Unorthodox practices

[GA8314]

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So I've recently encountered a few things I've found rather interesting at my new gig. I am seeing people ROUTINELY using vasopressin as their go to pressor
of choice during routine non cardiac cases. Like for post induction hypotension.......

Anyone ever see this?....

Also on a few occasions I've seen IM Dilaudid being used without any apparent REASON for it.

Anyone see or done this?? If so, why?

Am I out of line for being annoyed by these two things?

 

[gasdoc77]

Neither would be my choice, but I don't see them placing the patient at risk. As long as they respect our differences, to each his own.

 

[gasdoc1]

So I've recently encountered a few things I've found rather interesting at my new gig. I am seeing people ROUTINELY using vasopressin as their go to pressor
of choice during routine non cardiac cases. Like for post induction hypotension.......

Anyone ever see this?....

Also on a few occasions I've seen IM Dilaudid being used without any apparent REASON for it.

Anyone see or done this?? If so, why?

Am I out of line for being annoyed by these two things?

I'm just curious, have you taken your oral boards yet? Unless things have changed in the last 10 years, oral boards are all about being flexible and being able to make unorthodox situations work. You are allowed to be annoyed at whatever you want, but if other people's practice works for them and their patients, who are you to tell them to change? I wouldn't do either of these things either, but unless you see something dangerous going on, let them practice their way, and you practice yours.

 

[Yangkower]

I've had the opposite experience. What I've seen in private practice is a much more pragmatic approach to anesthesia that works. Things are done much differently than the way I was trained but it works and doesn't put the patient at risk. In academics many of my attendings practiced based on fear of being brought before the draconian M&M inquest so they became rigid and dogmatic about trivia. The best training I had as a resident was the private practice guys that were moonlighting in academics. I see nothing wrong with using vasopressin and even saw a shift to that towards the end of my training. As far as IM dilaudid, I don't know, but I do know in some parts of the world they use IM nsaids with good results for post op pain.

 

[Stank811]

In regards to treating hypotension after induction I don't see a difference really in using anything you want if it is a for a short period and it corrects the hypotension and doesn't create tachycardia. Some people will argue that vaso has some benefit in that it doesn't effect pulmonary pressures to the degree that phenyl does. Others support NE bc of its beta agonist properties so it doesn't decrease CO to the extent of phenyl. But in my opinion if it is a one time bolus to treat post induction hypotension it is not going to make a difference. My favorite is one people give a couple cc of phenyl prior to a stick of propofol in an 80yo…..why not just go with a .5-1mg/kg and wait a additional 10cc and avoid hypotension a together.

 

[dhb]

IM narcotics is a good option for post op pain control for procedures that don't warrant an iv PCA. I do it all the time.

 

[urge]

IM narcotics is a good option for post op pain control for procedures that don't warrant an iv PCA. I do it all the time.

What are you injecting? How much?

 

[Yangkower]

IM narcotics is a good option for post op pain control for procedures that don't warrant an iv PCA. I do it all the time.

What do you give, how much and where do you inject?


Ha, didn't see the above post.

 

[urge]

people ROUTINELY using vasopressin as their go to pressor
of choice during routine non cardiac cases. Like for post induction hypotension.......

Very popular in my place now. I think it is silly and dangerous. People are giving truck loads of it instead of starting an infusion. People do stupid stuff to avoid getting off their stool.

 

[urge]

What do you give, how much and where do you inject?


Ha, didn't see the above post.

Great minds think alike.

I'm curious. I might give it try. I used IM narcotics during intern year but the results were not impressive. The doses were too low in my opinion.... like 50 of Demerol or 4 of morphine. Maybe a hefty dose like 20 of morphine might do it. Haven't tried it since the pca became popular.

 

[sluggs]

Vaso in that context does not seem like the best choice. It has a long half-life, and depending on the cause of the hypotension and the length of the case, the patient could have rebound hypotension after the case that goes unrecognized (this is mostly true in the odd case where induction hypotension is really something other than induction hypotension).
Neo or Norepi.
Just my 2c.

 

[Yangkower]

Good point about the long half life, which is exactly the reason it is only given once during ACLS. Maybe useful in patient's who took their am lisinopril and aren't responding well to neo/ephedrine.

 

[BLADEMDA]

Vasopressin is a nonapeptide, synthesized as a pro-hormone in magnocellular neurone cell bodies of the paraventricular and supraoptic nuclei of the posterior hypothalamus. It is bound to a carrier protein, neurohypophysin, and transported along the supraoptic hypophyseal tract to the axonal terminals of magnocellular neurones located in the posterior pituitary. Synthesis, transport, and storage takes 1–2 h. Normal plasma concentrations are <4 pg ml−1. It has a half-life of 10–35 min, being metabolized by vasopressinases which are found in the liver and kidney. Vasopressin acts on V1, V2, V3, and oxytocin-type receptors (OTR).

 

[BLADEMDA]

Half life of drugs:

1. Vasopressin- 10-15 minutes (low dose like 1-2 units)
2. Phenylephrine 5 minutes
3. Norepinephrine 2 minutes.

Depending on the patient and situation any of these 3 drugs could be used to treat hypotension.

 

[BLADEMDA]

Vasopressin is a nonapeptide, synthesized as a pro-hormone in magnocellular neurone cell bodies of the paraventricular and supraoptic nuclei of the posterior hypothalamus. It is bound to a carrier protein, neurohypophysin, and transported along the supraoptic hypophyseal tract to the axonal terminals of magnocellular neurones located in the posterior pituitary. Synthesis, transport, and storage takes 1–2 h. Normal plasma concentrations are <4 pg ml−1. It has a half-life of 10–35 min, being metabolized by vasopressinases which are found in the liver and kidney. Vasopressin acts on V1, V2, V3, and oxytocin-type receptors (OTR).

 

[BLADEMDA]

Good point about the long half life, which is exactly the reason it is only given once during ACLS. Maybe useful in patient's who took their am lisinopril and aren't responding well to neo/ephedrine.

So which has a longer half life slim, ephedrine or vasopressin? And I'm talking about clinical redistribution half life and not elimination half life.

 

[Yangkower]

I don't know. If I'm really concerned about BP I don't rely on ephedrine unless the patient has demonstrated adequate response to it. My point was that vasopressin may be an appropriate choice but I would be careful using it for transient hypotension.

 

[Mman]

My problem with IM opioids is what are people taking care of the patient postop supposed to do for opioids? IM doses lead to long and somewhat unreliable half lives that can set a patient up for delayed respiratory depression postop. Morphine is notorious for this even in IV formulation, let alone IM. Big dose of IM morphine strike me as a recipe for a lawsuit on a patient that ends up needing postop narcotics in addition to it if they had a respiratory event.

 

[sluggs]

I stand corrected on faso half-life, and was thinking more about the prolonged activity after cessation of a drip