Switching Volatile Mid Case

[GaseousClay]

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Any of you guys switch up volatile anesthetics regularly? Like a long case use iso/sevo for most of the time then switch to DES near the end? Works great in terms of speed of emergence and you don't really need nitrous if you're worried about n/v.

 

[Libertas]

I think there have been studies that it doesn't work?

My personal favorite is to turn the gas off and flow way up and hang a bottle of propofol for the last 30-45 minutes of a super long case.

 

[risnwb]

I prefer to not wake people up on any volatile. I turn it off and put them on nitrous. No switch, just turn ISO off earlier😉 More reliable quicker wakeup than any other technique I've tried. And to boot at my current place we only have Sevo! I thought I was gonna hate not having des and iso because I never used Sevo aside from peds as a resident, but I've gotten used to it now and it's all the same. Tube comes out as drapes come down.

 

[Velefunt]

No on other inhalation agents. For the longest time, my "switch-up" gas at case end was 70% nitrous/sevo-off for wakeup; Anecdotally did not have increased n/v.

 

[criticalelement]

I think there have been studies that it doesn't work?

My personal favorite is to turn the gas off and flow way up and hang a bottle of propofol for the last 30-45 minutes of a super long case.

Why would you start a drug that is even less titratable than a volatile agent?

 

[WholeLottaGame7]

I think there have been studies that it doesn't work?

My personal favorite is to turn the gas off and flow way up and hang a bottle of propofol for the last 30-45 minutes of a super long case.

The study that I always see/hear quoted was a crap study looking at short exposures in healthy volunteers (no surgeries). I'll see if I can find it again...just, later, when it's not 70 and sunny and I got out early...

 

[pgg]

Any of you guys switch up volatile anesthetics regularly? Like a long case use iso/sevo for most of the time then switch to DES near the end? Works great in terms of speed of emergence and you don't really need nitrous if you're worried about n/v.

No. It's easier to just run desflurane at about 0.4 lpm of fresh gas flow the whole case. Only time I use isoflurane is if I don't plan on waking up the patient.

 

[fakin' the funk]

Only times I change are:

a) Blast with sevo for the first 10 minutes after LMA or intubation w/ sux, then switch to des after they're deep. This allows them to get deep quickly, but avoids the tachycardia and airway noxiousness of des
b) During case, the plan changes to keep pt intubated after surgery...then go to iso

 

[Maverikk]

Yep, for a 6 hour hepatic resection or intracranial AVM I use iso on low flow, then the last thirty minutes switch to sevo...seems to be faster than waiting for that last 0.3 mac of iso to redistribute in morbidly obese. Haven't tried the propofol drip at the end, maybe I will...I don't see how titration would be a problem. Anyone ever do a lidocaine gtt, it's great for preventing cough on thyroids/eyes and has a MAC lowering effect, didn't believe it until I did..turn the sevo to 0.3 or less with lido at 1.5cc/kg/hr, lido wears off in about 5 min and makes the wake up smooth

 

[Twiggidy]

I stick to one agent and turn it off at the right time. We don't have Des so it's either sevo or iso and really I base it on my mood. Some of the longer gyn once I may run ISO but I turn it off when closing starts and keep a syringe of propofol on hand to manage movement or bucking

 

[WholeLottaGame7]

Here is the article I see quoted most often: http://www.ncbi.nlm.nih.gov/pubmed/9579499

So many problems:
1) From 1998
2) 5(!) healthy volunteers
3) 2-hr TOTAL length of "case" - 90 min then switch
4) 2LPM flows
The list goes on.

So it doesn't really apply to the cases I would tend to use it on: those long 8-hr robotic gyn/uro cases on "fluffy" patients or something equivalent. I definitely like des wakeups much more than iso. You can wake someone up with iso equally fast, but anecdotally people seem to be much sharper and alert in PACU and on the floor afterwards.

Is switching better than doing the same thing with nitrous or propofol or just using des the whole time? Probably not. A little cheaper than using straight des, but c'mon, we're talking pennies here.

Just don't NOT do it because some attending told you that there was a study saying that there was no difference, is all I'm saying. Form your own conclusions.

 

[deleted162650]

I think switching agents is a little silly. If you're after a rapid emergence then just use the less soluble gas from the beginning as others have mentioned. If your after "cost savings" that's even sillier. To adequately get rid of the ISO you have to either run high flows once you switch or switch pretty early to the point where you're burning pretty much the same amount of pricey agent as if you just did the whole case with it. More importantly though, I really don't give a crap how expensive my anesthetic is. The patient is gonna be charged the same regardless of what you give and unless the hospital is floating you a fat subsidy and supplying you with all the latest and greatest toys when you ask for them I have no interest in trying to save them a few extra dollars just so the CEO can get a bigger pat on the back from the board members.

N2O won't increase PONV if you're running it for < 45 min and it's a great way to wake people up.

 

[fakin' the funk]

turn the sevo to 0.3 or less with lido at 1.5cc/kg/hr, lido wears off in about 5 min and makes the wake up smooth

What

 

[Gas you down]

I wonder if switching agents increases the anesthesia drug charges significantly. if so, I wouldn't do it, simply to save costs.

 

[pgg]

I know someone who goes the other direction and switches from sevo to iso to slow down wakeups. He does it for BMTTs he takes deep to the PACU, because the iso gives him more hallway transport time before the kid reaches stage 2. He also claims less emergence delirium.

 

[deleted162650]

I know someone who goes the other direction and switches from sevo to iso to slow down wakeups. He does it for BMTTs he takes deep to the PACU, because the iso gives him more hallway transport time before the kid reaches stage 2. He also claims less emergence delirium.

This actually makes good sense to me in this situation (as does switching to iso if the plan changes mid-case to go to the unit tubed). I think it's pretty well established that pediatric emergence delirium is worse/more common with the less soluble agents (Des being the worst offender). Our local children's hospital trailed des for a while back in the day but abandoned it due to emergence delirium issues.

 

[Twiggidy]

He also claims less emergence delirium.

i might buy that. i feel like people wake smoother on iso, slower, but smoother

 

[WholeLottaGame7]

I know someone who goes the other direction and switches from sevo to iso to slow down wakeups. He does it for BMTTs he takes deep to the PACU, because the iso gives him more hallway transport time before the kid reaches stage 2. He also claims less emergence delirium.

It certainly decreases his awareness of the emergence delirium... ;-)

 

[narcusprince]

Call me a heretic but in adults I feel the faster you emerge them the quicker they are to extubate and you speed through the adult emergence delerium phase. I switch after 3 hrs from iso/sevo to des/nitrous. It is my anecdotal evidence in adults the faster you emerge the quicker they are to extubate and follow commands, I have seen very few laryngospasms with this approach. In peds this is different because their brain higher centers are not complete. Also what decreases emergence delirium is not giving versed, also explaining to the patient that they may wake up witha breathing tube in place.

 

[pjl]

We got rid of Iso at our hospital, except in the 2 rooms that we use for hearts and ICU players. We were wasting a fair amount of money on expired Iso.

Why not just use your final volatile the whole case?
*Exception for those that like to wake up on nitrous but dont use during case (whole different discussion there)

Something for the residents:
On your forced PACU rotation, try to guess which gas patients got during the case based solely on appearance, alertness,, and recovery postoperatively. Then check the record. Let me know if you can do it, and if it alters your future practice.
You have to make that time interesting somehow...

 

[Mman]

If you know what you are doing you can use any of the gas agents and wake somebody up in a prompt manner regardless of how long the case is. Can you switch agents mid case? Sure. Seems overly complicated to me, though. We routinely use isoflurane and extubate patients promptly after 4+ hour cases.

 

[pgg]

It's not that one can't extubate any patient any time with any gas, with practice - it's that gas choice influences the rest of their emergence during phase 1 and 2 recovery, when we're long gone. If PACU time matters, then isoflurane is inferior to des and sevo for everything but short cases, no matter how skillfully you woke and extubated them in the OR.

This is of course just my opinion. 🙂

 

[Mman]

It's not that one can't extubate any patient any time with any gas, with practice - it's that gas choice influences the rest of their emergence during phase 1 and 2 recovery, when we're long gone. If PACU time matters, then isoflurane is inferior to des and sevo for everything but short cases, no matter how skillfully you woke and extubated them in the OR.

This is of course just my opinion. 🙂

Not exactly. It depends on how long patients spend in PACU and where they go after PACU and what criteria there are for moving from one place to the next. If you are sending somebody home straight from PACU, Iso is probably not the best choice for a 5 hour surgery. If they are getting admitted overnight and will be in their room on the floor in 60 minutes regardless it's far cheaper than any other agent.

 

[OB1🤙]

Decision tree:

Pt stays intubated after= use iso the whole time.

Pt wakes up at end=use low flow des the whole time.

Take over a case= finish with whatever is on.

 

[pgg]

Not exactly. It depends on how long patients spend in PACU and where they go after PACU and what criteria there are for moving from one place to the next. If you are sending somebody home straight from PACU, Iso is probably not the best choice for a 5 hour surgery. If they are getting admitted overnight and will be in their room on the floor in 60 minutes regardless it's far cheaper than any other agent.

I would agree that if PACU time doesn't matter, gas doesn't really matter either.

I think the cost angle is way overblown. Desflurane run at under 0.5 lpm fresh gas flows is inexpensive. Isoflurane with low flows is even less expensive than that, but it's the difference between $1-2 per MAC hour and $3-4 per MAC hour. They're both so cheap that it doesn't matter. Cost is lost in the noise of everything else we do for anesthesia, and that's not even considering the cost of everything else in the OR.

ETTs are a lot cheaper than LMAs, but no one looks at you funny for using a LMA.
Vecuronium is cheaper than rocuronium, but no one looks at you funny for using roc.
It's just odd to keep hearing the cost argument for using isoflurane.

 

[Mman]

I would agree that if PACU time doesn't matter, gas doesn't really matter either.

I think the cost angle is way overblown. Desflurane run at under 0.5 lpm fresh gas flows is inexpensive. Isoflurane with low flows is even less expensive than that, but it's the difference between $1-2 per MAC hour and $3-4 per MAC hour. They're both so cheap that it doesn't matter. Cost is lost in the noise of everything else we do for anesthesia, and that's not even considering the cost of everything else in the OR.

ETTs are a lot cheaper than LMAs, but no one looks at you funny for using a LMA.
Vecuronium is cheaper than rocuronium, but no one looks at you funny for using roc.
It's just odd to keep hearing the cost argument for using isoflurane.

A penny saved is a penny earned. We are approaching 100,000 cases per year. A couple bucks here or there per case adds up to a lot of money. And our Iso costs are a lot less than Des per MAC hour, I mean the bottle costs about 1/4 and the MAC is about 1/5.

 

[pgg]

A penny saved is a penny earned. We are approaching 100,000 cases per year. A couple bucks here or there per case adds up to a lot of money. And our Iso costs are a lot less than Des per MAC hour.

I wonder if your penny saved is five pennies lost by the hospital. Are you ignoring or not considering externalized costs to using isoflurane that your group doesn't care about, because they're borne by someone else?

If you save $2 per case by using isoflurane instead of desflurane, but PACU stays average 5 minutes longer and that extra time of 2:1 phase 1 nursing care costs the hospital an extra $10 compared to the 4:1 nursing care in phase 2 ... good for you and your group sure, not so good for the system.


It's analogous to what's being discussed in the other thread about IV acetaminophen. Another 5 mg of IV morphine might have equipotent analgesia compared to 1000 mg of IV acetaminophen, at a cost saving of $6. But if the extra PONV you get from the morphine costs a dose of ondansetron and 15 extra minutes in the PACU, are you really saving money by using cheap IV morphine instead of expensive IV acetaminophen?

 

[Mman]

I wonder if your penny saved is five pennies lost by the hospital. Are you ignoring or not considering externalized costs to using isoflurane that your group doesn't care about, because they're borne by someone else?

If you save $2 per case by using isoflurane instead of desflurane, but PACU stays average 5 minutes longer and that extra time of 2:1 phase 1 nursing care costs the hospital an extra $10 compared to the 4:1 nursing care in phase 2 ... good for you and your group sure, not so good for the system.

No, I'm considering all that. Our PACU patients have a minimum stay length. They don't get to leave whenever they first meet discharge criteria. So when we analyzed it there is no difference in PACU LOS based on choice of anesthetic gas. Now if your institution has a policy that they don't have to stay for a minimum amount of time, say they can be sent to outpatient area in 10 minutes after arrival if they meet criteria then it might be a different story.

 

[deleted162650]

A penny saved is a penny earned. We are approaching 100,000 cases per year. A couple bucks here or there per case adds up to a lot of money. And our Iso costs are a lot less than Des per MAC hour, I mean the bottle costs about 1/4 and the MAC is about 1/5.

So is the hospital somehow kicking back some of the money saved to your group, or are you guys responsible for providing your own drugs?

 

[Mman]

So is the hospital somehow kicking back some of the money saved to your group, or are you guys responsible for providing your own drugs?

Nope, just part of being a good partner with the hospital to maintain a profitable private enterprise. That's why an AMC trying to replace us would fall on their face. We care about the hospital's bottom line just like we care about our own.