Extubating deep

[pgg]

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While I maintain that you should be able to wake a patient up upon surgery end with iso, the desflurane patient will be more awake and alert in recovery, and will meet discharge criteria sooner. That is important in a busy practice.

Totally agree. This is where desflurane shines. The patients continue to wake up faster, even after they leave the OR.


Also, desflurane is really not significantly more expensive than sevoflurane if you use low flows.

As for isoflurane ... if there are two spots on the machine, I'd rather have des and sevo.

 

[pgg]

So my question to those who say they can wake up a patient on a dime with any inhalational agent- why do you desflurane at all?

1) PACU discharge times.
2) It lessens the time penalty of getting caught off guard with a fast/abrupt finish (happens to the best of us, especially with inconsistent and unpredictable surgeons).
3) It's easy. Why do things the hard way, just because you can?

 

[BLADEMDA]

Am J Health Syst Pharm. 2005 Jan 1;62(1):63-8.
Meta-analysis of trials comparing postoperative recovery after anesthesia with sevoflurane or desflurane.
Macario A1, Dexter F, Lubarsky D.
Author information

Abstract
PURPOSE:
Results of published, randomized controlled trials comparing sevoflurane and desflurane were pooled to measure differences in times until patients obeyed commands, were extubated, were oriented, were discharged from the postanesthesia care unit (PACU), and were ready to be discharged to home, as well as the occurrence of postoperative nausea and vomiting (PONV).

METHODS:
We reviewed all randomized clinical trials in MEDLINE through December 18, 2003, with a title or abstract containing the words sevoflurane and desflurane. Two reviewers independently extracted study data from papers that met inclusion criteria. Endpoints were pooled using random-effects meta-analysis.

RESULTS:
Twenty-two reports of 25 studies (3 reports each described 2 studies) met our inclusion criteria. A total of 746 patients received sevoflurane, and 752 received desflurane. Patients receiving desflurane recovered 1-2 minutes quicker in the operating room than patients receiving sevoflurane. They obeyed commands 1.7 minutes sooner (p < 0.001; 95% confidence interval [CI], 0.7-2.7 minutes), were extubated 1.3 minutes sooner (p = 0.003; 95% CI, 0.4-2.2 minutes), and were oriented 1.8 minutes sooner (p < 0.001; 95% CI, 0.7-2.9 minutes). No significant differences were detected in the phase I or II PACU recovery times or in the rate of PONV.

CONCLUSION:
Meta-analysis of studies in which the duration of anesthesia was up to 3.1 hours indicated that patients receiving either desflurane or sevoflurane did not have significant differences in PACU time or PONV frequency. Patients receiving desflurane followed commands, were extubated, and were oriented 1.0-1.2 minutes earlier than patients receiving sevoflurane.

 

[BLADEMDA]

Use of desflurane for maintenance of anesthesia was associated with a faster emergence and a higher incidence of coughing. Despite the faster initial recovery with desflurane, no significant differences were found between the two volatile anesthetics in the later recovery period. Both volatile anesthetics should be available for ambulatory anesthesia.


http://www.ncbi.nlm.nih.gov/pubmed/19608808

 

[BLADEMDA]

Conclusions. Early but not intermediate recovery times of elderly patients undergoing a wide range of surgical procedures requiring two or more hours of anaesthesia is significantly (P≤0.05) faster after desflurane.


http://bja.oxfordjournals.org/content/91/4/502.full

 

[BLADEMDA]

Major Advantage of Desflurane Vs Sevoflurane is in the following 2 subgroups:

1. Elderly (over 80)
2. Extreme Morbid Obesity (BMI over 50)

The use of Desflurane helps get them extubated and out of the O.R. quicker especially when midlevels are administering the anesthetic.

 

[Noyac]

I've said this before on this site but I'll say it again. One thing I've noticed with des vs Sevo is that I can get away with less narcotics or even muscle relaxants with the DES. I noticed this when I first arrived at my current gig. All we had was Sevo. I would do typical case like a knee scope and the ET Sevo would be 2.0-2.5, pretty high. But at least half the PTS would move some on incision (ports) when they had an LMA and beating spontaneously. I didn't think a whole lot of it until we got DES and it all stopped. So I find that DES has more analgesic activity than Sevo. Can't comment on ISO.

 

[CodeBlu]

Well I can wake a pt up with ISO as fast as I can with DES nearly every time. Maybe that's arrogant or even unbelievable but it is true.

Also, at least half of my pts move themselves to the stretcher or bed at the end of the case when we are ready to transfer.

But I've been doing this a long time now.

I personally have only used Iso a handful of times... and with anesthesiologists trained in the UK. They could wake someone up at the end of the case no problem. It really was a skill.

Iso is great, but I guess I'm just not comfortable using it... if you don't practice with it, then you will suck later down the road.

 

[btbam]

I personally have only used Iso a handful of times... and with anesthesiologists trained in the UK. They could wake someone up at the end of the case no problem. It really was a skill.

Iso is great, but I guess I'm just not comfortable using it... if you don't practice with it, then you will suck later down the road.

It's just easy to get burned with Iso if you aren't paying close attention. Iso produces much smoother wakeups IMHO...if timed well, you could turn gas off 20-30 min before wakeup and keep flows at a minimum and extubate as the drapes come down.

 

[BLADEMDA]

It's just easy to get burned with Iso if you aren't paying close attention. Iso produces much smoother wakeups IMHO...if timed well, you could turn gas off 20-30 min before wakeup and keep flows at a minimum and extubate as the drapes come down.

Desflurane allows the provider to text on his/her phone or converse with the circulator without ever worrying that the surgeon is closing. You can literally turn the agent off as the drapes are being removed and have the patient awake as they bring in the bed. On the contrary, isoflurane requires you to pay attention and develop skill in the art of waking up your patients.

 

[Noyac]

Des is the reason I'm on this forum so much. It's just so easy that I don't know what to do with all the down time.

 

[pgg]

Desflurane allows the provider to text on his/her phone or converse with the circulator without ever worrying that the surgeon is closing. You can literally turn the agent off as the drapes are being removed and have the patient awake as they bring in the bed. On the contrary, isoflurane requires you to pay attention and develop skill in the art of waking up your patients.

🙄

 

[sevoflurane]

I'm not feeling the love from this thread.... @%! you guys..!

(I secretly use Des on nearly every case... 😱 🙂)

I also extubate deep as much as I can... usually in conjunction with milk of amnesia.

 

[sevoflurane]

We don't even carry ISO.

 

[deleted171991]

(I secretly use Des on nearly every case... 😱 🙂)

You should change your username. 😛

 

[BLADEMDA]

I'm not feeling the love from this thread.... @%! you guys..!

(I secretly use Des on nearly every case... 😱 🙂)

I also extubate deep as much as I can... usually in conjunction with milk of amnesia.

No big deal . Des is a great agent and 0.5 mg/kg of propofol will pretty much guarantee you won't laryngospam even on 0.2 MAC of Des. When I cover 4 rooms I simply don't allow the Midlevels to do this type of stuff as I'm sure you can understand.

Midlevels:

Induction agent, muscle relaxant if ETT
ETT or LMA
Gas on- at least 0.5-0.7 MAC agent to prevent recall
End of Case- Gas off and extubation with less than 0.1 MAC of agent or patient arousal.
(not to mention REVERSAL with NEO/GLYCO as discussed in other threads)

 

[kazuma]

In my future pp group, the PACU nurses would prefer no airway, but they'd rather have an LMA than an OPA and/or jaw thrust.

 

[btbam]

I do peds so no Des... 🙁

 

[sevoflurane]

Peds is not a contraindication to DES use.

 

[btbam]

Peds is not a contraindication to DES use.

Of course, but as I'm sure you know Des was originally marketed for inhalational inductions and after seeing some of the side effects of that, our hospital got rid of Des vaporizers...

 

[sevoflurane]

Of course, but as I'm sure you know Des was originally marketed for inhalational inductions and after seeing some of the side effects of that, our hospital got rid of Des vaporizers...

I don't know of any anesthesiologists that use it for inhalational inductions. Your hospital is either clueless or penny pinching.

 

[deleted171991]

Your hospital is either clueless or penny pinching.

Usually it's both. My hospital got rid of it because of penny pinching. They were clueless about the reason why we spent more on des than on sevo: a bunch of stupid "providers" were running des at 2L/min, too.

 

[IlDestriero]

I don't know of any anesthesiologists that use it for inhalational inductions. Your hospital is either clueless or penny pinching.

Research was done in 1995 showing it was a horrible induction agent and not recommended. I find it hard to believe it was ever marketed as a potential mask indication drug. Anyway, it's still here 20 years later, so there must be some uses for it. 😉

 

[Noyac]

Of course, but as I'm sure you know Des was originally marketed for inhalational inductions and after seeing some of the side effects of that, our hospital got rid of Des vaporizers...

I don't understand this at all. Dumbest thing I have heard of is a long time. The hospital I'm talking about.
But if your Dr's were on the ball, you would have the better agent (except for inhalation inductions of course).