Small dose precedex on induction?

[anaesthetic]

I've given dexmedetomidine intra-operatively exactly twice (both as infusions). One person developed complete heart block and the other took so long to wake-up that I extubated them and stuck an LMA in for PACU.

I like giving IV clonidine 0.5 - 1mcg/kg for bigger abdominal cases or for people on lots of opioids at baseline both prescription and otherwise.

On the other hand, I’ve given hundreds of patients dexmedetomidine via boluses/infusions and can’t remember any high degree heart block ever. Moderate chance of bradycardia but rarely hemodynamically significant. More issues with PACU hypotension in wide awake patients which has made me use it a lot less.

Agree with longer extubation times which is why I stopped doing high-dose infusions and turn it off early (if I use it at all).

I like low-dose infusions for TAVIs (in addition to prop/opioids) and “awake” carotids, but overall agree it’s probably over-used in a lot of situations. I’m not sure I agree that clonidine is any better than dexmedetomidine given its lower alpha-2 selectivity and propensity for hypotension. Maybe more cost effective at some institutions but not here.

---

Members don't see this ad.

 

[anaesthetic]

Precedex as a sole or main agent for tavi must be miserable. I think a colleague tried it once, and hated it...

It's just a miserable halfway house... not potent enough for sedation or apneic

Agreed. I’ve done a lot of variations of “MAC” TAVI anesthetics, and using only dexmedetomidine/fentanyl is the worst of them all, even with dosing above 0.7-1 mcg/kg/hr started within 5 minutes of room time. They fall asleep eventually but almost always start waking up and lifting their arms/legs as soon as the sheaths start going in. It just isn’t strong enough as the primary anesthetic.

 

[abolt18]

Precedex as a sole or main agent for tavi must be miserable. I think a colleague tried it once, and hated it...

It's just a miserable halfway house... not potent enough for sedation or apneic

Every single MAC TAVR I've done is with precedex +/- 100mcg fentanyl. Occasionally it's not enough or you've got an old lady that just wiggles or moans a bunch so I'll give 1mg midazolam and it's enough. It's the way I was trained

I think the key is setting up appropriate expectations with the patient and the cardiologist. Our cardiologists actually request that patients be very mildly sedated so this level is about perfect for them. I tell the patients that they'll be mostly awake and able to drift off to sleep if they wish. I have never had a problem with this. Occasional reminder to the patient to hold still if they startle. I'll also wake them up at the time of valve deployment just to warn them they may feel strange for a minute. My colleagues (who historically just ran a deep propofol gtt) have also started switching to precedex+fentanyl with positive feedback.

I typically hit them with 100mcg fentanyl immediately, then start working in 40-80mcg of dexmedetomidine via hand bolus of 12-16mcg at a time while they prep/drape. Precedex has variable effect on different people (as you know from the ICU, some are totally zonked and others are wide awake), so it's definitely not the end-all-be-all. It gets the job done for most.

 

[vector2]

. My colleagues (who historically just ran a deep propofol gtt) have also started switching to precedex+fentanyl with positive feedback.

Haha, ironically I was trained with light precedex +- other adjuncts for tavr but the longer I've been out the more I find myself just doing deep propofol on all but the sickest of the sick cause it's a lot less headache for me to just do unprotected airway generals.

As you say though, it all comes down to the pt and the cardiologist. A lot of ICs want to eventually jump to procedural sedation and stop involving anesthesia (and CT surgery for that matter), so these folks are highly motivated to get the pt through the procedure with true mild + verbal reassurance.

 

[drmwvr]

Precedex as a sole or main agent for tavi must be miserable. I think a colleague tried it once, and hated it...

It's just a miserable halfway house... not potent enough for sedation or apneic

agreed...the folks that say they use it for tavr's (and there's quite a few, I think) must have some weird voodoo to go along with it they're not copping to. You do get crappy sedation, but at least there's the bradycardia and hypotension in PACU to make up for it. Any more for me it's an LMA.

 

[PpfSuxTube]

A lot of ICs want to eventually jump to procedural sedation and stop involving anesthesia (and CT surgery for that matter), so these folks are highly motivated to get the pt through the procedure with true mild + verbal reassurance.

Where is this?
What if they have to convert?

 

[vector2]

Where is this?
What if they have to convert?

I'm in the south and the ICs here have trialed a couple cases with procedural sedation (one didn't go so hot). Another hospital I've done locums at a couple hrs away does almost all their TAVRs with procedural sedation. The hybrid room is set up, so if they have to convert they call us and we do what needs to be done (rare occurrence after the initial jitters got worked out and with good pt selection).

There's a few papers out there too about TAVR with local anesthesia or TAVR without anesthesia services if you search for it.

 

[PpfSuxTube]

. The hybrid room is set up, so if they have to convert they call us and we do what needs to be done (rare occurrence after the initial jitters got worked out and with good pt selection).

There's a few papers out there too about TAVR with local anesthesia or TAVR without anesthesia services if you search for it.

Hold up, in an aortic root rupture with tamponade they 'call you'?
So then I assume there is a free anesthesiologist dedicated to Tavis backup that day anyway?

If there isn't someone dedicated, what if they're busy or don't hear the call? How is any of that valid?

A tavi disaster is some of the worst disasters I've seen.. thankfully only 1 a year approximately

 

[kb1900]

Hold up, in an aortic root rupture with tamponade they 'call you'?
So then I assume there is a free anesthesiologist dedicated to Tavis backup that day anyway?

If there isn't someone dedicated, what if they're busy or don't hear the call? How is any of that valid?

A tavi disaster is some of the worst disasters I've seen.. thankfully only 1 a year approximately

I wish ours were one a year. The amount of people they’ve killed is wild. Usually the TAVR in TAVR in TAVR aortic rupture or the wire thru free wall or massive aortic dissection or access site bleed. It’s more like 2 deaths per month. With having to code for at least 5-10mins for sheaths to go in.

Crashing onto bypass when there’s no perfusuonist on standby and no CTS readily available (the one they have is just for show- hasn’t touched a scalpel in 25 years).

This same IC team will also take 6+ hours for a mitraclip(longer than our surgical MVRs..) then complain it’s anesthesias and ICUs fault that the subsequent TAVRs go to 4am.

Yet they still want to push for procedural sedation. “Top 5 heart hospital” supposedly. Don’t even have space for a bypass machine in the labs…we legit route extension tubing out the door into the hall when doing bypass cases in there.

I’m going into cardiac and loathe the fact that I’ll have to cover this room in any capacity ever again probably for the foreseeable future

 

[DrOwnage]

Precedex as a sole or main agent for tavi must be miserable. I think a colleague tried it once, and hated it...

It's just a miserable halfway house... not potent enough for sedation or apneic

Precedex is like the La Croix of anesthetics. One time I had a patient solely on precedex in the cath lab and I asked them if they were awake and they were like "duh." I was like oh **** that's the perfect response to just being on precedex.

 

[vector2]

Hold up, in an aortic root rupture with tamponade they 'call you'?
So then I assume there is a free anesthesiologist dedicated to Tavis backup that day anyway?

If there isn't someone dedicated, what if they're busy or don't hear the call? How is any of that valid?

A tavi disaster is some of the worst disasters I've seen.. thankfully only 1 a year approximately

At the hospital that does them routinely it's a supervision model so there's an anesthesiologist who can respond if need be.

If they're busy then they're busy and the people in the room will do whatever they need to do until the anesthesiologist (and CT surgery) can respond.

As for being valid...uh it sounds like the fact that you only see one TAVR disaster a year makes a pretty strong case for the model being potentially valid (although personally I think anesthesia should be involved). For instance, we don't anesthetize every STEMI LHC or complex PCI just because of the small risk of decompensation or aortic injury or coronary dissection/rupture.

 

[Beeftenderloin]

agreed...the folks that say they use it for tavr's (and there's quite a few, I think) must have some weird voodoo to go along with it they're not copping to. You do get crappy sedation, but at least there's the bradycardia and hypotension in PACU to make up for it. Any more for me it's an LMA.

I’m one of these folks. I load 0.5mcg/kg over 10min (then 1mcg/kg/hr after that) and turn prop on at 30-40 while I place my art line. Work in 50 of ketamine between local for groins and big sheath going in. My most recent nonagenarian was essentially under GA, breathing spontaneously requiring 1-2mcg of levo to keep mean around 70 on that cocktail. Dex off when we rapid pace. Prop off once big sheath comes out.

 

[PpfSuxTube]

. It’s more like 2 deaths per month. With having to code for at least 5-10mins for sheaths to go in.

Yeah that's wild. By any metric grounds to pause the program

 

[PpfSuxTube]

.

As for being valid...uh it sounds like the fact that you only see one TAVR disaster a year makes a pretty strong case .

Yeah maybe you have a point but there's no appetite at my place for that and we're happy enough with it. Our guys are fast and good. Usually 5 done by 5. It's a good day



However nice try on trying to compare pci to tavi but as you well know they bear little comparison. Far bigger sheaths, much more arrythmia, much more hypotension and very little the IC can do about their major complications whereas in pci, they can stent almost any perf...

 

[vector2]

Yeah maybe you have a point but there's no appetite at my place for that and we're happy enough with it. Our guys are fast and good. Usually 5 done by 5. It's a good day



However nice try on trying to compare pci to tavi but as you well know they bear little comparison. Far bigger sheaths, much more arrythmia, much more hypotension and very little the IC can do about their major complications whereas in pci, they can stent almost any perf...

And nice try only quoting the "PCI" portion of my post when I specifically said "STEMI LHC" and "complex PCI." No, they're not a TAVR, but both of those are usually far more involved than a routine PCI, and in many major centers involve impella assistance due to procedure length and hemodynamic/metabolic instability. There's also plenty of coronary lesions (especially in CTOs) which are not easily stentable if there's a rupture.

The ultimate point is that catastrophic complications in TAVR are generally getting rarer and rarer and thus it makes somewhat less practical and financial sense to routinely have the pump primed and perfusionist watching, CTS scrubbed in, anesthesiologist at the head of the bed, etc, etc.

 

[gunnershow]

And nice try only quoting the "PCI" portion of my post when I specifically said "STEMI LHC" and "complex PCI." No, they're not a TAVR, but both of those are usually far more involved than a routine PCI, and in many major centers involve impella assistance due to procedure length and hemodynamic/metabolic instability. There's also plenty of coronary lesions (especially in CTOs) which are not easily stentable if there's a rupture.

The ultimate point is that catastrophic complications in TAVR are generally getting rarer and rarer and thus it makes somewhat less practical and financial sense to routinely have the pump primed and perfusionist watching, CTS scrubbed in, anesthesiologist at the head of the bed, etc, etc.

Well from my limited observation, those complex STEMI LHCs could probably benefit from our involvement. Whenever I've been called to the cath lab, they're too focused on the procedure to even have bothered to apply the monitors correctly (much less actually look at them). Eg, falsely reassured by 100 on the pulse ox when the pleth is nonexistent, so in reality their ischemic patient has been hypoxemic for a looong time before we've been called.

 

[vector2]

Well from my limited observation, those complex STEMI LHCs could probably benefit from our involvement. Whenever I've been called to the cath lab, they're too focused on the procedure to even have bothered to apply the monitors correctly (much less actually look at them). Eg, falsely reassured by 100 on the pulse ox when the pleth is nonexistent, so in reality their ischemic patient has been hypoxemic for a looong time before we've been called.

You're 100% right about their tunnel vision.

Just don't tell them, though. I'm trying to do less work in the cathlab, not more. ;p

 

[medicine2wallstreet]

I don't mean to be that guy but what a completely worthless thread. I mean this many responses about crna's giving precedex carte blanche? Who cares. Much bigger fish to fry in the perioperative setting.

 

[DesiredMemberName?]

I don't mean to be that guy but what a completely worthless thread. I mean this many responses about crna's giving precedex carte blanche? Who cares. Much bigger fish to fry in the perioperative setting.

From what I’ve read, you seem to love being that guy.

 

[pgg]

I wish ours were one a year. The amount of people they’ve killed is wild. Usually the TAVR in TAVR in TAVR aortic rupture or the wire thru free wall or massive aortic dissection or access site bleed. It’s more like 2 deaths per month. With having to code for at least 5-10mins for sheaths to go in.

Crashing onto bypass when there’s no perfusuonist on standby and no CTS readily available (the one they have is just for show- hasn’t touched a scalpel in 25 years).

This same IC team will also take 6+ hours for a mitraclip(longer than our surgical MVRs..) then complain it’s anesthesias and ICUs fault that the subsequent TAVRs go to 4am.

Yet they still want to push for procedural sedation. “Top 5 heart hospital” supposedly. Don’t even have space for a bypass machine in the labs…we legit route extension tubing out the door into the hall when doing bypass cases in there.

I’m going into cardiac and loathe the fact that I’ll have to cover this room in any capacity ever again probably for the foreseeable future

What. The. ****.

2 deaths per month?
TAVRs going to 4 AM?
Extension tubing out the door?
A credentialed CT surgeon who hasn't operated in 25 years?

That program needs to be shut down.

I’m going into cardiac

Are you a resident? Graduate, get away from this place, and never go back.

 

[drmwvr]

I’m one of these folks. I load 0.5mcg/kg over 10min (then 1mcg/kg/hr after that) and turn prop on at 30-40 while I place my art line. Work in 50 of ketamine between local for groins and big sheath going in. My most recent nonagenarian was essentially under GA, breathing spontaneously requiring 1-2mcg of levo to keep mean around 70 on that cocktail. Dex off when we rapid pace. Prop off once big sheath comes out.

I appreciate that...not gonna lie...5 or 6 tavr's with bang, bang turnover...I'm not gonna put that kind of effort into it when a little prop, sevo and an lma will get the same result. Your's is way more elegant than mine, but I gotta pace myself for retirement...

 

[kb1900]

What. The. ****.

2 deaths per month?
TAVRs going to 4 AM?
Extension tubing out the door?
A credentialed CT surgeon who hasn't operated in 25 years?

That program needs to be shut down.


Are you a resident? Graduate, get away from this place, and never go back.

Yep. When I discuss with faculty they say that this was just an unlucky string of 3 months. I had no exposure to this department until this academic year. Since the last event they have significantly slowed volume down and wrap up 4ish cases by 10pm most days with a significantly more appropriate population..supozedlt


My biggest issue though is that this CT “surgeon” is the consultant who decides these patients are too sick for surgical AVRs. He’s actually not credentialed to operate at the hospital yet the policy is every TAVI needs a CTS on standby which is…him. It’s the bigge$t conflict of interest ever. My last TAVR was this great functional status 71yo retired physician with controlled diabetes and no other comorbidities, preserved biv fxn, severe AS with 1x syncopal episode 3 months ago leading to diagnosis. I asked my anesthesia attending and he gave me the full breakdown on how morally bankrupt the IC department is at our hospital.


IC/EPS erroded lead extraction literally my first CT case. It was a very tenuous case where we started out with cannulation sheaths, put the bypass machine on standby in the hallway, had perfusion in the room set up. We even took CTS nursing staff to open a table and set up in the tiny cath lab. It was horribly cramped. The worst part though was the surgeon was scrubbed into a cabg and the plan was they would scrub out in an emergency. The entire plan made so little sense. Why we weren’t in an OR was beyond me. Actually holding that echo probe below the c-arm for a live view for 4 hours was the worst part.


It’s supposedly a very strong/reupable Acta program with a strong CTS department as well though I haven’t decided if I’ll stay. It’s really just the IC stuff that we all abhor here (TAVI and peds cath). Covering those rooms is hot potato by our attendings. Our cardiac anesthesia attendings are very forthcoming about this being a downside and do effectively shield fellows from this BS. As a resident though I managed to get through my time there without any horrific outcomes. I guess it made for good training? Neck lines and swans with fluoro, extremely sick patients getting the full range of no anesthesia to deep sedation or emergent conversion to GA. Lot of echo etc.


Sorry to derail the thread. Probably doxed myself with these details