Sevoflurane or Desflurane for COPD?

[Planktonmd]

With Des I find that I can get away with little to no muscle relaxant when compared to Sevo.

The next time you are doing knee scopes or something with an LMA pay attention to the frequency with which the pts move a little bit at the moment the incision is made. It isn't much movement but it's there. With Des it nearly never occurs but with Sevo it does. I also get away with much less narcotics when using Des. All of this matters and makes a difference in recovery. It's just style but my style is with lots of DES use.

If they are moving under Sevo then maybe you are not giving enough Sevo???
I think you can achieve any level of anesthesia you want with any inhaled agent, it's a question of dosage, nothing more.

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[Mman]

If they are moving under Sevo then maybe you are not giving enough Sevo???
I think you can achieve any level of anesthesia you want with any inhaled agent, it's a question of dosage, nothing more.

correct, there is no difference in efficacy between the various inhaled volatile anesthetic gases.

 

[Noyac]

If they are moving under Sevo then maybe you are not giving enough Sevo???
I think you can achieve any level of anesthesia you want with any inhaled agent, it's a question of dosage, nothing more.

Not exactly true. Sevo just doesn't have the analgesic properties that Des has. I routinely ran Sevo at 1.5 MAC or more to prevent this. Des doesn't even bpneed to be at 1MAC. What I'm talking about is subtle and I would bet most people don't even notice it. But it is just an indication of what I believe is a superior agent.

 

[BLADEMDA]

Not exactly true. Sevo just doesn't have the analgesic properties that Des has. I routinely ran Sevo at 1.5 MAC or more to prevent this. Des doesn't even bpneed to be at 1MAC. What I'm talking about is subtle and I would bet most people don't even notice it. But it is just an indication of what I believe is a superior agent.

Okay, so Des has some minor, subtle analgesic benefits over SEVO. For patients with COPD the bronchodilating benefits of SEVO vs DES make it the clear winner in this scenario. We used to wake everybody up quickly just using ISO so I don't see the issue with using SEVO in these cases and actually paying attention.

 

[Noyac]

Okay, so Des has some minor, subtle analgesic benefits over SEVO. For patients with COPD the bronchodilating benefits of SEVO vs DES make it the clear winner in this scenario. We used to wake everybody up quickly just using ISO so I don't see the issue with using SEVO in these cases and actually paying attention.

True.
I will say that it is rare that I will switch over to Sevo on pt with COPD or PHTN. But I have and I do agree that there is an advantage in SEVO here. But just like the subtle analgesic effect these are also relatively subtle as well.

 

[pgg]

Okay, so Des has some minor, subtle analgesic benefits over SEVO. For patients with COPD the bronchodilating benefits of SEVO vs DES make it the clear winner in this scenario. We used to wake everybody up quickly just using ISO so I don't see the issue with using SEVO in these cases and actually paying attention.

Well, first, it's not a matter of "paying attention" because I think all of us would agree that given practice and diligence, you can wake virtually any patient up, any time, with any agent. But after the patient is awake and extubated, the differences between the volatile agents don't vanish and their properties don't change. Continued recovery along the spectrum of wakefulness is very different, especially for longer cases and fatter patients.

"Clear winner" is kind of an all-or-none term implying you think it should be used for all patients with COPD. Do you use sevo in everyone with COPD? Just the O2 dependent ones? Just the ones with PFTs worse than a certain threshold? Just COPD'ers that are current smokers? Mild COPD'ers? What about smokers without a COPD diagnosis ... have a pack-year cutoff? Asthma? Just kind of a not-bad vs bad COPD gestalt?

I like des because the patients are more awake, sooner, in the PACU. The +/- analgesic effects at a given MAC value, relative to other agents, aren't part of my rationale.

I sometimes find myself using sevo or iso because the resident turned that dial, or because I'm cursed with taking over someone else's case, and that's OK.

 

[Mman]

Not exactly true. Sevo just doesn't have the analgesic properties that Des has. I routinely ran Sevo at 1.5 MAC or more to prevent this. Des doesn't even bpneed to be at 1MAC. What I'm talking about is subtle and I would bet most people don't even notice it. But it is just an indication of what I believe is a superior agent.

I don't think your subtle difference is supported by any evidence in the literature. I suspect the difference is at the start of the case the difference in solubility between Des and Sevo leading to a bigger difference in ETSevo vs CNS concentration when compared to Desflurane.

Do you have any pharmacologic reason to suspect a difference between their effect on patient movement at equi-MAC doses?

 

[Noyac]

I don't think your subtle difference is supported by any evidence in the literature. I suspect the difference is at the start of the case the difference in solubility between Des and Sevo leading to a bigger difference in ETSevo vs CNS concentration when compared to Desflurane.

Do you have any pharmacologic reason to suspect a difference between their effect on patient movement at equi-MAC doses?

Nah. I'm talking about ET gas.
You don't have to believe me. I'm not a researcher so I won't be doing any studies to prove or disprove my assertions.
And if people choose not to believe me then that only works in my favor.

 

[GasOrBust]

I was under the impression that the inhaled anesthetics - with the exception of nitrous oxide - do not provide analgesia...only amnesia and muscle relaxation.

 

[Noyac]

I was under the impression that the inhaled anesthetics - with the exception of nitrous oxide - do not provide analgesia...only amnesia and muscle relaxation.

Well the definition of MAC is the minimum alveolar concentration required to prevent 50% of the population from moving during a painful stimulus. So there in lies the ability to provide some sort of "tolerance" to painful stimulus.

 

[GasOrBust]

Well the definition of MAC is the minimum alveolar concentration required to prevent 50% of the population from moving during a painful stimulus. So there in lies the ability to provide some sort of "tolerance" to painful stimulus.

Or simply immobility. The patient can still be in pain and just unable to move and still fall within the definition of MAC.

 

[Mman]

Nah. I'm talking about ET gas.
You don't have to believe me. I'm not a researcher so I won't be doing any studies to prove or disprove my assertions.
And if people choose not to believe me then that only works in my favor.

I'm also talking about ET gas. There is a gradient between ET gas and the concentration in the CNS at the start of a case. If you put the sevo vaporizer on 8% with 15L flows, after a few breaths you will be reading 4-5% ET Sevo. That doesn't mean that is the effective concentration in the CNS. They aren't that deep yet. Takes a little time to equilibrate into their CNS. Des equilibrates faster. That's why at the start of a case for a relatively equal (on MAC basis) ET concentration of Des vs Sevo, they will be deeper with the Des vs the Sevo. By later in the case the Sevo has caught up.

We think of ET gas as being equal to the effective concentration in the CNS, but that is only true at a steady state. At the start of a case there is still a gradient that exists.

 

[Noyac]

I'm also talking about ET gas. There is a gradient between ET gas and the concentration in the CNS at the start of a case. If you put the sevo vaporizer on 8% with 15L flows, after a few breaths you will be reading 4-5% ET Sevo. That doesn't mean that is the effective concentration in the CNS. They aren't that deep yet. Takes a little time to equilibrate into their CNS. Des equilibrates faster. That's why at the start of a case for a relatively equal (on MAC basis) ET concentration of Des vs Sevo, they will be deeper with the Des vs the Sevo. By later in the case the Sevo has caught up.

We think of ET gas as being equal to the effective concentration in the CNS, but that is only true at a steady state. At the start of a case there is still a gradient that exists.

How long would you say it takes?
And how would you explain that I also can get away with much less narcotic for the entire case?
I understand gas dynamics.
I agree that the Sevo needs to be driven in and I account for that. I'm not an amateur.

 

[Mman]

How long would you say it takes?
And how would you explain that I also can get away with much less narcotic for the entire case?
I understand gas dynamics.
I agree that the Sevo needs to be driven in and I account for that. I'm not an amateur.

I didn't say you are an amateur. But your explanation of things is contradicted by science and research. No more, no less. When you say you account for the time it takes to get the gas on board, what monitor do you use to tell that? Because patient movement is the very definition of MAC. Why can you get away with less narcotic for an entire case? Many reasons. You can do almost any case with no narcotic if you so desire.

 

[Noyac]

I didn't say you are an amateur. But your explanation of things is contradicted by science and research. No more, no less. When you say you account for the time it takes to get the gas on board, what monitor do you use to tell that? Because patient movement is the very definition of MAC. Why can you get away with less narcotic for an entire case? Many reasons. You can do almost any case with no narcotic if you so desire.

I know you didn't. Just jabbing back a bit. It's all good.
And as far as this debate goes I will leave it at my previous statements.

 

[deleted171991]

I learned it from that etherweb link I posted in the other thread that pgg mentioned.

http://etherweb.bwh.harvard.edu/education/PHILIP/Tech_Block_04/1_LowFlowO2Agt.pdf

 

[Noyac]

http://etherweb.bwh.harvard.edu/education/PHILIP/Tech_Block_04/1_LowFlowO2Agt.pdf

Holy crap that's 137 pages. I can't read that much anymore.
You have any cliff notes?

 

[Dr-Junior]

As a side, does anyone here use desflurane for LMA cases? I don't as I'm concerned about desflurane irritating the airway, but I do know some that use it. Just seeing what are others thoughts.

I use Des with LMA frequently but some patients start coughing when they are waking up and then I fear that they are going to aspirate so I just pull the LMA out. I must say I never saw a patient cough with Sevo

 

[deleted171991]

Holy crap that's 137 pages. I can't read that much anymore.
You have any cliff notes?

My thoughts exactly.

 

[CriTICAL]

As a side, does anyone here use desflurane for LMA cases? I don't as I'm concerned about desflurane irritating the airway, but I do know some that use it. Just seeing what are others thoughts.


Sent from my iPhone using SDN mobile app

I used to use DES on almost all my LMA cases until in my own experience started seeing too freq instances of laryngospasm to be by chance where as I never had an issue with LMA and Sevo so now I never use DES with an LMA

But with GETA havent really seen much of a difference personally in terms of bronchospasm and I tend to favor DES over Sevo

 

[pgg]

Holy crap that's 137 pages. I can't read that much anymore.
You have any cliff notes?

It's mostly pictures. You can get through it in 10 minutes.

 

[Noyac]

It's mostly pictures. You can get through it in 10 minutes.

Who has 10 minutes?

 

[Chloroform4Life]

Holy crap that's 137 pages. I can't read that much anymore.
You have any cliff notes?

TL;DR:
After intubation, turn total gas flow to 1L. Set DES vaporizer to 18%. Once ET-DES reaches 6-7%, turn down dial on vaporizer...Save $$$$$$$

 

[periopdoc]

I use Des for everything except cardiac cases where I use Iso (because that is what is on the bypass machine), pediatric inhalational cases, and cases where high flows are required (shared airway, bronch etc).

It is definitely more analgesic than other agents. So I use less opiates and patients have higher minute ventilation at the end of the case. Patients are more awake faster in PACU. I never have to play the closure timing game when the surgeon decides to hand the closure over to his unpredictable PA. Severely morbidly obese patients wake up more predictably. I have far fewer of those outlier, long emergence cases, and the ones I do have don't take as long to wake up.

The patient would have to have extreme COPD, needing oxygen to survive the ride from preop to OR, before I really gave it a second thought.

One does have to be careful about not increasing concentration too quickly, but at low flows that is never an issue UNLESS the patient goes apneic for a bit and you don't take over breathing for them. I typically run my flows at .2 to .4 LPM.

Anything that makes my job easier, more predictable, and arguably faster is a good thing in my book. Love Des.

-pod

 

[Noyac]

I use Des for everything except cardiac cases where I use Iso (because that is what is on the bypass machine), pediatric inhalational cases, and cases where high flows are required (shared airway, bronch etc).

It is definitely more analgesic than other agents. So I use less opiates and patients have higher minute ventilation at the end of the case. Patients are more awake faster in PACU. I never have to play the closure timing game when the surgeon decides to hand the closure over to his unpredictable PA. Severely morbidly obese patients wake up more predictably. I have far fewer of those outlier, long emergence cases, and the ones I do have don't take as long to wake up.

The patient would have to have extreme COPD, needing oxygen to survive the ride from preop to OR, before I really gave it a second thought.

One does have to be careful about not increasing concentration too quickly, but at low flows that is never an issue UNLESS the patient goes apneic for a bit and you don't take over breathing for them. I typically run my flows at .2 to .4 LPM.

Anything that makes my job easier, more predictable, and arguably faster is a good thing in my book. Love Des.

-pod

Best post on this thread.
Experience comes to the forefront.

 

[Noyac]

I used to use DES on almost all my LMA cases until in my own experience started seeing too freq instances of laryngospasm to be by chance where as I never had an issue with LMA and Sevo so now I never use DES with an LMA

But with GETA havent really seen much of a difference personally in terms of bronchospasm and I tend to favor DES over Sevo

What was your FGF?
I cannot remember ever having laryngospasm with DES and an LMA.

 

[periopdoc]

What was your FGF?
I cannot remember ever having laryngospasm with DES and an LMA.

I never had laryngospasm in Seattle, and I used Des extensively. I have had a few cases here in NW Montana, and it hasn't been in just the old COPD patients. I don't know if it is elevation, humidity, or ??? I do have to be more careful with rate of Des concentration rise here.

 

[deleted171991]

What was your FGF?
I cannot remember ever having laryngospasm with DES and an LMA.

I remember some people coughing more on wakeup with Des (back when I had it, before the bean counters removed it due to four letter *****s running it at 2L/min). But I also remember the speed and clarity of those wakeups, even in inexperienced hands. After years of solo experience, it is still difficult to match it with other agents.

 

[periopdoc]

After years of solo experience, it is still difficult to match it with other agents.

I would wager that if one is routinely matching his des wake ups with other agents, he is not using des to its full potential. Probably giving too much opiate.

-bsd

 

[BLADEMDA]

Sevoflurane was given to 746 patients, and 752 received desflurane. Three studies included children, with average ages of 3-4 years. Adult studies included patients with average ages of 29-74 years. Average surgical durations ranged from 18 minutes to 2.9 hours, and average anesthetic durations ranged from 19 minutes to 3.1 hours. The average patient among all studies was 38 years old, had a surgical duration of 1.2 hours, and had an anesthetic duration of 1.6 hours.

No significant correlation was detected between any of the study properties and one or more measures of patient recovery from anesthesia.

Patients receiving desflurane recovered 1 to 2 minutes earlier in the OR than patients receiving sevoflurane. They were obeying commands 1.7 minutes sooner (p < 0.001; 95% confidence interval [CI], 0.7-2.7 minutes), extubated 1.3 minutes sooner (p = 0.003; 95% CI, 0.4-2.2 minutes), and oriented 1.8 minutes sooner (p < 0.001; 95% CI, 0.7-2.9 minutes) ( Table 2 ).

We subtracted the time in minutes it took for the desflurane-treated groups to be discharged from the PACU from the time it took to discharge the sevoflurane-treated groups. No significant difference was detected in the recovery times in phase I PACU (indicates a patient:nurse ratio of 1:2 or less) or phase II (a nurseatient ratio of 1:3 or more) ( Table 3 ). Patients receiving desflurane were discharged from phase I PACU 1.0 minute sooner to 6.6 minutes later than patients receiving sevoflurane (p = 0.07) and were ready to be discharged to home 6.2 minutes earlier to 11.6 minutes later than patients receiving sevoflurane (ranges are the 95% CIs) (p = 0.28).

Twenty-two studies included PONV measurements, with 691 patients receiving sevoflurane and 691 patients receiving desflurane. No significant differences were detected in early or late nausea, vomiting, or treatment ( Table 4 ).

http://www.medscape.com/viewarticle/497811

 

[BLADEMDA]

Desflurane is superior in two groups of patients: the elderly and the obese
Other than those two groups of patients or wanting a fast wake up after 4-5 hours of anesthetic vapor sevo is just as good.

http://bja.oxfordjournals.org/content/91/4/502.full

http://www.ncbi.nlm.nih.gov/pubmed/15562085

 

[periopdoc]

Desflurane is superior across all age groups. A meta-analysis with severe limitations (combining results from 25 separate papers with no way to control for the actual method of anesthetic delivery), by pharmacists, that couldn't even get published in a real journal, does little to convince me otherwise.

I may only have 5-ish years of solo practice under my belt, but the evidence in that time is simply overwhelming. Now, if we are talking about a situation where one is working with CRNA's or residents, there may not be much of a difference. I wouldn't know

- bsd

 

[OB1🤙]

The pacu nurses asked me just the other day why my patients come out so much more awake than everyone else's.

It's the des.

 

[BLADEMDA]

The pacu nurses asked me just the other day why my patients come out so much more awake than everyone else's.

It's the des.

Sure. They may seem more awake but discharge time from pacu is similar so the net result is no difference. I've seen it make a difference in the elderly and the obese but not much in the other subgroups in terms of discharge time from PACU.

 

[periopdoc]

Although it can be extended by poor anesthetic technique, discharge time from PACU has almost nothing to do with anesthetic technique in all but the tightest run ships. The institutions who did the studies in the Medscape articles aren't running the tightest ships.

I have yet to be lucky enough to work in an evironment where my patients who arrive in PACU wide awake, talking and readdy to pee and eat get discharged faster than the inpatient who is just rousable and actually needs oxygen to maintain a reasonable oxygen saturation or still has an hour left on a spinal block.

Ok, that's a bit of an exaggeration, but not a huge one

-bsd

 

[BLADEMDA]

Although it can be extended by poor anesthetic technique, discharge time from PACU has almost nothing to do with anesthetic technique in all but the tightest run ships. The institutions who did the studies in the Medscape articles aren't running the tightest ships.

I have yet to be lucky enough to work in an evironment where my patients who arrive in PACU wide awake, talking and readdy to pee and eat get discharged faster than the inpatient who is just rousable and actually needs oxygen to maintain a reasonable oxygen saturation or still has an hour left on a spinal block.

Ok, that's a bit of an exaggeration, but not a huge one

-bsd

Desflurane results in more awake patients by about 10 minutes for most patients (except the elderly or obese) vs Sevoflurane. So, unless you are bypassing the PACU altogether (which may be possible with DES or TIVA with propofol the advantages of one vs the other is minimal for the majority of anesthetics under 3 hours in duration. I continue to use Sevo as my primary inhalational anesthetic of choice due to cost, convenience and bronchodilation vs Desflurane. I'm even using Isoflurane still from time to time in the right situations.

If the Desflurane is saving you time in turnover or getting your patients out of the PACU faster then it makes sense in your practice.

 

[BLADEMDA]

Savings of more than one hundred thousand dollars resulted from the change of using Desflurane to using Sevoflurane in the operating rooms at Montefiore Medical Center in the Bronx, New York. Traynor noted that three bottles of Desflurane are needed to maintain a level of anesthesia equal to that of one bottle of Sevoflurane, making this agent much less expensive for the hospital to utilize, with no difference in patient discharge times. Reviews of Literature indicated that patients who received Desflurane could be extubated in the operating room about two minutes sooner than the patients who received Sevoflurane; an advantage seen meaningless in the large scale of the operating room sequences.9,15

https://www.ukessays.com/essays/bio...le-inhalational-anesthetics-biology-essay.php

_______

If you use 2 liter flows for Sevo and 1.0 Liter flows for Des the cost analysis favors Sevo by a wide margin. That said, if the case is longer than 2 hours and you reduce the Flow to 0.5 liters for the DES the cost analysis shifts in favor of DES. I don't want my CRNAs to run less than 1 liter flows (air/Oxygen) so the cost equation shifts in favor of SEVO.

 

[Noyac]

Although it can be extended by poor anesthetic technique, discharge time from PACU has almost nothing to do with anesthetic technique in all but the tightest run ships. The institutions who did the studies in the Medscape articles aren't running the tightest ships.

I have yet to be lucky enough to work in an evironment where my patients who arrive in PACU wide awake, talking and readdy to pee and eat get discharged faster than the inpatient who is just rousable and actually needs oxygen to maintain a reasonable oxygen saturation or still has an hour left on a spinal block.

Ok, that's a bit of an exaggeration, but not a huge one

-bsd

Bingo!!!!

 

[Noyac]

Desflurane results in more awake patients by about 10 minutes for most patients (except the elderly or obese) vs Sevoflurane. So, unless you are bypassing the PACU altogether (which may be possible with DES or TIVA with propofol the advantages of one vs the other is minimal for the majority of anesthetics under 3 hours in duration. I continue to use Sevo as my primary inhalational anesthetic of choice due to cost, convenience and bronchodilation vs Desflurane. I'm even using Isoflurane still from time to time in the right situations.

If the Desflurane is saving you time in turnover or getting your patients out of the PACU faster then it makes sense in your practice.

I routinely skip PACU in shorter cases with little postop pain issues or with regional added.
But I will absolutely tell you that DES is way faster than TIVA for wake ups and recovery. Way faster!!!
I hate it when I am the late guy at the ambulatory center and I have to wait for someone's TIVA pt to recover at the end of the day because they didn't want them to puke.

Take that Blade

 

[Mman]

I routinely skip PACU in shorter cases with little postop pain issues or with regional added.
But I will absolutely tell you that DES is way faster than TIVA for wake ups and recovery. Way faster!!!
I hate it when I am the late guy at the ambulatory center and I have to wait for someone's TIVA pt to recover at the end of the day because they didn't want them to puke.

Take that Blade

I equally hate when I'm the last guy at the ambulatory center and the last patient of the day has severe PONV keeping me there for 2 hours after I'd otherwise have been home.

 

[pgg]

Savings of more than one hundred thousand dollars resulted from the change of using Desflurane to using Sevoflurane in the operating rooms at Montefiore Medical Center in the Bronx, New York. Traynor noted that three bottles of Desflurane are needed to maintain a level of anesthesia equal to that of one bottle of Sevoflurane, making this agent much less expensive for the hospital to utilize, with no difference in patient discharge times. Reviews of Literature indicated that patients who received Desflurane could be extubated in the operating room about two minutes sooner than the patients who received Sevoflurane; an advantage seen meaningless in the large scale of the operating room sequences.9,15

https://www.ukessays.com/essays/bio...le-inhalational-anesthetics-biology-essay.php

_______

If you use 2 liter flows for Sevo and 1.0 Liter flows for Des the cost analysis favors Sevo by a wide margin. That said, if the case is longer than 2 hours and you reduce the Flow to 0.5 liters for the DES the cost analysis shifts in favor of DES. I don't want my CRNAs to run less than 1 liter flows (air/Oxygen) so the cost equation shifts in favor of SEVO.

Sure, in the hands of the incompetent and untrainable, a lot of desflurane can be wasted. Not sure I see how your CRNAs' inability to turn the fresh gas flows down is a point in favor of sevoflurane.

Also, much as I love des and <0.5 lpm flows, there's another cost that usually doesn't get factored in: CO2 absorbent is consumed much more quickly with low flow / closed circuit anesthesia.

The honest truth is that I just don't care about the small difference in cost of anesthesia consumables, given the clinical superiority of desflurane.


Next topic: 9mm is superior to .45ACP. Go.

 

[deleted162650]

Next topic: 9mm is superior to .45ACP. Go.

Real men shoot 10mm

 

[deleted171991]

Real men shoot 10mm

Actually, real men shoot 50 µm.

 

[fakin' the funk]

I like that. What I do: turn des to 12 and FGF to 1L/min. Once ETdes is where I want it, I leave the gas at 12 and turn FGF to 0.4 oxygen and 0.1 air. Once the ET des stays around a MAC on this half liter/min, I turn down the dial to around 7-8.

Pacu recoveries with des are simply superior to anything else.

Funny you posted this.

Over the last month, this has become my exact technique/flows/des dial setting for maintenance.

You do have to run the flows higher (1-2L/min) after induction if your surgeon is fast in prep/drape/timeout. Or IV bolus of whatever.

 

[fakin' the funk]

You have them somewhat paralyzed on pressure support?

Yeah. That's what the flow/min trigger setting is for.

 

[fakin' the funk]

As a side, does anyone here use desflurane for LMA cases? I don't as I'm concerned about desflurane irritating the airway, but I do know some that use it. Just seeing what are others thoughts.

All the time. I prefer not to blast it in; in those cases I might blast in some 4-6% sevo and then convert to des.

 

[periopdoc]

Savings of more than one hundred thousand dollars resulted from the change of using Desflurane to using Sevoflurane in the operating rooms at Montefiore Medical Center in the Bronx, New York. Traynor noted that three bottles of Desflurane are needed to maintain a level of anesthesia equal to that of one bottle of Sevoflurane, making this agent much less expensive for the hospital to utilize, with no difference in patient discharge times. Reviews of Literature indicated that patients who received Desflurane could be extubated in the operating room about two minutes sooner than the patients who received Sevoflurane; an advantage seen meaningless in the large scale of the operating room sequences.9,15

https://www.ukessays.com/essays/bio...le-inhalational-anesthetics-biology-essay.php

_______

If you use 2 liter flows for Sevo and 1.0 Liter flows for Des the cost analysis favors Sevo by a wide margin. That said, if the case is longer than 2 hours and you reduce the Flow to 0.5 liters for the DES the cost analysis shifts in favor of DES. I don't want my CRNAs to run less than 1 liter flows (air/Oxygen) so the cost equation shifts in favor of SEVO.

A new low in essay selection for you Blade. An article who's results section reads

Results
Results are pending until the quasi-experimental research study is completed.

But, I will humor you by reading this "professional anesthesia student's" essay and perusing the references.



Regarding the Montefiore cost savings (published in the Pharmacy News Section of the throwaway ASHP rag), all I have to say is this

I'm certainly not going to change my practice because a residency program in NY ESTIMATED cost savings of $100k per year by removing Des from all their rooms rather than teaching their residents and CRNAs how to tailor their anesthetic technique (rather than drug selection) for optimal cost reduction.

How do I know they weren't optimizing their anesthetic technique for cost?

...three bottles of desflurane are needed to maintain the same level of anesthesia as one bottle of sevoflurane

Remind me not to hire any residents from Montefiore.



I would point you to a different article in this student essay's references that is actually from a reputable journal, Economic Considerations of the Use of New Anesthetics: A Comparison of Propofol, Sevoflurane, Desflurane, and Isoflurane - Anesthesia and Analgesia 1998;86:504-9

Propofol-based anesthesia was associated with the highest costs, whereas the costs of the new inhaled anesthetics sevoflurane and desflurane did not differ from those of a standard, isoflurane-based anesthesia regimen.

From a theoretical perspective, their conclusion blows me out of the water. I have never been able to get the numbers to work out similarly, when using similar FGF rates and a proper equation for calculating volatile anesthetic consumption. My calculations have always shown similar MAC hour cost between low flow Des and standard flow Sevo with both vastly exceeding low flow Iso. Their empiric evidence suggests my theoretical evidence has underrated the benefit of Des.

Their conclusion likely supports a long-held supposition of mine that the key cost differential is to be found in pharmacy acquisition cost. Any savings in consumption is completely overshadowed by the acquisition cost of the agents being compared.


Ultimately, in my practice setting, Des makes the most sense. Within a short time of dropping my patient off in PACU, I am back in the OR with the next patient. With Des, the first patient is much less likely to need some time of airway intervention. (admittedly an extremely rare issue with any agent, but still less common with Des). All I need in my entire career is one patient saved from a disastrous outcome to completely blow the economic arguments against Des out of the water.



-bsd

 

[deleted171991]

If I may point out that you cannot base your decisions on an article from 1998, when prices might have been much different (there was no generic sevo).

The truth is that, where money is an issue, people tend to use sevo (plus nitrous) to achieve almost the same outcomes as with Des. What is really unfortunate is that I see more and more academic programs restricting Des, which is a crime against resident education.

 

[periopdoc]

Real men shoot 10mm

Actually, real men shoot 50 µm.

Actually real men shoot 120 mm

-bsd

 

[BLADEMDA]

I've used DES and SEVO for many cases. I just don't see that much of a difference after extubation especially in the PACU. I do see the elderly and obese wake up much, much quicker with DES and I clearly see the advantages with Sleep Apnea or other airway concerns. But, for the average 45 year old getting a knee scope or Lap Chole I just don't see any demonstrable clinical difference in wake-up times or discharge times.

Anyway, for LMA cases SEVO is the superior agent but for the obese or elderly DES wins hands down. POD is convinced DES is the way to fly for his cases so until he does a few thousand with SEVO his mind is made up.