04/11/2021
I hopes of remembering to feed the brain, I’m sharing knowledge on my page so I don’t have to scroll back through FB Group ECC.
copy/pasted. Response by: Stephen Cital
While a lot of literature suggests treating if the MAP is falling below 60mmHg, my preference is starting to intervene when we see a trend of lowering BP’s and the MAP falling below 70mmHg.
Your actions of decreasing the gas are smart as we would love to decrease the MAC as much as possible. Fluids may or may not be best for each individual patient so while that is a trick that works, I would stress caution that we don’t get too crazy. Colloids have largely fallen out of favor and I would only use those in a huge pinch. Instead, I would consider, when appropriate, CRI’s, or what I do - micro injections of various drugs such as ketamine, dexmedetomidine or short acting opioid to decrease the gas further. I usually reach for ketam1ne first 0.1-0.5mg/kg as it can increase GRF, which will increase your BP- and they don’t wake up in a K-hole at these doses. I will use dexmed for the affects you are trying to achieve with norepinephrine and dopamine, plus it has some analgesic effects. Remember peripheral vasoconstrictors may increase BP but doesn’t necessarily mean good perfusion is occurring- I do prefer norepinephrine. Dobutamine will increase cardiac contractility- eventually alpha stimulation (dose dependent too but we will want to make sure it warranted. A syringe pump would be a great investment and we have our favorite on our favorite things list. I also LOVE phenylephrine, which is nice because it is quick acting but short lived and the patient’s heart rate won’t elevate compared to other options. Another investment would be this guide. It has all the major pressors with dilution and recommended rates. https://www.veccs.org/product/constant-rate-infusion/ So many little nuances to sort out in choosing the best drug for the job- hence I try the ketamine first.