Tranexamic Acid vs. Amicar

** Updated June 2022**

Over the years, our hospital has been using Amicar… until there was a drug shortage.  With that drug shortage came a different drug called tranexamic acid.  We’ve been using it for awhile and I can’t seem to tell a difference in coagulation between the two drugs.  Let’s break down each one and also discuss cost-effectiveness.


What is it?

From MedPage Today

Tranexamic Acid

What is it?

Tranexamic acid acts by reversibly blocking the lysine binding sites of plasminogen, thus preventing plasmin activation and, as a result, the lysis of polymerised fibrin.12 Tranexamic acid is frequently utilised to enhance haemostasis, particularly when fibrinolysis contributes to bleeding. In clinical practice, tranexamic acid has been used to treat menorrhagia, trauma-associated bleeding and to prevent perioperative bleeding associated with orthopaedic and cardiac surgery.13–16 Importantly, the use of tranexamic acid is not without adverse effects. Tranexamic acid has been associated with seizures,17 18 as well as concerns of possible increased thromboembolic events, including stroke which to date have not been demonstrated in randomised controlled trials.

Fibrinolysis is the mechanism of clot breakdown and involves a cascade of interactions between zymogens and enzymes that act in concert with clot formation to maintain blood flow.25 During extracorporeal circulation, such as cardiopulmonary bypass used in cardiac surgery, multiplex changes in haemostasis arise that include accelerated thrombin generation, platelet dysfunction and enhanced fibrinolysis.26 Tranexamic acid inhibits fibrinolysis, a putative mechanism of bleeding after cardiopulmonary bypass, by forming a reversible complex with plasminogen.


  • Ortho/Spine
  • OB
  • Trauma

Currently at our hospital (June 2022):


How supplied from PharmacyTXA 1000mg/10mL vials Will not provide premade bags like with Amicar; Amicar is a more complex mixture than TXA Will take feedback on this after go-live and reassess
Where it will be supplied from PharmacyPOR-SUR1 Omnicell (in HeartCore Room)   Perfusion Tray (will replace aminocaproic acid vials 6/7)  
Recommended Dosing (see below for evidence)~20 mg/kg total dose Can give as: 20 mg/kg x 1, OR 10 mg/kg x 1, followed by 1-2 mg/kg/h*   Perfusion may also prime bypass solution with 2 mg/kg x 1*
Preparation & AdministrationIV push straight drug (1000mg/10mL) from vial   AND/OR   Mix vial of 1000mg/10mL TXA with 250mL NS for continuous infusion*

TXA & Amicar ADRs

  • Seizure risk may be increased also by duration of prolonged open-chamber surgery based on findings from Zuffery, et al. Anesthesiology 2021.
  • Per OR pharmacist at Scripps Mercy, they have not seen an increased incidence of seizures in their patient-population (anecdotally)


There are a number of dosing strategies in the literature. What I recommend for maximal safety and efficacy is taken from Zuffery, et al. Anesthesiology 2021 meta-analysis and is practiced at Scripps Mercy.

  • ~ 20 mg/kg total dose recommended in this meta-analysis.
  • Two dosing strategies they report that were as effective as high-dose but with lower seizure risk than high dose:

Tricuspid Clip

Updated: August 2021

Echocardiographic Imaging for Transcatheter Tricuspid Edge‐to‐Edge Repair. Journal of the American Heart Association. 2020;9:e015682.

State of the Art Review of Echocardiographic Imaging in the Evaluation and Treatment of Functional Tricuspid Regurgitation. Circ Cardiovasc Imaging.2016;9:e005332.

Screening TEE for Transcatheter Tricuspid Valve Repair. Cardiac Interventions Today. May/June 2020.

Echocardiography for Tricuspid Valve Intervention. Cardiac Interventions Today. July/August 2018.

Tricuspid Clip in Tricuspid Regurgitation. Amer Coll of Card, Feb 2020.

Percutaneous management of tricuspid regurgitation. Image-guided step-by-step MitraClip procedure. REC Interv Cardiol. 2020;2:118-128.

Intraprocedural Imaging of Transcatheter Tricuspid Valve Interventions. JACC: Cardiovascular Imaging,Volume 12, Issue 3, March 2019, Pages 532-553.

Transcatheter Tricuspid Valve Intervention: Coaptation Devices. Front. Cardiovasc. Med., 13 August 2020.


From US Cardiology Review

Aprepitant (Emend)

Prevention and Treatment of Postoperative Nausea and Vomiting (PONV): A Review of Current Recommendations and Emerging Therapies. Ther Clin Risk Manag. 2020; 16: 1305–1317.

Patient risk factors (including female gender, non-smoker, history of PONV, or motion sickness) could be quantified using risk scores such as the Apfel score and the Koivuranta score, while surgical procedures such as laparotomy and cholecystectomy confer additional PONV risk. Other perioperative risk factors of PONV includes the length of surgery, the use of volatile anesthesia, including nitrous oxide, as well as perioperative opioid administration. Perioperative risk reduction interventions include multimodal, opioid sparing anesthesia, avoidance of volatile anesthetic, as well as nitrous oxide exposure. Gan et al2 have extensively reviewed various options for PONV prophylaxis and rescue treatment, which includes pharmacological and non-pharmacological interventions. The authors acknowledged that currently the biggest challenge in PONV management is often low compliance to the guidelines.

Fig 1. Summary of the expert consensus guidelines on postoperative nausea and vomiting (PONV) management.

Palonosetron monotherapy for PONV prophylaxis is more effective than other 5-HT3 antagonists, including ondansetron, granisetron, ramosetron; it is also more effective than dexamethasone. Palonosetron has comparable efficacy to aprepitant.

Aprepitant is a competitive Neurokinin (NK)-1 receptor antagonist which was also initially approved for the treatment of chemotherapy-induced nausea and vomiting. It is administered orally, although an intravenous equivalent is also available, in the form of a pro-drug Fosaprepitant. It has a half-life of 9–13 hours, and it has been suggested that its duration of action may be as long as 40 hours.  Fosaprepitant is approved only for chemotherapy-induced nausea and vomiting. As a single agent prophylaxis, 40 mg aprepitant has similar efficacy as 0.075 mg palonosetron. Clinical trials and meta-analyses have reported that aprepitant is more effective in preventing PONV when compared to ondansetron. Similar to palonosetron, the aprepitant is also shown to be beneficial in ambulatory surgery due to its long duration of action and lower risk of postdischarge nausea and vomiting. Vallejo et al59 conducted a clinical trial of 150 patients with moderate-to-high risk undergoing ambulatory plastic surgery, and found that aprepitant plus ondansetron was associated with significantly lower incidence of postdischarge nausea and vomiting than ondansetron alone.

Amisulpride is a dopamine receptors antagonist. While initially licensed as an antipsychotic, in February 2020 the FDA approved its IV formulation for prophylactic and rescue therapy of PONV. The anti-emetic dose for prophylaxis is 5 mg IV, 10 mg IV for rescue treatment, whereas its antipsychotic dose is 50–1,200 mg/day orally.

Comparing the efficacy of aprepitant and ondansetron for the prevention of postoperative nausea and vomiting (PONV): A double blinded, randomised control trial in patients undergoing breast and thyroid surgeries. Indian J Anaesth. 2019 Apr; 63(4): 289–294.

This study found that the antiemetic efficacy of ondansetron and aprepitant was comparable in preventing PONV in patients undergoing thyroidectomy and mastectomy. We found both ondansetron and aprepitant were equally efficacious in preventing emetic episodes, reducing the incidence of nausea and delaying the time to request of a rescue antiemetic. Although not statistically significant, the aprepitant group had a higher incidence of vomiting in the 12-24 h period. However, this group took longer to develop the first episode of vomiting and also to receive the first dose of rescue antiemetic, when compared with ondansetron group. Although the ondansetron group had less vomiting after 12 h, there was a higher incidence of nausea (both being statistically insignificant). So, overall there was no statistically significant difference in the incidence of PONV in both the groups.

Single-dose aprepitant vs ondansetron for the prevention of postoperative nausea and vomiting: a randomized, double-blind Phase III trial in patients undergoing open abdominal surgery. BJA: AUGUST 01, 2007; VOLUME 99, ISSUE 2, P202-211.

BJA:Aug2007, Vol99;Issue2,P202-211. Fig4. Kaplan–Meier curves for the time to first vomiting during the 48 h after surgery.
BJA. Fig 3 Proportions of patients with no vomiting 0–24 and 0–48 h after surgery, by treatment group (modified intent-to-treat population). For each group, the error bar represents the value of the upper bound of the 95% CI for the percentage of patients achieving the endpoint. For 0–24 h, n = 293 for aprepitant 40 mg, n = 293 for aprepitant 125 mg, and n = 280 for ondansetron 4 mg. For 0–48 h, n = 292 for aprepitant 40 mg, n = 290 for aprepitant 125 mg, and n = 279 for ondansetron 4 mg.


Aprepitant at both doses was non-inferior to ondansetron for complete response 0–24 h after surgery (64% for aprepitant 40 mg, 63% for aprepitant 125 mg, and 55% for ondansetron, lower bound of 1-sided 95% CI > 0.65), superior to ondansetron for no vomiting 0–24 h after surgery (84% for aprepitant 40 mg, 86% for aprepitant 125 mg, and 71% for ondansetron; P < 0.001), and superior for no vomiting 0–48 h after surgery (82% for aprepitant, 40 mg, 85% for aprepitant, 125 mg, and 66% for ondansetron; P < 0.001). The distribution of peak nausea scores was lower in both aprepitant groups vs ondansetron (P < 0.05).


Aprepitant was non-inferior to ondansetron in achieving complete response for 24 h after surgery. Aprepitant was significantly more effective than ondansetron for preventing vomiting at 24 and 48 h after surgery, and in reducing nausea severity in the first 48 h after surgery. Aprepitant was generally well tolerated.

Neurokinin-1 Receptor Antagonists in Preventing Postoperative Nausea and Vomiting: A Systematic Review and Meta-Analysis. Medicine (Baltimore). 2015 May; 94(19): e762.

Fourteen RCTs were included. Meta-analysis found that 80 mg of aprepitant could reduce the incidences of nausea (3 RCTs with 224 patients, pooled risk ratio (RR) = 0.60, 95% confidence interval (CI) = 0.47 to 0.75), and vomiting (3 RCTs with 224 patients, pooled RR = 0.13, 95% CI = 0.04 to 0.37) compared with placebo. Neither 40 mg (3 RCTs with 1171 patients, RR = 0.47, 95% CI = 0.37 to 0.60) nor 125 mg (2 RCTs with 1058 patients, RR = 0.32, 95% CI = 0.13 to 0.78) of aprepitant showed superiority over 4 mg of ondansetron in preventing postoperative vomiting. NMA did not find a dose-dependent effect of aprepitant on preventing postoperative vomiting.

Limited data suggested that NK-1R antagonists, especially aprepitant were effective in preventing PONV compared with placebo. More large-sampled high-quality RCTs are needed.

In conclusion, our study found that NK-1R antagonists, especially aprepitant, helped preventing PONV in patients undergoing surgery with general anesthesia by decreasing the incidence of nausea and vomiting, and delaying the time to first vomiting. However, more data from high-quality RCTs and a comprehensive evaluation of related adverse events were needed before a recommendation of using NK-1R antagonists to prevent PONV could be made.

Consensus Guidelines for the Management of Postoperative Nausea and Vomiting. Anesthesia & Analgesia: January 2014 – Volume 118 – Issue 1 – p 85-113.

Postoperative nausea and vomiting (PONV) are common and distressing to patients. The general incidence of vomiting is about 30%, the incidence of nausea is about 50%, and in a subset of high-risk patients, the PONV rate can be as high as 80%. Unresolved PONV may result in prolonged postanesthesia care unit (PACU) stay and unanticipated hospital admission that result in a significant increase in overall health care costs. The goal of PONV prophylaxis is therefore to decrease the incidence of PONV and thus patient-related distress and reduce health care costs.

Figure 1: Risk score for PONV in adults. Simplified risk score from Apfel et al.9 to predict the patient’s risk for PONV. When 0, 1, 2, 3, and 4 of the risk factors are present, the corresponding risk for PONV is about 10%, 20%, 40%, 60%, and 80%, respectively. PONV = postoperative nausea and vomiting.
Figure 2
Simplified risk score for PDNV in adults. Simplified risk score from Apfel et al.19 to predict the risk for PDNV in adults. When 0, 1, 2, 3, 4, and 5 risk factors are present, the corresponding risk for PDNV is approximately 10%, 20%, 30%, 50%, 60%, and 80%, respectively. PDNV = postdischarge nausea and vomiting; PONV = postoperative nausea and vomiting; PACU = postanesthesia care unit.
Table 2: Strategies to Reduce Baseline Risk. Consensus Guidelines for the Management of Postoperative Nausea and Vomiting. Anesthesia & Analgesia118(1):85-113, January 2014.
Table 3. Antiemetic Doses and Timing for Prevention of PONV in Adults. Consensus Guidelines for the Management of Postoperative Nausea and Vomiting. Anesthesia & Analgesia118(1):85-113, January 2014.
Figure 4. Algorithm for management of postoperative nausea and vomiting. PONV = postoperative nausea and vomiting. Consensus Guidelines for the Management of Postoperative Nausea and Vomiting
Anesthesia & Analgesia118(1):85-113, January 2014.
Table 4. Pharmacologic Combination Therapy for Adults and Children. Consensus Guidelines for the Management of Postoperative Nausea and Vomiting. Anesthesia & Analgesia118(1):85-113, January 2014.

Ondansetron is also as effective as dexamethasone and haloperidol 1 mg IV, with no difference in effect on the QTc interval. However, it is less effective than aprepitant for reducing emesis and palonosetron for the incidence of PONV.

Compared with palonosetron 0.075 mg, granisetron 2.5 mg is as effective at 3 hours and 3 to 24 hours but less effective at 24 to 48 hours. Palonosetron 0.075 mg is more effective than granisetron 1 mg and ondansetron 4 mg in preventing PONV.

Aprepitant was significantly more effective than ondansetron for preventing vomiting at 24 and 48 hours after surgery and in reducing nausea severity in the first 48 hours after surgery. It also has a greater antiemetic effect compared with ondansetron. When used in combination, aprepitant 40 mg per os, plus dexamethasone, is more effective than ondansetron plus dexamethasone in preventing POV in patients undergoing craniotomy. A dose-ranging study for gynecologic laparotomy patients found a 80 mg per os dose of aprepitant is the most appropriate dose and is more effective than a 40 mg dose.

Preoperative dexamethasone 8 mg enhances the postdischarge quality of recovery in addition to reducing nausea, pain, and fatigue. Dexamethasone also has dose-dependent effects on quality of recovery. At 24 hours, patients receiving dexamethasone 0.1 vs 0.05 mg/kg required less opioid and reported less nausea, sore throat, muscle pain, and difficulty falling asleep. A meta-analysis evaluating the dose-dependent analgesic effects of perioperative dexamethasone found that doses >0.1 mg/kg are an effective adjunct in multimodal strategies to reduce postoperative pain and opioid consumption.

A recent meta-analysis suggests that with prophylactic low-dose droperidol (<1 mg or 15 µg/kg IV) in adults, there is still significant antiemetic efficacy with a low risk of adverse effects.

When haloperidol 1 mg was compared with ondansetron 4 mg and placebo, there was no difference in QTc effect among the 3 groups. There was no difference in PONV incidence between haloperidol and ondansetron given before the end of surgery, but both were not significantly better than placebo at 24 hours. There was no difference in early antiemetic efficacy between haloperidol 1 mg and ondansetron 4 mg and no difference in the risk of QT prolongation. Comparing haloperidol 2 mg IV vs ondansetron 4 mg IV given before the end of surgery, there was no difference in effect on early versus late PONV or QTc prolongation. However, Meyer-Massetti et al. recently reviewed the literature and all FDA Med Watch reports of haloperidol-associated adverse events and recommended doses of haloperidol <2 mg to reduce the risk of side effects and QT prolongation. 

Meclizine 50 mg per os plus ondansetron 4 mg IV is more effective than either ondansetron or meclizine alone.

Scopolamine patch can be applied the evening before surgery or 2 to 4 hours before the start of anesthesia due to its 2- to 4-hour onset of effect. Adverse events associated with TDS are generally mild, the most common being visual disturbances, dry mouth, and dizziness.

Perphenazine is a phenothiazine derivative that has been used for the prevention of PONV at doses between 2.5 mg to 5 mg IV or IM.

Metoclopramide is a weak antiemetic and at a dose of 10 mg is not effective in reducing the incidence of nausea and vomiting. Metoclopramide in 25 and 50 mg doses had an effect similar to ondansetron 4 mg for early PONV but a smaller effect than ondansetron for late PONV. Dyskinesia or extrapyramidal symptoms were 0.6%, and 0.6%, respectively, and can increase with increasing metoclopramide doses.

Mirtazapine 30 mg per os plus dexamethasone 8 mg reduces the incidence of late PONV by >50% compared with dexamethasone 8 mg alone. Less rescue medication is needed with the combination of antiemetics.

Gabapentin doses of 600 mg per os given 2 hours before surgery effectively decreases PONV. Given 1 hours before surgery, gabapentin 800 mg per os is as effective as dexamethasone 8 mg IV, and the combination is better than either drug alone.

Midazolam 2 mg when administered 30 minutes before the end of surgery was as effective against PONV as ondansetron 4 mg.

The following strategies are not effective for PONV prophylaxis: music therapy, isopropyl alcohol inhalation, intraoperative gastric decompression, the proton pump inhibitor esomeprazole, and administration of nicotine patch 7 mg to nonsmokers. The latter modality may actually increase the incidence and severity of PONV. Although isopropyl alcohol inhalation is not effective for the prophylaxis of PONV, aromatherapy with isopropyl alcohol was effective in achieving a quicker reduction in nausea severity compared with promethazine or ondansetron when used for the treatment of PONV (Evidence A2).

A meta-analysis of 40 articles including 4858 subjects concluded that P6 stimulation with 10 different acupuncture modalities reduces nausea, vomiting, and the need for rescue antiemetics compared with sham stimulation (Evidence A1). The efficacy of P6 stimulation is similar to that of prophylactic antiemetics such as ondansetron, droperidol, metoclopramide, cyclizine, and prochlorperazine. In subgroup analysis, there was no difference in effectiveness in adults compared with children or invasive versus noninvasive modalities for P6 stimulation. The timing of transcutaneous acupoint electrical stimulation does not impact PONV, with similar reductions being achieved with stimulation initiated before or after induction of anesthesia. Neuromuscular stimulation over the median nerve also reduces the incidence of PONV in the early postoperative period, particularly when tetanic stimulation is used.

The additional costs associated with PONV in placebo patients are up to 100 times higher compared with prophylaxis with a generic antiemetic, and the cost of treating vomiting is 3 times higher than the cost of treating nausea. When using a willingness to pay rate of $100 per case avoided, PONV prophylaxis proved cost-effective in groups with a 40% risk of PONV. Lower drug acquisition costs would generally support PONV prophylaxis in patient groups at a lower risk for PONV. The decision about whether or not to use PONV prophylaxis, or to treat patients with established symptoms, not only depends on the efficacy of the drug but also on the baseline risk for PONV, adverse effects of the antiemetics, and drug acquisition costs, which will vary from 1 setting to another.

When nausea and vomiting occur postoperatively, treatment should be administered with an antiemetic from a pharmacologic class that is different from the prophylactic drug initially given, or if no prophylaxis was given, the recommended treatment is a low-dose 5-HT3 antagonist. During the first 4 postoperative hours, patients who failed PONV prophylaxis with ondansetron 4 mg did not respond either to a second administration of ondansetron 4 mg or to crossover with granisetron 0.1 or 1 mg.

The results show that mixing IV and per os antiemetics at various perioperative times decreases PDNV. For instance, 1 study found that dexamethasone 8 mg IV at induction plus ondansetron 4 mg IV at the end of surgery plus ondansetron 8 mg per os postoperatively had a greater effect on decreasing PDNV than ondansetron 4 mg IV alone at the end of surgery.

Table 7. PONV-Prevention Algorithm in All Patients Including Low-Risk Patients Plus Additional Interventions for High-Risk Patients. Consensus Guidelines for the Management of Postoperative Nausea and Vomiting. Anesthesia & Analgesia118(1):85-113, January 2014.

When developing a management strategy for each individual patient, the choice should be based on patient preference, C/E, and level of PONV risk. Among the interventions considered, a reduction in baseline risk factors and use of nonpharmacologic therapy are least likely to cause adverse events. PONV prophylaxis should be considered for patients at moderate to high risk for PONV. Depending on the level of risk, prophylaxis should be initiated with monotherapy or combination therapy using interventions that reduce baseline risk, nonpharmacologic approaches, and antiemetics. Antiemetic combinations are recommended for patients at moderate and high risk for PONV. When rescue therapy is required, the antiemetic should be chosen from a different therapeutic class than the drugs used for prophylaxis, and potentially one with a different mode of administration. If PONV occurs within 6 hours postoperatively, patients should not receive a repeat dose of the prophylactic antiemetic. An emetic episode more than 6 hours postoperatively can be treated with any of the drugs used for prophylaxis except dexamethasone, TDS, aprepitant, and palonosetron.

Category A: Supportive Literature

Randomized controlled trials report statistically significant (P < 0.01) differences between clinical interventions for a specified clinical outcome.

Level 1: The literature contains multiple randomized controlled trials, and aggregated findings are supported by meta-analysis.

Level 2: The literature contains multiple randomized controlled trials, but the number of studies is insufficient to conduct a viable meta-analysis for the purpose of these guidelines.

Level 3: The literature contains a single randomized controlled trial.

Multimodal Analgesia Pain Management

Methadone: perioperative use; acute and chronic pain


Orthopedic Surgery

Updates on Multimodal Analgesia for Orthopedic Surgery. Anesthesiol Clin. 2018 Sep;36(3):361-373.

Enhanced Recovery After Surgery (ERAS)

ERAS for general surgery

Cardiac ERAS

Non-Opioid Analgesics

Postoperative Multimodal Analgesia Pain Management With Nonopioid Analgesics and Techniques: A Review. JAMA Surg. 2017 Jul 1;152(7):691-697.

Preemptive Analgesia Decreases Pain Following Anorectal Surgery: A Prospective, Randomized, Double-Blinded, Placebo-Controlled Trial. Dis Colon Rectum. 2018 Jul;61(7):824-829.




Regional Anesthesia

TAP block

Regional for Cardiothoracic Anesthesia

PECS and serratus blocks

Thoracic blocks: ESP, PVB, TEA block

Paravertebral catheters

Regional Anesthesia catheters

Adjuncts to prolong regional anesthesia


With an opioid crisis at its peak, physicians need to be more cognizant of the various pain modalities available to patients. Gabapentinoids are one of the many non-opioid options to help with acute and chronic pain.

What are gabapentinoids?


Analgesic mechanisms of gabapentinoids and effects in experimental pain models: a narrative review. British Journal of Anaesthesia. Volume 120, Issue 6, June 2018, Pages 1315-1334.



Non-opioid IV adjuvants in the perioperative period: pharmacological and clinical aspects of ketamine and gabapentinoids. Pharmacol Res. 2012 Apr;65(4):411-29.

Systemic analgesia and co-analgesia. Acta Anaesthesiol Belg. 2006;57(2):113-20.

A comparison of gabapentin and ketamine in acute and chronic pain after hysterectomy. Anesth Analg. 2009 Nov;109(5):1645-50.

Perioperative gabapentin reduces 24 h opioid consumption and improves in-hospital rehabilitation but not post-discharge outcomes after total knee arthroplasty with peripheral nerve block. Br J Anaesth. 2014 Nov;113(5):855-64.

From BJA Anaesth 2914 Nov. Fig 2.

Post‐operative analgesic effects of paracetamol, NSAIDs , glucocorticoids, gabapentinoids and their combinations: a topical review. Acta Anaesthesiol Scand. 2014 Nov;58(10):1165-81.

What our patients are getting:

  • July 2020
    • Cardiac pre-op: Lyrica 150mg PO

Cardiac myxoma

Myxoma is the most common primary benign cardiac tumor, which could lead to some fatal complications because of its strategic position. Although any age can be affected, it predominates in the age group of 30-60 years of age with more than 75% of the affected being women. The occurrence of myxomas in left and right atrium are 75% and 20% respectively.The majority of myxomas present with systemic emboli, fever and/or weight loss, or intracardiac obstruction to blood flow.1 A ‘tumor plop’ is a sound that typically occurs during early diastole and is believed to be caused by motion of the tumor striking the wall of the endocardium. The treatment is surgical excision and key aims of anesthesia care include constant monitoring of systemic blood pressure, adequate IV fluids, and judicious use of vasoactive medications to prevent a fall in systemic vascular resistance.3


  • A-line/CVP
  • Assess patient symptomatology: SOB, chest pain, changes in pulse pressure/CVP with positioning, heart sounds
  • Adequate PIV access
  • Vasopressors to help with SVR and heart rate control – mass can act as stenotic valve


  • Induction: maintain SVR and consider slowing heart rate if mass blocking valves


2D TEE: X-plane
2D TEE: color flow through mitral valve
2D TEE: LA myxoma
2D TEE: LA myxoma w color
3D TEE: LA myxoma
From OpenAnaesthesia
2D TEE: measurement of stalk
Resected myxoma


Surgical approach

Cardiac myxomas: 24 years of experience in 49 patients. European Journal of Cardio-thoracic Surgery 22 (2002) 971–977.

Anesthesia management

Hemodynamic management of a patient with a huge right atrium myxoma during thoracic vertebral surgery: A case report. Medicine (Baltimore). 2018 Sep; 97(39): e12543.

Anesthetic Management of a Patient With a Giant Right Atrial Myxoma. Semin Cardiothorac Vasc Anesth. 2016 Mar;20(1):104-9.

Anesthetic management of a patient with asymptomatic atrial myxoma for hernia repair. Anaesth Pain & Intensive Care 2016;20(2):246-248

Giant Left Atrial Myxoma Obstructing Mitral Valve Bloodflow. Anesthesiology 7 2019, Vol.131, 151-152.

Anesthetic Management of a Voluminous Left Atrial Myxoma Resection in a 19 Weeks Pregnant with Atypical Clinical Presentation. Case Reports in Anesthesiology, Volume 2019, Article ID 4181502, 6 pages.

Large myxoma causing cardiac arrest during surgery. A Clinical Reports volume 1, Article number: 24 (2015).

Atrial myxomas causing severe left and right ventricular dysfunction. Annals of Cardiac Anaesthesia. Case Report: Year : 2017  |  Volume : 20  |  Issue : 4  |  Page : 450-452.

Intraoperative Diagnosis of Left Atrial Myxoma. Anesthesia & Analgesia: January 1995 – Volume 80 – Issue 1 – p 183-184

Anesthetic experiences of myxoma removal surgery in two patients with Carney complex -A report of two cases-. Korean J Anesthesiol. 2011 Dec; 61(6): 528–532.


Virtual TEE: Cardiac Myxoma

Intraoperative transesophageal echocardiography assessment of right atrial myxoma resulting in a change of the surgical plan. Ann Card Anaesth 2014;17:306-8.

TransCarotid Artery Revascularization (TCAR)

Surgery and anesthesia for TCAR. #anesthesia #TCAR #carotid #local #stroke #CEA

SilkRoad Medical: TCAR Procedure

Technical aspects of transcarotid artery revascularizationusing the ENROUTE transcarotid neuroprotection and stent system. J Vasc Surg 2017;65:916-20.

TCAR PPT Stony Brook

TCAR With Flow Reversal Is Equal To CEA For Treating High Risk Patients With Carotid Stenosis:DWMRI Findings Prove It (From The PROOF Trial)

Long-term comparative effectiveness of carotid stenting versus carotid endarterectomy in a large tertiary care vascular surgery practice. Journal of Vascular Surgery. Volume 68, Issue 4, October 2018, Pages 1039-1046.


Challenging Case: The Consequence of Unmanaged Hypotension After TCAR. Endovascular Today. August 2019.


  • Dual antiplatelet therapy: Aspirin and clopidogrel
  • Statins
  • Beta blocker


  • Local/MAC vs General
  • arterial line
  • Target systolic blood pressure is 140 – 160 mmHg. Consider glycopyrrolate adn vasopressors for hemodynamics.
  • Surgical access: common carotid artery and femoral vein
  • Goal ACT: 250-300


  • Neuro checks – quick emergence from anesthesia prior to leaving OR
  • ICU postop
  • Tight BP control

Methadone: perioperative pain use

Methadone for perioperative pain #methadone #pain #ERAS

There’s a lot of great data that methadone use decreases postoperative narcotics use in cardiac surgery patients, and I believe it would really be a beneficial drug in an ERAS pathway for early extubation, decreased LOS in ICU and hospital, and better patient satisfaction.  Please see the articles below/attached for references.

Methadone for cardiac surgery: 0.2-0.3 mg/kg prior to incision – perhaps different metabolism on CPB so consider split dosing pre-pump and post-pump. Dose adjustment with age and other co-morbidities. At induction, one half of the study opioid (either 0.15 mg/kg of methadone or 6 μg/kg of fentanyl) was administered via an infusion pump over 5 min. The remainder of the study opioid (0.15 mg/kg of methadone or 6 μg/kg of fentanyl) was infused over the next 2 h. Either 0.3 mg/kg of methadone (maximum dose of 30 mg) or 12 μg/kg of fentanyl (maximum dose of 1200 μg) was added to 100-ml bags of normal saline (total volume 100 ml).

Methadone for non-cardiac surgery: 0.2mg/kg prior to incision. REVIEW: Intraoperative Methadone in Surgical Patients: A Review of Clinical Investigations. Anesthesiology 9 2019, Vol.131, 678-692.

Methadone for obesity: 0.15 mg/kg IBW+20% at induction. J Pain Res. 2018; 11: 2123–2129. Intraoperative use of methadone improves control of postoperative pain in morbidly obese patients: a randomized controlled study.

Methadone for outpatient surgery: 0.15 mg/kg ideal body weight. Anesth Analg. 2019 Apr; 128(4): 802–810. Intraoperative Methadone in Same-Day Ambulatory Surgery: A Randomized, Double-Blinded, Dose-Finding Pilot Study.

OVERALL: A variety of doses have been used in clinical trials, ranging from 0.1 to 0.3 mg/kg, with the majority of studies using a dose of either 0.2 mg/kg or a fixed dose of 20 mg.

Methadone has a long elimination half-life (1–2 days). It is cleared predominantly by hepatic metabolism, primarily via N-demethylation to 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine (EDDP), which is pharmacologically inactive, and thence secondarily to 2-ethyl-5-methyl-3,3-diphenylpyrroline (EMDP).

Together these investigations established that a) CYP3A has no influence on single-dose intravenous or oral methadone plasma concentrations, b) CYP3A plays a minimal (if any) role clinically in single-dose methadone N-demethylation and clearance, c) methadone is not a clinical CYP3A substrate, and d) clinical guidelines stating that methadone is a CYP3A4 substrate and warning about CYP3A4 drug interactions needed revision. In addition, CYPs 2C9, 2C19, and 2D6 do not appear to contribute materially to clinical methadone N-demethylation and clearance.

In summary, it is now obvious that CYP2B6 a) is a predominant catalyst of methadone metabolism in vitro; b) mediates clinical methadone metabolism, clearance, stereoselective disposition, and drug-drug interactions; and c) genetic polymorphisms influence methadone disposition. Thus, both constitutive variability due to CYP2B6 genetics, and CYP2B6-mediated drug interactions, can alter methadone disposition, clinical effect, and drug safety. Rewritten clinical guidelines stating that methadone is a CYP2B6 substrate and warning about CYP2B6 drug interactions may improve methadone use, treatment of pain and substance abuse, and patient safety.

FDA Drug Datasheet

From Anesthesiology 5 2015, Vol.122, 1112-1122.
From Anesth Analg. 2019 Apr; 128(4): 802–810.

What I’m doing these days:

  • March 2021
    • Cardiac: Ketamine current pt weight (non-adjusted) 0.2mg/kg/hr start after induction (after lines placed) + 0.35 mg/kg 5-10 minutes prior to incison. Change from 0.2mg/kg/hr to 0.1mg/kg/hr when rewarming. Infusion off when driving sternal wires. Methadone currently not available.
    • Non-cardiac (cases 2+ hours duration) Ketamine: 0.3mg/kg (non-adjusted, current weight) at induction. Methadone currently not available.
    • Outpatient: ketamine not currently available for use.
  • July 2020
    • Cardiac: Ketamine IBW 0.3mg/kg total: 0.2mg/kg prior to incision + 0.1mg/kg when separate from CPB
    • Excel spreadsheet dosing

Adult Cardiothoracic

Adult Non-Cardiac

From Perioperative Methadone and Ketamine for Postoperative Pain Control in Spinal Surgical Patients: A Randomized, Double-blind, Placebo-controlled Trial. Anesthesiology Newly Published on March 2021. doi:

Adult Outpatient

Pediatric Surgery

Methadone Pharmacology & Effects

Prescription of Controlled Substances: Benefits and Risks. [Updated 2020 Jun 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from:

The role of methadone in opioid rotation-a Polish experience. Support Care Cancer. 2009 May;17(5):607-12.

Mitral Valve analysis

Review article: TEE of Mitral Valve. International Journal of Perioperative Ultrasound and Applied Technologies, September-December 2013;2(3):122-130.

New Concepts for Mitral Valve Imaging.  . 2013 Nov; 2(6): 787–795.

A Quantification Approach to Echocardiography of Mitral Valve for Repair. Anesthesia & Analgesia 12(1):34-58 · July 2015

4D-transesophageal echocardiography and emerging imaging modalities for guiding mitral valve repair.  Ann Cardiothorac Surg 2015;4(5):461-462.

Method—Comparison of Transthoracic and Transesophageal Echocardiography. Clin. Cardiol. 25, 517–524 (2002)

Virtual TEE: spectral Mitral valve

Echocardiographic atlas of the mitral regurgitation. J Saudi Heart Assoc. 2011 Jul; 23(3): 163–170.

Intraoperative transesophageal echocardiographic assessment of the mitral valve repair. Ann Card Anaesth 2010;13:79-85.


Computer-based comparison of different methods for selecting mitral annuloplasty ring size. Journal of Cardiothoracic Surgeryvolume 12, Article number: 8 (2017)

Prediction of the annuloplasty ring size in patients undergoing mitral valve repair using real-time three-dimensional transoesophageal echocardiography. . 2011 Jun; 12(6): 445–453.


The choice of mitral annuloplastic ring—beyond “surgeon’s preference”.  Ann Cardiothorac Surg 2015;4(3):261-265

Gold Standard to Measure MR – PPT 2016 U of Wash.

Spinal drain for TEVAR

I had a patient come in for a 2 stage endovascular aortic repair. The patient had a 1st stage left carotid to subclavian bypass done about 3 days ago. We did a 2nd stage TEVAR for a descending aortic aneurysm. The patient did really well. Stayed in constant communication with the vascular surgeon as well as endovascular surgeon. A plan was in place. Patient was maximally beta blocked. I found dexmetetomidine to be a great drug for sedation pre-induction as well as blunting any responses to laryngoscopy during induction. Cordis for volume. Used the side port of the cordis for drips (nicardipine, phenylephrine). There were various times during the surgery where the surgeon wanted hypotension vs. hypertension. During deployment of the stent, SBP < 90. Once the stent was deployed, goal SBP 140 (MAP>90). Overall great case and great outcome for the patient.

What is a TEVAR (Thoracic EndoVascular Aortic Repair)?

Why place a spinal drain?

Management of spinal drain:

Potential complications

Key Points:

  • Pre-op planning: chat with the surgeon before hand regarding a plan. Make sure the OR team understands the plan.
  • Communication: before, during, after the case.
  • Be vigilant about tight BP control