Anesthesia may not be for every one... but it's exactly what I've been looking for in a life long career in medicine.
I don't miss that). Were you using the epidural, Sevo? I run some background Neo if I need it but with a HR of 30 that may be hard to do and Dopa is a good alternative.
Hey Jet those night calls getting to you uh? I know what you mean bro but sometimes night calls are cool if you get some sleep and you have the post call day off
Multiple papers by G. Joshi from Texas and others agree that the traditional 4-2-1 claculation for maint fluid replacement & 10ml/kg evap loss may be overestimating actual requirements. So Mil I agree with you but here's my question:
Thanks Mil & Noyac... I guess it is simply too difficult sometimes
. I see the both of your points and this is exactly what happens routinely here. The ICU dudes always complain that we gave too much fluid and now he has to diurese the pt before attempting extubation given plum Edema but in the OR my attendings freak out about BP and renal hypoperfusion so we go lala with the fluids. But I will take your advice to heart. Thanks Mil & Noyac... I guess it is simply too difficult sometimes
BTW Mil why would you place the TEE to check for fluid status but confuse the pic with neosynephrine? I think its going to be a lmisleading study since SVR is now increased iatrogenically no?
that reminds me of the good old days.
) Mostly get about 1L in the induction/lines period, and then pretty much replace volume for volume of blood loss only, but tending very much to the dry side. I don't believe in the CVP as a measure of whether or not the patient is behind or over hydrated, and we use it as a portal for inotropes and GIK infusions as required only. On the topic of inotropes, I don't touch Dopamine as I am not convinced that it does the kidneys any good at all. Our institution is very anti-dopamine, and we prefer to use Phenyl, and/or Dobutamine as required. All get a low thoracic epidural which we try and load up in the last hour or so. We also plan to extubate in theatre for that majority of cases, barring any major intraop disaster, although I think our patients in SA tend to be younger and have less comorbidity than your patients. (avg age of the Whipples I've done has been about 45)
In continuing to hijack the thread, I'll offer my comments. I tend to run my Whipples very dry. (In my huge experience of about 6 cases
As someone else pointed out, I use Acid/Base status to guide fluids, and I also talk to my surgeon a lot about how the bowel feels. If he starts complaining of boggy bowel (the patients bowel, not his!), then I know I've overdone the fluids. Run your patients dry and your surgeons will stay sweet. I'm pretty sure our guys would rather we use judicious inotropy than give them a completely edematous bowel to try and stitch together. If the bowel is edematous at anastomosis, when that fluid comes off, that anastomosis stands a high chance of leaking.
Unfortunately our budget does not extend to TEE, and the use of the Swan is very much the exception rather than the rule.
