opinions

Specialties CRNA

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looking for opinions - let's say you have a pt. on beta blockers. they come in for surgery and their HR is in the 60's-70's (which is their baseline) and their pressure is in the 70's/40's range. you've given fluid, blah, blah blah. my question is, which would be more appropriate for a pt on beta blockers to get, ephedrine or neosynephrine - to increase their bp? neo is of course a direct alpha agonist, so you have that going for you. ephedrine has some alpha action as well as beta action which would compete with the beta blockers for sites and reduce their effect, yada, yada, yada. any opinions?

Ephedrine will act as a competitive antagonist with respect to beta-blockers and will treat the hypotension but may negate the beta blocker effects. Phenylephrine can be used if the patient has adequate ventricular function, otherwise increasing the afterload precipitously could cause you some problems. In this scenario, what was the patient's calcium labs? Working in a calcium (in small boluses) will help you by mobilizing into the smooth musculature of the vessels and promoting actin activity. If your in the OR already, I find that 500 cc of a colloid also helps. Sounds like the patient's HR is high (for that patient) and SVR is low. What was the urine output? CVP? A-line waveform? What kind of surgery was it, did it involve pressure on the vessels? What was your ET agent concentration, did it need to come down? How much narc on board? Is it immediately after induction? Did the surgeon ask you to give anything?

Just some thoughts and questions you might be asked in the OR.

Mike

colloids are expensive and usually unnecessary.

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colloids are expensive - but hetastarch 6% is helpful for up to 48 hours - so the expense over time vs. benefit isn't that great... the more expensive albumin is short-lived.

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colloids are expensive - but hetastarch 6% is helpful for up to 48 hours - so the expense over time vs. benefit isn't that great... the more expensive albumin is short-lived.

Hetastarch.........ahhh music to my ears. (kept many soldiers going on the table when blood wasn't available). :)

As for cost, if you review a patient's bill (the entire bill) for surgery, anesthesia, hospital stay, labs, etc. The cost of our interventions is just a fraction of that bill. The argument that colloids are expensive loses strength when you view the content of the patient's overall bill.

(Also one of the benefits of practicing in the military is the "profit" issue, we pretty much use what we prefer)

Mike

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colloids are expensive - but hetastarch 6% is helpful for up to 48 hours - so the expense over time vs. benefit isn't that great... the more expensive albumin is short-lived.

true....but some people dislike the coagulation abnormalities associated with this product.

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true....but some people dislike the coagulation abnormalities associated with this product.

It is a theoretical point, but I have never had that problem and it is quite rare to need more than the 20 ml/kg recommended (usually switch to good ole' cells by that point).

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As for cost, if you review a patient's bill (the entire bill) for surgery, anesthesia, hospital stay, labs, etc. The cost of our interventions is just a fraction of that bill. The argument that colloids are expensive loses strength when you view the content of the patient's overall bill.

Mike

Agreed. Ever hear an orthopod cry about a certain instrument not being available on "his" tray and then the OR staff opens another sterile instrument tray just to obtain this one tool? That one tray most likely costs more than your day's income...Consider that. Then use whatever you want for delivery of anesthesia. Given the benefits and long-term duration of Hespan, use it if you want. I do all the time. Ever gotten a dehyrated GYN patient that has had a gallon on GoLytely and then run into unexpected blood loss? Could 4 liters of 99 cent/liter of LR do the trick. Sure, but then mom goes home from OPS looking like a balloon for the next 2 days. Screw the 'relative costs'. Hespan rules.

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the thread side tracked though---basically he was asking the question between the two drugs---that's why the fluid blah, blah, blah quote----without getting into all the questions asked, between the two drugs, neo is the choice---besides, if you are worried about the heart's ventricle to not give Neo, I would definitely be cautious loading up with colloids for the same reason---you could ask a thousand scenarios and try to impress, but he asked between the two drugs----

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the thread side tracked though---basically he was asking the question between the two drugs---that's why the fluid blah, blah, blah quote----without getting into all the questions asked, between the two drugs, neo is the choice---besides, if you are worried about the heart's ventricle to not give Neo, I would definitely be cautious loading up with colloids for the same reason---you could ask a thousand scenarios and try to impress, but he asked between the two drugs----

That's a question he asked in isolation.....without any background. The art of anesthesia is that it is dynamic and not a "recipe". Both drugs are good drugs, problem is they are appropriate for certain situations, NOT just to give in a single point in time.

"Cook book" anesthetics are trouble especially if someone forgets the recipe. Got to learn to make things from scratch.

Mike

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I've found that all patients react differently when beta blocked. Some don't respond with increases in HR with ephedrine because of the beta blockade, some respond with a greater bp increase than with neo, and some respond with a great bp increase with the neo. My first choice would be neo, but if you're giving multiple boluses of it, switch to ephedrine.

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Specializes in Critical Care.

Wow. Somebody said something about scenarios to impress. As a CCRN w/ 9yrs in CCU, lurking in your thread, I was impressed with how thoroughly all this stuff was being considered.

Most times, once in CCU, I think I'm the only one that ever looks at Swan data (CO aside - that's the only data I ever see commented on by MDs). If it weren't for Post OP PRN Albumin/Hespan/Dopa/Neo/Nipride/Ntg orders, I'd have no luck at all . . .

~faith,

Timothy

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Wow. Somebody said something about scenarios to impress

Yeah, Yeah---you are missing my point---if you look at original post, he asked what to give to increase BP, drug A or B----I am not saying that this is bad, to look at all angles, but that wasn't his question---they didn't ask how to increase the BP overall, just between the two drugs---this is said with tongue in cheek and really just picking, not malicious---but when I read the original post, I wondered how long it would take before it went into a crazy direction, with made up scenarios, and people interjecting their experiences all over the place with hypotensive patients---the original post didnt post any scenarios or other angles----just a simple question---I just failed to see what the calcium level, the level of narcotics on board, whether the surgeon had made incision yet, the end tidal of the agent was at the time, etc etc--I mean damn, he just asked what drug you would give to bring the BP up with the pressure 70/40--I mean, I would assume you would give one of the two drugs at this time while you are analyzing what is going on---Its kind of insulting to ask whether or not the agent is up too high, or you are waiting for the surgeon to cut---It just kind of cracks me up to see how some of these threads shoot off in these ways,

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Yeah, Yeah---you are missing my point---if you look at original post, he asked what to give to increase BP, drug A or B----I am not saying that this is bad, to look at all angles, but that wasn't his question---they didn't ask how to increase the BP overall, just between the two drugs---this is said with tongue in cheek and really just picking, not malicious---but when I read the original post, I wondered how long it would take before it went into a crazy direction, with made up scenarios, and people interjecting their experiences all over the place with hypotensive patients---the original post didnt post any scenarios or other angles----just a simple question---I just failed to see what the calcium level, the level of narcotics on board, whether the surgeon had made incision yet, the end tidal of the agent was at the time, etc etc--I mean damn, he just asked what drug you would give to bring the BP up with the pressure 70/40--I mean, I would assume you would give one of the two drugs at this time while you are analyzing what is going on---Its kind of insulting to ask whether or not the agent is up too high, or you are waiting for the surgeon to cut---It just kind of cracks me up to see how some of these threads shoot off in these ways,

A little sensitive are we? As a practitioner, you had better be asking those questions......

Mike

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