Simulect vs Campath vs thymo induction

[coffeebythelake]

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Never understood this. We give roc to cirrhotic liver failure patients without batting an eye but get nervous giving it to a patient that has maybe impaired clearance of the minor pathway for elimination.

We use rocuronium readily for kidney transplant cases. No big deal. We used to be careful with dosing to time for neo/glyco and i think that hesitation persists. I think part of concern now is because elimination of sugammadex is 100% through the kidneys.

 

[Urzuz]

Never understood this. We give roc to cirrhotic liver failure patients without batting an eye but get nervous giving it to a patient that has maybe impaired clearance of the minor pathway for elimination.

I think you need to reread what I wrote. Who said anything about getting nervous?

The half-life of roc is less predictable in ESRD patients, which is why I use cisatracurium.

 

[KetamineForAll]

CVL, no art line unless indicated, surgeon throws a fit if we give anything but NS or if we give meds for pain control (pain=perfusion). He is very good so everyone puts up with it.

 

[vector2]

or if we give meds for pain control (pain=perfusion).

This sounds absurd. What do you give for pain / what is the pain regimen for the case?

 

[coffeebythelake]

CVL, no art line unless indicated, surgeon throws a fit if we give anything but NS or if we give meds for pain control (pain=perfusion). He is very good so everyone puts up with it.

🤡

 

[coffeebythelake]

This sounds absurd. What do you give for pain / what is the pain regimen for the case?

By the sounds of it: Meditation

 

[Magoun]

We are a top center by volume (300+/year for the past few years, though the fact that I do 2-3 almost every call makes me wonder who the lucky ones are that never do them).

A-line if patient's comorbidities indicate it (mostly no). CVC if you can't get a decent 2nd IV. We started giving thymo peripherally ~4 years ago. Whatever immunosuppression the transplant team wants. ~2L of crystalloid, manitol and lasix prior to unclamping. Start albumin if you need more volume after that. Can't think of a case of volume overload in the last 5 years.

Surgeons have stopped disagreeing with phenyleprhine since we had a run of a couple cases of coronary vasospasm with dopamine a few years ago, though we try not to start it until we have volume loaded the patient as above.

Depending on surgeon I'm sometimes a bastard and make the resident use cis, just so they learn how. Roc + sugammadex is almost always fine, but if the graft looks real sketchy I might not. (As a resident -- long pre-sugammadex -- I had to do a kidney transplant that needed an RSI and had a borderline potassium so we gave high dose roc and they didn't recover any twitches until dialyzed in PACU 6 hours later. That sucked.)

 

[IMGASMD]

We are a top center by volume (300+/year for the past few years, though the fact that I do 2-3 almost every call makes me wonder who the lucky ones are that never do them).

A-line if patient's comorbidities indicate it (mostly no). CVC if you can't get a decent 2nd IV. We started giving thymo peripherally ~4 years ago. Whatever immunosuppression the transplant team wants. ~2L of crystalloid, manitol and lasix prior to unclamping. Start albumin if you need more volume after that. Can't think of a case of volume overload in the last 5 years.

Surgeons have stopped disagreeing with phenyleprhine since we had a run of a couple cases of coronary vasospasm with dopamine a few years ago, though we try not to start it until we have volume loaded the patient as above.

Depending on surgeon I'm sometimes a bastard and make the resident use cis, just so they learn how. Roc + sugammadex is almost always fine, but if the graft looks real sketchy I might not. (As a resident -- long pre-sugammadex -- I had to do a kidney transplant that needed an RSI and had a borderline potassium so we gave high dose roc and they didn't recover any twitches until dialyzed in PACU 6 hours later. That sucked.)

Very similar experience.
Except we wouldn’t necessarily explicitly let the surgeons know that we’ve been supplement some phenylephrine. We also used more Cis, since suggmadex is/was expensive.
There was only one surgeon who was the most junior that would complain that the patient isn’t “fully” paralyzed.
“Muscle still twitching” and “Artery is pulsing” were frequently cited as inadequate anesthesia.

I miss that team, they were highly competent, efficient and less micromanagement.

 

[coffeebythelake]

There was only one surgeon who was the most junior that would complain that the patient isn’t “fully” paralyzed. “Muscle still twitching” and “Artery is pulsing” were frequently cited as inadequate anesthesia.

🤡

Wow wonder if he learned that in surgery school. Almost as bad as "patient is waking up" when a sedated patient moves

 

[IMGASMD]

Wow wonder if he learned that in surgery school. Almost as bad as "patient is waking up" when a sedated patient moves

My favorite is “patient is breathing…..”
Yes he is.

 

[nimbus]

Very similar experience.
Except we wouldn’t necessarily explicitly let the surgeons know that we’ve been supplement some phenylephrine. We also used more Cis, since suggmadex is/was expensive.
There was only one surgeon who was the most junior that would complain that the patient isn’t “fully” paralyzed.
“Muscle still twitching” and “Artery is pulsing” were frequently cited as inadequate anesthesia.

I miss that team, they were highly competent, efficient and less micromanagement.

I hate it when patients have a pulse.

 

[IMGASMD]

I hate it when patients have a pulse.

That’s what “ALIVE” looks like. Doctor.

 

[pgg]

“Artery is pulsing” were frequently cited as inadequate anesthesia.

Pfftt

If you were any good you'd time doses of adenosine for when the Surgeon was looking in that direction.

 

[IMGASMD]

Pfftt

If you were any good you'd time doses of adenosine for when the Surgeon was looking in that direction.

Still so much to learn……