Didn't know anesthesia was something a pt could simply decide to comply with or not

[LowWafer8]

i've been out of residency for a while now. is this some sort of new evidence being taught that a pt could successfully resist anesthesia if they tried hard enough??

edit: anecdotally i've never found the redhead thing to be true. some of have needed more and others not in my personal experience. but whatever, i guess we have to believe the experts who write the books.

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[GrizzMint]

I'm not going to lie the Anesthesiologist sounds a little like a jerk. Who says all that stuff? Why wouldn't you just give more induction agent in that situation instead of getting the patient all riled up.

That being said, I've had patients tell me they want to try and fight it and it seems like it takes more for them but that is just my personal experience.

 

[UscGhost]

I don't take much stock in patients who report higher or lower "tolerances". They are usually wrong or misinterpret their prior experiences in how they relate to anesthetic tolerance.

Some say they have a high tolerance because they are afraid of being "awake". Some report low tolerances because they don't take many medications in general.

Some report higher tolerances because they were awake during their last colonoscopy under conscious sedation.

Either way I just reassure them and proceed as usual

 

[coffeebythelake]

Post was removed. Not sure what this is about.

There is plenty of interindividual variability in responses to anesthesia.

But someone's will to resist the anesthesia doesn't change their responses to the anesthetic.

 

[NICMAN]

I tell patients it is like jumping off a building and thinking they are going to fly.

Physics and chemistry are more than just good ideas; they are the law.

 

[Iso4ane]

I've had GA several times, and I don't know my tolerance to propofol, only because I already blacked out from the 2mg of midazolam. My guess is I have a low tolerance.

 

[Arch Guillotti]

Post was removed. Not sure what this is about.

No idea. OP edit probably.

 

[Lecithin5]

I don't take much stock in patients who report higher or lower "tolerances". They are usually wrong or misinterpret their prior experiences in how they relate to anesthetic tolerance.

Some say they have a high tolerance because they are afraid of being "awake". Some report low tolerances because they don't take many medications in general.

Some report higher tolerances because they were awake during their last colonoscopy under conscious sedation.

Either way I just reassure them and proceed as usual

The best is when a patient says “I’m slow to wake up”. Literally means nothing to me- I smile and acknowledge it and move on.

 

[repititionition]

The best is when a patient says “I’m slow to wake up”. Literally means nothing to me- I smile and acknowledge it and move on.

Interesting. This is the one patient-reported subjective thing I actually find true more often than not.

Low threshold for intraop EEG in these people, and I generally find them super deep with “normal” doses of anesthetic, allowing me to adjust accordingly.

 

[coffeebythelake]

The best is when a patient says “I’m slow to wake up”. Literally means nothing to me- I smile and acknowledge it and move on.

Interesting. This is the one patient-reported subjective thing I actually find true more often than not.

Low threshold for intraop EEG in these people, and I generally find them super deep with “normal” doses of anesthetic, allowing me to adjust accordingly.

i'd just avoid giving them benzos. i'm not going to underdose the anesthetic if the patient said this
god forbid they had awareness under GA and you claim that your 0.4 MAC of sevo was enough because their BIS was reading 60.
medtronic will be first to tell you that's not what the BIS is designed for
i'm still sticking to the APSF recommendations

 

[vector2]

The best is when a patient says “I’m slow to wake up”. Literally means nothing to me- I smile and acknowledge it and move on.

Especially in people over 50 I usually pay attention to this line. Pts typically know with some degree of accuracy if they spent a long time in PACU and/or phase 2 after an outpatient procedure finished.

 

[repititionition]

i'd just avoid giving them benzos. i'm not going to underdose the anesthetic if the patient said this
god forbid they had awareness under GA and you claim that your 0.4 MAC of sevo was enough because their BIS was reading 60.
medtronic will be first to tell you that's not what the BIS is designed for
i'm still sticking to the APSF recommendations

^ EEG like sedline, not BIS garbage.

 

[anbuitachi]

The best is when a patient says “I’m slow to wake up”. Literally means nothing to me- I smile and acknowledge it and move on.

i actually like this one . has been true a few times before. gas off for ages and then wake up.

 

[dannyboy1]

i've been out of residency for a while now. is this some sort of new evidence being taught that a pt could successfully resist anesthesia if they tried hard enough??

edit: anecdotally i've never found the redhead thing to be true. some of have needed more and others not in my personal experience. but whatever, i guess we have to believe the experts who write the books.

Lol. You can try but I push the prop and roc simultaneously so you may as well go with it…

 

[DocVapor]

I mean most of the time when someone tells me they are slow to wake up it's because some doofus gave them 250 mcg Fentanyl and 2mg Dilaudid for their lap chole 15 years ago.

If their surgery was more recent it's because some doofus gave them 20 mcg precedex before extubation to "smooth out the wakeup."

 

[GassYous]

What did the original post say

 

[Agast]

What did the original post say

 

[anaesthetic]

I mean most of the time when someone tells me they are slow to wake up it's because some doofus gave them 250 mcg Fentanyl and 2mg Dilaudid for their lap chole 15 years ago.

If their surgery was more recent it's because some doofus gave them 20 mcg precedex before extubation to "smooth out the wakeup."

This has been my experience as well. “Slow to wake up” shows up in the history once or twice every week, and I haven’t noticed a difference in wake up times at all. Caveat is I don’t ever give 1 mg Dilaudid up front like some people do. I usually minimize opioid administration and titrate to RR at the end of the case.

 

[coffeebythelake]

^ EEG like sedline, not BIS garbage.

maybe the EEG quality is better, but has it been validated for this purpose?

 

[coffeebythelake]

View attachment 366429View attachment 366430

Always take whatever is posted out there with a big grain of salt. Pt probably colored things to make herself in the best possible light.
When I read that post, I thought she had a personality disorder or was not entirely truthful with her interactions. Several parts of her story stand out:

1. She had complete recollection after given an anesthetizing dose. Redheads require a bit more anesthesia but it still falls within the realm of normal variability. Something isn't right and it isn't the fact she is a redhead. This sort of situation make me think either the IV wasn't working or she is on some recreational drug. Marijuana? Something else undisclosed?

2. Make you wonder why everyone is telling her she is being disrespectful including her own family. She probably toned it down a bit for her AITA post but she was probably yelling and screaming and throwing expletives all around. We've all had to deal with these sort of people.

3. Anesthesia wins at the end. It always does.

 

[Iso4ane]

On a off note, when patients tell me they want to fight it, I wait until about half of my induction dose of propofol is in, before I tell them, ‘If you want yo fight it, here is where you start trying.’ And usually they’re like ‘Okay, here I g……’

 

[jwk]

I have patients tell me all the time that they're "hard to put to sleep". I tell them some take more than others but in 40 years I've never lost.

 

[2Fast2Des]

I get the self proclaimed fighters, but just give the usual or just a touch more prop. Then the ones who claim they took hours or days to wake up and then for me to wake em up in my usual manner with no delay. I try to acknowledge most pts but then do what I usually do anyway because I have feeling pts don't really have a clue or misinformed of what happened in their previous experience. Of course on the occasion I get the heavy etoh or MJ peeps that are wide awake after an induction dose of an elephant, those guys I take seriously because they aren't joking.

That being said, had one guy, obese, in his 60s who told me he needed a CT head last time he had anesthesia because he wouldn't wake up or be responsive after hours in recovery. This time our CRNA did his total joint under I think 4mg midaz, spinal, 50mg ketamine, propofol sedation, with a little bit of narcotics (50mcg fent) because he was a little squirrely. No joke guy did not wake up again for a couple of hours until I had to narcan him because the flumazenil didn't reverse him. Then it all made sense why his last encounter sent people panicking thinking he stroked out and he woke up the next day or later in the previous anesthetic.

 

[repititionition]

That being said, had one guy, obese, in his 60s who told me he needed a CT head last time he had anesthesia because he wouldn't wake up or be responsive after hours in recovery. This time our CRNA did his total joint under I think 4mg midaz, spinal, 50mg ketamine, propofol sedation, with a little bit of narcotics (50mcg fent) because he was a little squirrely. No joke guy did not wake up again for a couple of hours until I had to narcan him because the flumazenil didn't reverse him. Then it all made sense why his last encounter sent people panicking thinking he stroked out and he woke up the next day or later in the previous anesthetic.

seems like you guys could have just skipped the spinal

 

[woopedazz]

our CRNA did his total joint under I think 4mg midaz, spinal, 50mg ketamine, propofol sedation, with a little bit of narcotics (50mcg fent) because he was a little squirrely. No joke guy did not wake up again for a couple of hours ...

Ya reckon? 😜

 

[GassYous]

Ya reckon? 😜

That's not that much depending on the patient

 

[DonFL]

I mean most of the time when someone tells me they are slow to wake up it's because some doofus gave them 250 mcg Fentanyl and 2mg Dilaudid for their lap chole 15 years ago.

If their surgery was more recent it's because some doofus gave them 20 mcg precedex before extubation to "smooth out the wakeup."

Hell I know people that still do this

 

[2Fast2Des]

That's not that much depending on the patient

I've learned that it really doesn't take a lot in some, especially ones you least expect. Thankfully narcan exists for these outliers

 

[Beeftenderloin]

I mean most of the time when someone tells me they are slow to wake up it's because some doofus gave them 250 mcg Fentanyl and 2mg Dilaudid for their lap chole 15 years ago.

Hell I know people that still do this

There was a post on Reddit over the weekend that read like a midlevel, asking about adjuncts. They casually mentioned how they routinely pull 500mcg of fentanyl for every cases. Seems crazy, and ripe for diversion, especially considering most patients need no more than 100mcg, with many needing none at all.

 

[UscGhost]

Ya reckon? 😜

That is how most of our totals are done.

Great anesthetic if doses properly. No more than 1mg versed, 7.5mg bupiv, 50mcg ketamine, 20ncg fent in spinal and prop gtt to comfort.

Patients happy and wiggling toes upon arrival in pacu

 

[coffeebythelake]

That is how most of our totals are done.



Great anesthetic if doses properly. No more than 1mg versed, 7.5mg bupiv, 50mcg ketamine, 20ncg fent in spinal and prop gtt to comfort.



Patients happy and wiggling toes upon arrival in pacu

Why the ketamine though? When pt has a surgical anesthetic

 

[repititionition]

Probably less propofol and less obstruction. I am a fan for these reasons, but I never give 50. Commonly 10-30, usually 20.

 

[repititionition]

That is how most of our totals are done.

Great anesthetic if doses properly. No more than 1mg versed, 7.5mg bupiv, 50mcg ketamine, 20ncg fent in spinal and prop gtt to comfort.

Patients happy and wiggling toes upon arrival in pacu

I’ve become amazed at how little spinal bupi you can get away with if you have a surgeon who is quick enough, and you are willing to bolus something for skin (ketamine vs prop)

 

[Robotic Wis-Hipple]

Especially in people over 50 I usually pay attention to this line. Pts typically know with some degree of accuracy if they spent a long time in PACU and/or phase 2 after an outpatient procedure finished.

I’d wager this is likely due to one of two things;

Giving versed to anyone over 60 or PACU nurses giving 2mg dilaudid for every hangnail that shows up in their bay.

 

[UscGhost]

Ketamine mixed in with the propofol. Reduces total propofol dose and part of overall multimodal approach

 

[nimbus]

That is how most of our totals are done.

Great anesthetic if doses properly. No more than 1mg versed, 7.5mg bupiv, 50mcg ketamine, 20ncg fent in spinal and prop gtt to comfort.

Patients happy and wiggling toes upon arrival in pacu

Curious. Are you putting the 50mcg ketamine intrathecal?

 

[UscGhost]

Curious. Are you putting the 50mcg ketamine intrathecal?

Never tried it. And we don't have preservative free version.

I just mix it the 100ml bottle of propofol and run it

 

[vector2]

Never tried it. And we don't have preservative free version.

I just mix it the 100ml bottle of propofol and run it

You wrote "50mcg" in your post instead of mg and I think he thought you meant you were putting some intrathecal.

 

[UscGhost]

You wrote "50mcg" in your post instead of mg and I think he thought you meant you were putting some intrathecal.

Oops my mistake. Yea 50mg, not 50mcg

 

[Twiggidy]

I have patients tell me all the time that they're "hard to put to sleep". I tell them some take more than others but in 40 years I've never lost.

Undefeated

 

[The Duck Knows]

Always take whatever is posted out there with a big grain of salt. Pt probably colored things to make herself in the best possible light.
When I read that post, I thought she had a personality disorder or was not entirely truthful with her interactions. Several parts of her story stand out:

1. She had complete recollection after given an anesthetizing dose. Redheads require a bit more anesthesia but it still falls within the realm of normal variability. Something isn't right and it isn't the fact she is a redhead. This sort of situation make me think either the IV wasn't working or she is on some recreational drug. Marijuana? Something else undisclosed?

2. Make you wonder why everyone is telling her she is being disrespectful including her own family. She probably toned it down a bit for her AITA post but she was probably yelling and screaming and throwing expletives all around. We've all had to deal with these sort of people.

3. Anesthesia wins at the end. It always does.

That was my initial thought as well. Had real “and then everybody clapped vibes to it.”

I smile and nod when people bring up being redheads because ultimately it doesn’t really matter. But yeah, none of this really makes much sense and the OP comes off as an arrogant person to anyone who understands anything about anesthesia.

 

[FiO2@21]

He asked me what exactly I was doing to not be knocked out and I insisted that I wasn't doing anything. He continued to berate me and at one point said that the surgery would be taking place whether I fall asleep or not, so I better comply.

This seems highly unlikely. Can't think of a single person who'd assume their patient somehow had the ability to "do something to not be knocked out".

 

[anaesthetic]

This seems highly unlikely. Can't think of a single person who'd assume their patient somehow had the ability to "do something to not be knocked out".

It reads like a fantasy novel written by someone not familiar with anesthesia. I’ve had several young, healthy patients ask me if it’s okay for them to try to fight it. I tell them, “Sure,” and unsurprisingly, 100% of the time, they go out just like any other patient would.