steep trendelenburg

[dfk]

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has anybody had experience/evidence of cerebral edema when utilizing steep trendelenburg for radical prostatectomy? in my rather quick lit search, i've only found theoretics and "can occur" type stuff...
also, how judicious is your fluid administration during such a procedure?
i tend to guide my fluid management on the basis of scleral edema..
j/k of course, but any thoughts appreciated~

 

[toughlife]

has anybody had experience/evidence of cerebral edema when utilizing steep trendelenburg for radical prostatectomy? in my rather quick lit search, i've only found theoretics and "can occur" type stuff...
also, how judicious is your fluid administration during such a procedure?
i tend to guide my fluid management on the basis of scleral edema..
j/k of course, but any thoughts appreciated~

I thought they covered that topic in CRNA school. Maybe www.allnurses.com has the answer.

 

[dfk]

I thought they covered that topic in CRNA school. Maybe www.allnurses.com has the answer.

thanks tough,
always miagi-type insight.
besides, i wasn't looking for "if they covered the topic"..
looking for actual experience.

 

[toughlife]

thanks tough,
always miagi-type insight.

www.allnurses.com is that way ----->

 

[dfk]

so you're saying only physicians can only seek guidance?
i thought this was an open forum sans criticism ..
btw/ allnurses is a joke~

 

[goodoc]

He cannot answer because he does not know, his experience is pretty thin so do not take it too hard, tough forte is smarmy remarks.

 

[jetproppilot]

has anybody had experience/evidence of cerebral edema when utilizing steep trendelenburg for radical prostatectomy? in my rather quick lit search, i've only found theoretics and "can occur" type stuff...
also, how judicious is your fluid administration during such a procedure?
i tend to guide my fluid management on the basis of scleral edema..
j/k of course, but any thoughts appreciated~

I've never seen cerebral edema attributable to trendelenberg.

Your question about fluid administration is a good one.

We are taught to give too much.

 

[cchoukal]

We do a buttload of these cases and have seen a lot of eye conditions that casually get diagnosed as corneal abrasions. Our CQI guy did a little digging and what seems to be happening is that the steep t-berg causes facial edema and chemosis, or swelling and inflammation of the sclerae and conjunctivae. This on its own is painful and can be misdiagnosed as corneal abrasion, but also can cause the eye to puff open under the eye tape and CAUSE a bona fide abrasion. Although we have not done a randomized trial of fluid administration in these cases, we did examine cases by attending and found that the cases with the fewest eye complications were given the least amount of IV fluid.

 

[dfk]

thanks et al...
i have used roughly 2300ml of crystalloid (less +/- 250 of albumin), and
was wondering what others thought of as "too much"..
is there a direct correlation betw/ IVF administration and edema?
i would not have thought so in "healthy" individuals...
from what i gather, it is rather 'insignificant' ...

 

[jetproppilot]

is there a direct correlation betw/ IVF administration and edema?
i would not have thought so in "healthy" individuals...
from what i gather, it is rather 'insignificant' ...

I thought the same (quite a while ago) since thats how I was trained.

But its not insignificant, even in a young healthy dude/dudette.

 

[urge]

Posted via Mobile DeviceJet,
What rule of thumb will you teach your future residents for fluid management?

 

[Noyac]

Posted via Mobile DeviceJet,
What rule of thumb will you teach your future residents for fluid management?

Less is best😎

 

[Noyac]

dfk, Why do you use albumin in these cases?

 

[coprolalia]

THE FACT IS we are trained from academia to GIVE TOO MUCH IV FLUID.

Hear, hear.

But, this is usually a rookie mistake. By the time you get to the senior levels of residency, you figure this out (if you're paying attention and truly being a thoughtful clinician).

-copro

 

[Planktonmd]

The rule is:
Give fluids if patient is showing signs of dehydration and to maintain BP, HR, and urine output reasonable.
Also give appropriate amounts of fluids to replace blood loss and that includes giving blood products if needed.

 

[loveumms]

I try to give my patients 250-500 in the pre-op holding area, especially if they are an afternoon case because I feel that they truly are a little dehydrated. After that I try and watch urine output + vitals and give only maintenance plus losses (unless it's a huge abdominal surgery).

The whole maintenance times # of hours NPO - half given in first hour, then the rest in the next two hours can add up to be a lot of fluid. We all go to bed at night and don't drink anything - when we wake up we don't all go guzzle a L of fluid. Granted we are not going through surgery. I jsut think it's a little much.

I try and really use less on my TURPs because they can actually absorb a lot of the fluid used for resection.

 

[dfk]

dfk, Why do you use albumin in these cases?

i don't make this a habit or routine.
i did it once because i kept getting refractory hypotension
after several bouts with neosyn and ephedrine. i probably
could have used a neosyn gtt in high concentration looking back, but
was led to believe to not give the patient IVF, except KVO.
well, to me, a patient who had fleets the night before told me he
was on the toilet at least ten times. now, figure in NPO for however many
hours, i thought this guy needed something more. since albumin stays intravascularly longer than IVF (and his baseline alb.level was low normal 3.7 i think), i took that route.
what i got out of it all was that the patient should get what they need in order to maintain. nothing more, nothing less.

 

[rsgillmd]

i don't make this a habit or routine.
i did it once because i kept getting refractory hypotension
after several bouts with neosyn and ephedrine. i probably
could have used a neosyn gtt in high concentration looking back, but
was led to believe to not give the patient IVF, except KVO.
well, to me, a patient who had fleets the night before told me he
was on the toilet at least ten times. now, figure in NPO for however many
hours, i thought this guy needed something more. since albumin stays intravascularly longer than IVF (and his baseline alb.level was low normal 3.7 i think), i took that route.
what i got out of it all was that the patient should get what they need in order to maintain. nothing more, nothing less.

I think Noyac was asking why albumin as opposed to say Hextend -- less likelyhood of disease transmission.

I wouldn't worry about albumin = 3.7. Albumin concentrations take weeks to change -- i.e. it likely represents a chronic issue. I doubt that level would be clinically significant anyway -- I think you have to get down closer to 2 (can't quote sources right now).

The others have already discussed fluid management well, so I won't comment further on that.

 

[dfk]

I think Noyac was asking why albumin as opposed to say Hextend -- less likelyhood of disease transmission.

I wouldn't worry about albumin = 3.7. Albumin concentrations take weeks to change -- i.e. it likely represents a chronic issue. I doubt that level would be clinically significant anyway -- I think you have to get down closer to 2 (can't quote sources right now).

The others have already discussed fluid management well, so I won't comment further on that.

albumin was at the ready.
at the current rotation i'm at now, i couldn't even tell you
if they have hespan or the like.
i guess it's worth looking into.

 

[SleepIsGood]

albumin was at the ready.
at the current rotation i'm at now, i couldn't even tell you
if they have hespan or the like.
i guess it's worth looking into.

so if they had FFP or pRBCs 'at the ready' you would have given that?

'worth looking into'...my CRNA friend, a patient is not someone you should be experimenting on. You shouldnt just 'try' things on them. Know the indications and risks/benefits.

 

[dfk]

so if they had FFP or pRBCs 'at the ready' you would have given that?

'worth looking into'...my CRNA friend, a patient is not someone you should be experimenting on. You shouldnt just 'try' things on them. Know the indications and risks/benefits.

no, i wouldn't have used them if 'at the ready'.
besides, there was no indication/need for ffp or reds.
experimenting? not to play down the role, but anesthesia
is also an art, of which is based on previous research and experience.
i'm comfortable with my decision.

 

[Jeff05]

the role of albumin vs crystalloid in treatment of hypotension has been exhaustively discussed.

using baseline albumin for iv albumin administration during a case is not based on ANY rational medical reality.

exposing a patient to risk of infection just because you gave a couple of bumps of phenylephrine is not optimal.

patients who are severely hypovolemic will not get edema if you give them some fluids and guide them closer to euvolemia.

we have a surgeon who does robotic prostates in about 3 hrs. steeeeeep trendy. we give 600 ml upfront, and another 1.5 L after anastom. no problems with cerebral edema in over 450 cases.

 

[urge]

I wouldn't use hespan at all. I used to, for my off pump cabgs, but they all ended up needing a blood transfusion. It wasn't the case with a00lbumin. I saw a paper about a year ago saying that mortality was higher in ICU pts with some sort of starch colloid. I'm not sure if it was hespan. I avoid hespan like the plague.

 

[dfk]

the role of albumin vs crystalloid in treatment of hypotension has been exhaustively discussed.

using baseline albumin for iv albumin administration during a case is not based on ANY rational medical reality.

exposing a patient to risk of infection just because you gave a couple of bumps of phenylephrine is not optimal.

patients who are severely hypovolemic will not get edema if you give them some fluids and guide them closer to euvolemia.

we have a surgeon who does robotic prostates in about 3 hrs. steeeeeep trendy. we give 600 ml upfront, and another 1.5 L after anastom. no problems with cerebral edema in over 450 cases.

fair enough.
however, i don't really consider 200mcg x 6 of neosyn along with 50 mg ephedrine a "couple of bumps".
anyway, i should probably have gone with neosyn gtt.
live and learn.

 

[Intubate]

exposing a patient to risk of infection just because you gave a couple of bumps of phenylephrine is not optimal.

What are you talking about? Albumin is not the same as FFP. Its sterile. Almost no infection risk. Prions maybe, not sure.

 

[cchoukal]

we have a surgeon who does robotic prostates in about 3 hrs. steeeeeep trendy. we give 600 ml upfront, and another 1.5 L after anastom. no problems with cerebral edema in over 450 cases.

Our attg I mentioned above with the very low ocular complication rate does his cases this way. Minimal IVF during the case, bolus 1-2 L at the end... I'm sure there's no evidence behind this, but his results are good.

 

[Jeff05]

prions are correct. why expose patients to an intervention that carries ANY risk, when there is NO benefit.

What are you talking about? Albumin is not the same as FFP. Its sterile. Almost no infection risk. Prions maybe, not sure.

 

[Intubate]

my guess is that the risk of a prion infection from an albumin prep is slightly less than the risk of alien abduction. you pretty much need transmission of neural tissue to get such an infection. a blood transfusion from a known CJD patient would probably be safe. they just don't circulate. so in my opinion this is not a valid reason for avoiding albumin. there's no reason to stoop to this silly excuse though because as you mentioned, there's probably no benefit.

 

[cchoukal]

my guess is that the risk of a prion infection from an albumin prep is slightly less than the risk of alien abduction. you pretty much need transmission of neural tissue to get such an infection. a blood transfusion from a known CJD patient would probably be safe. they just don't circulate. so in my opinion this is not a valid reason for avoiding albumin. there's no reason to stoop to this silly excuse though because as you mentioned, there's probably no benefit.

there are actually cases (4, last I checked) in the UK of blood-transfusion-associated transmissions of CJD. The current science suggests that WBC are the "vector," so to speak, and most of europe is leukoreducing all of their RBCs to prevent this and other infections.