Cardiac Anesthesia Question

Let's try another clinical question. I need some opinions. During our CABGs, I try to give 2 mg. Versed every 45 min or so even when on "pump". I usually bolus about 4-6 during induction depending on the patient and give at least 2 additional when rewarming. Finally, I give 2 -4 when leaving the room to insure amnesia in the early ICU stay. This usually means about 20 or so mg of Versed. I usually run some background iso at about .2 to .5% titrating if needed. We do not "fast track" anyone. Question 1: Does this dose seem excessive? Question 2: What dosing regimes do you follow? Question3: We have just put lorazapam into the heart rooms, those that use that drug, what dosing schedual do you use? Thanks in advance.

I know at the VA in Alberquerque, we used doses of that amount. They do not fast-track at this point either.

IM tesnesma and get his point of view. Its been over a year that I have been involved with cardiac surgery, he may have more current info.

Mike

Just out of curiosity--how do you define "fast tracking" at your insititution?

Thanks!

we are doing more and more fast-tracking... with some of the quicker surgeons we actually extubate about 15-20 mins after chest closure... it is pretty sweet :) but you have to pick those patients carefully

I think if you aren't planning on extubating your hearts until the next day, then 20mg is more than enough... I average a total of 7-8mg per case (except for fast-track - they get 2-4mg), but i also run iso to mess up their brains a bit...

i think it is appropriate to make sure the patient stays amnestic, especially when they are on pump... but remember that memories don't form when the brain is hypothermic, so if your pump runs are at 18C or 25C or even 32C, you should be pretty safe.

instead of bolusing though, i would consider running a fent/versed drip or a prop drip, and that way you can focus on other things...

I prefer ativan over versed, primarily because it has a better clearance profile - in fact, you can give ativan 1-2mg PO in the AM before the patient comes down to the OR, then give 1-2mg IV prior to induction, and then run an ativan infusion (1-2mg/hr) ... people sometimes are concerned about running ativan infusions because they are worried about toxic accumulation of polyethylene glycol (a constituent of ativan solutions).... i think if you are running them on low-dose ativan you should be fine...

Thanks for the info, keep posting.