Extubating deep

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RMortis

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Question about extubating deep with an LMA: Can you do it at whatever MAC as long as the person has adequate tidal volume. My reasoning: the LMA is just increased resistance and dead space in spontaneous ventilation. The only risk I can see is obstruction which you can just put an oral airway (if your PACU can handle that). Seems to better in cases where you don't want coughing or you have to keep really deep to prevent movement without muscle relaxant. How often is this done? Could you hypothetically laryngospasm in the PACU during wakeup when they have a light plane of anesthesia?
 
RMortis said:
Question about extubating deep with an LMA: Can you do it at whatever MAC as long as the person has adequate tidal volume. My reasoning: the LMA is just increased resistance and dead space in spontaneous ventilation. The only risk I can see is obstruction which you can just put an oral airway (if your PACU can handle that). Seems to better in cases where you don't want coughing or you have to keep really deep to prevent movement without muscle relaxant. How often is this done? Could you hypothetically laryngospasm in the PACU during wakeup when they have a light plane of anesthesia?
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The closer the patient is to being awake and the longer s/he's been breathing spontaneously with good volumes, the better. You want the airway and swallowing reflexes recovered. You want to decrease the chances of complications in the PACU.

Do not extubate "deep". You'll just get yourself in trouble. Extubate close to wakeup, after preoxygenation, at about 0.2 MAC or less, while the patient is still asleep but able to protect the airway. It's an art. 🙂

Yes, I do it all the time, even in obese patients; many of my patients wake up when I reach the PACU. Rare laryngospasms, only when there are copious secretions in the pharynx, or when I extubate too soon.
 
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As a resident you want to try all techniques and I have done deep extubation, but why take out the ultimate oral airway in the lma and replace it with something else?.....
 
RMortis said:
Question about extubating deep with an LMA: Can you do it at whatever MAC as long as the person has adequate tidal volume. My reasoning: the LMA is just increased resistance and dead space in spontaneous ventilation. The only risk I can see is obstruction which you can just put an oral airway (if your PACU can handle that). Seems to better in cases where you don't want coughing or you have to keep really deep to prevent movement without muscle relaxant. How often is this done? Could you hypothetically laryngospasm in the PACU during wakeup when they have a light plane of anesthesia?
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LMAs are pretty much the best oral airway you can have. At case end, I put in a bite block (had one case of NPPE from biting down on the LMA), turn the gas off, and proceed as if it's an oral airway. Usually, the patient spits them out about the time we get to PACU. Easy cheesy.

ETTs I pull deep with easy airways. If thick necks or difficult masks, I just use desflurane and take the extra few minutes to wake 'em up.
 
Scotty_G said:
As a resident you want to try all techniques and I have done deep extubation, but why take out the ultimate oral airway in the lma and replace it with something else?.....
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The answer to that is: because PACU nurses will freak out from an LMA, but are happy with the much worse oral/nasal airway. Residents should learn how to keep the PACU nurses happy. 😉
 
FFP said:
The answer to that is: because PACU nurses will freak out from an LMA, but are happy with the much worse oral/nasal airway. Residents should learn how to keep the PACU nurses happy. 😉
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Academics, yes. Private practice, they will thank you from saving them a jaw thrust.
 
Scotty_G said:
but why take out the ultimate oral airway in the lma and replace it with something else?.....
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Because some (?many) PACUs are more comfortable handling a patient with a traditional oral airway than with an LMA? Whether you think it's a good reason or not, an oral airway could decrease turnover time.

ETA: too late
 
twoliter said:
Because some (?many) PACUs are more comfortable handling a patient with a traditional oral airway than with an LMA? Whether you think it's a good reason or not, an oral airway could decrease turnover time.

ETA: too late
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Teach PACU nurses to become comfortable with LMAs. I let my patients spit them out when ready.
 
I do it from time to time. Did it today because my pt had some questionable teeth and I didn't want him to bite down on the LMA. So I pulled it deep. One trick when pulling deep and any time you are pulling an LMA for that matter is not to deflate the thing. This way any secretions will come up with the LMA and away from the cords.

But it is not as beneficial pulling an LMA deep as it is to pull an ETT. I usually just pull the LMA right at the moment that I know they are ready to open their eyes.

You shouldn't have to bring a pt to the pacu with an LMA all that often. If you are then you are waiting too long to turn off the gas or infusion. Even if they require the pt to remain still for splint application or whatever you should be able to wake the pt up within a few seconds of them being ready. If not, you need to figure out how to do this. There is nothing really wrong with bringing the pt to the pacu with an LMA in place BUT in my opinion this is a CRNA move. Any time you bring a pt to a lesser skilled provider ( I hate that term but it works in this setting) not fully awake you have some additional risks. Saliva on the cords can happen quickly for example.
 
Noyac said:
This way any secretions will come up with the LMA and away from the cords.
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Read "most" instead of "any". That's why, in juicy patients, it's worth giving glycopyrrolate during the case, and/or suctioning after LMA removal.
 
Noyac said:
I do it from time to time. Did it today because my pt had some questionable teeth and I didn't want him to bite down on the LMA. So I pulled it deep. One trick when pulling deep and any time you are pulling an LMA for that matter is not to deflate the thing. This way any secretions will come up with the LMA and away from the cords.

But it is not as beneficial pulling an LMA deep as it is to pull an ETT. I usually just pull the LMA right at the moment that I know they are ready to open their eyes.

You shouldn't have to bring a pt to the pacu with an LMA all that often. If you are then you are waiting too long to turn off the gas or infusion. Even if they require the pt to remain still for splint application or whatever you should be able to wake the pt up within a few seconds of them being ready. If not, you need to figure out how to do this. There is nothing really wrong with bringing the pt to the pacu with an LMA in place BUT in my opinion this is a CRNA move. Any time you bring a pt to a lesser skilled provider ( I hate that term but it works in this setting) not fully awake you have some additional risks. Saliva on the cords can happen quickly for example.
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Not sure how long your handoff is, but I bring every patient with an LMA in to the PACU and pull it with them awake before I leave. Having a great oral airway like an LMA is probably ideal in the setting of a lesser skilled provider. Agree to disagree. I think it's a cRNA move thinking the patient has to wake up on the table or else bad stuff can happen.
 
Ignatius J said:
Not sure how long your handoff is, but I bring every patient with an LMA in to the PACU and pull it with them awake before I leave. Having a great oral airway like an LMA is probably ideal in the setting of a lesser skilled provider. Agree to disagree. I think it's a cRNA move thinking the patient has to wake up on the table or else bad stuff can happen.
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Fair enough. But when I supervised crna's we had an unwritten policy that CRNA's should bring pts to pacu with whatever airway device that they did the case with in place. This limited the amount of running back and forth btw rooms for airway issues. We supervised many many more than 3 at a time. This is one reason I left that group.
But I will tell you that in my experience, if you do this job long enough you should be able to wake up a pt within a few minutes of the end of the case nearly every time.
So I agree with you, a lesser skilled provider should keep the LMA in place if they can't wake up the pt at the appropriate time.
 
Noyac said:
Fair enough. But when I supervised crna's we had an unwritten policy that CRNA's should bring pts to pacu with whatever airway device that they did the case with in place. This limited the amount of running back and forth btw rooms for airway issues. We supervised many many more than 3 at a time. This is one reason I left that group.
But I will tell you that in my experience, if you do this job long enough you should be able to wake up a pt within a few minutes of the end of the case nearly every time.
So I agree with you, a lesser skilled provider should keep the LMA in place if they can't wake up the pt at the appropriate time.
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I think we differ on thinking there is an "absolute time" that the patient has to wake up, and that has to be in the OR. On the table. Waking up within a few minutes isn't difficult. Use desflurane and problem solved. Anyone who says they use isoflurane and wake patients up on a dime is a little full of it, IMO.
 
Ignatius J said:
I think we differ on thinking there is an "absolute time" that the patient has to wake up, and that has to be in the OR. On the table. Waking up within a few minutes isn't difficult. Use desflurane and problem solved. Anyone who says they use isoflurane and wake patients up on a dime is a little full of it, IMO.
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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 exclusively remove my LMAS out deep. If you wait for them to awaken, you risk them biting down on the LMA (Now you cant remove it and you risk pulm edema) moreover when they awake frequently they cough and breath hold and every other wierd thing patients do in stage 2 with an airway stimlus and hard to control an airway with an LMA in stage 2. So I avoid and pull it out deep. BUt they have to be deep otherwise you will get into trouble.
 
Do you guys routinely deflate LMAs before you pull them out? Granted my n = very small with LMAs, but I haven't deflated any yet before pulling them.
 
criticalelement said:
I exclusively remove my LMAS out deep. If you wait for them to awaken, you risk them biting down on the LMA (Now you cant remove it and you risk pulm edema) moreover when they awake frequently they cough and breath hold and every other wierd thing patients do in stage 2 with an airway stimlus and hard to control an airway with an LMA in stage 2. So I avoid and pull it out deep. BUt they have to be deep otherwise you will get into trouble.
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No!!!
You won't get pulmonary edema or more correctly stated, negative pressure pulmonary edema if they bite on an LMA. I'm sure very rare cercumstances exist but the seal is not great enough to generate this level of negative pressure.

Also, awakening on an LMA should not cause coughing and breath holding. Sorry to say this but if you are seeing this then you are doing something wrong. Why would they breath hold when they have been breathing all along? The coughing would only come if secretions irritate the airway.
 
I extubate children deep almost every day, several times today. They wake up comfortably in the pacu without any drama. Kids with secretion concerns get the recovery position.
I don't extubate in stage 2, or near it. Awake or deep. Of course deep doesn't have to mean 1.2 MAC, it can be 1/2. Deep enough to not react to suctioning and airway stimulation.
 
Noyac said:
No!!!
You won't get pulmonary edema or more correctly stated, negative pressure pulmonary edema if they bite on an LMA. I'm sure very rare cercumstances exist but the seal is not great enough to generate this level of negative pressure.

Also, awakening on an LMA should not cause coughing and breath holding. Sorry to say this but if you are seeing this then you are doing something wrong. Why would they breath hold when they have been breathing all along? The coughing would only come if secretions irritate the airway.
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I have seen this several times, unfortunately once to me. It definitely does happen. All of my LMAs get a bite block if I am not using the Supreme.
 
Ignatius J said:
I have seen this several times, unfortunately once to me. It definitely does happen. All of my LMAs get a bite block if I am not using the Supreme.
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I would bet that there was some amount of laryngospasm as well that caused this.

I have never seen the bite block used with an LMA. Interesting.
 
Noyac said:
I would bet that there was some amount of laryngospasm as well that caused this.

I have never seen the bite block used with an LMA. Interesting.
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Can't rule out laryngospasm but it was more consistent with obstruction from biting the LMA. You can get very good seals when you seat them at leaks 20-25 cm H20. I think the negative pressure creates a vacuum seal too. I will still have the young bucks biting the bite block to where I just wait for them to spit it out. Rarely laryngospasm, if ever.
 
I'd much rather extubate most patients deep, LMA or ETT, but I'm old and set in my ways since I did thousands of mask cases in my pre-LMA days. When you pull an LMA deep (or an ETT), you're just changing to a mask technique to finish the case. In the appropriate patient, not sure why this is problematic.
 
Noyac said:
No!!!
You won't get pulmonary edema or more correctly stated, negative pressure pulmonary edema if they bite on an LMA. I'm sure very rare cercumstances exist but the seal is not great enough to generate this level of negative pressure.

Also, awakening on an LMA should not cause coughing and breath holding. Sorry to say this but if you are seeing this then you are doing something wrong. Why would they breath hold when they have been breathing all along? The coughing would only come if secretions irritate the airway.
Click to expand...

i had a case of negative pressure pulmonary edema during residency from an adolescent biting down on an LMA. It was ugly - nearly had to reintubate in PACU. Took 8 hours to resolve. The seal is often great enough to generate sufficient negative pressure.

larygospasm was doubtful - deflating the cuff allowed air movement around the LMA.
 
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RMortis said:
Question about extubating deep with an LMA: Can you do it at whatever MAC as long as the person has adequate tidal volume. My reasoning: the LMA is just increased resistance and dead space in spontaneous ventilation. The only risk I can see is obstruction which you can just put an oral airway (if your PACU can handle that). Seems to better in cases where you don't want coughing or you have to keep really deep to prevent movement without muscle relaxant. How often is this done? Could you hypothetically laryngospasm in the PACU during wakeup when they have a light plane of anesthesia?
Click to expand...

if you remove an LMA you aren't "extubating" anyone - it's just a big ol' fancy oral airway.

the deep versus awake thing is imho a moot point with LMA's.

i take all of my LMA's out at 0.5-1.0 etsev (peds included)

why? it's early enough that they don't bite down, and late enough that i don't have to support the airway long. they usually emerge before we hit pacu. 50% open their eyes when i take it out. never had a problem with this technique - not even once. 0.5-1.0 is also a nice big window so you can usually take the LMA out exactly when the drapes come down despite that "one last" stitch or five...

there are always exceptions to this rule, but most exceptions preclude LMA placement to begin with and i place a tube in those instance anyway...

there are other threads discussing LMA techniques ad nauseum on this forum - check em out.

deep vs awake for LMA's is academic dogma...
 
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[QUOTE="Noyac, post: 16059187, member: 72522"

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.[/QUOTE]


Sorry to thread jack but I'd love to hear more about your technique. How long from dressing application? What kind of cases?

I wanna do that!
 
Dude, that's like asking a old Italian grandmother to give up her lasagna recipe that she has perfected for years.
 
Ahh what the hell

It's not difficult. When the surgery is over and they are starting to close I turn the DES down to at least half MAC. Sometimes I just turn the vaporizer off and leave the flows low. Don't try to blow the gas off too fast. If you turn off the vaporizer and keep the flows low (<2 lpm) then when you are ready to get the gas off it will go fast. Also, I almost never use Sevo. It's a good gas but it just isn't as good as DES IMO. But this technique works with any gas, even ISO. But that's another discussion.

When I have about 5min before I want the pt to open their eyes I give 2-5cc of propofol depending on the age and size of the pt. Usually I also have the pt breathing spontaneously about 12 bpm. Now when I'm pulling the tube or LMA deep I just have them deeper on propofol. The other nice thing about this technique is let's say you under estimated the actually closing time or they screw up the closer and start all over. Just give the pt more propofol.

Disclaimer: all of this is adjusted to the pt and the surgery. But you get the idea.
 
We've hashed out this topic a number of times in the past. I like deep extubations on everyone who won't be difficult to mask/reintubate. I especially like them on procedures where you really don't want the patient bucking/thrashing- arterial vascular cases, etc.

I also use des. I agree with Noy that any consultant anethesiologist should be able to wake up a patient on a dime regardless of what gas is used. That job is just much more involved with iso, and IMO even sevo. With des, you don't even have to think about it, it comes off so fast.

I am also in the camp that sees LMAs as glorified oral airways. I don't believe in the necessity of pulling them deep. When they wake up, they spit them out, no problem. I have never seen NPPE from an LMA, though I have heard of it.

My trick is this- if they bite the LMA, I push down on the frenulum of the lower lip. They will open their mouths with that maneuver. Every time. So I don't use a bite block with LMAs, but I don't think any less of people that do.
 
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Hawaiian Bruin said:
We've hashed out this topic a number of times in the past. I like deep extubations on everyone who won't be difficult to mask/reintubate. I especially like them on procedures where you really don't want the patient bucking/thrashing- arterial vascular cases, etc.

I also use des. I agree with Noy that any consultant anethesiologist should be able to wake up a patient on a dime regardless of what gas is used. That job is just much more involved with iso, and IMO even sevo. With des, you don't even have to think about it, it comes off so fast.

I am also in the camp that sees LMAs as glorified oral airways. I don't believe in the necessity of pulling them deep. When they wake up, they spit them out, no problem. I have never seen NPPE from an LMA, though I have heard of it.

My trick is this- if they bite the LMA, I push down on the frenulum of the lower lip. They will open their mouths with that maneuver. Every time. So I don't use a bite block with LMAs, but I don't think any less of people that do.
Click to expand...

After I read this frenulum trick on another thread (maybe also your post) I started using it and it has saved my ass a few times. Great trick. Thanks
 
The other thing that drives me crazy is when I see a pt biting down on the LMA and reaching up for it, everyone tries to grab the pts hands and fight them. Just let the pt be. If they want to pull the LMA out then fine, they are ready. Plus if they grab it and pull they instinctively will open their mouths. If you fight them they will continue to bite down.
 
The other nice tricks for for when pts are biting their airways:

1) with and ETT, quickly deflate the cuff. This prevents any significant negative pressure and NPPE.

2) with an LMA, instead of trying to pull it out, push it in further. The pt will "gag" and open their mouth.
 
Oh and FWIW, with LMAs- unless there is a compelling reason to do so, I leave them exactly as they come- no further inflation or deflation. I don't even take the red tab off. People look at me like I don't know WTF I'm doing sometimes, but I think it comes with just the right amount of air.

It goes in as is. Seals just fine through the case as is. And as Noy points out, when there is some air in it, secretions will come out with it.

I usually give a single test ventilation to see how my seal is. I don't monkey with it unless the seal is poor.
 
The red tab on the Supreme pushes in the one-way valve. So, during insertion, if there is excess air in the LMA, it will get out, allowing the LMA to better conform to the pharynx. The only reason to remove the red tab is to inject more air.

Before injecting more air, I make sure that the leak is not due to the LMA being too deep.
 
Noyac said:
Ahh what the hell

It's not difficult. When the surgery is over and they are starting to close I turn the DES down to at least half MAC. Sometimes I just turn the vaporizer off and leave the flows low. Don't try to blow the gas off too fast. If you turn off the vaporizer and keep the flows low (<2 lpm) then when you are ready to get the gas off it will go fast. Also, I almost never use Sevo. It's a good gas but it just isn't as good as DES IMO. But this technique works with any gas, even ISO. But that's another discussion.

When I have about 5min before I want the pt to open their eyes I give 2-5cc of propofol depending on the age and size of the pt. Usually I also have the pt breathing spontaneously about 12 bpm. Now when I'm pulling the tube or LMA deep I just have them deeper on propofol. The other nice thing about this technique is let's say you under estimated the actually closing time or they screw up the closer and start all over. Just give the pt more propofol.

Disclaimer: all of this is adjusted to the pt and the surgery. But you get the idea.
Click to expand...

Thanks.

I've played with variations of this for years. Still half my patients can't move themselves over, not even close. And I take a lot of my patients to PACU with the LMA in. Maybe I'm just not willing to wait long enough. Or they wake up faster in the mountains than at sea level.🙁
 
You guys need to turn off the VAPOR and turn on the Nitrous oxide; you get the second gas effect with emergence. Most expert Anesthesiologists who know their staff/surgeon can wake the patient up at the end of the case as the stretcher comes into the room; FYI, when using Isoflurane the timing is a little different but it isn't more difficult than using Sevo.
 
I have had 2 cases of Negative pressure pulmonary edema with LMAs. The patients weren't deep enough nor were they awake. Be careful you understand the MAC requirement for deep removal of LMAs.
 
Anesth Analg. 2005 Oct;101(4):1034-7, table of contents.
Optimal end-tidal sevoflurane concentration for the removal of the laryngeal mask airway in anesthetized adults.
Shim YH1, Shin CS, Chang CH, Shin YS.
Author information

Abstract
Sevoflurane provides smooth and rapid emergence from anesthesia and can be used when the removal of a laryngeal mask airway (LMA) is required in anesthetized patients. We sought to determine the optimal end-tidal concentrations of sevoflurane required for the removal of LMA in anesthetized adults. We studied 35 adults, aged 22-64 years old with an ASA physical status I or II, who were undergoing perineal surgery. General anesthesia was induced with thiopental, and the LMA was then inserted. Anesthesia was maintained with sevoflurane, oxygen, and air. After the surgery, the target concentration was maintained for at least 10 min, and then the LMA was removed. Each target concentration at the time of removal was predetermined by the Dixon up-down method (with 0.1% as a step size) starting at 1.7% end-tidal concentration of sevoflurane. The LMA removal was considered successful when there was no coughing, clenching of teeth, or gross purposeful movements during or within 1 min after removal and also if there was no breath holding, laryngospasm, or desaturation after removal. The end-tidal concentration of sevoflurane to achieve successful LMA removal in 50% of adults was 0.99% +/- 0.09% (mean +/- SD) and in 95% of adults was 1.18% (95% confidence limits, 1.07%-1.79%). In conclusion, we have determined that LMA removal in 50% and 95% of anesthetized adults can be safely accomplished without coughing, moving, or any other airway complications at 0.99% and 1.18% end-tidal concentrations of sevoflurane.

IMPLICATIONS:
Because the removal of the laryngeal mask airway (LMA) in the anesthetized state is required in some clinical situations, we sought to determine the end-tidal concentration of sevoflurane to safely remove the LMA in anesthetized adults.
 
BLADEMDA said:
I have had 2 cases of Negative pressure pulmonary edema with LMAs. The patients weren't deep enough nor were they awake. Be careful you understand the MAC requirement for deep removal of LMAs.
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There is this white substance called propofol...
 
Thanks to Blade and others for bringing the NPPE with LMA to my attention. I had never seen it and just couldn't wrap my head around it. Of course, I understand how it can happen. I just didn't think it happened all that often. But I'm sure if you've seen it once, you never forget it. I still wonder if some of these are laryngospasm. It seems reasonable to deflate the LMA if the pt bites down on it. I usually just pull it up and away from the glottis opening and in the back of the mouth in order to remove the obstruction to air flow. You don't have to pull it very far. Just enough to break the seal. And when they bite down you still can slide it some in their teeth. I never thought about it as preventing NPPE. But the more you do this job the more you make aha it of doing cetain things without even thinking about it.
 
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? Isoflurane is much cheaper, has less tachycardia, and has less airway pungency. So it makes no sense to use the much more expensive gas if you can achieve the same thing with isoflurane, which is a perfectly times wake-up.
 
Ignatius J said:
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? Isoflurane is much cheaper, has less tachycardia, and has less airway pungency. So it makes no sense to use the much more expensive gas if you can achieve the same thing with isoflurane, which is a perfectly times wake-up.
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Mostly because we don't have ISO. Just Sevo and Des. The tachycardia is a none issue. You just can't drive up the conc too fast. Crank it to 12 on the vaporizer and turn the combined flow to less than 2 lpm. No tachy cardia. Come down on the conc when you get to the ET you are aiming for. No tachycardia. No airway irritation.

Btw, you ever tried to breath ISO? It's pretty bad too.
 
BLADEMDA said:
For Children the deep removal of the LMA requires an even greater concentration of Vapor:

http://www.ncbi.nlm.nih.gov/pubmed/17312202
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the N in this study was 25. ages 7mos-10years. not a sufficient sample size, not specific to age groups. anytime a study generalizes to "pediatrics" ie <18yo, you know it's prolly gonna be hogwash.

they recommend etsev 1.8%. imho this is too deep - there will be too much time before the kid emerges. i maintain that 0.5-1% is ideal for patients of any age to emerge before signout is complete in pacu with a minimum of airway support.
 
Noyac said:
Mostly because we don't have ISO. Just Sevo and Des. The tachycardia is a none issue. You just can't drive up the conc too fast. Crank it to 12 on the vaporizer and turn the combined flow to less than 2 lpm. No tachy cardia. Come down on the conc when you get to the ET you are aiming for. No tachycardia. No airway irritation.

Btw, you ever tried to breath ISO? It's pretty bad too.
Click to expand...

Tachycardia was a side point, but yes, desflurane is much more pungent than isoflurane. Of course, none are pleasant. Not even sevo.

I would recommend getting isoflurane at your center if it doesn't make a difference with your wake-ups. The difference in cost is not a little bit.

I think every place needs isoflurane. If leaving the patient intubated, that .2 of iso that sticks around forever is great help for the duration of transport to the next destination.
 
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Ignatius J said:
I think every place needs isoflurane. If leaving the patient intubated, that .2 of iso that sticks around forever is great help for the duration of transport to the next destination.
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+1. During residency, I used to run iso on all cases that would stay intubated post-op, until leaving the room. Never had to supplement it during the transport to the ICU.

It's also good for cases that need smooth wake-up. Plus it's much cheaper than other volatiles.
 
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.

I use iso on all cases that will stay intubated postop- so 80% of the time in my practice. I like isoflurane, I like it a lot. But if the patient has to wake up at the end of the anesthetic, the quality of the desflurane wakeup is superior to both iso and sevo.

I tell you what I'll never understand- practices that use sevo in their heart rooms and on their pumps. Now that makes zero sense.
 
I don't disagree with any of you here. But I don't do hearts or long crani's any longer. So I prefer to keep my des. Plus I only have two vaporizer spots on my anesthesia machine so I would have to exchange them out and would have to go find one whenever I wanted to use it. No thanks.
 
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