Anesthesia without scavening systems

[jwizle]

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Hey guys,

I'm looking to hear what you all think. I'm starting a new gig at a outpatient plastics place that does not have a scavenging system and no anesthesia gas. The previous doc mixes remi and propofol in 1 syringe and apparently has done this for 10 years without issue. Thoughts ?

 

[deleted87051]

That is a reasonable tiva but what else don’t they have? That place wouldn’t pass our inspection/survey for new sites.

 

[cchoukal]

Devils advocate: no gas, no need to scavenge. But Nimbus’ point is correct. What else is missing?

 

[CopaceticOne]

I’m going to guess no succinylcholine, no dantrolene

 

[painquestions8989]

I’m going to guess no succinylcholine, no dantrolene

Would you be ok if there's roc?

 

[CopaceticOne]

Would you be ok if there's roc?

I’m not working in that place, so it isn’t a question I’ll need to answer.

What’s the IM dose of roc for a 80kg adult?

 

[Lab Lover]

I’m not working in that place, so it isn’t a question I’ll need to answer.

What’s the IM dose of roc for a 80kg adult?

I’d be ok working at a surgicenter without sux. No IV—No surgery. Hence no need for IM roc. Should an IV fall out and subsequent laryngospasm and desire for IM roc—->the correct dose is ALL.

 

[<(^_^)>]

The market is good right now. Why subject yourself to this? I can make plenty working at places with adequate equipment/medications. Chances are you can too.

 

[CopaceticOne]

I’d be ok working at a surgicenter without sux. No IV—No surgery. Hence no need for IM roc. Should an IV fall out and subsequent laryngospasm and desire for IM roc—->the correct dose is ALL.

I don’t need a Joan Rivers type outcome.

I guess we all drawn the line somewhere.

 

[dannyboy1]

I work at a center like this. NBD, I just bring paralytics and reversals with me. Also McGrath, LMA, oral and nasal airways,ETTs. Emergency meds. This stuff is easily transportable in a small backpack. No need to make a big deal about it

 

[CopaceticOne]

I work at a center like this. NBD, I just bring paralytics and reversals with me. Also McGrath, LMA, oral and nasal airways,ETTs. Emergency meds. This stuff is easily transportable in a small backpack. No need to make a big deal about it

Or the facility can actually provide the proper equipment. NBD

Especially since they can afford it if plastic surgery.

 

[dannyboy1]

Or the facility can actually provide the proper equipment. NBD

Especially since they can afford it if plastic surgery.

I just care that the stuff is available. Why cause a problem. Dosent cost me anything to bring it.

 

[CopaceticOne]

I just care that the stuff is available. Why cause a problem. Dosent cost me anything to bring it.

You are buying all those supplies, right?

 

[dannyboy1]

You are buying all those supplies, right?

😉. My main job is in the hospital….

 

[deleted87051]

😉. My main job is in the hospital….

When McGraths first came out, our hospital bought 3 for the ORs. They all disappeared within a month. We’ve only had stand mounted glidescopes since then.

 

[dannyboy1]

When McGraths first came out, our hospital bought 3 for the ORs. They all disappeared within a month. We’ve only had stand mounted glidescopes since then.

They do tend to grow legs. That being said the McGrath is my personal one. Don’t think anyone at the hospital is missing some ETT, LMA sux and roc

 

[deleted87051]

They do tend to grow legs. That being said the McGrath is my personal one. Don’t think anyone at the hospital is missing some ETT, LMA sux and roc

Surgicenter should provide all of that stuff. You and they are stealing from the hospital.

 

[DesiredMemberName?]

Surgicenter should provide all of that stuff. You and they are stealing from the hospital.

Don’t make such a big deal about it! He’s just taking all the risk stealing from the hospital so the surgery center can save some money on supplies/meds. No big deal!

 

[dannyboy1]

Don’t make such a big deal about it! He’s just taking all the risk stealing from the hospital so the surgery center can save some money on supplies/meds. No big deal!

This is kind of getting out of hand. No one is talking about taking drugs that are used on a regular basis. I am basically carrying an “oh $hit bag of a few emergency drugs to be used in case of emergency. I have never actually needed to open the bag but it’s good to know it’s there. Almost everyone who works in an office based setting does the same….

 

[CopaceticOne]

This is kind of getting out of hand. No one is talking about taking drugs that are used on a regular basis. I am basically carrying an “oh $hit bag of a few emergency drugs to be used in case of emergency. I have never actually needed to open the bag but it’s good to know it’s there. Almost everyone who works in an office based setting does the same….

It is still blatant theft.

 

[CopaceticOne]

This is kind of getting out of hand. No one is talking about taking drugs that are used on a regular basis. I am basically carrying an “oh $hit bag of a few emergency drugs to be used in case of emergency. I have never actually needed to open the bag but it’s good to know it’s there. Almost everyone who works in an office based setting does the same….

That is why the facility needs to provide the supplies.

 

[dannyboy1]

Don’t make such a big deal about it! He’s just taking all the risk stealing from the hospital so the surgery center can save some money on supplies/meds. No big deal!

Think you are under the impression of a well stocked surgicenter. Think more along the lines of a doctors office that has a monitor, oxygen tank, and and ambu bag. Cases are all prop sedation. Healthy patients. There is a med room somewhere but I don’t know what it has and when it was purchased. That’s why I prefer to bring my own airway equipment. Guess I shouldn’t have some peace of mind while taking care of patients. You guys are making a huge deal over a vial of sux, roc and suggamadex. It literally costs pennies and is used and wasted without regard in the hospital. Probably less cost than one minute of a locums doc.

 

[painquestions8989]

This is kind of getting out of hand. No one is talking about taking drugs that are used on a regular basis. I am basically carrying an “oh $hit bag of a few emergency drugs to be used in case of emergency. I have never actually needed to open the bag but it’s good to know it’s there. Almost everyone who works in an office based setting does the same….

What about all the other docs that work at that center who don't steal and bring supplies with them? You are setting a bad precedent for everyone else and lowering standards by doing so.

 

[dannyboy1]

What about all the other docs that work at that center who don't steal and bring supplies with them? You are setting a bad precedent for everyone else and lowering standards by doing so.

Most docs that I know of that do office based carry their own emergency drugs and airway equipment.

 

[CopaceticOne]

Think you are under the impression of a well stocked surgicenter. Think more along the lines of a doctors office that has a monitor, oxygen tank, and and ambu bag. Cases are all prop sedation. Healthy patients. There is a med room somewhere but I don’t know what it has and when it was purchased. That’s why I prefer to bring my own airway equipment. Guess I shouldn’t have some peace of mind while taking care of patients. You guys are making a huge deal over a vial of sux, roc and suggamadex. It literally costs pennies and is used and wasted without regard in the hospital. Probably less cost than one minute of a locums doc.

Theft is still theft.

If you want piece of mind, do the right (and legal) thing - have the facility have proper supplies. Or just purchase your own.

Also, are you bringing the hospital’s dantrolene with that vial of sux?

 

[CopaceticOne]

Most docs that I know of that do office based carry their own emergency drugs and airway equipment.

I’m fine with that.

My issue is your stealing equipment and medications (which have finite expirations times at room temp) from your employer and making it seem like No Big Deal.

 

[deleted87051]

It literally costs pennies and is used and wasted without regard in the hospital. Probably less cost than one minute of a locums doc.

What is your justification for stealing supplies that cost “pennies”? Just buy it or have the facility buy it.

 

[dannyboy1]

I’m fine with that.

My issue is your stealing equipment and medications (which have finite expirations times at room temp) from your employer and making it seem like No Big Deal.

Sometimes I also use the hospitals printer and fax. I have even been known to take some ginger ale from the patient fridge in recovery. What can I say, I like to live on the edge 🙄

 

[deleted643396]

Think you are under the impression of a well stocked surgicenter. Think more along the lines of a doctors office that has a monitor, oxygen tank, and and ambu bag. Cases are all prop sedation. Healthy patients. There is a med room somewhere but I don’t know what it has and when it was purchased. That’s why I prefer to bring my own airway equipment. Guess I shouldn’t have some peace of mind while taking care of patients. You guys are making a huge deal over a vial of sux, roc and suggamadex. It literally costs pennies and is used and wasted without regard in the hospital. Probably less cost than one minute of a locums doc.

Are you in private practice or are you an employee? Is this office based anesthesia location very lucrative? Why are you willing to bear liability so a plastic surgeon can have a few extra bucks in his bank account? No one is shedding a tear about the hospital being stolen from. The problem is this kind of behavior enables these surgicenters to cut corners. If these medications are pennies then the surgicenter should be perfectly fine maintaining an adequate supply. Keep a few vials in a code box somewhere.

 

[dannyboy1]

Are you in private practice or are you an employee? Is this office based anesthesia location very lucrative? Why are you willing to bear liability so a plastic surgeon can have a few extra bucks in his bank account? No one is shedding a tear about the hospital being stolen from. The problem is this kind of behavior enables these surgicenters to cut corners. If these medications are pennies then the surgicenter should be perfectly fine maintaining an adequate supply. Keep a few vials in a code box somewhere.

Just per diem. Local, good rate. Pleasant people. Easy work. Why cause a stink when the solution is so simple? For the record, even if they have the drugs I need (they may, I never asked) I prefer to have them readily accessible in my bag than having to yell for some nurse to dust off a code cart while the patient is going south fast.

 

[pgg]

Think you are under the impression of a well stocked surgicenter. Think more along the lines of a doctors office that has a monitor, oxygen tank, and and ambu bag. Cases are all prop sedation. Healthy patients. There is a med room somewhere but I don’t know what it has and when it was purchased. That’s why I prefer to bring my own airway equipment. Guess I shouldn’t have some peace of mind while taking care of patients. You guys are making a huge deal over a vial of sux, roc and suggamadex. It literally costs pennies and is used and wasted without regard in the hospital. Probably less cost than one minute of a locums doc.

You risk getting fired from hospital if anyone finds out. Not worth it. There's someone at that hospital with no sense of humor and no tolerance who will relish burning you at the stake. They'll call the cops, the $ value of the stuff you swiped will be inflated (that 4x6 Tegaderm is probably $178) and next thing you know you're pleading out some felony because the DA was bored. Just don't.

Get on the internet and spend $200 and order the stuff for yourself, if subsidizing a substandard office-based-practice is what you want to do. (No judgment there; the cost/benefit analysis of doing so is a separate conversation.)

I have used henryschein.com in the past for things I wanted to take with me into the wilderness or on int'l travel to places with sketchy medical systems. They'll need a copy of your medical license for some things and any rx medications. So long as you don't want any scheduled drugs, it's easy.

 

[jwizle]

Back to my original question, for those with experience mixing remi and propofol in one syringe... any tips ?

 

[CopaceticOne]

Back to my original question, for those with experience mixing remi and propofol in one syringe... any tips ?

Shake it, don’t stir.

 

[deleted87051]

Back to my original question, for those with experience mixing remi and propofol in one syringe... any tips ?

I squirt remi 1mg into a 100ml bottle of propofol. Run the propofol at 50-100mcg/kg/min. Give small dose (50mg) ketamine up front. Usually lower end of that range is adequate. Do it for intubated MEP/SSEP spine patients…often run phenylephrine infusion with it. Probably not what you’d do in an office setting.

 

[ans2021]

Are these MAC cases or GA? Usually for GA its 1mg remi in 50mL prop start at 100mcg/kg/min. For MAC cases usually .5mg remi in 50mL prop and run much lower, but takes some practice so they don't go apneic. If there's no anesthesia machine/drugs I'd recommend not doing prop/remi and just running a prop infusion.

 

[pgg]

Back to my original question, for those with experience mixing remi and propofol in one syringe... any tips ?

I know some people do that and have success, but I don't like to mix infusions for the simple reason that I usually want to titrate the drugs independently.

On the occasions when I use propofol and remifentanil, I will usually keep the remi more or less constant throughout the procedure, maybe within a range of 0.1 - 0.2 mcg/kg/min, while propofol might get titrated anywhere between 50 and 200 or more mcg/kg/min. You can't do that if the ratios are fixed. It's not too much of an ordeal to get a second pump.

Beyond that there's a dealkilling problem - wasting/returning controlled substances doesn't really work if you're making anesthesia stew in one syringe.

The only person I've ever known who really swore that one-syringe TIVAs were awesome was a guy who was using the technique as subterfuge to conceal how much sufentanil he was diverting.

So, I'm not a fan.

 

[cchoukal]

I know some people do that and have success, but I don't like to mix infusions for the simple reason that I usually want to titrate the drugs independently.

On the occasions when I use propofol and remifentanil, I will usually keep the remi more or less constant throughout the procedure, maybe within a range of 0.1 - 0.2 mcg/kg/min, while propofol might get titrated anywhere between 50 and 200 or more mcg/kg/min. You can't do that if the ratios are fixed. It's not too much of an ordeal to get a second pump.

Beyond that there's a dealkilling problem - wasting/returning controlled substances doesn't really work if you're making anesthesia stew in one syringe.

The only person I've ever known who really swore that one-syringe TIVAs were awesome was a guy who was using the technique as subterfuge to conceal how much sufentanil he was diverting.

So, I'm not a fan.

My move, as well. I don't mix.

 

[deleted87051]

I know some people do that and have success, but I don't like to mix infusions for the simple reason that I usually want to titrate the drugs independently.

On the occasions when I use propofol and remifentanil, I will usually keep the remi more or less constant throughout the procedure, maybe within a range of 0.1 - 0.2 mcg/kg/min, while propofol might get titrated anywhere between 50 and 200 or more mcg/kg/min. You can't do that if the ratios are fixed. It's not too much of an ordeal to get a second pump.

Beyond that there's a dealkilling problem - wasting/returning controlled substances doesn't really work if you're making anesthesia stew in one syringe.

The only person I've ever known who really swore that one-syringe TIVAs were awesome was a guy who was using the technique as subterfuge to conceal how much sufentanil he was diverting.

So, I'm not a fan.

Had an attending during residency in the 1990s who was a TIVA enthusiast. He wrote a bunch of pharmacokinetics/pharmacodynamics papers about them. We used to do midaz/sufentanil TIVA in main OR. He also helped develop a midaz/ketamine/room air sedation protocol for pedi cath lab. He moved on to another institution because his wife started law school there. I later heard he died of an overdose there while at work. He always used multiple syringes. It’s easy to fill any syringe with saline, LR, or whatever and call it remi. If you put remi 1000mcg in 1000mg propofol, the pump will tell you exactly how much remi was infused.

 

[pgg]

Had an attending during residency in the 1990s who was a TIVA enthusiast. He wrote a bunch of pharmacokinetics/pharmacodynamics papers about them. We used to do midaz/sufentanil TIVA in main OR. He also helped develop a midaz/ketamine/room air sedation protocol for pedi cath lab. He moved on to another institution because his wife started law school there. I later heard he died of an overdose there while at work. He always used multiple syringes. It’s easy to fill any syringe with saline, LR, or whatever and call it remi. If you put remi 1000mcg in 1000mg propofol, the pump will tell you exactly how much remi was infused.

Our pharmacy requires returns of unused drugs via Pyxis. And then they (supposedly) spot check returns with density checking to verify it's not saline or something else.

For that reason alone, single-syringe cocktails containing controlled substances are a no-go here. Propofol is tracked here because "reasons" ...

Anyway. The clever addicts just document the drugs they divert as given to patients. It's foolproof and undetectable until either they overdose, get caught in the act of using, or start diverting ("administering") such large quantities that pharmacy notices.

It's been my experience that pharmacies don't really pay attention to quantities given to patients or patterns of use. We had a CRNA diverting at a hospital when I was in the Navy, and we only found out when he got caught in the act on a weekend day when he wasn't scheduled to work. Looking back at his records, he'd been documenting 2-4 mg of hydromorphone given to every colonoscopy he'd done for several months. Pharmacy never blinked, just kept filling and refilling and refilling that Pyxis.

 

[PpfSuxTube]

I just care that the stuff is available. Why cause a problem. Dosent cost me anything to bring it.

Isn't that called stealing actually?

 

[PpfSuxTube]

Back to my original question, for those with experience mixing remi and propofol in one syringe... any tips ?

Yeah don't do it. Its Ludacris.
Mixing oil and water and hoping it doesn't separate... all you end up giving it propofol after about the first 20 minutes of the case and the remi usually never gets in causes it volume is so small it sits on top and gets wasted...


Not just my opinion look it up

 

[T-burglar]

lol dude what’s your explanation to the people standing around and the EMS crew that takes the patient to the hospital for using drugs and equipment in an emergency that you shouldn’t legally have on your person?

 

[T-burglar]

so I’m just documenting for report to the receiving ED doctor, this patient got a gram of rocuronium IM? Where did the rocuronium come from?

 

[deleted87051]

Yeah don't do it. Its Ludacris.
Mixing oil and water and hoping it doesn't separate... all you end up giving it propofol after about the first 20 minutes of the case and the remi usually never gets in causes it volume is so small it sits on top and gets wasted...


Not just my opinion look it up

Those are theoretical considerations. In practice it works very well and is practiced widely all over the world. It doesn’t separate in 20min. I’ve done 6+ hour cases using the technique.

Single-Syringe Total Intravenous Anesthesia With Propofol... : Anesthesia & Analgesia

An abstract is unavailable.

journals.lww.com

 

[dannyboy1]

so I’m just documenting for report to the receiving ED doctor, this patient got a gram of rocuronium IM? Where did the rocuronium come from?

An anesthesiologist gave rocuronium to secure an airway emergently. What’s wrong or suspicious about that. Why in the world would an ED doctor care where the drugs were sourced. Also why is 1gram being given IM???

 

[CopaceticOne]

An anesthesiologist gave rocuronium to secure an airway emergently. What’s wrong or suspicious about that. Why in the world would an ED doctor care where the drugs were sourced. Also why is 1gram being given IM???

In the horrible even the patient had a bad outcome, the lawyers would absolutely find out.

 

[Lab Lover]

In the horrible even the patient had a bad outcome, the lawyers would absolutely find out.

Yup. They would next investigate where the drug came from and the truth would likely come ou. Next they would threaten to notify the hospital where they came from. The doc would be facing potential criminal charges, there are probably multiple violations of pharmacy rules for storage of meds., possible med staff or med board discipline if this came out. They would leverage this to get you to settle. Would look really bad.

 

[propadope]

Yeah don't do it. Its Ludacris.
Mixing oil and water and hoping it doesn't separate... all you end up giving it propofol after about the first 20 minutes of the case and the remi usually never gets in causes it volume is so small it sits on top and gets wasted...


Not just my opinion look it up

A potential issue with syringe pumps that hold the syringe vertical. Not really an issue if the syringe is horizontal like most pumps these days

 

[Gern Blansten]

An anesthesiologist gave rocuronium to secure an airway emergently. What’s wrong or suspicious about that. Why in the world would an ED doctor care where the drugs were sourced. Also why is 1gram being given IM???

The hospital local leadership would want answers. Local peer review would become involved. The state medical board would then be very interested. Then the civil litigation attorneys would get involved. It would likely also be headline worthy, depending on the circumstances.
It is all pretty standard stuff. You’d go from “hero to zero” pretty quickly, even if the outcome was favorable.

 

[T-burglar]

An anesthesiologist gave rocuronium to secure an airway emergently. What’s wrong or suspicious about that. Why in the world would an ED doctor care where the drugs were sourced. Also why is 1gram being given IM???

You… really can’t envision the questions and conversations that go on when you transfer a patient from a surgical center to a hospital ?