avoiding opioid use in cancer surgery

[Iso4ane]

Come on, you don't use IV pumps to do propofol drip? 100ml bottle runs for a while.

Not if they weigh more in Kg than the average American does in Lbs and have a drug problem.

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[San Marzano]

So much braggadocio on this board about "slick" wakeups "on a dime"

Get a life y'all

I have a case next Thursday that I’m planning on running a TIVA for. I paged the surgeon this morning to let him know what time his patient is going to be waking up because I already have it calculated down to a 3 second window. He was really appreciative of the page and told me he wished more anesthesiologists were as slick as me.

 

[JWebar]

Some of my colleagues have been avoiding opioids altogether (and using ketamine) for cancer surgery, based on some animal and in-vitro studies showing that opioids may lead to immunosuppression of protective mechanisms and may increase risk of cancer recurrence. From what I've read it is mostly with morphine and there has not been any RCTs performed for this.

I haven't jumped on the bandwagon on this. Most of the attendings here like to use remi for head and neck, other surgeries where there is neuro monitoring. What is your practice? Yea? Nay?

I've seen this. This is the best depiction of how most of us are terrible scientists, but love to play the role.

 

[MoMoGesiologist]

It seems like there are a couple studies showing intraop narcotics result in more post op narcotic use/need. Should we really even be using fentanyl intraop? Someone under GA doesn’t really even feel pain, right?

 

[deleted875186]

It seems like there are a couple studies showing intraop narcotics result in more post op narcotic use/need. Should we really even be using fentanyl intraop? Someone under GA doesn’t really even feel pain, right?

A couple? More like numerous.

 

[MoMoGesiologist]

A couple? More like numerous.

Numerous? Maybe even a preponderance...

 

[sevoflurane]

I am not an expert on the subject but wasn’t there some talk about mu receptor activation influencing tumor progression in some negative way?

 

[deleted50478]

It doesnt smooth out extubation, it just puts the patients back to sleep or even worse in stage 2.
May look pretty to you, but not the safest practice and eventually i can see it being a real problem if its taught routinely to residents. Extubation criteria doesnt state give a smidge of propofol to smooth out extubation because I dont know what IM doing..

You don’t put people in stage 2 with propofol. If they’re in Stage 2 you failed to get the gas off.
The only problem with adding propofol at the end of surgery is that you’re likely to delay emergence if you don’t basically convert to tiva and get the gas off early.

 

[deleted131481]

You don’t put people in stage 2 with propofol. If they’re in Stage 2 you failed to get the gas off.
The only problem with adding propofol at the end of surgery is that you’re likely to delay emergence if you don’t basically convert to tiva and get the gas off early.

This exactly. Wakeup is smoother with propofol. Not saying you can't consistently have a smooth wakeup with gas, but it will be as good not better than propofol all else equal. Gas easier to time emergence than propofol. Propofol >> gas for PONV.

Gas is simpler to titrate depth and no extra work otherwise TIVA would be used more often.

 

[PieOHmy]

You don’t put people in stage 2 with propofol.

What Stage do you call a patient who is delirius, not following commands, breathing shallow and irregular upon emergence? Awake? Asleep? Somewhere in the middle? Stage 2?

 

[abolt18]

It doesnt smooth out extubation, it just puts the patients back to sleep or even worse in stage 2.
May look pretty to you, but not the safest practice and eventually i can see it being a real problem if its taught routinely to residents. Extubation criteria doesnt state give a smidge of propofol to smooth out extubation because I dont know what IM doing..

I don't think anyone is saying they'd bolus propofol WHILE extubating. My impression was that they turn off the gas early and if the patient starts coughing or moving before the surgeon is done, THEN give a little bump of propofol to chill them out for the last few minutes. Continue like this for a few minutes until you feel like it's no longer necessary (surgeons can place dressings on moving targets).

 

[deleted697535]

I can’t name a TCI algorithm. Educate this old dinosaur. And please describe one of your typical TIVAs. I am here to learn.

For reference, my TIVA is typically squirting ketamine 100mg into a 1000mg vial of propofol. Rarely I add remi 2mg into the mix. Start it at propofol 100mcg/kg/min and titrate to vitals and BIS. If I don’t put remi in the cocktail, I give fentanyl. Admittedly my volatile wakeups are usually faster than my TIVA wakeups.

Also I have zero experience with raw EEG. Never once saw it during my entire medical training or career. Am I supposed to know this?

I dont have much time to answer this. It could be an essay!!

But to get you started there are about 5 TCI algorithms for propofol. But Schneider is the most commonly used
They all use a variety of 3 compartment modelling
Most work on Bolus Elimation Transfer theory

Oldest was marsh way back in 1991. This had a very large V1 and hence its initial bolus was very high. Not recommended for Elderly or obese. It has fallen by the wayside. Ive not used it for years despite Dr Marsh being a local hero!! It also doesnt use age as a parameter despite it being required as an input

The most commonly used model for propofol is Schneider. This is my personal favourite. It causes much less hypotension due to a fixed V1 and V3 with variable V2.

The other models are eveld and one called cortinez. Ive not used them much but eveld has much promise in that it is models on obese and various disease states.

Not to get going with them there are apps that actually run sims of them. my favourite is itiva. It works very well once you get the hang of it. It tells you what effect or plasma site conc you should have. Effect site conc is mostly recommended

Now as for mixing things into the bottle of propofol well thats not a great idea and that being generous. Ppf is an emulsion, remi is a solution. They dont mix like oil and water. So you end up with ppf at the bottom and the rest on top of the bottle and get absolutely no idea what your giving and when

Lastly for raw eeg. Its not hard. heres 2 lectures and an hour long video and you basically are more qualified than 99% of your colleagues lol

Can anaesthetists be taught to interpret the effects of general anaesthesia on the electroencephalogram? Comparison of performance with the BIS and spectral entropy

Practical use of the raw electroencephalogram waveform during general anesthesia: the art and science. - PubMed - NCBI

 

[nimbus]

I dont have much time to answer this. It could be an essay!!

But to get you started there are about 5 TCI algorithms for propofol. But Schneider is the most commonly used
They all use a variety of 3 compartment modelling
Most work on Bolus Elimation Transfer theory

Oldest was marsh way back in 1991. This had a very large V1 and hence its initial bolus was very high. Not recommended for Elderly or obese. It has fallen by the wayside. Ive not used it for years despite Dr Marsh being a local hero!! It also doesnt use age as a parameter despite it being required as an input

The most commonly used model for propofol is Schneider. This is my personal favourite. It causes much less hypotension due to a fixed V1 and V3 with variable V2.

The other models are eveld and one called cortinez. Ive not used them much but eveld has much promise in that it is models on obese and various disease states.

Not to get going with them there are apps that actually run sims of them. my favourite is itiva. It works very well once you get the hang of it. It tells you what effect or plasma site conc you should have. Effect site conc is mostly recommended

Now as for mixing things into the bottle of propofol well thats not a great idea and that being generous. Ppf is an emulsion, ketamine/remi etc are solutions. They dont mix like oil and water. So you end up with ppf at the bottom and the rest on top of the bottle and get absolutely no idea what your giving and when

Lastly for raw eeg. Its not hard. heres 2 lectures and an hour long video and you basically are more qualified than 99% of your colleagues lol

Can anaesthetists be taught to interpret the effects of general anaesthesia on the electroencephalogram? Comparison of performance with the BIS and spectral entropy

Practical use of the raw electroencephalogram waveform during general anesthesia: the art and science. - PubMed - NCBI

Thanks for your reply. Still curious how you actually conduct your TIVA’s.

As for propofol/ketamine/remi compatibility, I and others have been mixing them for decades. Never saw a separation or encountered a problem.

http://www.newcastle-hospitals.org.uk/downloads/NECTAR/TVCCN_IV_Compatibility_Chart_v2.1.pdf

http://www.asaabstracts.com/strands/asaabstracts/abstract.htm?year=2008&index=7&absnum=1255

 

[abolt18]

I dont have much time to answer this. It could be an essay!!

But to get you started there are about 5 TCI algorithms for propofol. But Schneider is the most commonly used
They all use a variety of 3 compartment modelling
Most work on Bolus Elimation Transfer theory

Oldest was marsh way back in 1991. This had a very large V1 and hence its initial bolus was very high. Not recommended for Elderly or obese. It has fallen by the wayside. Ive not used it for years despite Dr Marsh being a local hero!! It also doesnt use age as a parameter despite it being required as an input

The most commonly used model for propofol is Schneider. This is my personal favourite. It causes much less hypotension due to a fixed V1 and V3 with variable V2.

The other models are eveld and one called cortinez. Ive not used them much but eveld has much promise in that it is models on obese and various disease states.

Not to get going with them there are apps that actually run sims of them. my favourite is itiva. It works very well once you get the hang of it. It tells you what effect or plasma site conc you should have. Effect site conc is mostly recommended

Now as for mixing things into the bottle of propofol well thats not a great idea and that being generous. Ppf is an emulsion, ketamine/remi etc are solutions. They dont mix like oil and water. So you end up with ppf at the bottom and the rest on top of the bottle and get absolutely no idea what your giving and when

Lastly for raw eeg. Its not hard. heres 2 lectures and an hour long video and you basically are more qualified than 99% of your colleagues lol

Can anaesthetists be taught to interpret the effects of general anaesthesia on the electroencephalogram? Comparison of performance with the BIS and spectral entropy

Practical use of the raw electroencephalogram waveform during general anesthesia: the art and science. - PubMed - NCBI

I recently read all about these TCI algorithms in Barash and while the pharmacokinetics of it are interesting, I wasn't sure about the physical application of it. I downloaded iTIVA a couple months ago but have not yet put it to use. This is nice to know about the different algorithms. I've talked to one attending about it and he wanted to use it with me so I think I'll give it a go in the near future.

Also, I got to work with Michael Avidan a few times in med school (visiting rotator at WashU) and he was all about the raw EEG. He was in the middle of a big RCT monitoring burst suppression on EEG and seeing if less burst suppression would lead to less post-op delirium. I should have taken time to learn a little more from him I guess!