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Open ended question...What do you consider a "cardiac induction"? It's a term that is thrown around a lot but there isn't a hard and fast definition as to what it actually means.

wtbcrna, MSN, DNP, CRNA

Specializes in Anesthesia.

To me a cardiac induction is any induction that is designed to keep the HR/BP as close to their baseline as possible.

To me a cardiac induction is any induction that is designed to keep the HR/BP as close to their baseline as possible.

But for cardiac specific cases..."narcotic" inductions have been kind of the gold standard. I agree with the target HR/BP, but that's a good goal for almost any GA induction, especially of 3's and 4's.

I guess the conversation I was trying to get at was about the utility of "high" narcotic techniques in cardiac surgery these days. We seem to be working off of a paradigm that was developed in the 50's and 60's, that is benzo and narcotic overdoses.

The idea of a pure narcotic induction being the most stable we have, I think, is flawed.

wtbcrna, MSN, DNP, CRNA

Specializes in Anesthesia.

But for cardiac specific cases..."narcotic" inductions have been kind of the gold standard. I agree with the target HR/BP, but that's a good goal for almost any GA induction, especially of 3's and 4's.

I guess the conversation I was trying to get at was about the utility of "high" narcotic techniques in cardiac surgery these days. We seem to be working off of a paradigm that was developed in the 50's and 60's, that is benzo and narcotic overdoses.

The idea of a pure narcotic induction being the most stable we have, I think, is flawed.

What does literature state?

What does literature state?

About induction agents for cardiac anesthesia? What it has stated for the last 25 years at least about induction of anyone, which is that, on balance, there is no single best way to do a GA. There are obvious things not to do, like induce a cardiac patient with ketamine or desflurane, but I took that as a given for the conversation.

The point was that we do narcotic inductions in cardiac anesthesia as much out of "tradition" as for the physiologic advantages.

wtbcrna, MSN, DNP, CRNA

Specializes in Anesthesia.

About induction agents for cardiac anesthesia? What it has stated for the last 25 years at least about induction of anyone, which is that, on balance, there is no single best way to do a GA. There are obvious things not to do, like induce a cardiac patient with ketamine or desflurane, but I took that as a given for the conversation.

The point was that we do narcotic inductions in cardiac anesthesia as much out of "tradition" as for the physiologic advantages.

I understand what you are saying, but how can we judge a particular anesthetic regimen is better than another without studies/research to back it up.

There are probably numerous studies that have been done on this particular topic. Anesthesia in general seems to lagging behind on the utilization of research with a lot of what we do based on dogma and "that is the way I was taught" or "that is the way I have always done it".

I understand what you are saying, but how can we judge a particular anesthetic regimen is better than another without studies/research to back it up.

There are probably numerous studies that have been done on this particular topic. Anesthesia in general seems to lagging behind on the utilization of research with a lot of what we do based on dogma and "that is the way I was taught" or "that is the way I have always done it".

Is it necessary to qualify and validate every statement in a conversation with a reference to a paper? I think that, in advanced practice anyway, there should be the assumption that those things have been considered and are understood as elements of the question.

The citation cut and paste wars that some folks embark on with some clinical issues are pretty embarrassing sometimes and reflect a lack of independent and creative thinking given what should be baseline knowledge.

There is something to be said of idea synthesis that is not specifically examined widely in the literature. It's where ideas for studies come from and if the nursing literature is any indication, there isn't a lot of out of the box thinking going on.

It's the difference between A and A and the AANA journal.

wtbcrna, MSN, DNP, CRNA

Specializes in Anesthesia.

Is it necessary to qualify and validate every statement in a conversation with a reference to a paper? I think that, in advanced practice anyway, there should be the assumption that those things have been considered and are understood as elements of the question.

The citation cut and paste wars that some folks embark on with some clinical issues are pretty embarrassing sometimes and reflect a lack of independent and creative thinking given what should be baseline knowledge.

There is something to be said of idea synthesis that is not specifically examined widely in the literature. It's where ideas for studies come from and if the nursing literature is any indication, there isn't a lot of out of the box thinking going on.

It's the difference between A and A and the AANA journal.

What you just described is the lower tier of the pyramid of evidence. Why would a hospital/ASC or an anesthesia provider not perform valid literature review for the answers to clinical questions, if that proves fruitless or there isn't time then by all means peer to peer advice is great.

My personal choices for cardiac stable induction are propofol/ketamine (2mg/ml) or propofol 20ml with 100mcg of phenylephrine. I like ketafol dosing better and the last time I saw this presented at conference it was considered better than etmodiate.

So, studies like these just answer the rhetorical question "Can you stand up in a canoe?". The answer is, yes, you can, but why would you do that? Comparing ketamine to propofol while giving fentanyl and versed in the same doses gives the unsurprising result that ketamine, in this narrow circumstance, is better than propofol.

I wouldn't use propofol in that way any sooner than I'd use ketamine. It's like asking if you'd walk or crawl across a freeway when you could just not cross at all. Again, stuff I'd expect as a given when having this conversation.

My personal choices for cardiac stable induction are propofol/ketamine (2mg/ml) or propofol 20ml with 100mcg of phenylephrine. I like ketafol dosing better and the last time I saw this presented at conference it was considered better than etmodiate.

I like ketofol too, but in the .5 to 1 mg/ml range. But if my concern is DCM or significant CAD/PVD, I'll use a 50/50 volume mix of propofol and amidate. Comes out to 5mg/ml of propofol and 1 mg/ml etomidate. I'll give about .15 ml/kg of that for a very hemodynamically stable induction that is sustained well up to incision. I avoid more than about 0.5 mg/kg of ketamine in those patients.

wtbcrna, MSN, DNP, CRNA

Specializes in Anesthesia.

So, studies like these just answer the rhetorical question "Can you stand up in a canoe?". The answer is, yes, you can, but why would you do that? Comparing ketamine to propofol while giving fentanyl and versed in the same doses gives the unsurprising result that ketamine, in this narrow circumstance, is better than propofol.

I wouldn't use propofol in that way any sooner than I'd use ketamine. It's like asking if you'd walk or crawl across a freeway when you could just not cross at all. Again, stuff I'd expect as a given when having this conversation.

I understand what you are saying, but I respectfully disagree. Understanding when and how to best use research to base our practices on is the future and that is the path we are being expected to follow more and more.

I understand what you are saying, but I respectfully disagree. Understanding when and how to best use research to base our practices on is the future and that is the path we are being expected to follow more and more.

So, if I'm giving the impression that I'm anti research, I feel really dumb...using it means being very critical and suspicious of it, though. Leaving the beta blocker fiasco aside, just day to day stuff like ACEI/ARB's in the perioperative period or the goofiness of so called perioperative tight glucose control should be enough to temper the weight of single studies or even meta analyses people place on their day to day practice.

It's disheartening to see someone change their practice in some big element of their care based on one study.

wtbcrna, MSN, DNP, CRNA

Specializes in Anesthesia.

So, if I'm giving the impression that I'm anti research, I feel really dumb...using it means being very critical and suspicious of it, though. Leaving the beta blocker fiasco aside, just day to day stuff like ACEI/ARB's in the perioperative period or the goofiness of so called perioperative tight glucose control should be enough to temper the weight of single studies or even meta analyses people place on their day to day practice.

It's disheartening to see someone change their practice in some big element of their care based on one study.

Proper use of research is basing decisions on high quality evidence and in general that rarely applies to one study. We have a lot of dogma in anesthesia based on single studies: MP scores ( originally an n=10), no phenylephrine in OB, no ketamine for neuro, sevoflurane needs at least 2lpm....etc. I try to do my best to base my department and my practice on high quality evidence. That is also the way we teach are USUHS SRNAs.

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