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PinchandBurn

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so now that Thiopental is not here any longer what are you using for:

1) Burst Suppression
2) Barbituate Comas (if people still do this)
3) If a cerebral aneursym was going to be clipped and the surgeon tells you write before clipping, to 'give thiopental' to "protect" against ischemia.

Thoughts?

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MTGas2B

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so now that Thiopental is not here any longer what are you using for:

1) Burst Suppression
Propofol

2) Barbituate Comas (if people still do this)
Done it once, pentobarbital


3) If a cerebral aneursym was going to be clipped and the surgeon tells you write before clipping, to 'give thiopental' to "protect" against ischemia
Propofol with burst suppression monitoring

Thoughts?

Potentially good Oral Board Q's also..[/QUOTE]




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michigangirl

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This. Pentobarbital infusion for barbituate coma is still commonly used at least in the pediatric icu for refractory status epilepticus with continuous EEG monitoring. Have to monitor pentobarbital levels very carefully particularly in the critically ill patient-- very easy to get to toxic levels in a short period with repeated boluses to reach clinical goals and increasing infusion rate.

so now that Thiopental is not here any longer what are you using for:

1) Burst Suppression
Propofol

2) Barbituate Comas (if people still do this)
Done it once, pentobarbital


3) If a cerebral aneursym was going to be clipped and the surgeon tells you write before clipping, to 'give thiopental' to "protect" against ischemia
Propofol with burst suppression monitoring

Thoughts?

Potentially good Oral Board Q's also..




On the iPhone[/QUOTE]
 

PinchandBurn

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propofol?

You can get burst suppression with that? How much are you guys bolusing to get that? 1mg/kg?
 

PMPMD

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so now that Thiopental is not here any longer what are you using for:

1) Burst Suppression
2) Barbituate Comas (if people still do this)
3) If a cerebral aneursym was going to be clipped and the surgeon tells you write before clipping, to 'give thiopental' to "protect" against ischemia.

Thoughts?

Potentially good Oral Board Q's also..

I used methohexital for burst supression for a peds crani once in training.
 

Hawaiian Bruin

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I've always thought that if

1) Burst suppression is thought to be neuroprotective, and
2) propofol can result in burst suppression (or even isoelectricity, if that's your goal), then
3) I can use propofol to achieve burst suppression for neuroprotection.

I've never seen the advantage of barbs over propofol for burst suppression, and have never seen data on a well-controlled prospective head-to-head comparison. I figure since barbs had always been used for this purpose prior to the advent of propofol, that it was something that was just grandfathered in as the "right way of doing it" despite the newer agent being clearly superior in its offset.

I also use propofol for isoelectricity during DHCA (well, antegrade cerebral perfusion usually), though I realize the temperature itself is achieving most of that effect. What else are people using for DHCA?

Aside: this is one of the better uses of the BIS monitor IMO.
 

proman

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I've always thought that if

1) Burst suppression is thought to be neuroprotective, and
2) propofol can result in burst suppression (or even isoelectricity, if that's your goal), then
3) I can use propofol to achieve burst suppression for neuroprotection.

I also use propofol for isoelectricity during DHCA (well, antegrade cerebral perfusion usually), though I realize the temperature itself is achieving most of that effect. What else are people using for DHCA?

Aside: this is one of the better uses of the BIS monitor IMO.

Point 1 is where the argument falls apart right? There is no pharmacologic intervention in clinical practice that's been shown to be neuroprotective. Hypothermia is the sole intervention that reduces both functional and structural CMRO2 and is really the only thing needed to provide cerebral protection during DHCA, ACP or not. The major problem with hypothermia is the need to rewarm, and all the protective effect of hypothermia can be lost by cerebral hyperthermia (a weakness of IHAST).
 

Hawaiian Bruin

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proman- my statement is based on the presumption that there is neuroprotection that can be achieved.

That said, I remain thoroughly unconvinced of the benefit. However, I also think that propofol to achieve this effect is (in your hands and mine) a safe thing to do with virtually no morbidity. So to me the risk benefit analysis (for propofol) goes:

In favor of treatment:
May help
Doesn't hurt

Against treatment:
May not help

So I'll treat. However, change propofol to barbs, and the whole equation changes. Now arguments against treatment include prolonged sedation, which may definitely hurt. So I would tend not to treat.

What I'm saying is: absent compelling evidence that there is definitely no benefit to treatment, I'll go ahead and use propofol since it's so benign. But absent compelling evidence that there IS a benefit to treatment, I would not tend towards use of barbs, because they are by no means benign.

Re: DHCA: I've seen people who still use a gram of solumedrol (in addition to the gram they already got in the pump prime) plus dilantin (wtf) plus prop plus temperature. I think this is chickenshit medicine. I use temperature (only thing with proven benefit) plus prop (may or may not help, doesn't hurt). And put in a nasal temp probe so the perfusionist doesn't sous vide the brain during rewarming, which as you point out removes the entire benefit.
 

proman

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proman- my statement is based on the presumption that there is neuroprotection that can be achieved.

Re: DHCA: I've seen people who still use a gram of solumedrol (in addition to the gram they already got in the pump prime) plus dilantin (wtf) plus prop plus temperature. I think this is chickenshit medicine. I use temperature (only thing with proven benefit) plus prop (may or may not help, doesn't hurt). And put in a nasal temp probe so the perfusionist doesn't sous vide the brain during rewarming, which as you point out removes the entire benefit.

I agree with what you're saying, but we should be clear that it's never been shown to be useful, so why bother with what drug to use?

I think nasal temp monitoring is a must for any cardiac case. I've come to learn that isn't standard practice in many many places, which is unfortunate. But even NP can have a 2 degree gradient with jugular bulb temperature.
 

Idiopathic

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we are using pentobarb for status pretty routinely (6-8 times a year?) but propofol for burst suppression in the OR, usually before applying a temporary clip to resect/coil an aneurysm. when pentobarb fails we have switched to propofol for status in the ICU
 

PinchandBurn

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we are using pentobarb for status pretty routinely (6-8 times a year?) but propofol for burst suppression in the OR, usually before applying a temporary clip to resect/coil an aneurysm. when pentobarb fails we have switched to propofol for status in the ICU


so you are not using pentobarb intra op?

Also advant/disadvant of pentobarb versus thiopental? the biggest disadvantage I could come up with is that pentobarb is longer acting.
 
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