How often do you do tivas?

[Maverikk]

I'm a relatively new attending in a private practice I like. I wanted to get an idea of how often people do tivas in PP. I rarely have a case go over 3/4 hours and I do neuro/vascular. How often do you do tivas for the longer cases? I was thinking straightforward prop and a little fentanyl on the hour. I did this in training for neuromonitoring cases, most often with remi which now I think is mostly unneeded.

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[shepardsun]

Aside from the clear indications for TIVA (MH, some types of neuromonitoring), most of the literature I've seen is equivocal at best with the typical considerations of decreased PONV, better wake-ups/analgesia, etc. Given the relative cost and amount of work required to set a good one up, I'd be interested to hear the situations where people are choosing them over a balanced volatile based anesthetic. As a tangential question, how often are people doing some sort of EEG based depth monitoring when they run them?

 

[shepardsun]

Second set of tangential questions- does anyone consider using remifentanil in patients with chronic pain conditions at increased risk for hyperalgesia? How about opioids in general in patients undergoing oncologic surgery?

 

[facted]

I will often do prop infusion for any high risk ponv case/pt. Setting up a bottle of prop takes me about 30 seconds.

 

[shepardsun]

Food for thought

 

[polar403]

I do TIVA for neuromonitoring combined with bolus fentanyl or sufentanil or a continuous sufentanil drip.

I’ll also do it for severe PONV with other anti-emetic adjuvants (and multimodal pain control limiting opioids).

I find that the patients tend to have a smooth emergence with TIVA, similar to emergence under volatile anesthesia with a heavy dose of opioids (or alternatively if I’ve bolused precedex during the case for opioid sparing).


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[anbuitachi]

Food for thought

i dont know about other people, but i still give zofran even in TIVAs. it's not like i do TIVA and dont give any other antiemetic

 

[Hoya11]

I'm a relatively new attending in a private practice I like. I wanted to get an idea of how often people do tivas in PP. I rarely have a case go over 3/4 hours and I do neuro/vascular. How often do you do tivas for the longer cases? I was thinking straightforward prop and a little fentanyl on the hour. I did this in training for neuromonitoring cases, most often with remi which now I think is mostly unneeded.

Volatile and propofol mix (usually 100-150 prop and 0.6-1.0% ET Sevo) Plus fentanyl/dilaudid boluses intra-op.

I find that even that little amount of volatile helps with stillness/smoothness moreso than remi, and it makes me feel good that if the IV came out I would at least be giving something until i detected it

I dont do remi

 

[Hoya11]

Aside from the clear indications for TIVA (MH, some types of neuromonitoring), most of the literature I've seen is equivocal at best with the typical considerations of decreased PONV, better wake-ups/analgesia, etc. Given the relative cost and amount of work required to set a good one up, I'd be interested to hear the situations where people are choosing them over a balanced volatile based anesthetic. As a tangential question, how often are people doing some sort of EEG based depth monitoring when they run them?

disagree. the difference between someone who had pure volatile vs pure propofol or a mix is OFTEN apparent. i work both in a hospital and an ASC. At the ASC literally everyone gets propofol gtt plus minus sevo. No EEG monitoring, Im confident that 10 100 of prop plus 0.8 of sevo the person is asleep. I use a propofol gtt in the majority of my cases period unless i wam worried about hypotension, its a very old person or very young kid, the surgery is less than 30-40 mins, thats pretty much it

 

[Mman]

Food for thought

doesn't pass the smell test

The incidence of PONV when giving a propofol TIVA plus other antiemetics is extremely low even in patients with significant PONV history.

 

[DM27]

I do TIVA for probably 60% cases, and of the 40% I don't do TIVA, at least 1/2 of those are cardiac.

 

[Noyac]

Second set of tangential questions- does anyone consider using remifentanil in patients with chronic pain conditions at increased risk for hyperalgesia? How about opioids in general in patients undergoing oncologic surgery?

Yes. Avoid it if possible. Use other narcotics if needed.

 

[Noyac]

I do lots of TIVA bc I do a lot of spine cases. Other than that I rarely use TIVA. Not convinced of any superiority. However, every case gets a little propofol to wake up on for various reasons.

To the ones that think it is obvious in the PACU which pts got TIVA and which didn’t. I would agree. The volatile pts wake up faster when used well. But it’s only by a few minutes so therefore, a wash.

 

[dhb]

doesn't pass the smell test

The incidence of PONV when giving a propofol TIVA plus other antiemetics is extremely low even in patients with significant PONV history.

I often see patients that have a history of PONV but say that their last surgerie(s) were ok when they were given prophylaxis...
With that said i also do TIVA in cases of persistent PONV.

 

[Mman]

I often see patients that have a history of PONV but say that their last surgerie(s) were ok when they were given prophylaxis...
With that said i also do TIVA in cases of persistent PONV.

Oh I agree. Most people who tell me about PONV mention that "they gave me something last time and I didn't get sick". I let them know we give everybody prophylaxis against PONV and if it was successful the last few times it should work this time. If they are particularly high risk and have had persistent PONV despite multi-agent prophylaxis against it, I will TIVA with propofol plus at least 3-4 antiemetics and they basically never get sick. I mean I've had 1 or 2 still get a little nausea in PACU but they assure me it's way better than previous times.

 

[deleted162650]

TIVA is rarely necessary for neuromonitoring. Even for motors, unless the patient has significant baseline deficits or the baselines are garbage they tolerate 1/2 MAC of volatile no problem.

I probably only do a handful of TIVA’s per year (unless you count GI cases or the prop sedation after spinal for joints)

 

[deleted162650]

Oh, and Remi is the devil’s medicine.

 

[Noyac]

Oh I agree. Most people who tell me about PONV mention that "they gave me something last time and I didn't get sick". I let them know we give everybody prophylaxis against PONV and if it was successful the last few times it should work this time. If they are particularly high risk and have had persistent PONV despite multi-agent prophylaxis against it, I will TIVA with propofol plus at least 3-4 antiemetics and they basically never get sick. I mean I've had 1 or 2 still get a little nausea in PACU but they assure me it's way better than previous times.

I’m not disagreeing with you but I would offer that there is more the the PONV than the anesthetic used. Things like the surgical procedure I believe makes a greater impact. I ask what surgery they had when they became nauseated and if it was in PACU or later in the day ( usually related to narcotics given while on the floor or at home).
Occasionally, they say the surgery was a c section, well duh!
Lap chole or total knee are high on the list as well.
I push for Regional if I theY are truly high risk.

 

[CommonMan]

Why no mention of the study in JAMA about lower mortality rates when TIVA is used in cancer surgery? I'm not a physician but to me this seems like a big deal.

 

[2Fast2Des]

TIVA is rarely necessary for neuromonitoring. Even for motors, unless the patient has significant baseline deficits or the baselines are garbage they tolerate 1/2 MAC of volatile no problem.

I probably only do a handful of TIVA’s per year (unless you count GI cases or the prop sedation after spinal for joints)

Do you run opioid with neuromonitoring case? I've been doing multimodal infusion without opioids and pts seem pretty good

 

[deleted162650]

Do you run opioid with neuromonitoring case? I've been doing multimodal infusion without opioids and pts seem pretty good

Couldn’t tell you the last time I ran an opioid gtt. Just bolus fent/dilaudid prn.

 

[caligas]

Take a 100 cc vial of propofol, add a 1mg vial of remi powder and 100 mg ketamine. Titrate to effect.

Any questions from neuromonitoring tech are answered with:
“I’m running a ‘White Lightning’ drip”

 

[deleted875186]

Take a 100 cc vial of propofol, add a 1mg vial of remi powder and 100 mg ketamine. Titrate to effect.

Any questions from neuromonitoring tech are answered with:
“I’m running a ‘White Lightning’ drip”

Honestly, excellent combo, we should compound these and sell them.

 

[anbuitachi]

I’m not disagreeing with you but I would offer that there is more the the PONV than the anesthetic used. Things like the surgical procedure I believe makes a greater impact. I ask what surgery they had when they became nauseated and if it was in PACU or later in the day ( usually related to narcotics given while on the floor or at home).
Occasionally, they say the surgery was a c section, well duh!
Lap chole or total knee are high on the list as well.
I push for Regional if I theY are truly high risk.

what is the mechanism for more PONV for TKR?

 

[Psai]

The limitation to doing widespread TIVA in the US is the unavailability of target controlled infusion pumps in the US like they have in Europe due to the complexity of the FDA process.Hard to wake patients up in a timely fashion without them.

Target-Controlled Infusion: A Mature Technology : Anesthesia & Analgesia

*link deleted by mod*

No it's not

 

[AdmiralChz]

Why no mention of the study in JAMA about lower mortality rates when TIVA is used in cancer surgery? I'm not a physician but to me this seems like a big deal.

Evidence on that is pretty equivocal, even in cases like breast surgery where it was thought there was a significant difference. There are some good review articles and newer evidence on this in Jan 2019 issue of Anesthesia.

 

[nimbus]

what is the mechanism for more PONV for TKR?

Probably the intrathecal morphine😉

 

[epidural man]

I'm a relatively new attending in a private practice I like. I wanted to get an idea of how often people do tivas in PP. I rarely have a case go over 3/4 hours and I do neuro/vascular. How often do you do tivas for the longer cases? I was thinking straightforward prop and a little fentanyl on the hour. I did this in training for neuromonitoring cases, most often with remi which now I think is mostly unneeded.

I do TIVA in every case, all the time, every time.

Unless I am too lazy to get my resident to change after I take over the case...but I'm usually not lazy, because it is a great experience for them to run TIVA.

When I ask, "have you done a TIVA?" - they usually say" yes" and I say "explain"and they explain a propofol background while running a volatile anesthetic. I tell them "that isn't TIVA."

My recipe: 2000mcg Alfenta mixed in 100ml of propofol. +/- ketamine on induction (0.5mg/kg). +/- precedes 10-20mcg boluses PRN. +/- lidocaine infusion 30mcg/kg/min.

I always start at 180mcg/kg/min - and titrated after this.

 

[epidural man]

Food for thought

No one will ever convince an astute, thoughtful, educated anesthesiologist with a meta-analysis. Meta-analysis is the sneakiest form of a lie.

If you want some food for thought - it is this.

Run gas for 6 hours, then, turn it off, run a regular flow (like 1 liter), and see how long it takes for gas to come off. It takes forever for it to disappear from the system. I bet if you had a sensitive way to measure gas, a person would be off-gasing for a couple of days, and that low level of gas makes people feel like crap. Don't believe me eh? Start paying attention to people in the PACU how annoyed they are that they can't wake up..but the gas is making them super sleepy. They hate that feeling. Now imagine that for 24 hours! That is the exact opposite with propofol. Propofol has teetered with being controlled substance because people feel awesome with it. People wake up feeling "happy, hungry, and horny:" as my attending would say. And I'm sure - like the gas - this sticks around for several hours...so this low level of feeling great can't be a bad thing.

And more food.

We are all taught that anesthesia messes with sleep/wake cycle (as does surgery). But that is mostly with volatile anesthetic. In fact, if you have a sleep deficit, volitile anesthetic makes this worse. That isn't true with propofol. In fact, propofol REVERSES the sleep deficit!

Here is the downside to using propofol. Gas prevents movement. Propofol is horrible at getting people to not move under surgical stimulus. You can paralyze them, but TIVA has classically been listed as a higher risk of recall. That may be why people love their gas. I have learned to deal with these two pesky things, so I love using it. I feel like I am doing my patients a favor - even if I am not...I feel that way.

 

[epidural man]

Second set of tangential questions- does anyone consider using remifentanil in patients with chronic pain conditions at increased risk for hyperalgesia? How about opioids in general in patients undergoing oncologic surgery?

By the way, the hyperalgesia with REMI happens with ALL intra-operative opioids...but at leasts for REMI, it can be reversed (or prevented) with ketamine. I assume that is true for all intra-operative opioids.

I read a great quote about REMI one time. Someone wrote (with regards to if they use REMI)...."REMI is like standing up in a canoe. Sure I COULD stand up in a canoe, but why would I ever want to?"

I love that quote.

 

[deleted875186]

By the way, the hyperalgesia with REMI happens with ALL intra-operative opioids...but at leasts for REMI, it can be reversed (or prevented) with ketamine. I assume that is true for all intra-operative opioids.

I read a great quote about REMI one time. Someone wrote (with regards to if they use REMI)...."REMI is like standing up in a canoe. Sure I COULD stand up in a canoe, but why would I ever want to?"

I love that quote.

I don’t understand. Most people believe hyperalgesia happens more frequently with Remi due to the increased potency and increased doses we give intraop, you disagree? Why would you prefer to use Remi just because adding ketamine is thought to prevent hyperalgesia?

I think using remifentanyl often is just lazy, it’s easy for the anesthesiologist to use but in most cases has no advantage for the patient themselves.

 

[dhb]

My recipe: 2000mcg Alfenta mixed in 100ml of propofol. +/- ketamine on induction (0.5mg/kg). +/- precedes 10-20mcg boluses PRN. +/- lidocaine infusion 30mcg/kg/min.

Explain to me why i should do this when i can intubate with propofol + paralysis turn on the gas do a tap block and forget about all the nonesense.
My incidence of PONV is low and when i see the patients in the afternoon they look pretty awake and well to me.

 

[nimbus]

My fastest wake ups are block plus low dose volatile. They’re the ones who wake up and say, “What? We’re done? You’re kidding me.”

 

[abolt18]

I do TIVA in every case, all the time, every time.

Unless I am too lazy to get my resident to change after I take over the case...but I'm usually not lazy, because it is a great experience for them to run TIVA.

When I ask, "have you done a TIVA?" - they usually say" yes" and I say "explain"and they explain a propofol background while running a volatile anesthetic. I tell them "that isn't TIVA."

My recipe: 2000mcg Alfenta mixed in 100ml of propofol. +/- ketamine on induction (0.5mg/kg). +/- precedes 10-20mcg boluses PRN. +/- lidocaine infusion 30mcg/kg/min.

I always start at 180mcg/kg/min - and titrated after this.

Every single case? Every time? Seriously?

 

[deleted162650]

No one will ever convince an astute, thoughtful, educated anesthesiologist with a meta-analysis. Meta-analysis is the sneakiest form of a lie.

If you want some food for thought - it is this.

Run gas for 6 hours, then, turn it off, run a regular flow (like 1 liter), and see how long it takes for gas to come off. It takes forever for it to disappear from the system. I bet if you had a sensitive way to measure gas, a person would be off-gasing for a couple of days, and that low level of gas makes people feel like crap. Don't believe me eh? Start paying attention to people in the PACU how annoyed they are that they can't wake up..but the gas is making them super sleepy. They hate that feeling. Now imagine that for 24 hours! That is the exact opposite with propofol. Propofol has teetered with being controlled substance because people feel awesome with it. People wake up feeling "happy, hungry, and horny:" as my attending would say. And I'm sure - like the gas - this sticks around for several hours...so this low level of feeling great can't be a bad thing.

And more food.

We are all taught that anesthesia messes with sleep/wake cycle (as does surgery). But that is mostly with volatile anesthetic. In fact, if you have a sleep deficit, volitile anesthetic makes this worse. That isn't true with propofol. In fact, propofol REVERSES the sleep deficit!

Here is the downside to using propofol. Gas prevents movement. Propofol is horrible at getting people to not move under surgical stimulus. You can paralyze them, but TIVA has classically been listed as a higher risk of recall. That may be why people love their gas. I have learned to deal with these two pesky things, so I love using it. I feel like I am doing my patients a favor - even if I am not...I feel that way.

I wish there was a “dislike” button.

 

[T-burglar]

No one will ever convince an astute, thoughtful, educated anesthesiologist with a meta-analysis. Meta-analysis is the sneakiest form of a lie.

If you want some food for thought - it is this.

Run gas for 6 hours, then, turn it off, run a regular flow (like 1 liter), and see how long it takes for gas to come off. It takes forever for it to disappear from the system. I bet if you had a sensitive way to measure gas, a person would be off-gasing for a couple of days, and that low level of gas makes people feel like crap. Don't believe me eh? Start paying attention to people in the PACU how annoyed they are that they can't wake up..but the gas is making them super sleepy. They hate that feeling. Now imagine that for 24 hours! That is the exact opposite with propofol. Propofol has teetered with being controlled substance because people feel awesome with it. People wake up feeling "happy, hungry, and horny:" as my attending would say. And I'm sure - like the gas - this sticks around for several hours...so this low level of feeling great can't be a bad thing.

And more food.

We are all taught that anesthesia messes with sleep/wake cycle (as does surgery). But that is mostly with volatile anesthetic. In fact, if you have a sleep deficit, volitile anesthetic makes this worse. That isn't true with propofol. In fact, propofol REVERSES the sleep deficit!

Here is the downside to using propofol. Gas prevents movement. Propofol is horrible at getting people to not move under surgical stimulus. You can paralyze them, but TIVA has classically been listed as a higher risk of recall. That may be why people love their gas. I have learned to deal with these two pesky things, so I love using it. I feel like I am doing my patients a favor - even if I am not...I feel that way.

Damn. That’s wild playa

 

[shepardsun]

No one will ever convince an astute, thoughtful, educated anesthesiologist with a meta-analysis. Meta-analysis is the sneakiest form of a lie [...] I feel like I am doing my patients a favor - even if I am not...I feel that way.

Sounds like a strong foundation for evidence based clinical practice.

 

[pgg]

If you want some food for thought - it is this.

Run gas for 6 hours, then, turn it off, run a regular flow (like 1 liter), and see how long it takes for gas to come off. It takes forever for it to disappear from the system.

Of course it takes forever - at 1 lpm they'll rebreath ~80%+ of the volatile they exhale! You're about half a liter away from closed circuit anesthesia there.

Tissue offgassing, which is what I think you're trying to get at here, is heavily dependent on the oil:gas partition coefficient of the gas you choose (des 19, sevo 53, iso 97). This problem is solved by choosing the right gas for the patient and case.

I bet if you had a sensitive way to measure gas, a person would be off-gasing for a couple of days, and that low level of gas makes people feel like crap.

Maybe if the patient is obese and you're using methoxyflurane (oil:gas partition coefficient of 950 🙂) your couple of days speculation would pan out.

Use a modern volatile anesthetic, especially desflurane, and I'd take that bet.

(Side note, when I looked up those numbers I saw that cyclopropane has better numbers than desflurane. MAC of 9, smells nice, cheap. Too bad about the explosions and ventricular arrhythmmias and a boiling point of -34 C.)

Don't believe me eh? Start paying attention to people in the PACU how annoyed they are that they can't wake up..but the gas is making them super sleepy.

No ... have to disagree.

In almost every case, the thing that makes people sleepy in the PACU is the total dose of opioid they got, not residual volatile. Unless you've got the obese / long case / isoflurane trifecta in play, in which case you clearly don't care about rapid emergence in the first place.

They hate that feeling. Now imagine that for 24 hours! That is the exact opposite with propofol. Propofol has teetered with being controlled substance because people feel awesome with it. People wake up feeling "happy, hungry, and horny:" as my attending would say. And I'm sure - like the gas - this sticks around for several hours...so this low level of feeling great can't be a bad thing.

Propofol wakeups are nice, I won't argue that. But so are desflurane wakeups. Or sevo/iso for short cases.

And more food.

We are all taught that anesthesia messes with sleep/wake cycle (as does surgery). But that is mostly with volatile anesthetic. In fact, if you have a sleep deficit, volitile anesthetic makes this worse. That isn't true with propofol. In fact, propofol REVERSES the sleep deficit!

I ... just don't care.

Someone comes in for outpatient surgery with a sleep deficit - so what? This person had a sleep deficit yesterday too. And last Thursday. And he's going to have one the day after tomorrow. He has a sleep deficit because he has lousy sleep hygiene. A couple hours of propofol isn't going to fix that.

Now, he goes home, and still has a sleep deficit. So what? He just had surgery and is going to spend at least a day or two doing what? Laying around and sleeping.

Now, if you could show me a meta-analysis that demonstrated propofol was more conducive to subliminal introp messaging to inspire weight loss and a reasonable bedtime, maybe ...

Here is the downside to using propofol. Gas prevents movement. Propofol is horrible at getting people to not move under surgical stimulus. You can paralyze them, but TIVA has classically been listed as a higher risk of recall. That may be why people love their gas. I have learned to deal with these two pesky things, so I love using it.

I'd like to think (nearly) everyone exits residency with the ability to run an anesthetic that involves amnesia, analgesia, and akinesia using a variety of techniques.

I feel like I am doing my patients a favor - even if I am not...I feel that way.

Heh. I guess there's no point in arguing that. 🙂

 

[deleted875186]

No one will ever convince an astute, thoughtful, educated anesthesiologist with a meta-analysis. Meta-analysis is the sneakiest form of a lie.

If you want some food for thought - it is this.

Run gas for 6 hours, then, turn it off, run a regular flow (like 1 liter), and see how long it takes for gas to come off. It takes forever for it to disappear from the system. I bet if you had a sensitive way to measure gas, a person would be off-gasing for a couple of days, and that low level of gas makes people feel like crap. Don't believe me eh? Start paying attention to people in the PACU how annoyed they are that they can't wake up..but the gas is making them super sleepy. They hate that feeling. Now imagine that for 24 hours! That is the exact opposite with propofol. Propofol has teetered with being controlled substance because people feel awesome with it. People wake up feeling "happy, hungry, and horny:" as my attending would say. And I'm sure - like the gas - this sticks around for several hours...so this low level of feeling great can't be a bad thing.

And more food.

We are all taught that anesthesia messes with sleep/wake cycle (as does surgery). But that is mostly with volatile anesthetic. In fact, if you have a sleep deficit, volitile anesthetic makes this worse. That isn't true with propofol. In fact, propofol REVERSES the sleep deficit!

Here is the downside to using propofol. Gas prevents movement. Propofol is horrible at getting people to not move under surgical stimulus. You can paralyze them, but TIVA has classically been listed as a higher risk of recall. That may be why people love their gas. I have learned to deal with these two pesky things, so I love using it. I feel like I am doing my patients a favor - even if I am not...I feel that way.

It’s not even debateable. Past 4 hours or something (forget the exact time), propofol infusion starts to have a longer context sensitive half life than iso. People will be much slower to awake in the PACU from a many hour prolonged prop infusion.

Also agree that there are many confounders here. Total opioid dose, other adjuvants, lyrics or gavapentin preop, OSA, obesity ....

 

[Hork Bajir]

My favorite way to wake people up from long cases is to use gas for the first however many hours, and then turn it off maybe an hour before wakeup and switch over to LOW dose propofol (30-80mcg/kg/min) +/- nitrous depending on how quickly the volatile is coming off. Can reliably wake patients up on a dime doing this- though like @pgg says, there are multiple ways to skin a cat. This one just happens to be my favorite. Nice side-benefit is that there's some anti-emetic effect, particularly if the end-tidal concentration of volatile is zero when the tube comes out. As long as patient is breathing spontaneously, I'll usually feel comfortable doing a "sedated" extubation (rather than truly awake or asleep) knowing that the elimination of the residual propofol won't be slowed even if they hypo ventilate a little bit- typically they're still gorked when the tube comes out, but starting to open eyes spontaneously and say "it's over already!?" by the time we roll into PACU... Obviously this is only in carefully selected patients (not for neuro cases, intra-abdominal cases, full stomach, severe OSA, difficult intubation, airway surgery, etc).

It does raise the question, though, of whether you can speed wakeup by "starting a new context sensitive half-life"... ie does switching from iso to sevo an hour before wakeup speed emergence in the same manner. I've always anecdotally felt like it does, and mechanistically it makes sense to me- but I've had a few attendings who are much, much, much smarter than I argue that the whole business of starting a new context sensitive half time is bogus. FWIW, I've always had more luck trying to do this technique with gas --> propofol or propofol --> gas than with iso --> sevo or sevo/iso --> des. Curious to hear other people's thoughts here?

 

[abolt18]

My favorite way to wake people up from long cases is to use gas for the first however many hours, and then turn it off maybe an hour before wakeup and switch over to LOW dose propofol (30-80mcg/kg/min) +/- nitrous depending on how quickly the volatile is coming off. Can reliably wake patients up on a dime doing this- though like @pgg says, there are multiple ways to skin a cat. This one just happens to be my favorite. Nice side-benefit is that there's some anti-emetic effect, particularly if the end-tidal concentration of volatile is zero when the tube comes out. As long as patient is breathing spontaneously, I'll usually feel comfortable doing a "sedated" extubation (rather than truly awake or asleep) knowing that the elimination of the residual propofol won't be slowed even if they hypo ventilate a little bit- typically they're still gorked when the tube comes out, but starting to open eyes spontaneously and say "it's over already!?" by the time we roll into PACU... Obviously this is only in carefully selected patients (not for neuro cases, intra-abdominal cases, full stomach, severe OSA, difficult intubation, airway surgery, etc).

It does raise the question, though, of whether you can speed wakeup by "starting a new context sensitive half-life"... ie does switching from iso to sevo an hour before wakeup speed emergence in the same manner. I've always anecdotally felt like it does, and mechanistically it makes sense to me- but I've had a few attendings who are much, much, much smarter than I argue that the whole business of starting a new context sensitive half time is bogus. FWIW, I've always had more luck trying to do this technique with gas --> propofol or propofol --> gas than with iso --> sevo or sevo/iso --> des. Curious to hear other people's thoughts here?

Iso to Des around an hour before the end of the case, or just run 65% nitrous plus a small amount of iso = some super smooth and fast wake-ups for me. I've done a total of 8 months of OR anesthesia now as a resident and I'm always experimenting with different ways to better time or smooth out my wake-ups. I've received a lot of compliments on the past month or two from attendings for it. I'm enjoying the challenge of getting better and better at it.

I find it hard though with really short cases. I feel like I barely have time to get the patient settled in before it's time to take the tube out.

 

[Psai]

Iso to Des around an hour before the end of the case, or just run 65% nitrous plus a small amount of iso = some super smooth and fast wake-ups for me. I've done a total of 8 months of OR anesthesia now as a resident and I'm always experimenting with different ways to better time or smooth out my wake-ups. I've received a lot of compliments on the past month or two from attendings for it. I'm enjoying the challenge of getting better and better at it.

I find it hard though with really short cases. I feel like I barely have time to get the patient settled in before it's time to take the tube out.

Short cases are a lot easier since the gas comes off quick no matter what it is. Low gas/70%nitrous and heavy opioids make for a really nice and timely wakeup.

Instead of running a prop drip I like doing prop boluses at the end

 

[CommonMan]

Isn't the cost of tiva significantly higher than gas. I asked a resident why he didn't run tiva more and he said the hospital would squawk because of the cost. Its also my impression its more work than gas.

 

[Mman]

Isn't the cost of tiva significantly higher than gas. I asked a resident why he didn't run tiva more and he said the hospital would squawk because of the cost. Its also my impression its more work than gas.

yes it costs more and yes it is more work

 

[deleted162650]

yes it costs more and yes it is more work

And no, it’s not any better.

 

[narcotics999]

Why no mention of the study in JAMA about lower mortality rates when TIVA is used in cancer surgery? I'm not a physician but to me this seems like a big deal.

Read some meta-analysis on it. While the conclusions were not statistically significant, there was a tendency that regional with TIVA was associated with less cancer metastasis. The presumed rationale (at least partly) is less spreading of circulating cancer cells during perioperative period.

Did it change my way of practicing? Yes, partly.

 

[deleted9493]

The incidence of emergence delirium in kids after a propofol-based anesthetic is non-existent. There are kids out there in whom all the Precedex in the world won't keep them from raging coming off a volatile anesthetic. That's one common reason I use TIVA. The second is for history of intractable PONV. If narcotics are able to be avoided with good regional, PONV is not going to be a problem on straight propofol. Multi-modal anti-emesis + TIVA when narcotics are needed will very rarely fail to capture everybody on DOS. The next day when they're taking PO narcotics after their LeFort is another story.

 

[epidural man]

I don’t understand. Most people believe hyperalgesia happens more frequently with Remi due to the increased potency and increased doses we give intraop, you disagree? Why would you prefer to use Remi just because adding ketamine is thought to prevent hyperalgesia?

I think using remifentanyl often is just lazy, it’s easy for the anesthesiologist to use but in most cases has no advantage for the patient themselves.

I never use remi. I don't see a point to it - hence my story about a canoe.

I never said anything about the degree of hyperalgesia. I only said, that hyperalgesia happens with every opioid that has been looked at during the intraoperative period. I have no idea about the degree. I suspect it happens to a much more significant degree with REMI.

But my main point was that the hyperalgesia that happens with REMI has been shown to reverse with ketamine.

 

[epidural man]

Every single case? Every time? Seriously?

Seriously.

Can you give me compelling reason NOT to do it?

 

[epidural man]

I am a little surprised at the disdain on here against TIVA....in fact some really need to make that point that it isn't any better.

As the protagonist from Green Eggs and Ham says, try and you will see! I know you all think you are very experience with TIVA, and great if you are and you hate it, but if you aren't...try getting experienced. Try not having to worry about laryngospams (to the same degree) at the end of the case. Try seeing how people feel after a long propofol infusion vs a sevoflurane anesthetic. Try not having to worry about getting someone through stage II. It's really good stuff. I'm really really surprised it is used so little.

But again...people are strange. Try telling someone they should eat more broccoli and avoid milk and meat and people have a nervous breakdown.