PACU hypotension and acute AV graft failure

[GassYous]

Infra harder than supra clav??? Lol, more like hardly. I like performing the block, spares phrenic and it’s just so satisfying seeing all three cords bathed in local! I personally think it’s a safer block.

I trained with one of the guys who invented the us guided infra block and I still think it's a pita. No problems with phrenic in any supraclav I've done so far. I love hitting the corner pocket.

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[ProwlerturnGas]

I trained with one of the guys who invented the us guided infra block and I still think it's a pita. No problems with phrenic in any supraclav I've done so far. I love hitting the corner pocket.

Maybe I am just good at it, and you aren’t?? I don’t know what to tell ya.

 

[vector2]

It's not about pain but bucking. A lot of my thyroids are fat anxious ladies who buck on incision or even head movement. Surgeons hate that. So I just load em up with opioids.

I just run them at ~1.5 mac and start a neo drip.

 

[GassYous]

Maybe I am just good at it, and you aren’t?? I don’t know what to tell ya.

Probably. I suck at it cause I never do em. Never missed it. Supraclav is the spinal of the arm

I just run them at ~1.5 mac and start a neo drip.

Man I rarely go above 0.6 mac + prop maybe that's why. I like adding nitrous for most nerve monitoring case to keep em deep but they definitely get more ponv

 

[deleted162650]

I trained with one of the guys who invented the us guided infra block

Nav or the other guy?

 

[mimelim]

I do ~8-12 fistula/graft creations/insertions per week and about 20 access related procedures/surgeries a week total (also trained under one of the biggest access gurus in the US...) So, I think I can comment on this from a surgical side a little bit.

#1 Until proven otherwise, a new access failing in PACU is technical error. If a thrombectomy is performed, a fistulagram is performed and no technical problems can be found, THEN we can have a discussion about what else might have happened. By far the most common cause of early access failure and it is not close.

#2 Hypotension causes accesses to go down. It happens all the time. HeRO grafts in particular (because of their length and lack of compliance) go down routinely if SBP drops below 100mmHg. This mostly happens in the dialysis unit when the patient is super dry, but happens when patients get admitted to the hospital as well for other reasons or peri-op. Rarer, but definitely happens with a traditional PTFE grafts as well and almost unheard of with an AVF. I had a patient come in in afib w/ RVR with relative hypotension and thrombosed off their AVG. Declotted and it was pristine. I have had one access go down in PACU on me that I strongly suspect was hypotension related. It was a HeRO and when I thrombectomized it, I couldn't find anything technically wrong with it. But, I don't think I even talked to anesthesia about it afterwards. I got the clot out and then went back to my other cases...

Regarding the blocks... I have done creations under local/versed, but an insertion I think is asking for trouble. I have gone to doing virtually everything under a regional block of some kind. Patients tend to tolerate things better and tend to use less narcotics post-op, but that is my anecdotal experience.

 

[coffeebythelake]

I do ~8-12 fistula/graft creations/insertions per week and about 20 access related procedures/surgeries a week total (also trained under one of the biggest access gurus in the US...) So, I think I can comment on this from a surgical side a little bit.

#1 Until proven otherwise, a new access failing in PACU is technical error. If a thrombectomy is performed, a fistulagram is performed and no technical problems can be found, THEN we can have a discussion about what else might have happened. By far the most common cause of early access failure and it is not close.

#2 Hypotension causes accesses to go down. It happens all the time. HeRO grafts in particular (because of their length and lack of compliance) go down routinely if SBP drops below 100mmHg. This mostly happens in the dialysis unit when the patient is super dry, but happens when patients get admitted to the hospital as well for other reasons or peri-op. Rarer, but definitely happens with a traditional PTFE grafts as well and almost unheard of with an AVF. I had a patient come in in afib w/ RVR with relative hypotension and thrombosed off their AVG. Declotted and it was pristine. I have had one access go down in PACU on me that I strongly suspect was hypotension related. It was a HeRO and when I thrombectomized it, I couldn't find anything technically wrong with it. But, I don't think I even talked to anesthesia about it afterwards. I got the clot out and then went back to my other cases...

Regarding the blocks... I have done creations under local/versed, but an insertion I think is asking for trouble. I have gone to doing virtually everything under a regional block of some kind. Patients tend to tolerate things better and tend to use less narcotics post-op, but that is my anecdotal experience.

For ESRD pt who are borderline hypotensive from the get go, what would you do? Does that play into any surgical decision making?

 

[Shimmy8]

Already been discussed, but anecdotally in my practice lots of these folks who are borderline hypotensive in PACU are on midodrine and didn’t take their morning dose.

Neo drip for a bit and they’re fine couple hours later.

 

[robellis]

Tbh I think this is just surgeon blaming anesthesia whenever there is a complication. For your reference:

View attachment 339726

This is so hilarious!! LOL

 

[IlDestriero]

This is so hilarious!! LOL

The problem is that it is not a joke.
Patient bleeds after surgery. “He was bucking on emergence.”
6 hour prone case goes 12, has some positioning injury/abrasion. “Anesthesia is in charge of positioning.”
Plastics removes my paper eye tape placed during induction, then places and removes eye cup shields, patient gets a corneal abrasion. “I don’t know anything about that, anesthesia manages eye protection. I do recall that they eyes were untaped at the end of the case.” Implying we forgot to protect the eyes in the craniofacial case.
Real stories, Real dinguses.

 

[mimelim]

For ESRD pt who are borderline hypotensive from the get go, what would you do? Does that play into any surgical decision making?

I try not to put HeRO grafts into people that have trouble keeping their pressures up. Merit, the company that makes the device specifically tells you not to use in patients that need Midodrine. I already push PD catheters pretty hard, but I would be much more pushy in those patients. I would still put a normal PTFE graft in though, we just lose too many options otherwise.

 

[coffeebythelake]

The problem is that it is not a joke.
Patient bleeds after surgery. “He was bucking on emergence.”
6 hour prone case goes 12, has some positioning injury/abrasion. “Anesthesia is in charge of positioning.”
Plastics removes my paper eye tape placed during induction, then places and removes eye cup shields, patient gets a corneal abrasion. “I don’t know anything about that, anesthesia manages eye protection. I do recall that they eyes were untaped at the end of the case.” Implying we forgot to protect the eyes in the craniofacial case.
Real stories, Real dinguses.

We all have stories like this. Ridiculous things. Really unprofessional things.

One patient said he needed ICU postop because of hypotension due to the anesthesia, when it was because the surgeon decided to do a 2L impromptu bloodletting.

 

[dhb]

I still think it's a pita

I suppose it depends on your patient population, in thick patients is not great but for normal bmi's it's easy/fast/convenient for wrist fractures

 

[ProwlerturnGas]

Just did one this morning. 4 minutes prep to done.

 

[FiO2@21]

For the people who block for these, which local do you use?

Ropi was used for another patient. They developed steal syndrome. Duration of the block and associated vasodilation is being blamed for a delay in diagnosis.

Ignoring the above, I do wonder if extended post op pain relief is actually needed for these cases. Maybe the patients would prefer getting use of their arm sooner.

 

[patriot6]

For the people who block for these, which local do you use?

Ropi was used for another patient. They developed steal syndrome. Duration of the block and associated vasodilation is being blamed for a delay in diagnosis.

Ignoring the above, I do wonder if extended post op pain relief is actually needed for these cases. Maybe the patients would prefer getting use of their arm sooner.

Low pain scores -- no need for a block with the intention of providing post-op analgesia imo.

I use 0.5% ropi + 2% lido -- our surgeons are quick. I'm only blocking the ones I think won't survive gen/LMA.

 

[FiO2@21]

Low pain scores -- no need for a block with the intention of providing post-op analgesia imo.

I use 0.5% ropi + 2% lido -- our surgeons are quick. I'm only blocking the ones I think won't survive gen/LMA.

Do you find the duration of your block is someplace midway lido and ropi when you combine them?

 

[epidural man]

Oh atipamezole, where are you? When will you be on a shelf for human use?

 

[epidural man]

Block, low dose prop infusion if needed.

why anyone chooses anything but propofol for sedation is beyond me. Fast one and off, predictable, effects are almost always off before leaving the Or and patient is back to their crappy hypertensive everyday life in PACU.

Because sedation with propofol doesn't exist. They are usually out, or not sedated, or trying to get off the bed because they won't follow commands and they have no idea where they are.

People on lots of opioids will follow commands, and not move. Alfenta is really a great sedation drug. Tell them to take a breath once they stop breathing, they open their eyes, take a deep breath, and then chill out.

 

[epidural man]

As I’m starting my CA-3 year I’m trying to tighten things up and develop “complaint-proof” anesthetics.

Good luck!

When you do, please let us know exactly what it is.

 

[GassYous]

Because sedation with propofol doesn't exist. They are usually out, or not sedated, or trying to get off the bed because they won't follow commands and they have no idea where they are.

People on lots of opioids will follow commands, and not move. Alfenta is really a great sedation drug. Tell them to take a breath once they stop breathing, they open their eyes, take a deep breath, and then chill out.

You just aren't using enough propofol.

 

[fakin' the funk]

Because sedation with propofol doesn't exist. They are usually out, or not sedated, or trying to get off the bed because they won't follow commands and they have no idea where they are.

People on lots of opioids will follow commands, and not move. Alfenta is really a great sedation drug. Tell them to take a breath once they stop breathing, they open their eyes, take a deep breath, and then chill out.

Propofol sedation tends to be an "on/off" phenomenon. Either awakeish and disinhibited or totally asleep. You think that's a bug, but it's a feature.

Precedex for light-moderate sedation that is more gradated.

 

[vector2]

Propofol sedation tends to be an "on/off" phenomenon. Either awakeish and disinhibited or totally asleep. You think that's a bug, but it's a feature.

Precedex for light-moderate sedation that is more gradated.

I maintain that 20-50 mcg/kg/min of propofol is the most dangerous place in anesthesia. I either run my prop drips as an unprotected airway general or if the pt is sick enough from a cardiopulmonary or OSA standpoint I skip it all together and use precedex and/or a little versed/fent/ketamine.

 

[epidural man]

Propofol sedation tends to be an "on/off" phenomenon. Either awakeish and disinhibited or totally asleep. You think that's a bug, but it's a feature.

Precedex for light-moderate sedation that is more gradated.

It’s a feature if that is what you want.
If you want actual sedation,ie… a relaxed, fall asleep easily, but responsive to commands patient, it is a bug.
By providing our surgeons with propofol sedation, they think sedation means not moving and little local is needed. We have screwed ourselves.

MAC should mean “I don’t need you. I could do this in the office, but I’d love a little anxiolysis and some analgesia to maximize me not having to talk to the patient during the case.”

 

[GassYous]

It’s a feature if that is what you want.
If you want actual sedation,ie… a relaxed, fall asleep easily, but responsive to commands patient, it is a bug.
By providing our surgeons with propofol sedation, they think sedation means not moving and little local is needed. We have screwed ourselves.

MAC should mean “I don’t need you. I could do this in the office, but I’d love a little anxiolysis and some analgesia to maximize me not having to talk to the patient during the case.”

It does. That's a versed/fent prop gtt maybe ketamine anesthetic