Changing agent during case

[pie944]

We priced Amsorb Plus using 1 liter SEVO flow rates vs. Standard CO2 absorbent with 2 liter flows and decided it was cheaper to buy the Standard absorbent.

I think the people who make the decisions on this issue are not a fan of the cost of Desflurane. Especially since a fair amount of people run Desflurane at fairly significant flows(~2L). However, the people who liked Desflurane responded that running Desflurane at low flows vs Sevoflurane at 2L was approximately the same cost financially. Therefore, to overcome this argument they decided to utilize Amsorb Plus and remove Desflurane as an option. I think they are citing a savings of a few hundred thousand dollars a year based off this change. I guess the high flows with Desflurane was a common problem and this move is probably easier to implement than controlling the flows?

---

Members don't see this ad.

 

[BLADEMDA]

I think the people who make the decisions on this issue are not a fan of the cost of Desflurane. Especially since a fair amount of people run Desflurane at fairly significant flows(~2L). However, the people who liked Desflurane responded that running Desflurane at low flows vs Sevoflurane at 2L was approximately the same cost financially. Therefore, to overcome this argument they decided to utilize Amsorb Plus and remove Desflurane as an option. I think they are citing a savings of a few hundred thousand dollars a year based off this change. I guess the high flows with Desflurane was a common problem and this move is probably easier to implement than controlling the flows?

Why not just use Generic, dirt cheap, ISO at low flows with standard absorbent? This saves a ton of money.

Alternatively, place the Amsorb Plus only in the rooms with long cases (greater than 4 hours) and run 1 liter flows.

The evidence that 1 liter flows of SEVO for 4-5 hours is dangerous just isn't really there especially for healthy patients.

 

[pie944]

Why not just use Generic, dirt cheap, ISO at low flows with standard absorbent? This saves a ton of money.

Alternatively, place the Amsorb Plus only in the rooms with long cases (greater than 4 hours) and run 1 liter flows.

The evidence that 1 liter flows of SEVO for 4-5 hours is dangerous just isn't really there especially for healthy patients.

That makes the most sense. I'd say except for the rare occasion Isoflurane is only used in our Cardiac/Liver cases where the patient automatically goes intubated to the intensive care unit.

I agree with you on the evidence supporting low flows and Compound A, the problem is the package insert has the warning against it.

 

[BLADEMDA]

That makes the most sense. I'd say except for the rare occasion Isoflurane is only used in our Cardiac/Liver cases where the patient automatically goes intubated to the intensive care unit.

I agree with you on the evidence supporting low flows and Compound A, the problem is the package insert has the warning against it.

Back in my day we used ISO all the time for long, big cases. Wake-up in the room can be quick provided you learn how to do it correctly. Even in 2012 I'm using a lot of ISO in big cases. Low flow ISO is the way to go for saving money.

 

[DrN2O]

I vaguely remember one pedi attending talking about switching from sevo to iso near the end of cases for a smooth and fast wake up for kids. I can't remember his explanation why it works. Anyone?

 

[dhb]

if you flip flop agents, i just doesn't make any sense

 

[BLADEMDA]

I vaguely remember one pedi attending talking about switching from sevo to iso near the end of cases for a smooth and fast wake up for kids. I can't remember his explanation why it works. Anyone?

Sevoflurane is an inhalational anesthetic used widely as a pediatric or outpatient anesthesia due to its excellent hemodynamic stability and low blood solubility, which allows rapid induction and emergence from general anesthesia, as well as control of the depth of anesthesia. However, when sevoflurane is used alone it is associated with a higher incidence of emergence agitation in children. The rapid removal of residual anesthetics due to low blood solubility of sevoflurane has been suggested to cause emergence agitation in some patients [1,2]. In addition, a variety of other explanations have been proposed for the etiology of emergence agitation. These include the lack of a young child's ability to adapt to sudden changes due to an unfamiliar environment after awakening, immature neurological development, anxiety from being separated from their parents, increased pain sensation and sympathetic hyperactivation [2,3].

 

[Mman]

Sevoflurane is an inhalational anesthetic used widely as a pediatric or outpatient anesthesia due to its excellent hemodynamic stability and low blood solubility, which allows rapid induction and emergence from general anesthesia, as well as control of the depth of anesthesia. However, when sevoflurane is used alone it is associated with a higher incidence of emergence agitation in children. The rapid removal of residual anesthetics due to low blood solubility of sevoflurane has been suggested to cause emergence agitation in some patients [1,2]. In addition, a variety of other explanations have been proposed for the etiology of emergence agitation. These include the lack of a young child's ability to adapt to sudden changes due to an unfamiliar environment after awakening, immature neurological development, anxiety from being separated from their parents, increased pain sensation and sympathetic hyperactivation [2,3].

The problem with that is that if the cause of the emergence delirium is the rapid removal of the sevo, switching to iso for a brief time at the end of the case won't change anything because the iso will go away just as fast.

What I've seen many smart peds people do is induce with sevo and then as soon as the ETT (or LMA) is in, switch to iso for the rest of the case.

 

[Gern Blansten]

So I asked what his concearn was and he said something like "your the doctor" and left. So I looked for any studies about possible detrimental effects and could find none.

I can't believe no one has commented on this aspect of the encounter. This type of stuff really pisses me of. When someone takes a non-issue and tries to make it into an issue and then acts like you are the one at fault when you dismiss their concern. I have worked with a CRNA that does this crap and always adds in a "Well that's fine if you're going to sign the chart. I've got kids to put through college."
Really gets me pissed off.

 

[interleukin2]

Unfortunately it seems to be a trend whereby everyone who isn't a physician seems to know better. It seems medical school is a waste of time now a days. I don't mind it atl when patients ask questions I want them to take an interest in their health. It's when people who do not have the training you do judge u and feel they know better. Case in point: a few m