Episode 132: Key Words Part 3: Spinals and Etomidate

In this 132nd episode I welcome back Dr. Gillian Isaac to do more ABA keyword review. We review Spinals for the Basic Exam and Etomidate.

5 Replies to “Episode 132: Key Words Part 3: Spinals and Etomidate”

  1. Around 14 minutes in, Dr. Isaac states that if she “were in the operating room and saw someone getting bradycardic and the blood pressure going down, I would probably start with glycopyrrolate, ephedrine, phenylephrine, and not necessarily reach for the epi.” I was just wondering, what is her rationale for this?

    At our institution, a lot of people would start with low-dose epi and then administer the other agents due to epi’s short duration of action. Thanks!

    1. Hi Trent,

      In my experience a mild decrease in HR with some hypotension would tend to get ephedrine first, maybe glyco if HR is significantly low. If that doesn’t work, low dose epi is the go to. I tend to think of epi, even low dose epi, as a bigger gun. Here’s what Dr. Isaac said:

      “I don’t routinely make low-dose epi at the start of my cases but I always have glyco, ephedrine and phenylephrine at hand. I would give something to help stabilize while diluting epi. I do think epi is the better drug but I don’t have it ready to go and on hand but maybe I should change my practice!”

      1. Thanks for the reply! We have pre-made sticks of 10mcg/mL epi in our drug carts and have to dilute out our ephedrine, so that is probably a major source of differences in practice.

    1. Just to give a other practice.

      We don’t have glycopyrrulate available.
      The first drug I would give would be Akrinor (Cafedrin/Theodrenalin) -which is very common in German anaesthesia practice- and atropine. It comes in 2 cc and 1 cc will generally have the same effects as about 2.5-4 cc ephedrine , so potent but still well manageable.

      There has been some evidence from a meta analyses that indicated a higher risk for neonatal acidosis when this agent is used [1] vs ephedrine, but retrospective study in 700+ patients didn’t show a statistical difference [2].

      [1]Acta Anaesthesiol Scand. 2012 Aug;56(7):810-6. doi: 10.1111/j.1399-6576.2011.02646.x. Epub 2012 Feb 7.

      [2]Anaesthesist. 2019 Apr;68(4):228-238. doi: 10.1007/s00101-019-0560-8. Epub 2019 Mar 27.

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