Favorite MAC tricks?

[fakin' the funk]

You could also insist that they infuse a carrier fluid at 100cc/hr on the pump with the remi plugged in as distal as possible. With our tubing, each drop of carrier is 1/20th of an ml so I usually run 1-2 drops a second or the equivalent of 90-180ml a minute.

Can also make the remi infusion very dilute (10-20mcg/ml) for less swingage

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[FiO2@21]

This was a thing before sugammadex.

I have remi in line already, I use it for thyroids.

 

[CavGas]

Thanks for the answers everybody!

I also like to use LMA's for that type of surgery but not all attendings are up to it..

We usually apply the 10% lido spray on the ETT cuff but I 'll try the 2% gel we carry, see if there is any difference!

 

[GassYous]

5-10 liters/hr?

They had a really bad experience with remi

 

[Toothpickwars]

5-10 liters/hr?

Check your math. 1 drop a second is 3ml a minute.

 

[nimbus]

Check your math. 1 drop a second is 3ml a minute.

I was replying to your post that said “90-180ml a minute”.

 

[deleted875186]

This was a thing before sugammadex.

100%, give a normal 0.5 mg/kg dose of roc, intubated, make sure deep, then give 200 suga, not the technically recommended dose by manufacturer but will get good neuro monitoring signals.

 

[IMGASMD]

I was replying to your post that said “90-180ml a minute”.

They had a really bad experience with remi

They ded?

 

[vector2]

100%, give a normal 0.5 mg/kg dose of roc, intubated, make sure deep, then give 200 suga, not the technically recommended dose by manufacturer but will get good neuro monitoring signals.

Why not use sux?

 

[Toothpickwars]

I was replying to your post that said “90-180ml a minute”

Ah you’re right, my bad.

 

[dhb]

If you don't like intubating with 4mcg/kg of remi then you don't like anesthesia.

 

[fakin' the funk]

If you don't like intubating with 4mcg/kg of remi then you don't like anesthesia.

As long as the pads are on and atropine ready

 

[FiO2@21]

As long as the pads are on and atropine ready

I give 10 mg of ephedrine with the remi

 

[deleted875186]

I give 10 mg of ephedrine with the remi

I never give more than 200 mcg, usually around 3 mcg/kg, give it over a couple minutes. I will pretreat with ephedrine or glyco if older.

 

[dhb]

As long as the pads are on and atropine ready

Never had a significant bradycardia...

 

[dhb]

I never give more than 200 mcg, usually around 3 mcg/kg, give it over a couple minutes. I will pretreat with ephedrine or glyco if older.

I liked to bolus 4 to 500: i don't like to wait more than a minute to intubate.

 

[Arch Guillotti]

Glyco, epehedrine, neo, remi, small amount of propofol. Works great in certain circumstances.

 

[FiO2@21]

I liked to bolus 4 to 500: i don't like to wait more than a minute to intubate.

My biggest pet peeve is that you use up so much of the remi vial for induction

 

[Toothpickwars]

Speaking of, how do y’all titrate long acting opiates in prop/remi tivas? I typically cut my remi gtt in half and give HM to a rr in the low teens within the last half hour but was thinking about how it might conserve remi to work it in through the case.

 

[FiO2@21]

Speaking of, how do y’all titrate long acting opiates in prop/remi tivas? I typically cut my remi gtt in half and give HM to a rr in the low teens within the last half hour but was thinking about how it might conserve remi to work it in through the case.

I don’t use remi for painful cases. I use sufentanil or fentanyl for those more painful neuromonitoring cases. Thyroids aren’t that painful and get 50-100 mcg fentanyl

 

[dhb]

My biggest pet peeve is that you use up so much of the remi vial for induction

One 2mg vials is good for 5 intubations. I don't use it for anything else.

 

[GassYous]

One 2mg vials is good for 5 intubations. I don't use it for anything else.

You don't need to account for opioids for each patient?

 

[dhb]

You don't need to account for opioids for each patient?

Hell no

 

[GassYous]

Hell no

Weird, there are places that even ask you to account for prop and pentothal

 

[fakin' the funk]

Glyco, epehedrine, neo, remi, small amount of propofol. Works great in certain circumstances.

This is a joke right

 

[Hork Bajir]

I’ll chime in:

Haldol and diphenhydramine, when used in the appropriate patient population, can be very slick drugs for MAC cases (esp when the patient has been on the table for too long, is starting to get squirmy, and you still need them relatively rousable to follow commands)

Also, in the right patient population, a very judicious dose of meperidine can go a long way (will sometimes give a bit during awake cranis, mostly for the euphoric effects, to counteract how much the whole experience sucks for the patient)

 

[GassYous]

Has anyone used droperidol for intraop?

 

[MirrorTodd]

Has anyone used droperidol for intraop?

Like similar to the aforementioned Haldol? I never have, previous place I rotated worked it into their PONV algorithm, so we frequently gave it during surgeries.

 

[MirrorTodd]

I remember reading that a nasal trumpet will alleviate hiccups from propofol during mac cases.

 

[IMGASMD]

I remember reading that a nasal trumpet will alleviate hiccups from propofol during mac cases.

I’m 50/50 on that. N=6 tho.

 

[ProwlerturnGas]

I’m 50/50 on that. N=6 tho.

Yeah me too. I remember that snipet and started doing it with hiccups. 50% of the time, it works all the time.

 

[MirrorTodd]

I’m 50/50 on that. N=6 tho.

That sounds like an NNT of two though. Pretty good, I'd say.

 

[GassYous]

I remember reading that a nasal trumpet will alleviate hiccups from propofol during mac cases.

Try sticking a q tip straight down the nose and touch the back

 

[MirrorTodd]

Try sticking a q tip straight down the nose and touch the back

And then send it for a covid test right?

 

[Arch Guillotti]

This is a joke right

try it man!

 

[repititionition]

I’ll chime in:

Haldol and diphenhydramine, when used in the appropriate patient population, can be very slick drugs for MAC cases (esp when the patient has been on the table for too long, is starting to get squirmy, and you still need them relatively rousable to follow commands)

Also, in the right patient population, a very judicious dose of meperidine can go a long way (will sometimes give a bit during awake cranis, mostly for the euphoric effects, to counteract how much the whole experience sucks for the patient)

Love a haldol Benadryl Mac. I also think Benadryl is my favorite sedation for moms freaking out after baby is out s/p c/s abs baby has gone to NICU. Try it.

Has anyone used droperidol for intraop?

I routinely give 1mg to overnight traumas or anyone who comes across as (sorry) “crazy” on call. It’s changed the way I use precedex. Used to wake up a lot of trauma call cases on precedex. Now almost never have to, the droperidol has them smoothed out.

 

[DocVapor]

My favorite MAC trick is telling the surgeon that they are really asking for GA and then performing it and charting it appropriately as GA

 

[soorg]

What dose of Haldol are you using?

 

[propadope]

Can also make the remi infusion very dilute (10-20mcg/ml) for less swingage

+1. I also like the idea of a TIVA infusion set like this

Don’t have to worry about interaction between drugs and the fluid carrier and less lag time when titrating due to minimal deadspace. Also no need for a separate IV

 

[GassYous]

+1. I also like the idea of a TIVA infusion set like this View attachment 343134
Don’t have to worry about interaction between drugs and the fluid carrier and less lag time when titrating due to minimal deadspace. Also no need for a separate IV

Which drugs do you worry about interaction with the fluid carrier? I just mix drugs together like ketafol for example.

 

[anbuitachi]

Hey everybody!
I was reading this thread and I thought I 'd ask here since the discussion started as cough related..

Over the last month or so I 've had 3-4 patients, young,fit ASA 1-2 having minor surgery ( i.e. hernia, ENT stuff etc ) ,for which they received minimal opioids, have a reallyyyyy nasty post - extubation cough. They had no pain at the surgery site but were miserable cos of this persistent cough. Only 1 of them was a smoker and in my limited experience I 've never seen this happen when the patient receives heavy handed opioid ( i.e around 350ug fent for a lap chole would be average here)
I was wondering what could cause this and how could it be treated in the PACU? ( more opioid? lidocaine? some magic nebulizer?)

Intubation was not complicated for any of them and they didn't really strain at the extubation phase..

Thanks in advance for the answers!

its your intubation. you lift too hard. and you jam the tube in too hard.

 

[propadope]

Which drugs do you worry about interaction with the fluid carrier? I just mix drugs together like ketafol for example.

I don’t necessarily mean a chemical interaction or incompatibility but the rate of infusion of one affecting the other

 

[DrOwnage]

When the preop nurse puts in the IV and its taped like a pile of @#$% with the catheter halfway out and they go "its positional" and of course the case is TIVA.

Edit: This was supposed to go in the pet peeves thread lol.

 

[deleted697535]

Just for giggles?

One of my attending blouses remi for induction once. Couldn’t ventilate, just attributed to chest wall rigidity. He sort of just laughed about it, because he “knows” how short acting remi is. I was not amused. Not sure if I will ever use that technique, or why would I…..

What do you mean?
Boluses remi for induction without roc so 4 per kilo or just like 1 to 2 per kilo of remi?

Remi bolus is beautiful for all inductions outside of cardiac surgery and even then its beautiful for clip cases...

 

[deleted697535]

Hey everybody!
I was reading this thread and I thought I 'd ask here since the discussion started as cough related..

Over the last month or so I 've had 3-4 patients, young,fit ASA 1-2 having minor surgery ( i.e. hernia, ENT stuff etc ) ,for which they received minimal opioids, have a reallyyyyy nasty post - extubation cough. They had no pain at the surgery site but were miserable cos of this persistent cough. Only 1 of them was a smoker and in my limited experience I 've never seen this happen when the patient receives heavy handed opioid ( i.e around 350ug fent for a lap chole would be average here)
I was wondering what could cause this and how could it be treated in the PACU? ( more opioid? lidocaine? some magic nebulizer?)

Intubation was not complicated for any of them and they didn't really strain at the extubation phase..

Thanks in advance for the answers!

It might just be secretions.
But anyway...

Extubate deep, you'll never have that problem again...
But be careful!
You will get your ass handed to you when you **** it up

 

[repititionition]

It might just be secretions.
But anyway...

Extubate deep, you'll never have that problem again...
But be careful!
You will get your ass handed to you when you **** it up

Based on clinical scenario, my best guess is over-inflation of ETT balloon. Hook up a manometer sometime and you’ll likely see that 90+% of all balloons are overinflated, some well into the range of mucosal ischemia.

Second, and more likely if you’re supervising, would be early trainees manipulating the ETT while taping and placing outward traction on the balloon, engaging/pressing on the cords.

 

[Guillemot]

Remi works fine for intubation, but using high doses of remi + propofol for intubation will not be as hemodynamically stable as using Roc + sugammadex. I still use remi to intubate often times though if already using remi d/t neuromonitoring. Usually chase the remi with 25-50mg of ephedrine which in general keeps the patient normotensive, but still have occasional hypotension or hypertension.

If you get chest wall rigidity you can give narcan or a regular muscle relaxant. I maybe had this happen once before. Its not common.

 

[dhb]

Its not common

It's not real

 

[BobLoblaw78]

What Remi dose do you use? Honestly in this elderly parkinsons population I would be hesitant.

Enough to cause rigidity. It really diminishes the tremor

 

[GassYous]

It's not real

I thought we decided that it was due to laryngeal closure