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[chocomorsel]

Do it all the time. I never extubate “awake” (eyes opening and following commands). Rarely give propofol.

I used to work in a very fast turnover place out west doing a lot of spines. Had my share of bad experiences trying to extubate deep, semi deep with lots of narcs, etc.
I stopped doing it because I am a small female with a BMI of 20 who can’t outmuscle a fit 30 year old, or more realistically an obese 50 year old man with a BMI double mine. I had too many turning ashen, desating patients and decided the extra five minutes turn over was just gonna have to be.

Now I rarely do it unless the person is about my size or smaller. I find the rush of turnover in some ORs to be often unnecessary.

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[Noyac]

What I’m there for primarily is to train residents how to do anesthesia safely. Also, I’m not exactly sure how the F you think what I said “That [pulling the tube near-awake] is what I do as well and what I tell my residents to do once I’m confident they can manage minor airway complications” has anything to do with insecurities. Insecure would be making them wake every pt up til the point of gagging, bucking, coughing, coming off the table, punching the circulator in the face and then telling them not to pull it until I’ve finished my coffee and can be physically present.

Sorry I must have misread or misunderstood what I read.

 

[Noyac]

People are forgetting that Noyac works in a physician only practice, which means he is not placing an LMA and handing the patient to some nurse "anesthesiologist" keeping his fingers crossed.
There are many things I do differently when I am the one doing the case.

Hell I forget it myself sometimes.

 

[Noyac]

People are forgetting that Noyac works in a physician only practice, which means he is not placing an LMA and handing the patient to some nurse "anesthesiologist" keeping his fingers crossed.
There are many things I do differently when I am the one doing the case.

Wait a minute! Are you saying that I have it easy?

 

[chocomorsel]

Hell I forget it myself sometimes.

You are a lucky dude.

 

[Beeftenderloin]

I see a lot of people talking about specific MAC values and EtSevo numbers none of which have anything to do with the risk of laryngospasm. Laryngospasm happens when you mess with airway (pull the tube) in stage 2 (disconjugate gaze, irratic breathing pattern, tachycardia, excitation etc). If pull the tube before or after that you’re safe. Doesn’t matter if EtSevo is at 2.0 or 0.3. Though I will say I typically supplement with prop at lower MAC values. I would guess that folks who have run into trouble with L-spasm at lower MAC values were likely entering stage 2 and did realize it.

I’m open to someone changing my mind on this, but this is what I was taught and this has been my experience.

 

[vector2]

I see a lot of people talking about specific MAC values and EtSevo numbers none of which have anything to do with the risk of laryngospasm. Laryngospasm happens when you mess with airway (pull the tube) in stage 2 (disconjugate gaze, irratic breathing pattern, tachycardia, excitation etc). If pull the tube before or after that you’re safe. Doesn’t matter if EtSevo is at 2.0 or 0.3. Though I will say I typically supplement with prop at lower MAC values. I would guess that folks who have run into trouble with L-spasm at lower MAC values were likely entering stage 2 and did realize it.

I’m open to someone changing my mind on this, but this is what I was taught and this has been my experience.

You’d agree that Stage 2 is related to MAC in as far as something like laryngospasm has essentially a 0% incidence at 1.5-2 MAC (isoelectric eeg, no airway reflexes, volatile causing dose dependent muscle relaxation) and a 0% incidence at 0 MAC (awake, perfectly intact higher cortical function control over laryngeal muscles)?

 

[Beeftenderloin]

You’d agree that Stage 2 is related to MAC in as far as something like laryngospasm has essentially a 0% incidence at 1.5-2 MAC (isoelectric eeg, no airway reflexes, volatile causing dose dependent muscle relaxation) and a 0% incidence at 0 MAC (awake, perfectly intact higher cortical function control over laryngeal muscles)?

Of course I would agree with that. I was merely pointing out that stage 2 is assessed clinically, not based on specific MAC or Etvapor numbers.

 

[vector2]

Of course I would agree with that. I was merely pointing out that stage 2 is assessed clinically, not based on specific MAC or Etvapor numbers.

I agree that stage 2 ultimately has to be assessed clinically, but I disagree with your statement “doesn’t matter if Etsevo is at 2.0 or 0.3” ....at least if we’re playing the probabilities of something bad happening at each of those respective levels before knowing anything else about the patient.

 

[deleted697127]

You’d agree that Stage 2 is related to MAC in as far as something like laryngospasm has essentially a 0% incidence at 1.5-2 MAC (isoelectric eeg, no airway reflexes, volatile causing dose dependent muscle relaxation) and a 0% incidence at 0 MAC (awake, perfectly intact higher cortical function control over laryngeal muscles)?

Definitely agree that likelihood is lower deep or essentially awake but i don’t think you ever reach 0% chance of laryngospasm. You can laryngospasm without any anesthesia as can happen during drowning. It’s a reflex that i don’t believe you could ever completely turn off.