Narcotic administration in cardiac surgery cases

[psychbender]

Patient comfort. Remove 7 fr. double or introducer after a day or so if all is stable.

The central line should be coming out POD1, anyway, unless there are complications.

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[PpfSuxTube]

Patient comfort. Remove 7 fr. double or introducer after a day or so if all is stable.

How is comfortable for patients to have 2 then 1 line in their neck? And if they're stable why do they need any central line?
If they do become unstable with the triple lumen still in situ, what resus could you do well with a triple lumen anyways?

A decent PIV and an introducer is all that's needed, swan with infusion port is fine too

 

[pgg]

Brought a patient down from the floor for surgery this morning. Looking for a nurse to get report. Oops! They were never assigned a nurse at shift change. Guess nothing bad happened.

The best thing about the floor is that it's close to a hospital.

 

[pgg]

Patient comfort. Remove 7 fr. double or introducer after a day or so if all is stable.

Patients are even more comfortable if they don't have any central lines in at all.

I'll concede there's some convenience (and patient comfort) in having a triple lumen in patients who have tenuous or otherwise crappy PIV access, and you can get labs off them without extra needle sticks.

 

[pgg]

For whatever it's worth, the CDC has said since 2011 that arterial lines should be done under sterile conditions:

1. A minimum of a cap, mask, sterile gloves and a small sterile fenestrated drape should be used during peripheral arterial catheter insertion [47, 158, 159]. Category IB

Goddamn good idea fairies ought to be first against the wall when the revolution comes.

I'll do all that when using the micropuncture kits since my hands have to touch the wire and the catheter.

The 20g Arrow with integral wire? Ridiculous. I'll take my chances with a jury.

 

[sevoflurane]

Patients are even more comfortable if they don't have any central lines in at all.

I'll concede there's some convenience (and patient comfort) in having a triple lumen in patients who have tenuous or otherwise crappy PIV access, and you can get labs off them without extra needle sticks.

My first job we put in mac catheters in everybody. This is just how we do it here and it’s a change as of about 5 years ago.
No reason to concede.
Just different way of doing things..

 

[sevoflurane]

The central line should be coming out POD1, anyway, unless there are complications.

I don’t disagree.

 

[sevoflurane]

How is comfortable for patients to have 2 then 1 line in their neck? And if they're stable why do they need any central line?
If they do become unstable with the triple lumen still in situ, what resus could you do well with a triple lumen anyways?

A decent PIV and an introducer is all that's needed, swan with infusion port is fine too

A lot more comfortable.
Not everyone is stable.

 

[Iso4ane]

We used to do doubles stick for frequent Amio infusions post-op. Our director was hot for that.

Funny, I was thinking about this today. And was trying to figure out the logistics. Is it high wire, (cranially) > low wire > Dilate high > Introducer > Dilate Low > Triple/Quad (or even a second introducer; which I heard some places do for liver tx.)

The best thing about the floor is that it's close to a hospital.

But, depending where the ORs are the floor may to closer to Jesus.

 

[Bertelman]

Funny, I was thinking about this today. And was trying to figure out the logistics. Is it high wire, (cranially) > low wire > Dilate high > Introducer > Dilate Low > Triple/Quad (or even a second introducer; which I heard some places do for liver tx.)

I’ve pretty much perfected it.

First needle closest to clavicle. Wire. Next needle cranial. Wire. Load both dilators, sheath close to clavicle. Insert sheath, pull wire. Dilate/insert dub lumen, pull wire.

More bulky sheath ends up laying on top of double. It’s more comfortable for patient, easier to secure, and easier to remove first.

I had an old attending when I was first in the OR. Loooiong before ultrasound. Would grasp two pig stickers, 1-2cm apart, landmark, hit IJ, and off he goes. Was remarkable.

 

[drmwvr]

Goddamn good idea fairies ought to be first against the wall when the revolution comes.

I'll do all that when using the micropuncture kits since my hands have to touch the wire and the catheter.

The 20g Arrow with integral wire? Ridiculous. I'll take my chances with a jury.

Give 'em Hell, bro...I'll hold your coat so it's clean when they hang you.....

 

[sevoflurane]

I’ve pretty much perfected it.

First needle closest to clavicle. Wire. Next needle cranial. Wire. Load both dilators, sheath close to clavicle. Insert sheath, pull wire. Dilate/insert dub lumen, pull wire.

More bulky sheath ends up laying on top of double. It’s more comfortable for patient, easier to secure, and easier to remove first.

I had an old attending when I was first in the OR. Loooiong before ultrasound. Would grasp two pig stickers, 1-2cm apart, landmark, hit IJ, and off he goes. Was remarkable.

When we made the change, I was a little hesitatnt as I always had mac catheters or introducers in the neck for all my cases.
It doesn't take long to double stick and a 7 fr. flows incredibly well. If things get sticky (very rare) a belmont is immediately available and you are still delivering a ton of products in a short amount of time plus you have a totally seperate infusion CVL line for the 6-8 pumps you may need.

If things are dry post op but still in need of limited support, that's what the triple is for. Pull the other lines out if not needed (patients love it when they start getting uncomfortable things out of their necks). If the patient is asking for food POD 0, everytning comes out the next day given normal labs/echo/hemodynamics.

I have partners that do triple lumens and a 14/16G peripherals for routine cases. I'm hesistant with that as I don't trust tucked arms I can't examine, but that has not been an issue (although it has in other general cases).

A big part of the decision process is knowing who your surgeon is and knowing their skills.

A long track record of coming off pump with no drama changes what i do. Some of the surgeons I work with I have known for 10+ years and make the most difficult cases seem like a breeze. I am still humbled by them.

Recently had a AVR/MVR on a 75 y/o gentlemen. Those are always big cases ( and I love them). At the end of the case there wasn't a single pixel I could show my Ct surgeon despite turning down my nyquist/scale

Patient still got lined up ready for war... but, it wasn't needed.

He just looked over the drapes, stared at the echo and said... you owe me starbucks.

 

[YadaYadaNext]

50/50 anesthesia and ICU. I do some hearts in the OR and take care of lots of them in the unit.

250-1000mcgs total for the case, plus 2-4mg versed.

However, I routinely ask the cardiac guys to start precedex early in the case and let it run through transport to the unit in addition to the propofol they hang at the end of the case when coming off ISO. This is especially helpful with young patients, mental health patients including severe anxiety, substance abusers, chronic pain patients. Start at about 0.4mcg/kg/hr and let it run. Turn it off in the unit or can even let it run through extubation.

Most underused drug in the OR in my opinion. Should replace ketamine for “pain” 100%.

 

[Bertelman]

He just looked over the drapes, stared at the echo and said... you owe me starbucks.

Great to have you back here, Sevo!

 

[psychbender]

Patients are even more comfortable if they don't have any central lines in at all.

I'll concede there's some convenience (and patient comfort) in having a triple lumen in patients who have tenuous or otherwise crappy PIV access, and you can get labs off them without extra needle sticks.

Nurses repeatedly accessing the line to draw blood increases probability of CLABSI. At our hospital, it is now verboten. Now, for a line that should be coming out 24hrs after it went in, probably not an issue.

 

[pgg]

Nurses repeatedly accessing the line to draw blood increases probability of CLABSI. At our hospital, it is now verboten.

I don't know that

All the more reason to get them out early.

 

[pgg]

However, I routinely ask the cardiac guys to start precedex early in the case and let it run through transport to the unit in addition to the propofol they hang at the end of the case when coming off ISO. This is especially helpful with young patients, mental health patients including severe anxiety, substance abusers, chronic pain patients. Start at about 0.4mcg/kg/hr and let it run. Turn it off in the unit or can even let it run through extubation.

Most underused drug in the OR in my opinion. Should replace ketamine for “pain” 100%.

I have a love/hate, mostly hate, relationship with Precedex.

Practically the only time I use it now is for sedation in cardiac patients taken to the ICU. I typically start it when rewarming. Maybe post cardiac patients have fewer tachydysrhythmmias when they get it, though I think the data is only good there for pediatric hearts.

I used to use Precedex for TAVRs, because that's what I saw done when I first started. I finally quit using it there and now just infuse propofol for TAVRs. I'll never go back. Precedex sucks, sucks, sucks for any kind of procedural sedation.

And don't get me started on the CRNA habit of giving everybody bits and boluses of it during every case they do.

Next to midazolam it's the most overused drug we've got.

 

[medicine2wallstreet]

I have a love/hate, mostly hate, relationship with Precedex.

Practically the only time I use it now is for sedation in cardiac patients taken to the ICU. I typically start it when rewarming. Maybe post cardiac patients have fewer tachydysrhythmmias when they get it, though I think the data is only good there for pediatric hearts.

I used to use Precedex for TAVRs, because that's what I saw done when I first started. I finally quit using it there and now just infuse propofol for TAVRs. I'll never go back. Precedex sucks, sucks, sucks for any kind of procedural sedation.

And don't get me started on the CRNA habit of giving everybody bits and boluses of it during every case they do.

Next to midazolam it's the most overused drug we've got.

Remarkable how clownish we all are. Two post above guy says precedex is the most underused drug in the OR. This guy says it's the most overused drug in the OR. just goes to show none of this mental masturbation really matters when everyone is getting diametrically opposed anesthetics across this country. Relax and just keep the patient safe with whatever potions get your jimmies off. But dont fool yourself in thinking you're the smartest and best cocktail creator.

That said precedex seems foolish to me post bypass given that they all need pacing help to get off. Seems to me those patients would be addicted to pacing for a prolonged period of time versus non precedex patients given the bradycardia it causes. But do I really care? No.

 

[pgg]

Remarkable how clownish we all are. Two post above guy says precedex is the most underused drug in the OR. This guy says it's the most overused drug in the OR. just goes to show none of this mental masturbation really matters when everyone is getting diametrically opposed anesthetics across this country. Relax and just keep the patient safe with whatever potions get your jimmies off. But dont fool yourself in thinking you're the smartest and best cocktail creator.

That said precedex seems foolish to me post bypass given that they all need pacing help to get off. Seems to me those patients would be addicted to pacing for a prolonged period of time versus non precedex patients given the bradycardia it causes. But do I really care? No.

As usual, you're reading too much into this conversation. No one here is anxious. No one needs to relax.

I only care what other people do when it affects me. Which isn't often.

I wouldn't complain if Precedex was taken off formulary. Every time I supervise CRNAs I put up with the patients getting it because it's usually not a hill worth dying on.

Patients with pacemakers are probably the best patients to get the drug, since you don't have to concern yourself with the main side effect.

Anyway, go ahead and keep on feeling superior to everyone discussing the topic and sharing their experiences and opinions. You're the only one getting worked up over what other people think.

 

[sevoflurane]

That said precedex seems foolish to me post bypass given that they all need pacing help to get off. Seems to me those patients would be addicted to pacing for a prolonged period of time versus non precedex patients given the bradycardia it causes. But do I really care? No.

This isn't true.

 

[T-burglar]

Go ahead keep screaming at me that the patient doesn’t need pacing. It only makes me turn up the rate and output higher

 

[coffeebythelake]

It depends on if you use the kit or the quick cath.

The quick cath doesn’t require sentirle gloves because you never touch anything that goes into the body.

With the kit, you’re touching the wire that’s going to enter the vessel.

What's a quick cath? An arrow kit?

 

[medicine2wallstreet]

This isn't true.

Yes I know. Sorry for the generalization. Thought this thread appreciated generalizations.

 

[Twiggidy]

I have a love/hate, mostly hate, relationship with Precedex.

Practically the only time I use it now is for sedation in cardiac patients taken to the ICU. I typically start it when rewarming. Maybe post cardiac patients have fewer tachydysrhythmmias when they get it, though I think the data is only good there for pediatric hearts.

I used to use Precedex for TAVRs, because that's what I saw done when I first started. I finally quit using it there and now just infuse propofol for TAVRs. I'll never go back. Precedex sucks, sucks, sucks for any kind of procedural sedation.

And don't get me started on the CRNA habit of giving everybody bits and boluses of it during every case they do.

Next to midazolam it's the most overused drug we've got.

*Spiderman pointing at each other meme*

 

[Twiggidy]

What's a quick cath? An arrow kit?

Yes the Arrow with the wire the slides in. I used to hate these in residency but now I've realized that was all just "attending propaganda". This was also a place where they looked at you like you were incapable if you wanted the ultrasound. I'm sure that's changed over time (hopefully)

 

[Twiggidy]

Go ahead keep screaming at me that the patient doesn’t need pacing. It only makes me turn up the rate and output higher

I don't know. Maybe this new discussion about "need for pacing" says more about surgical skill (ie taking too long) or maybe some folks are giving too much drugs. When we come off pump I'm guess 50/50 of our patients need pacing, but we don't bring people to ICU on Precedex so I'm sure that's one significant factor.

 

[Twiggidy]

For whatever it's worth, the CDC has said since 2011 that arterial lines should be done under sterile conditions:

1. A minimum of a cap, mask, sterile gloves and a small sterile fenestrated drape should be used during peripheral arterial catheter insertion [47, 158, 159]. Category IB

I remember in internship ('06-07) placing an arterial line in ICU was a PRODUCTION. We did fully drape and do it sterile but it does make me chuckle given today when we place an A-line in ICU it's like a 5-10 minute nuisance....and admittedly not fully draped.

 

[Bertelman]

We run Precedex basically from induction to weaning. By the time we leave the OR, I’d bet our pacing rate is less than 1/3, excluding MVRs.

Some of this is surgeon preference. Current crop prefers NSR. Prior guy insisted pacing at 80, just because.

 

[psychbender]

We run Precedex basically from induction to weaning. By the time we leave the OR, I’d bet our pacing rate is less than 1/3, excluding MVRs.

Some of this is surgeon preference. Current crop prefers NSR. Prior guy insisted pacing at 80, just because.

Same. Once I have my swan floated, infusion line hooked up, I tend to hit start on dex at 0.6, and let it ride through the rest of the case. At this point, I've trained most of my ICU nurses to shut the dex OFF (rather than "wean") once they feel tucked in, so we don't see a prolonged time to wakefullness and extubation any longer. I also don't see a ton of severe bradycardia, unless they were quite brady beforehand.

 

[vector2]

There's some laboratory and clinical evidence that precedex is not only cardioprotective but also renal-protective. I run it routinely after induction and continue it in the ICU +- propofol if they actually need a real sedative.

Effect of Dexmedetomidine on Postoperative Renal Function in Patients Undergoing Cardiac Valve Surgery Under Cardiopulmonary Bypass: A Randomized Clinical Trial - PubMed

Dexmedetomidine may be considered as a way to reduce the incidence and severity of postoperative AKI in patients undergoing cardiac valve surgery under cardiopulmonary bypass.

pubmed.ncbi.nlm.nih.gov

 

[Bertelman]

There's some laboratory and clinical evidence that precedex is not only cardioprotective but also renal-protective. I run it routinely after induction and continue it in the ICU +- propofol if they actually need a real sedative.

Effect of Dexmedetomidine on Postoperative Renal Function in Patients Undergoing Cardiac Valve Surgery Under Cardiopulmonary Bypass: A Randomized Clinical Trial - PubMed

Dexmedetomidine may be considered as a way to reduce the incidence and severity of postoperative AKI in patients undergoing cardiac valve surgery under cardiopulmonary bypass.

pubmed.ncbi.nlm.nih.gov

Glad to hear it. Now maybe we can stop our dopamine protocol.

 

[Beeftenderloin]

Aside from the fact the vigileo/flotrac is complete and utter made up garbage data wtf is it for when you have a CCO?

SVR 🤷‍♂️

 

[medicine2wallstreet]

SVR 🤷‍♂️

Some people like meaningless CO numbers in the OR. In my opinion oximetric and CCO numbers stuff is an ICU thing. Things in the OR are way too fast and dynamic to rely those things. TEE, a line, ECG, and an open chest are plenty sufficient to evaluate if it's an SVR, contractility, or volume issue.

 

[Beeftenderloin]

Some people like meaningless CO numbers in the OR. In my opinion oximetric and CCO numbers stuff is an ICU thing. Things in the OR are way too fast and dynamic to rely those things. TEE, a line, ECG, and an open chest are plenty sufficient to evaluate if it's an SVR, contractility, or volume issue.

Yes... The whole point of my original comment was pointing out how redundant, unnecessary and wasteful our cardiac set-up is. The SVR comment was made in jest.

 

[PpfSuxTube]

Some people like meaningless CO numbers in the OR. In my opinion oximetric and CCO numbers stuff is an ICU thing. Things in the OR are way too fast and dynamic to rely those things. TEE, a line, ECG, and an open chest are plenty sufficient to evaluate if it's an SVR, contractility, or volume issue.

Yeah we cover the cvicu not the surgeons, and I like the swan only for the icu.
Intraop it's only useful for things like severe RV dysfunction which is even still better assessed by tee...

In the cvicu it allows me to quickly run thru the 16 odd patients and see who I'm worried about, who needs a tee and who can be deemed as doing well... no other tool allows this, and the nurses are decent at trending this...

One off values, in rapidly moving situations are relatively useless, I totally agree but on average swan is useful probably best in icu..

I can't drop a tee on 12 to 16 post ops daily. Tte is useless

 

[YadaYadaNext]

I have a love/hate, mostly hate, relationship with Precedex.

Practically the only time I use it now is for sedation in cardiac patients taken to the ICU. I typically start it when rewarming. Maybe post cardiac patients have fewer tachydysrhythmmias when they get it, though I think the data is only good there for pediatric hearts.

I used to use Precedex for TAVRs, because that's what I saw done when I first started. I finally quit using it there and now just infuse propofol for TAVRs. I'll never go back. Precedex sucks, sucks, sucks for any kind of procedural sedation.

And don't get me started on the CRNA habit of giving everybody bits and boluses of it during every case they do.

Next to midazolam it's the most overused drug we've got.

Wondering… when you say Precedex sucks for procedural sedation- are you bolusing? Or simply starting an infusion?

 

[Drwine]

We run Precedex basically from induction to weaning. By the time we leave the OR, I’d bet our pacing rate is less than 1/3, excluding MVRs.

Some of this is surgeon preference. Current crop prefers NSR. Prior guy insisted pacing at 80, just because.

The surgeon's "just because" is likely the observation that since the cardiac output is stroke volume times heart rate there will be much less playing around with drips for people obsessed with numbers like cardiac output and SVO2. Lots of ways to skin a cat but our surgeon that does this hates vasoconstrictors post CPB and in the CVICU and usually just a couple of fluid boluses kep these patients cruising.

 

[pgg]

Wondering… when you say Precedex sucks for procedural sedation- are you bolusing? Or simply starting an infusion?

Loading dose (over 10 or so minutes) of about 1 per kg, then an infusion.

It just ... doesn't sedate people well, and offers no analgesia or anxiolysis. It demands polypharmacy and competent/generous local administration from the surgeon. Might as well be infusing tap water.

I've been trying it in different recipes for 10+ years now and always go back to propofol. It's a neat drug, in theory, cool mechanism, nice lack of respiratory depression, but it just turns out to be completely superfluous if you're doing something the least bit painful or anxiety provoking.

 

[Bertelman]

The surgeon's "just because" is likely the observation that since the cardiac output is stroke volume times heart rate there will be much less playing around with drips for people obsessed with numbers like cardiac output and SVO2. Lots of ways to skin a cat but our surgeon that does this hates vasoconstrictors post CPB and in the CVICU and usually just a couple of fluid boluses kep these patients cruising.

I understand that CO=HRxSV. We have a swan that measures CO. I don't recall seeing a significant improvement, really ever, in the bump in HR that he orders. I didn't notice any significant difference in starting drips on his patients vs the other surgeon that preferred NSR at a reasonable rate over pacing. From my recollection, I think he would prefer V pacing at 80 over SR at 68.

This is the same surgeon that wants more protamine "just because". Always orders 4 FFP, 2 platelet, 2 fibrin on a dissection "just because" and gives it "just because". Famously quoted for saying "We do it the same way, every time. Unless we don't". But yeah, he would always quote me the HRxSV as justification.

 

[DesiredMemberName?]

The surgeon's "just because" is likely the observation that since the cardiac output is stroke volume times heart rate there will be much less playing around with drips for people obsessed with numbers like cardiac output and SVO2. Lots of ways to skin a cat but our surgeon that does this hates vasoconstrictors post CPB and in the CVICU and usually just a couple of fluid boluses kep these patients cruising.

Increasing HR doesn’t necessarily increase CO unless the SV is constant. This isn’t always the case when the HR increases as there is less time for ventricular filling, not to mention loss of atrial contribution and ****ty coordination of contraction if you’re V-pacing.

Also, are you really treating vasoplegia with fluid boluses? CI is 4, SVR 500, MAP is 50… give more fluid?

 

[Drwine]

Increasing HR doesn’t necessarily increase CO unless the SV is constant. This isn’t always the case when the HR increases as there is less time for ventricular filling, not to mention loss of atrial contribution and ****ty coordination of contraction if you’re V-pacing.

Also, are you really treating vasoplegia with fluid boluses? CI is 4, SVR 500, MAP is 50… give more fluid?

No way. SVR 500 and MAP 50 calls for a vasoconstrictor such as norepinephrine.

 

[Biochemist21]

I have a love/hate, mostly hate, relationship with Precedex.

I used to use Precedex for TAVRs, because that's what I saw done when I first started. I finally quit using it there and now just infuse propofol for TAVRs. I'll never go back. Precedex sucks, sucks, sucks for any kind of procedural sedation.

Loading dose (over 10 or so minutes) of about 1 per kg, then an infusion.

It just ... doesn't sedate people well, and offers no analgesia or anxiolysis. It demands polypharmacy and competent/generous local administration from the surgeon. Might as well be infusing tap water.

I've been trying it in different recipes for 10+ years now and always go back to propofol. It's a neat drug, in theory, cool mechanism, nice lack of respiratory depression, but it just turns out to be completely superfluous if you're doing something the least bit painful or anxiety provoking.

I think these discussions are fascinating and I love hearing what other people are doing. Your feelings are definitely mirrored by some of my colleagues who prefer Propofol + Remi for TAVRs.

My personal practice is Precedex + Remi. To overcome the slow-onset issues with Dex I usually just start it at 1mcg/kg/hr as soon as I get in the OR, then have a syringe to bolus 20-40mcg over 10min (just easier than trying to program our c***** pumps to give a loading dose). Remi at 0.03-0.05. Midaz 0-2mg. If they're really wiggly maybe bolus 20-30mg Prop when they're putting in the local for their sheaths. I keep the Dex at 1 until fully deployed and happy with the TTE, then cut it to 0.7 until sheaths out, then off. Remi off a few minutes before drapes coming down. Everyone is sleepy but responsive rolling to the PACU. Cardiologists are happy because people aren't trying to leg bend their way into a hematoma.

I found this works quite well, particularly as our patient population skews on the fluffy side and this makes hypoventilation is rarely an issue. I'll admit that my institution's patient throughout isn't the fastest which works in my favor. If I had faster turnovers and cardiologists that actually showed up to the OR on time I'd probably go back to Prop + Remi.

 

[Radetzky]

Increasing HR doesn’t necessarily increase CO unless the SV is constant. This isn’t always the case when the HR increases as there is less time for ventricular filling, not to mention loss of atrial contribution and ****ty coordination of contraction if you’re V-pacing.

Also, are you really treating vasoplegia with fluid boluses? CI is 4, SVR 500, MAP is 50… give more fluid?

Except (assuming sinus rhythm) SV drops less than HR increases until you reach rates of 140-150 in most patients, less for severe obstructive valves

 

[DesiredMemberName?]

Except (assuming sinus rhythm) SV drops less than HR increases until you reach rates of 140-150 in most patients, less for severe obstructive valves

That’s probably generally right.

I probably should have said something like, “even though CO=HRxSV, pacing at increased HR will not result in a linear increase in CO because of reductions in SV with reduced ventricular filling.”

My point is that the situation is more nuanced than the simplicity of CO=HRxSV may imply, especially when pacing post-CPB patients with diastolic dysfunction.

 

[Iso4ane]

That’s probably generally right.

I probably should have said something like, “even though CO=HRxSV, pacing at increased HR will not result in a linear increase in CO because of reductions in SV with reduced ventricular filling.”

My point is that the situation is more nuanced than the simplicity of CO=HRxSV may imply, especially when pacing post-CPB patients with diastolic dysfunction.

The A-wave on TEE is essentially your atrial kick contribution, so depending on the size of that pre bypass, can determine whether pacing or sinus is better. Also, I like to think of CO=HR*xSV, where * is inotropic/contractility manipulation.

 

[C4RD!@C_ANES86]

I usually do around 200-250 mcgs fentanyl for induction, but then with the bilateral transversus thoracic plane blocks immediately following induction, I tend to not have to give any more the rest of the case. Has served me well on standard pump run CABGs and valves thus far. POD zero into POD1 sees very minimal ICU narcotic administration as the blocks tend to do their job.

 

[PpfSuxTube]

I usually do around 200-250 mcgs fentanyl for induction, but then with the bilateral transversus thoracic plane blocks immediately following induction, I tend to not have to give any more the rest of the case. Has served me well on standard pump run CABGs and valves thus far. POD zero into POD1 sees very minimal ICU narcotic administration as the blocks tend to do their job.

Any data on this block?

We've been doing a parasternal intercostal block at end of the case. Results aren't amazing

 

[castafari]

I typically give about 10mcg/kg of fentanyl for a heart. Usually about half near the start of the case and the other half dripping in slowly. My typical doses are 1000mcg fentanyl and 5-10mg midazolam. I’ll decrease the midazolam doses over age 80.
No issues getting patients extubated in 4-6 hours at these doses.

 

[drmwvr]

For folks that give more than 2-4 versed, are you infusing sedation as well? There is a culture in some places of giving 2-3 anesthetics per case (over doses of fentanyl and versed + volatile agent + propofol +/- precedex, the main objective being amnesia apparently...

 

[PpfSuxTube]

For folks that give more than 2-4 versed, are you infusing sedation as well? There is a culture in some places of giving 2-3 anesthetics per case (over doses of fentanyl and versed + volatile agent + propofol +/- precedex, the main objective being amnesia apparently...

That's a pretty judgey tone there