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"Treat vasoactive changes with vasoactive drugs."

Discussion in 'Anesthesiology' started by Hawaiian Bruin, Dec 28, 2008.

  1. Hawaiian Bruin

    Hawaiian Bruin Breaking Good
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    This forum needs to get more clinical, so here's a CA-1 level thread.

    So as a resident I see two schools of thought when a scalpel gets put to skin or organ and the HR and BP shoot up.

    Let's assume MAC is 1.2 or so.

    Some- probably most- give narcotics in this spot. The "pain" or stimulation resulting in these vasoactive changes is mediated by nociceptor pathways and amenable to attenuation by opioids.

    More and more though, I'm working with people who think that these changes are best managed with vasoactive drugs (i.e. esmolol, nitro, etc). They save administration of long-active narcs for the end of the case, and use vasoactive agents in the beginning and the middle during periods of stimulation.

    As a believer in pre-emptive analgesia I tend to fall into the first camp, but because I'm seeing more of the second, I'm interested in hearing other opinions on this.
     
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  3. jetproppilot

    jetproppilot Turboprop Driver
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    Your goal as an anesthesiologist, my rounder friend, among other goals not addressed here is to ensure amnesia and hemodynamic control during surgery.

    How you accomplish that is up to you.

    Lets assume we all get the amnesia thing and how important it is.

    Assuming you've addressed that (a MAC of 1.2 would apply), yeah, you can add more anesthesia (gas, opioid, whatever) but why?

    Not a big deal how you address it if you arent pressed to wake the patient up quickly....but in private practice there is little leeway.

    Time is money.

    If you've provided an anesthetic that within the standard of care should provide amnesia and you're hit with ascending hemodynamic lability,

    use a hemodynamic drug. Not an anesthesia drug.

    Of course JMHO.
     
    #2 jetproppilot, Dec 28, 2008
    Last edited: Dec 28, 2008
  4. SleepIsGood

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    Here's where the "balanced" anesthesia theory comes into play.

    Assuming you are truly at 1.2 MAC, well then you've got amnesia as jet mentioned. Now, it's a question as to how much fentanyl,etc you want to use. Is a transient tachycardia of clinical relevance in a 29 yo healthy male...probably not.

    Is tachycardia in a pt with a h/o CAD with CHF, who needs 3 pillows to sleep on or else he will be SOB? Is so, then I agree, use things like esmolol,etc to attenuate the hemodynamic response.

    Otherwise, opiods. I agree with the OP. Use narcotics. I'd say typically speaking for a procedure lasting around 1 hour, 3 mcg/kg of fentanyl will not cause much of a delay of emergence as long as you turn things off sooner.

    I've recently rarely had to use esmolol, labetolol,NTG,etc. There are just soo may anesthetic drugs at our disposable that we can accurately control people's hemodynamics. All the gases we have nowa days leave the body relatively quick anyways. So, is it CLINICALLy relevant if we crank the SEvo to the 3-5 dial transiently to attenuate the initialy response...I doubt it.

    I jus tthink using all these vasoactive drugs is too high maintenance and CAN get you into trouble. Several case reports of just using '5-10mg' of a beta blocker and causing a bradyarryhtmia. You just dont know EXACTly how people will respond. With gas, you can turn it up and down, it's in and it's out.

    my two cents.
     
  5. Bertelman

    Bertelman Maverick!
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    How many times have you hung nitro to correct hypertension in a non-cardiac case?
     
  6. huktonfonix

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    depends on the case. If I dont want to use narcotics for the case (outpatient case with minimal post op pain) then I may use esmolol or something else to control hemodynamics. If Im gonna use narcotics anyway, I'll just give whatever narcotic I have handy. Depends on what your goal is for the case.
     
  7. Planktonmd

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    As others have said, it is really a judgment question.
    If you think that you have enough anesthetic on board for that specific patient and that specific surgery then there is nothing wrong with a little beta bloker or a vasodilator.
    We used to think that preemptive analgesia using narcotics is great for the patient but we now realize that giving too much narcotics intraop might actually be harmful post op and produces hyper algesia.
    Preemptive analgesia using regional is still a good thing though.
     
  8. urge

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    Run them really deep. 2 MAC is good stuff. Or, you can dink some propofol for incission. Other than labetalol I wouldn't be messing around with vasoactive stuff.
     
  9. huktonfonix

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    and the "book answer" will be MAC BAR will be 1.5 MAC.
     
  10. Pooh & Annie

    Pooh & Annie Member
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    If it's still gonna hurt when they wake up, I'll use opioid. If not, I'll consider more volatile (which is a relatively potent antihypertensive) and/or a vasoactive med.
     
  11. Pooh & Annie

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    That includes time in the PACU, which is lengthened with poor pain control.
     
  12. jetproppilot

    jetproppilot Turboprop Driver
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    I'd rather minimize opiods during the case and ensure rapid extubation.

    Clinicians overshoot opioid utilization more than they undershoot.

    If pain is an issue after extubation you can have it treated by the time you arrive at PACU with IV opioids administered concominant with monitor removal, transfer to the stretcher, and while rolling to the PACU.

    PACU time is also lengthened by too much anesthesia.
     
  13. Hawaiian Bruin

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    Good discussion.

    I tend to favor starting a longer-acting narcotic (i.e. dilaudid or morphine) for pts being admitted and who will have significant postop pain during these stimulating points in the case (though I'm gonna have to read more about the hyperalgesia that Plank points out). Then again, I agree with minimizing opiates if post-op pain is not expected to be significant, especially in an outpt setting.

    But, you could argue, if these temporary hemodynamic swings don't effect the course of postop pain, why bother to treat them at all? Assuming no underlying cardiac/neuro/other end-organ badness, who cares about transient elevations in BP and HR? With something quick-off like esmolol I don't mind as much, but I always squirm a little when they bust out labetalol.

    And BTW I wasn't talking about nitro drips here, just little bumps (50-100mcg) of the stuff at a time.
     
  14. Pooh & Annie

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    This does happen a lot, but I don't know if it's usually the case. I don't know if it was the AMA, or some other major organization that had that concensus statement a few years ago that hospital pain was grossly undertreated. Of course this is probably least applicable to anesthesiologists, who are more comfortable with pain meds than pretty much anyone else.

    Also, the surgeons seem to love it if you keep the patient from bucking by pulling the tube while still asleep. This also speeds turnover. Having them comfortably breathing with opioid on board, still asleep, works great on patients without contraindications (ie. PO issues, difficult airways, etc...)
     
  15. SleepIsGood

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    Hey Jet

    Good discussion.

    Of course pain control post op is a huge issue. We all know that pre emptive analgesia is probably the best way to prevent long term pain. However, as Plank pointed out and is evident in the literature we do have this phenomenon called hyperalgesia. How much is too much? I dont believe it's out there.

    ON the other end, none of us want our patients waking up in pain. Perhaps they dont remember it, because of the residual gas,etc. However, sometimes they do. Also, if you starting off, you dont want to be remembered by the surgeons and staff as the guy who wakes up his patients "writhing in pain". ...

    I guess it's a balance.
     
  16. jetproppilot

    jetproppilot Turboprop Driver
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    Yes, a balance.

    Certainly not implying avoiding intravenous analgetics altogether....giving a reasonable amount of opioid for whatever case is probably what most clinicians do.

    I tend to like the lower end of whats "reasonable" and if I've gotta catch up some after the tubes out thats OK.

    My point is its easy to experience delayed emergence if you're bumping with opioid frequently during a case. If you're satisfied with your depth of anesthesia intraoperatively consider treating the BP/HR with labetolol/hydralizine et al.

    Especially if you're near the end.
     
  17. dfk

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    hey jet, do you find in your experiences that catching up utilizes more narc than giving a little more to increase the pre-emptive/intraoperative effects?
     
  18. jetproppilot

    jetproppilot Turboprop Driver
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    Thats a difficult question to answer since the spectrum of anesthetic requirement varies so much from patient to patient.

    We have one MD who is "heavy handed" with opioid at induction and our CRNAs almost universally report more run-ins with delayed emergence with those cases than with others where opioid is given less heavy handed.

    Same concept applies to using opioid throughout the case for hemodynamic swings IMHO, assuming you are satisfied with your depth of anesthesia at the time of the hyperdynamic event intraoperatively.

    For my junior colleagues out there I wanna emphasize I am not calling any of the opinions above "wrong".

    If you are able to accomplish an expedient emergence, what you did was right.

    My point is I believe opioids are more "overshot" then "undershot."

    Its hard to call a style wrong if it works!
     
    #17 jetproppilot, Dec 30, 2008
    Last edited: Dec 30, 2008
  19. DrDre'

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    Pain in hospitalized patients IS vastly undertreated. There are lots of reasons.
    Provider lack of comfort. Lack of education or knowledge of pharm, multimodal analgesia.
    The impossibility of treating acute on chronic pain
    And SAFETY- I often worry about the quality of nursing assessment in the setting of heavy opioid dosing in the OSA, obese pop...

    Jet is talking about anesthesiologists often overtreating with opioid. this is a VERY specific population and he may well be right. I go back and forth between both extremes. I sure do love the baby bird wakeups on big opioids....

     
    #18 DrDre', Dec 30, 2008
    Last edited: Dec 30, 2008
  20. beezar

    beezar Senior Member
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    I've personally swung on both sides over the years, and now tend to use less opioids and more vasoactive agents. Sure that nice smooth high-dose opioid wakeup looks good in the OR, but when they are puking their guts out in the PACU because of lots of intraop narcs, and the fact there is more evidence with hyperalgesia following short-acting opioids, I don't think it's necessary.

    There was a study in Anesthesia and Analgesia a year ago or so that compared the traditional fentanyl boluses intraop vs. just esmolol drip with zero opioids intraop vs. continuous remifentanil infusion in lap choles. And they found that the esmolol drip group required significantly less fentanyl in the PACU, had less nausea, and were discharged quicker.

    And we all know that in lap choles sometimes that HR / BP shoot up occasionally in some patients, but they are not too painful postop, so why would you give a bunch of opioids to treat those hemodynamic changes?

    I'm not advocating using no opioids intraop, but just in moderation.
     
  21. Pooh & Annie

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    That seems like kind of a silly study. Anyone who uses more than minimal opioid dosing in a laparascopic procedure is negating the benefit of its minimal invasiveness and lack of post-op pain.
     
  22. jetproppilot

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    What about thyroid surgery?

    Knee scopes?

    ACLs with regional nerve blocks in place and an LMA?

    Shoulder surgery with an interscalene and an LMA?

    Laparoscopic anything?

    You've unknowingly corroborated my point.

    Opioids are frequently overgiven intraoperatively.
     
  23. dhb

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    Maybe i shouldn't be saying this but A LOT of procedures can be done under local anesthesia:
    -hernias
    -thyroid
    -carotids
    -peripheral ortho
    -appendix
    -eyes
    -plastic surgery
    -etc...

    After a while you start to master the "art" of anesthesia and you get a feel for when you should give opioids or a vasoactive drug. Typically i like to give clonidine when the BP starts ramping up when they insufflate the belly.

    As Tenesma put it in his infamous post, patient reaction isn't always pain related.

    Of course your not going to be right 100% of the time but respiratory rate at the end of the case is your friend and will tell you if your behinf with your narcs.
    If you're willing to extubate the patient deep then there's not much that's going to slow you down.

    A couple of weeks ago i took over a case; the dude apparently smoked a ridiculous amount of pot. They had be running the anesthesia with 2.5% et sevo plenty of narcs and some clonidine. At the end of the case i put him back in spontaneous breathing and the dude picked up at 35b/min i gave him 20mcg of sufenta in 5mcg increments to slow him down and extubated him when the wheels were coming under the table...

    Was it pain? i can't be sure but respiratory rate has not failed me yet so i'll continue to put faith in that variable.

    And yes i think on average we give too much opioids during anesthesia. Very rarely do i use more than 25-30mcg of sufenta and often much less.
     
  24. dfk

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    this is a similar thought with one of our surgeons. only, he prefers precedex gtt. works well so far.
     
  25. huktonfonix

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    i hope he doesnt use this for every case. It seems too expensive to justify.
     
  26. Planktonmd

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    And this is why it is not good for patients to have a surgeon dictating how to give anesthesia, and this is exactly why every anesthetic should be supervised by an anesthesiologist who actually knows when to use the right drug for the right indication.
     
  27. dfk

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    no. basically for roux-en-Y type stuff. he wants it on all of his cases, but doesn't get it. and yea, it's expensive.
     
  28. dfk

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    right.
    in case you didn't read my post clearly, i stated that the surgeon PREFERS precedex. surgeons don't dictate at my facility. in my experience, precedex works. and it isn't "cleared" by the anesthesiologist first..
     
  29. Planktonmd

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    What does that mean??
     
  30. Planktonmd

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    I think DFK is trying to say that he does not need input from an anesthesiologist to execute the surgeon's order to give Dex to patients, and this is correct because after all a nurse only needs an order from a physician to give a drug.
    What I was trying to say is that it's not about if it's legal or not for him to give a certain anesthetic ordered by a surgeon, I am saying that there are specialists who actually know these medications very well and can make an educated decision on when to give a certain drug to a certain patient, these specialists are called anesthesiologists.
     
  31. dfk

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    dude, i wasn't knocking anything. all's i was saying was that given the "fact" that it's known this surgeon likes what he likes (hint: brings in a lot of business), the pharmacy is willing to not question the request. so, if it deems feasable, i or any anesthesia provider will act accordingly..... sans doctor's orders. so, no legal or power or whatever issue going on here... i was merely stating what one surgeon likes, the Rx is aware of it, and it's our independent (ACT) decision to move forward with it.
    not for nothing, but in any relatively moderately healthy patient, they can "withstand" precedex. why not consider it an "advance" form of anesthesia if you will. i can't see why one has to be an anesthesiologist to grasp and handle various medications.
     
  32. bulgethetwine

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    Agreed. Or intensivists with lots of experience with these drugs, whatever be their background (anesthesia or otherwise)
     
  33. Planktonmd

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    First: If you are working in an ACT team as you claim then your supervising anesthesiologist is the one who decides who gets what medication not you acting on a surgeon's order.
    Second: Dex as you obviously know is an anesthetic and anesthetics are given as a part of an anesthesia plan, so a surgeon telling a nurse to give Dex is equivalent to him telling the nurse to give a certain inhaled agent or a certain induction agent. Surgeons are not trained nor do they have the experience to plan anesthetics.
     
  34. bulgethetwine

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    I see your point. But isn't there enough flexibility with Dex to not be dogmatic about it? I mean, a surgical intensivist is *never* going to order Sevo. (Wait, maybe I should never say never :)

    But it is quite reasonable for a surgical intensivist to order Dex. I see it all the time, appropriately in my opinion, for the patient who, say, has a history of big time alcohol abuse, is a little tough to handle in the ICU from a mental status standpoint, and especially if the co-morbidities include hypertension. Often this is more than 24 hours post-op... so the idea of the "anesthetic plan" has long since expired on the shelf.

    Dex drip for 12-24 hours, titrateable to mental status and pressure.

    I would think that an intensivist could at once use this drug appropriately and respect the autonomy and professional skill of the anesthesiologist who managed the case and the immediate post-op period.

    It is not lost on me that Plankton and I might be talking about two very different types of surgeons, though. Plank might be talking about the garden variety general surgeon who thinks he/she can dictate all aspects of care. Clearly I'm talking about a surgical intensivist who has extra, special training in drugs specific to the ICU, training that was probably gleaned while working very closely with anesthesia colleagues.

    There are other drugs that other non-anesthesia providers use in the ICU setting that are the realm of, but not exclusive to, the anesthetic world, too. Ketamine, Haldol, any opiate medication, so I think these points are generalizable beyond dex.

    Plank, is this fair? Do you have a constructive rebuttal? By all means, I'd like to hear your arguments if you feel a more heavy handed approach with even the surgical intensivists is warranted --
     
  35. Planktonmd

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    I am talking about intraoperative care where we administer anesthesia according to a certain plan based on our knowledge and experience.
    Obviously you are talking about care in the ICU postop which is a different situation and done by physicians with advanced training.
    And even in the intraop setting I will be more than happy to incorporate a medication suggested by a surgeon colleague as long as it makes sense and is discussed objectively.
    But on the other hand the surgeon should not order a nurse to administer an anesthetic intra-operatively without the anesthesiologist's approval.
     
  36. bulgethetwine

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    Absolutely, 100%, concur.
     
  37. SleepIsGood

    SleepIsGood Support the ASA !
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    I think Plank's statement which I agree with is in regards to the OR. Surgeons should not dictate OR management of an anesthetic. The NURSE is under the supervision of the anesthesiologist and should have to answer to the anesthesiologist.

    In the ICU it's a different story.
     
  38. dfk

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    dude, the surgeon did not order, it was not an order. as i stated previously, he PREFERS dex. ALL anesthesia providers are aware of the surgeon's PREFERENCE. and if the pharmacy will give it out, then other than knowing that the dex will be given, it's a go (aside from any contraindications.)
     
  39. Planktonmd

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    Back on the original subject:
    The bottom line:
    Too much narcotics intra-op is not always good and there is nothing wrong with using a little "vasoactive drugs" to make your anesthetic smoother.
    Sorry for the hijacking.:hijacked:
    :luck:
     
  40. nutmegs

    nutmegs ASA Member
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    [remi off]
    *eyes pop open*
    *blink*
    "hi! can you take a deep breath?"
    *nods*
    "ok, deep breath and that tube will come out!"
    *nods*
    "no, I need you to breathe, ok?"
    *nods*
     
  41. Pooh & Annie

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    I'm happy to corroborate your point because like I said, I don't disagree with you. Like I said already, if they're hurting and it's still gonna hurt when they wake up, I'll give pain meds.
     

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