Acute Hemodynamic Management – Aggressive Undertreatment
This post was inspired by a discussion I had with Dr. Les Yarmush, one of my cardiothoracic anesthesia attendings.
I’ve become accustomed to titrating many short acting medications to manage hemodynamics in the ICU and operating room arenas. I like to factor in a patient’s comorbidities and “test” their response to small doses of vasoactive medications, so I have an idea what to do if more severe circumstances arise. This also lets me hand off this information other providers who will be caring for the patient.
Many times when our patients become hypo/hypertensive or brady/tachycardic, we reach for our arsenal of medications (phenylephrine, ephedrine, norepinephrine, nitroglycerine, esmolol, etc.) to correct the situation as we investigate etiologies.
Dr. Yarmush phrased our tendency to overtreat these situations by asking:
What’s the onset of the first IV medication you administered? It’s the exact moment the second dose of the same medication reaches the patient.
We’re all guilty of it. Patient hypertensive and the CT surgeon is about to cannulate the aorta? Push some nitroglycerine. Ugh, the pressure is still high. Push some more. Oh yeah, and a little fentanyl.
Bam. Now the pressure is super low. Let’s push some norepinephrine… times three doses. Ugh, now we’ve overshot and are severely hypertensive. ?
Our rush to fix hemodynamics is often compounded by surgeons thinking that anesthesiologists have some magical blood pressure knob which can be adjusted at a moment’s notice to target an exact pressure. This isn’t reality, nor is it physiologic. The farther I’ve progressed in my training, the more comfortable I’ve become in telling them to “hold on for a few seconds.” Furthermore, I’ll anticipate when they’ll need the pressures high/low and tailor my anesthetic accordingly.
In general, aggressively undertreating fluctuations in hemodynamics to allow our medications to actually WORK will help reduce the lability and pitfalls we often create for ourselves.
Patience is a virtue. ?