prop/sux/tube. If it’s a cardiac case, I’ll give 10 mg of midazolam to minimize my propofol need. As a multitude of others have said though, it’s not what you do, but how you do it.