'Breathing down' an adult?

[Soparklion]

One of our attendings insists that we turn on 2% sevo after induction and ventilate for ~one minute before intubating. I can't see how 10 or even 20 breaths of 2% sevo can have a significant impact on an 80 lb adult patient... perhaps, perhaps it might reduce bronchoreactivity.

Is this a routine practice anywhere else?

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[abolt18]

One of our attendings insists that we turn on 2% sevo after induction and ventilate for ~one minute before intubating. I can't see how 10 or even 20 breaths of 2% sevo can have a significant impact on an 80 lb adult patient... perhaps, perhaps it might reduce bronchoreactivity.

Is this a routine practice anywhere else?

I have a few attendings who like to mask with some gas (usually put the sevo to 4-5% for that minute) then intubate. Just so you have the extra anesthetic onboard. No big difference for majority of cases where ETT goes in easily on first attempt, but definitely useful to have that gas in the lungs when you need to use a bougie or try a different blade.

 

[mikey014]

Yes I agree. If any of your attendings let you, have your patients breathe that for induction. It doesn't take long before they stop responding to verbal commands and painful stimuli especially if they are taking large frequent tidal volumes.

I find mask induction to be the most stable induction even compared to etomidate.

I use it for my ASA 4 - 5.

I have a few attendings who like to mask with some gas (usually put the sevo to 4-5% for that minute) then intubate. Just so you have the extra anesthetic onboard. No big difference for majority of cases where ETT goes in easily on first attempt, but definitely useful to have that gas in the lungs when you need to use a bougie or try a different blade.

 

[abolt18]

Yes I agree. If any of your attendings let you, have your patients breathe that for induction. It doesn't take long before they stop responding to verbal commands and painful stimuli especially if they are taking large frequent tidal volumes.

I find mask induction to be the most stable induction even compared to etomidate.

I use it for my ASA 4 - 5.

I should clarify, I'm not talking straight mask inductions. I'm talking about bolusing propofol and roc and then bagging for ~ a minute with sevo since the propofol redistributes so quickly sometimes.

 

[mikey014]

I should clarify, I'm not talking straight mask inductions. I'm talking about bolusing propofol and roc and then bagging for ~ a minute with sevo since the propofol redistributes so quickly sometimes.

Ya I think what doing straight mask inductions and they stop responding within a minute without anything on board .... Would suggest that the mask induction alone does have an effect.

You wouldn't be able to determine that if you have an IV induction or paralytic on board. ..... So I usually do combined IV and mask inductions for 1-2 min for young healthy or obese patients (110-120kg). Where 2mg/kg may be sufficient for most but not necessarily guarantee amnesia in 100% of patients. Since the propofol may wear off before you are ready for laryngoscopy from the roc.

 

[Chetamine]

i got away from masking with sevo for 1-2 minutes after pushing my propofol when I had a few pregnant OR nurses. I figured no reason to expose them if not necessary. I agree that it probably doesn't do much for an adult for such a short period of time. Now i just leave my O2 at 10L/min and don't mess with the vent/flows during the induction. I give an additional small dose of propofol right before I DL if I think they need it. I haven't noticed any real difference. Also it cuts down on the amount of things I am doing during induction.

 

[T-burglar]

just put the tube in and let em breathe sevo through that

 

[OTCAwesome]

Meh, I normally do it out of habit, if they have a good heart, normally 4-6 of sevo after I induce, if crappy heart +/-, if Trainwreck, you get versed and paralytic.

 

[woopedazz]

So you other guys induce with Propofol + Roc, and then sit there for 90-120 seconds BVM with plain O2?
Why not put on Sevo? You reduce the bolus of IV propofol and retain good depth at the time of intubation.

 

[coffeebythelake]

Because it is a HUGE waste for sevo. High gas flows and high sevo concentration. WHY. use more propofol

 

[deleted162650]

So you other guys induce with Propofol + Roc, and then sit there for 90-120 seconds BVM with plain O2?
Why not put on Sevo? You reduce the bolus of IV propofol and retain good depth at the time of intubation.

Because it’s one more (completely superfluous) step in your induction sequence.

You wanna be slick - cut out all unnecessary steps. Economy of movement.

 

[deleted162650]

Now if I was an academic attending, I would make my residents bag with the sevo on. Why?

A) higher chance it’s gonna take a while to secure the airway so nice to have some volatile already on board

B) it tells me how good your mask skills are. I can smell sevo = your mask skills suck = keep bagging till I can’t smell sevo anymore. I don’t care if your hand hurts. Need me to get you some Midol?? Here’s a straw - suck it up.

 

[thinkorswim]

If you're trying to be efficient and safe, this is neither...

1. It's a huge waste of sevoflurane and harmful to the environment.

2. The goal is to anesthetize the patient, not everyone else in the room. Turning the sevoflurane off once you're done masking will still blast it all over the operating room once you break that seal. If you turn your flows entirely off, that just adds one more step in turning them back up once you tube, which you may forget.

3. While masking, your end tidal sevo may show a high concentration, but take a closer look at it once the tube is in. You'll find that very little of it was actually making it into the patient.

If you want to add a little more anesthetic with a lot less effort, just put a squirt of propofol into your IV tubing after the paralytic and let it run in slowly while you mask. A poor man's propofol infusion.

 

[Maverikk]

This is definitely something to try in residency, in real clinical practice it's not necessary at best and at worst
1. pollutes the OR environment which if you have fertile OR circulators is a loss of style points
2. Probably doesn't anesthetize them as much as you think, that big end-tidal sevo you're seeing rapidly diminishes after the tube is in and how much you're seeing as end-tidal is a lot less than is in the blood
3. If you're doing just straight inhalational induction in adults which I did in training to see how it worked you'll see the downsides: longer than needed vs IV, if you're giving paralytic it's superfluous, you know how kids get a little agitated during stage 2 inhalational induction now picture an adult and hope you're circulator can hold them from squirming on the table and reaching for the mask.

The only reason I can think of for doing it in adults is for a potentially difficult airway where you're not going to paralyze and want to keep them spontaneous but don't want to do an awake. I actually haven't seen this method talked about much but I've done it a few times with good success, the downside is it's a longer induction, high flows but sevo at like 2-4. And you still have to anesthetize the airway/oropharynx bc they're not paralyzed.

 

[Hoya11]

Because it is a HUGE waste for sevo. High gas flows and high sevo concentration. WHY. use more propofol

is it a HUGE waste? disagree. make a seal with the mask. turn it off and flows down when intubating, worrying about the other people in the room inhaling a molecule of sevo from 10 feet away from your flows off/sevo off circuit? ridiculous. I do this all the time and no one has ever complained about smelling sevo.. do you worry about the people in the room when you are doing a mask induction with a kid? Even if you have 4% sevo in the line, 96% of the other molecules will be oxygen. You really think that from your mask, with the flows down and the gas off, that one of those molecules, which again is only 4% of the mix, will somehow travel to this person and have some sort of effect on their body?

And its not an extra step, it saves a step. it gets the ball rolling earlier.. as someone else said, your sitting there masking with no sevo anyhow, why not just turn on 1-2-3%. improve your intubating conditions, get the gas on sooner... and if any difficulty with airway you have gas on board now, i find it smoother since the longer acting sevo gets to work sooner, and you dont necessarily have to rely on the ups and downs of anesthesia from prop bolus

 

[Soparklion]

Given the amount of time required for inhalation induction in a large child, it is surprising that the inhalation induction time for adults is so short - about 60 seconds in a 70kg adult BJA 2005
Randomized comparison of three methods of induction of anaesthesia with sevoflurane † although time to induction was defined as:
"the sevoflurane vaporizer was set to 0.5%, and increased after every two breaths, in the sequence 1, 2, 4 and 8%. The time from when the vaporizer was set to 8% to the time when the arm became horizontal was taken as the time for induction of anaesthesia." but that would only be 8 breaths and <1 minute.

In the larger picture, the risk of adverse events in children was much higher with inhalation induction than IV induction. Although adults aren't big children...June 2018: Inhalational versus Intravenous Induction of Anesthesia in Children with a High Risk of Perioperative Respiratory Adverse Events:A Randomized Controlled Trial | Anesthesiology | ASA Publications

 

[deleted875186]

I typically turn on sevo in a healthy person because I feel it works better than giving more propofol.

BTW my opinion has slightly changed after reading that study on following commands after intubationwith the isolated forearm technique we were talking about a little while ago. Starting volatile before intubation tended to decrease the risk of being conscious after intubation.

Incidence of Connected Consciousness after Tracheal Intubation:A Prospective, International, Multicenter Cohort Study of the Isolated Forearm Technique | Anesthesiology | ASA Publications

 

[Robotic Wis-Hipple]

Yes I agree. If any of your attendings let you, have your patients breathe that for induction. It doesn't take long before they stop responding to verbal commands and painful stimuli especially if they are taking large frequent tidal volumes.

I find mask induction to be the most stable induction even compared to etomidate.

I use it for my ASA 4 - 5.

Now I admit I don’t mask induce in my practice, but it has been my experience that adult patients hate it, their stage 2 takes forever, and with my avg 100+kg Pt I’d rather not deal with a disoriented slightly disconnected yet reactive Pt on the table. But I also haven’t given etomidate since residency so maybe I’m weird.

 

[Beeftenderloin]

I don’t know if it’s just cultural or if people have actually thought about it and discussed it but this practice is standard across the board at my training institution. Virtually every attending on every (“normal”) patient. Prop, roc, mask with sevo in O2 while the roc circulates, then tube.

 

[Robotic Wis-Hipple]

I don’t know if it’s just cultural or if people have actually thought about it and discussed it but this practice is standard across the board at my training institution. Virtually every attending on every (“normal”) patient. Prop, roc, mask with sevo in O2 while the roc circulates, then tube.

Because there’s at least 10 ways to skin this cat. I don’t see anything wrong with this technique at all, especially in training institutions/scenarios.

 

[pgg]

If you need the fresh gas flow set at 10 to mask ventilate a patient, you should get better at mask ventilating.

In any case, if you're not mask inducing a kid or doing a heart, you should be using desflurane anyway.

 

[Soparklion]

In any case, if you're not mask inducing a kid or doing a heart, you should be using desflurane anyway.

These guys imply that you'll save money with iso... although it didn't include the cost of any propofol that they had to bolus if the patient woke up a bit too quickly...

 

[nimbus]

One of our attendings insists that we turn on 2% sevo after induction and ventilate for ~one minute before intubating. I can't see how 10 or even 20 breaths of 2% sevo can have a significant impact on an 80 lb adult patient... perhaps, perhaps it might reduce bronchoreactivity.

Is this a routine practice anywhere else?

No. Many of my partners and I don’t mask ventilate at all prior to intubation.

 

[nimbus]

So you other guys induce with Propofol + Roc, and then sit there for 90-120 seconds BVM with plain O2?
Why not put on Sevo? You reduce the bolus of IV propofol and retain good depth at the time of intubation.

No need to wait or ventilate with anything. Just mix the prop and roc and intubate when they become apneic. It works.

 

[Soparklion]

No. Many of my partners and I don’t mask ventilate at all prior to intubation.

I totally agree with that, especially when the patient is a known routine intubation - I work in an academic center with a lot of frequent fliers.

 

[Hork Bajir]

Beat argument I can think of for turning on the sevo prior to intubation (and this is only if you’re going to mask before intubation anyway for some other reason) is bc the time constant for equilibration of volatile between brain and blood is somewhere between 3 and 9 minutes depending on which volatile you’re using. So consider the following scenario:

- You use a judicious amount of prop to cause unconsciousness without way overdoing it and causing hypotension (good job!)
- However many minutes later, tube goes in +/- some extra prop first (crushing it!)
- You turn on some volatile, and adjust your flows so that you’re not overdosing the flurane and causing hypotension before incision (tastefully done!)
- Now your end tidal flurane is reading 0.8 MAC or whatever... but it could be up to 9 minutes before the brain really sees that same concentration! Not so slick, especially when you consider that a large proportion of cases of awareness happen in that period after induction but before incision

So in my mind, turning on the sevo early will start the timer on equilibration between blood and brain, and help prevent awareness/maintain stable depth of anesthesia after induction. Does it require marginally more twiddling of knobs and dials during induction? Sure. Could you accomplish something similar by giving more prop (either as small boluses or some kinda infusion)? Sure. But it’s a valid technique.

 

[skypilot]

No. Many of my partners and I don’t mask ventilate at all prior to intubation.

Yes, just one step: 1. Put it in.
Now, for residents its a whole different story. You want them to practice all the possible steps.

 

[2Fast2Des]

No. Many of my partners and I don’t mask ventilate at all prior to intubation.

In residency attendings wouldn't push roc until you could "prove" that you could ventilate with prop in. I still mask ventilate now as a habit but roc follows immediately after prop and make sure that good ETO2 gives me room in case, sometimes that "easy looking person" can throw a wrench at DL.

You guys don't feel mixing prop with roc causes any issue with any awareness? In case the roc kicks in a bit more than before prop?

 

[thinkorswim]

You guys don't feel mixing prop with roc causes any issue with any awareness? In case the roc kicks in a bit more than before prop?

I have not had or heard of any cases of awareness when mixing both. I even had attendings in training who would give some of the rocuronium even before pushing the propofol. At non-RSI dosing, the onset is long enough where it shouldn't matter if your propofol is dosed appropriately.

Now if you're using succinylcholine, that's a different story. I have actually heard of cases where patients felt awake and paralyzed following an RSI, albeit only for a moment until the propofol took effect.

 

[thinkorswim]

In any case, if you're not mask inducing a kid or doing a heart, you should be using desflurane anyway.

I've had a couple really nasty bronchospasms recently using desflurane. One was even while using an LMA and left the patient practically coughing up a lung in the PACU for an hour after surgery. I try to avoid it now in patients with asthma or any hint of reactive airway disease.

 

[nimbus]

You guys don't feel mixing prop with roc causes any issue with any awareness? In case the roc kicks in a bit more than before prop?

Not yet

 

[AdmiralChz]

Now if you're using succinylcholine, that's a different story. I have actually heard of cases where patients felt awake and paralyzed following an RSI, albeit only for a moment until the propofol took effect.

I saw this personally during CA-3 year. Patient looked at me and started fasciculating before unconsciousness. Patient didn’t remember but I won’t forgot that look of dread and pain. Now I wait just a few seconds before pushing sux rather than all at once.

 

[drmwvr]

I typically turn on sevo in a healthy person because I feel it works better than giving more propofol.

BTW my opinion has slightly changed after reading that study on following commands after intubationwith the isolated forearm technique we were talking about a little while ago. Starting volatile before intubation tended to decrease the risk of being conscious after intubation.

And so does appropriate pre-op sedation.

 

[drmwvr]

I should clarify, I'm not talking straight mask inductions. I'm talking about bolusing propofol and roc and then bagging for ~ a minute with sevo since the propofol redistributes so quickly sometimes.

This hits in an off way...For all the reasons of adding or not adding sevo to your induction, a perceived shortcoming of diprivan shouldn't be one of them. We employ the drug to behave in such a way that particular goals are met. It is entirely reasonable to expect the propofol to be all you need for a stable induction. Get passed that, then add complexity.

 

[abolt18]

This hits in an off way...For all the reasons of adding or not adding sevo to your induction, a perceived shortcoming of diprivan shouldn't be one of them. We employ the drug to behave in such a way that particular goals are met. It is entirely reasonable to expect the propofol to be all you need for a stable induction. Get passed that, then add complexity.

I was not saying the redistribution of propofol was a shortcoming, rather I'd say that it is just a property of the drug. In some people it seems to happen awfully fast, and rather than having to re-dose the propofol after your first airway attempts were unsuccessful, you've already got some gas onboard. Honestly though, this is not a technique I employ personally. It is just one that some of my attendings really seem to like.

 

[rakotomazoto]

To waste that much time and sevo on a routine induction just seems excessive. The roc will kick in faster if you give it before attempting ventilation. Most attendings I had in residency made us prove it first, too. But the smarter ones taught me that paralyzing will only make masking easier. If it still remains difficult to mask despite giving roc and using an OPA, then proceed to intubation or LMA placement and secure the airway more definitively.

I had attendings who did the Sevo induction thing in residency, but out in the real world, I find myself pushing all drugs together and if they are well pre-oxygenated (mask on prior to placing monitors) then I go straight to intubation and turn on the gas once intubated. Why waste time mask ventilating? I push the meds directly into the port most proximal to the patient, standing at their side, rather than flushing them in from the port closest to me at the head of the bed. By the time I walk those couple steps to the head of the bed and pick up the laryngoscope, most patients are sedated and relaxed and I put the tube in. If not, I wait for a few seconds and mask while waiting for the propofol/roc to do their thing. However, this is rarely necessary.

The whole process is sooo much faster now that I don't have to do it with an attending standing there slowing me down. Also, where I trained it was blasphemy to intubate without a stylet. It's a training institution, I guess I see why they might want that. But now, I just place an unopened stylet out on the machine and go for it. Only very rarely do I find myself reaching for it. That is one less awkard step of pulling it yourself or having an assistant do it for you.

 

[coffeebythelake]

is it a HUGE waste? disagree. make a seal with the mask. turn it off and flows down when intubating, worrying about the other people in the room inhaling a molecule of sevo from 10 feet away from your flows off/sevo off circuit? ridiculous. I do this all the time and no one has ever complained about smelling sevo.. do you worry about the people in the room when you are doing a mask induction with a kid? Even if you have 4% sevo in the line, 96% of the other molecules will be oxygen. You really think that from your mask, with the flows down and the gas off, that one of those molecules, which again is only 4% of the mix, will somehow travel to this person and have some sort of effect on their body?

And its not an extra step, it saves a step. it gets the ball rolling earlier.. as someone else said, your sitting there masking with no sevo anyhow, why not just turn on 1-2-3%. improve your intubating conditions, get the gas on sooner... and if any difficulty with airway you have gas on board now, i find it smoother since the longer acting sevo gets to work sooner, and you dont necessarily have to rely on the ups and downs of anesthesia from prop bolus

For adult patients, I use sevoflurane with induction very sparingly and in select situations. It irks me when people give IV induction agents then turn on the sevoflurane while masking the patient until they intubate. The benefit is minimal, the cost is high.

Most people induce patients on 10L FGF. They also overpressurize the system with >>2% sevo to quickly uptake the sevo. That's a HUGE waste of sevoflurane EVEN if you have a good mask seal.

At high FGF the patient will not be rebreathing the sevo. It leaves the OR and goes out a chimney.

It doesn't matter that you turn off the sevoflurane before you intubate.

Studies have shown that induction period is when greatest volatile anesthetic is "wasted" exactly for this reason.

Now if you have your own technique taking this into account, fine, but most people have no idea.

 

[coffeebythelake]

This hits in an off way...For all the reasons of adding or not adding sevo to your induction, a perceived shortcoming of diprivan shouldn't be one of them. We employ the drug to behave in such a way that particular goals are met. It is entirely reasonable to expect the propofol to be all you need for a stable induction. Get passed that, then add complexity.

I cycle my cuff Q1-2.5 minute during the induction phase.
I give propofol with induction, usually immediately after the cuff cycles, mask, then before intubation give another smaller dose of propofol if BP tolerates
works well.

 

[T-burglar]

Mixing sux and induction agent has beeen studied. zero recall. I mix hypnotic opioid and 100mg of roc in one syringe and push it. Never had an issue. Even in cardiac patients

 

[deleted162650]

I’ll mix prop/roc/lido in 1 syringe for robust ASA 1/2’s. For everyone else I like separate syringes so I can get all the roc in while maintaining the ability to titrate the prop.

I also like to mask while my prop/roc are soaking in. I think it gives me valuable information come emergence time. Easy to mask = I can be a little more cavalier on extubation. Bitch to mask = I’ll be more conservative.

Those who worry about recall haven’t spent enough time in GI lab. I’m continually surprised/amazed how long a 1/2 induction dose of prop lasts. Even when they get stimulated/light enough to make purposeful movements, they don’t remember jack.

 

[DrOwnage]

This practice has always bothered me, and when I've asked attendings to justify it they never give a legitimate answer to make me change my practice of using volatile during masking after intravenous induction. With the time constant of most volatiles you would need ~10 minutes of exposure to reach a solid end tidal in which your current level of volatile is actually being steadily experienced by the vessel rich compartment. Masking for 1 minute then removing the mask to intubate probably only offers a very low anesthetic equivalent because constant redistribution to other tissue is still occurring, like the redistribution of propofol however with a much smaller equivalent dose. IMO might as well just give another 10-30 of propofol prior to taking a look (owing to a normal heart).

Not to mention most people think they are masking effectively but when you get the tube in sometimes peoples ETCO2 can be near 50 which is not explained by that ~1 minute of apnea under normal conditions (most likely explained by increased deadspace when switching from negative to positive pressure ventilation). Which also makes me think mask ventilation during that time with volatiles is less effective.

 

[Hoya11]

For adult patients, I use sevoflurane with induction very sparingly and in select situations. It irks me when people give IV induction agents then turn on the sevoflurane while masking the patient until they intubate. The benefit is minimal, the cost is high.

Most people induce patients on 10L FGF. They also overpressurize the system with >>2% sevo to quickly uptake the sevo. That's a HUGE waste of sevoflurane EVEN if you have a good mask seal.

At high FGF the patient will not be rebreathing the sevo. It leaves the OR and goes out a chimney.

It doesn't matter that you turn off the sevoflurane before you intubate.

Studies have shown that induction period is when greatest volatile anesthetic is "wasted" exactly for this reason.

Now if you have your own technique taking this into account, fine, but most people have no idea.

Do you really think its a "huge waste" of sevo to mask for 1 minute at 10l flow? how much sevo would that really use? 1/10 of a bottle ?, 1/20th of a bottle is a high estimate, are you talking about monetary cost in dollars? Not sure where the strong objection to this practice is coming from based on "cost".

Do you warn the room when you extubate someone deep to a facemask, and they breath out this toxic sevo throughout the Or and PACU? Should we evacuate?

You are delivering the inhalational agent that you will be using for the case earlier on, giving bronchodilation, ensuring amnesia at least.

And to those thinking it takes 9 minutes for the gas to have an effect, or that the "stage 2" of an adult is a problem, you have not done it enough.

Its not something you do every case, but inhalational inductions in adults can be buttery smooth in the right situation. A few puffs and eyes are closed.

 

[anbuitachi]

Mixing sux and induction agent has beeen studied. zero recall. I mix hypnotic opioid and 100mg of roc in one syringe and push it. Never had an issue. Even in cardiac patients

propofol and sux mixed in one syringe. pushed. patient said ah and fasiculated with eyes wide open. thats what the 1st and last time i mixed it. the sux appeared to have worked much faster than propofol

 

[Radar26]

Do you warn the room when you extubate someone deep to a facemask, and they breath out this toxic sevo throughout the Or and PACU? Should we evacuate?

I do usually warn the PACU nurse after a deep extubation (for multiple reasons obviously) but specially to not get up in the patients face-nobody likes sevo breath

 

[coffeebythelake]

Do you really think its a "huge waste" of sevo to mask for 1 minute at 10l flow? how much sevo would that really use? 1/10 of a bottle ?, 1/20th of a bottle is a high estimate, are you talking about monetary cost in dollars? Not sure where the strong objection to this practice is coming from based on "cost".

1 cc of liquid sevo ~ 250 cc of sevo vapor. I'm sure someone can do the math here.

Benefit = bronchodilation, maybe better amnesia (more IV anesthetic does this too....)
Cost = greenhouse gas effect when released to outside environment, possible OR exposure, money
Ultimately for the vast majority of patients, the benefit is greatly outweighed by costs.
That's why I said I do this technique sparingly and in select situations.
Active smoker with recent URI? Worried about bronchospasm? Fine. But have a reason for doing it.

I am not aware of any studies that show improved patient outcomes or reduced complication rates when using IV induction + inhalational agent compared to IV induction alone prior to intubation.

You are delivering the inhalational agent that you will be using for the case earlier on, giving bronchodilation, ensuring amnesia at least.

See above. Giving IV anesthetic can do the same thing. Ketamine has bronchodilating properties. Hell, even propofol has some bronchodilating properties. Frequent cause of bronchospasm in a patient with no risk factors is inadequate anesthetic.

And to those thinking it takes 9 minutes for the gas to have an effect, or that the "stage 2" of an adult is a problem, you have not done it enough... Its not something you do every case, but inhalational inductions in adults can be buttery smooth in the right situation. A few puffs and eyes are closed.

Are you talking about inhalational induction now? I thought we were talking about IV induction followed by inhalational agent before intubation.

Do you warn the room when you extubate someone deep to a facemask, and they breath out this toxic sevo throughout the Or and PACU? Should we evacuate?

Several points:
1. If you have a good mask fit that's fine. Room contamination is minimal. I wouldn't extubate someone deep if I had any concerns about being unable to adequately mask. This is just asking for trouble. There are other ways to ensure a smooth emergence.
2. Expired sevoflurane here is MUCH MUCH lower than inspired sevoflurane in your FGF.
3. My concern for sevoflurane contamination of the OR is the reason why I prefer TIVA for cases where this is likely to occur / where circuit is frequently connected and disconnected (e.g., GA bronchoscopy, EBUS, etc)

 

[T-burglar]

propofol and sux mixed in one syringe. pushed. patient said ah and fasiculated with eyes wide open. thats what the 1st and last time i mixed it. the sux appeared to have worked much faster than propofol

Lol i feel bad for that dude. I don't know what you did here man but an induction dose of anything will cause lights out before fasciculation. Again, its been studied in healthy volunteers. RSI is induction agent administered virtually simultaneously with a paralytic. You can either push them together, or push paralytic literally seconds after the hypnotic. There's no difference unless you're purposefully being slow to give the paralytic.

 

[Hoya11]

1 cc of liquid sevo ~ 250 cc of sevo vapor. I'm sure someone can do the math here.

Benefit = bronchodilation, maybe better amnesia (more IV anesthetic does this too....)
Cost = greenhouse gas effect when released to outside environment, possible OR exposure, money
Ultimately for the vast majority of patients, the benefit is greatly outweighed by costs.
That's why I said I do this technique sparingly and in select situations.
Active smoker with recent URI? Worried about bronchospasm? Fine. But have a reason for doing it.

See above. Giving IV anesthetic can do the same thing. Ketamine has bronchodilating properties. Hell, even propofol has some bronchodilating properties. Frequent cause of bronchospasm in a patient with no risk factors is inadequate anesthetic.

Though you made the "high cost" claim, I went ahead and googled it. 1cc of sevo is 50 cents.

Your going to open a bottle of ketamine to avoid that? And do you really think an IV agent is a better bronchodilator than one that is inhaled directly?

Are you talking about inhalational induction now? I thought we were talking about IV induction followed by inhalational agent before intubation.

Yes sometimes I talk about two different subjects in the same post.

Several points:
1. If you have a good mask fit that's fine. Room contamination is minimal. I wouldn't extubate someone deep if I had any concerns about being unable to adequately mask. This is just asking for trouble. There are other ways to ensure a smooth emergence.

How is this relevant to the discussion? I agree never extubate deep without an adequate airway??

2. Expired sevoflurane here is MUCH MUCH lower than inspired sevoflurane in your FGF.

Is it? The kid is breathing out 2-3% sevo for 10 minutes here, vs masking with sevo 3% for 1 minute... buts its "much much" higher? , seems like the cost argument..

3. My concern for sevoflurane contamination of the OR is the reason why I prefer TIVA for cases where this is likely to occur / where circuit is frequently connected and disconnected (e.g., GA bronchoscopy, EBUS, etc)

[/QUOTE]

You often do TIVA for those cases because the endoscopist is right over the tube for the majority of the case, not because the circulator 10 feet away is at risk.

 

[itwasalladream]

Lol i feel bad for that dude. I don't know what you did here man but an induction dose of anything will cause lights out before fasciculation. Again, its been studied in healthy volunteers. RSI is induction agent administered virtually simultaneously with a paralytic. You can either push them together, or push paralytic literally seconds after the hypnotic. There's no difference unless you're purposefully being slow to give the paralytic.

I've seen the same thing, with prop chased with sux. Lights were "out." Then pt started screaming/fasciculating, then silent. I've only seen it once, but it sticks with you.

 

[Urzuz]

I've seen the same thing, with prop chased with sux. Lights were "out." Then pt started screaming/fasciculating, then silent. I've only seen it once, but it sticks with you.

So that's where the double entendre of your username comes from...

 

[deleted875186]

I've seen the same thing, with prop chased with sux. Lights were "out." Then pt started screaming/fasciculating, then silent. I've only seen it once, but it sticks with you.

I would say unless an RSI I would never mix prop and muscle relaxant. Sux woks much faster than prop. Even a small dose of roc can be felt pretty quick if someone’s still a little awake.