What is dexmedetomidine?
Update: April 2023
Resources:
Perioperative Dexmedetomidine Improves Outcomes of Cardiac Surgery. Circulation. 2013;127:1576–1584.
Dexmedetomidine
Tag: sedation
Anesthesia and Breastfeeding
I get a lot of questions from my friends about receiving anesthesia while breastfeeding. As more moms are breastfeeding, I think it’s an important question to tackle for the baby’s safety. I’ve included references and summarized key points below. If you have any questions, please do not hesitate to ask your anesthesiologist or physician who will be taking care of you.
KellyMom: breastfeeding and surgery resources
Key Points:
- Intrathecal and epidural anesthesia and opioids are ok for breastfeeding mothers.
- Acetaminophen, ibuprofen, and ketorolac are ok because they have relatively short half-lives.
- Celecoxib: ok.
- Naproxen: ok.
- Propofol is ok. Proceed with breastfeeding when mom is awake after anesthesia.
- Midazolam (sedation dose) is ok. Proceed with breastfeeding when mom is awake after anesthesia.
- Fentanyl is short-acting enough. Proceed with breastfeeding when mom is awake after anesthesia.
- Avoid meperidine in the post-operative unit – its metabolites have long half-lives.
- Hydromorphone has a long half-life (10hours). Best to avoid this medication or pump and dump.
- Morphine: low dose is ok. Caution if using morphine PCA.
- Hydrocodone: dosage should be <30mg/day in breastfeeding moms.
- Oxycodone: dosage should be <30mg/day in breastfeeding moms or not used at all.
- Tramadol: ok. But FDA not recommend for breastfeeding moms (USA).
Things to Consider
- Try to have your case booked as early in the morning to decrease the amount of time for fasting.
- Pump a stash of breast milk ahead of surgery for 1 day of feeds just in case. You can always use this expressed milk later.
- Breastfeed or express milk just before the start of the procedure.
- Have an adult supervise you post-operatively as well as the baby in case there are signs of medication transferred to the baby.
- Consider anesthetic techniques (local anesthesia, regional anesthesia, non-narcotics, etc.) to minimize opioid consumption.
TAVR Team: conscious sedation vs. general anesthesia
Today, we had a guest speaker Christian Spies from Queen’s Hospital in Hawaii who spoke on his experience with his TAVR team and conscious sedation vs. general anesthesia for these patients. More specifically, we are speaking of the transfemoral route.
Keypoints:
- Patient selection is key (consider for COPD; bad for OSA)
- Short surgical time for monitored anesthesia care (MAC)
- Decrease invasive monitoring (no PA catheter,+/-CVP)
- No difference in hospital LOS or 1 year mortality rate
- Move from TEE to TTE if MAC
- Be prepared to convert MAC to GA (can be difficult in already tenuous patient in a crowded space under the drapes)
- MAC agents: dexmetetomidine, propofol, ofirimev
- Decrease pressor use
- Develop an algorithm for MAC vs. GA and patient selection
For my own lit search:
- Anaesthesia Nov 2011: Sedation vs general anaesthesia for the ‘high-risk’ patient – what can TAVI teach us?
- JACC May 2012: The Minimalist Approach for Transcatheter Aortic Valve Replacement in High-Risk Patients
- Cardiac Interventions Today May 2012: Rouen Experience Supports Safety of TAVR Using Local Anesthesia
- MedPage Today July 2012: TAVI: No Need for Patients to ‘Go Under’
- Amer J Card Jan 2013: Effect of Local Anesthetic Management With Conscious Sedation in Patients Undergoing Transcatheter Aortic Valve Implantation
- SCA 2013: PBL — Anesthesia for TAVR
- Indian Heart J March 2014: Transcatheter aortic valve implantation under conscious sedation – the first Indian experience
- TCTMD Mar 2015:As TAVR Evolves, Local Anesthesia Could Be an Option for Lower-Risk Patients
What is the “Best” Anesthetic for Oocyte Retrieval
Pain Relief for Women Undergoing Oocyte Retrieval for Assisted Reproduction (review)
Published: January 2013
In: The Cochrane Collaboration
From: EPPI-Centre, University of London
Authors: Kwan I, Bhattacharya S, Knox F, McNeil A.
Review:
In investigating if spinal anesthesia might be the best anesthetic and analgesic approach for oocyte retrieval, I found a recent and complete review on anesthesia and oocyte retrieval. The main result of this review was that use of more than one pain relief modality improved patient comfort. My informal on-line survey of patient information provided for patients by fertility clinics suggests propofol infusion as procedural sedation/general anesthesia is likely the most common method employed for oocyte retrieval in the US.
Original Abstract:
BACKGROUND:
Various methods of conscious sedation and analgesia have been used for pain relief during oocyte recovery in in vitro fertilisation (IVF) and intra-cytoplasmic sperm injection (ICSI) procedures. The choice of agent has also…
View original post 584 more words
Don’t Dismantle the TAVR Heart Team
More and more in our daily lives, we see a push to make things more cost-effective. There are legitimate ways to cut costs, however, I really have trouble seeing any huge gains earned by the hospital when you eliminate anesthesiologists and/or surgeons. People need to look at risk assessment in these cases. What if an already sick patient decompensates during the procedure? Is the cost-effective strategy of eliminating caregivers really the best way to save money? It seems to me that liability would be a greater risk without having a surgeon for a crash sternotomy or an anesthesiologist to manage the airway and physiology.
TAVR Team: conscious sedation vs. general anesthesia
Today, we had a guest speaker Christian Spies from Queen’s Hospital in Hawaii who spoke on his experience with his TAVR team and conscious sedation vs. general anesthesia for these patients. More specifically, we are speaking of the transfemoral route.
Keypoints:
- Patient selection is key (consider for COPD; bad for OSA)
- Short surgical time for monitored anesthesia care (MAC)
- Decrease invasive monitoring (no PA catheter,+/-CVP)
- No difference in hospital LOS or 1 year mortality rate
- Move from TEE to TTE if MAC
- Be prepared to convert MAC to GA (can be difficult in already tenuous patient in a crowded space under the drapes)
- MAC agents: dexmetetomidine, propofol, ofirimev
- Decrease pressor use
- Develop an algorithm for MAC vs. GA and patient selection
For my own lit search:
- Anaesthesia Nov 2011: Sedation vs general anaesthesia for the ‘high-risk’ patient – what can TAVI teach us?
- JACC May 2012: The Minimalist Approach for Transcatheter Aortic Valve Replacement in High-Risk Patients
- Cardiac Interventions Today May 2012: Rouen Experience Supports Safety of TAVR Using Local Anesthesia
- MedPage Today July 2012: TAVI: No Need for Patients to ‘Go Under’
- Amer J Card Jan 2013: Effect of Local Anesthetic Management With Conscious Sedation in Patients Undergoing Transcatheter Aortic Valve Implantation
- SCA 2013: PBL — Anesthesia for TAVR
- Indian Heart J March 2014: Transcatheter aortic valve implantation under conscious sedation – the first Indian experience
- TCTMD Mar 2015:As TAVR Evolves, Local Anesthesia Could Be an Option for Lower-Risk Patients
***Update May 1, 2018***
We at Scripps Memorial Hospital in La Jolla do most of our transfemoral TAVRs via conscious sedation assuming appropriate patient selection. These patients still tend to be the inoperable patients not cleared for open heart AVR (aortic valve replacement). My techniques and choices for setup have changed over time as I’ve had a chance to fine-tune my plan based on prior experiences with TAVR. Patients typically come to the hybrid room with a 20g PIV placed by the pre-op RN.
My Setup:
- 4 channel Alaris pump:
- dexmedetomidine @ 0.7 mcg/kg/hr until incision –> 0.4 mcg/kg/hr until valve deployment –> off
- norepinephrine @ 2 mcg/min (titrating on/off, up/down as vitals suggest)
- Isolyte (IV carrier fluid) @ 200ml/hr until valve deployment –> 50ml/hr
- Cordis neck line
- Initially, I would have the interventional cardiologist setup a femoral venous line since they’re getting access to the groin. However, the cardiologist would use that femoral line for emergent ECMO cannulation and I would lose my venous access and have to depend on a measly 20g PIV. Nowadays, I try for a short 14g or 16g PIV. If I can’t get one, the patient gets an awake right IJ cordis for large venous access.
- Hot line fluid warmer with blood-Y tubing: this is for hookup to a large PIV or cordis line
- Right radial arterial line
- I started only placing right radial arterial lines because there was a case of a dissection and I immediately lost my left radial arterial line and couldn’t do pressure monitoring. I insist on only using the RIGHT radial for my arterial monitoring. Do not let the cardiologist only give you arterial monitoring based on their femoral arterial access. It will only give you intermittent monitoring and there are critical points leading up to the deployment where you need CONTINUOUS arterial monitoring. Therefore, I’ve found the right RADIAL arterial line best for continuous monitoring.
- Facemask for continuous oxygen at 10L/mim with ETCO2 monitoring
- For trans-subclavian/axillary approach vs. transfemoral approach TAVR, I’ll put in a supraclavicular block right after Cordis/large-bore PIV venous access for patient comfort while still utilizing conscious sedation/MAC.
My Technique:
- When the patient gets to the room, transfer patient to OR table. Start IV fluids @ 200ml/hr. Cases that go well are about 2 hours from start to end.
- Facemask O2 at 10L/min.
- Start sedation: precedex/dexmedetomidine @ 0.7 mcg/kg/hr. Some patients may receive 1-2mg midazolam x 1 and 25-50mcg fentanyl for radial art line placement.
- Place right radial art line with lidocaine for skin numbing. Place PIV with lidocaine. If unable to get access for PIV, prep neck –> sterile gown/glove/drapes for U/S guided Cordis placement with lidocaine.
- OR staff preps patient. Antibiotics prior to incision.
- At incision –> precedex to 0.4 mcg/kg/hr. 25-50mcg fentanyl PRN discomfort. 10-20mg propofol push for discomfort if needed while large sheath placed for valve deployment.
- Crossing valve –> BP changes. Manage with volume or levophed.
- Valvuloplasty
- Don’t treat over-drive pacing too aggressively when the valve is deployed. Typically, once the new valve is in, a little volume will help normalize the BP.
- Once valve is deployed, turn precedex off. No other sedation or BP meds needed. Change IVF rate to 50ml/hr.
- Patient heads to PACU awake, interactive, and comfortable.
What techniques do you like to do? Any suggestions on a different approach?
Sleepy Time 