How often do you do tivas?

[Psai]

Seriously.

Can you give me compelling reason NOT to do it?

Why many word when few do trick

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[psychbender]

eat more broccoli and avoid milk and meat and people have a nervous breakdown.

Well, damn, you lost me there.

 

[deleted162650]

I only said, that hyperalgesia happens with every opioid that has been looked at during the intraoperative period.

Please show me some evidence of this that isn't retrospective horse manure.

 

[epidural man]

Please show me some evidence of this that isn't retrospective horse manure.

Sure!

This took me two minutes to find.

Now you present some contrary evidence. I'll give you more time than two minutes.

 

[dhb]

Sure!

This took me two minutes to find.

Now you present some contrary evidence. I'll give you more time than two minutes.

Our results suggest that acute fentanyl tolerance develops after administration of high dose fentanyl
during surgery and, consequently, results in a higher postoperative pain intensity and greater fentanyl consumption.

I love how in papers they observe an effect and then just make up a phiological concept to justify it.

Imho, if you saturate your opiod receptors during surgery it seems obvious that you are going to need higher doses to treat post-operative pain.

 

[epidural man]

Imho, if you saturate your opiod receptors during surgery it seems obvious that you are going to need higher doses to treat post-operative pain.

Yes! And it wouldn't matter the opioid...that would be the point. The more opioids you use intra-op, the more you need post op.

I only mentioned that it has actually been shown in actually papers people have written, and for several opioids.

Not sure why some would find this concept akin to horse manure.

As a small derail and related to horse manure, don't you love how in Red Dead Redemption 2, you can see the horses often creating "manure"....nice little attention to detail on that.

 

[narcusprince]

I have found that using Gas in the beginning and bridging your anesthetic at the end with bolus propofol or propofol infusion is just as good as running a full tiva from the start in ponv patients.

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

 

[abolt18]

Seriously.

Can you give me compelling reason NOT to do it?

More work for (from my perspective so far) little to no major benefit. That, to me, is a compelling reason.

 

[deleted875186]

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.

I think the general anecdotal impression of most is that a prolonged prop infusion will linger longer than sevo or des, so people will be more awake and feel better quicker post op after gas. I generally do TIVA only if there’s concern for nausea, neuromonitoring, maybe if I want a smoother emergence. How often are you seeing people wake up more awake after a long TIVA case?

 

[epidural man]

I think the general anecdotal impression of most is that a prolonged prop infusion will linger longer than sevo or des, so people will be more awake and feel better quicker post op after gas. I generally do TIVA only if there’s concern for nausea, neuromonitoring, maybe if I want a smoother emergence. How often are you seeing people wake up more awake after a long TIVA case?

I started doing TIVA all the time at my main gig after getting experience with it at a plastic surgery center where I basically recover the patients and don't leave until they leave. My PACU/post - op patient experience at the hospital is WAY different from this...which is.. I see the patient at PACU turnover, and maybe sometimes when I get called back for an issue. Except for my rotation in PACU as a resident, in the hospital I rarely have seen the whole recovery experience. I suspect that is common among MOST anesthesiologists. Hospitals/surgery centers aren't going to pay for an anesthesiologist to watch patients in the recovery room. They want them working in the OR.

In the surgery center, I have run propofol for MANY hours (8+) , and yes, it may seem that it takes them longer to wake up in the first few post - op minutes, but they are always wide awake within 30-40 minutes...no matter how long I run the infusion. I could shorten this if I actually tried to time a wake up with the end of the case, but since I don't care about that (I will pull the tube with adequate spontaneous ventilation), it may seem like a longer wake up...small price to pay.

THIS study seems to indicate that recovery time is quicker with propofol vs SEVO but may be from the opioid effect. ( I only read the abstract). Alfentanil with propofol seems to work perfect..not as short as REMI, but doesn't hang around for long infusions.

THIS study shows that the difference between DES vs PROP was very small, but DES was quicker as they extubated in the room awake. Again, no need to extubate awake with a propofol infusion so this difference is insignificant. The propofol group had ZERO PONV, but DES had lots. In 2006, propofol was way more expensive so their comment about more cost with TIVA is probably not as applicable. Again, I just read the abstract.

THIS says the two techniques are compatible.

There are lots of studies, both industry sponsored and not sponsored, that say patients satisfaction was higher with TIVA.

Setting up a TIVA takes so little effort. I'm a little surprised people say it is work intensive. Like I said, however, haters should try it! I bet you'll like it.

 

[Drwine]

If vaporizer technology had not advanced beyond the copper kettle TIVA would be more popular in the US. However, we have sophisticated vaporizers and end tidal agent monitors. For TIVA in the USA, we have pumps and no way to account for accumulation of propofol at the target site with a constant infusion.

 

[CodeBlu]

Did a TIVA the other day for what was supposed to be a 3 hour lap gyne case... turned into an 8 hour open gyne case. Running propofol and a sufentanil infusion at 0.2mcg/kg/hr.... turned sufentanil off 2 hours before “emergence”... prop off as they start to close fascia. This lady took her sweet sweet time waking up.

Breathing was fine.... would open her eyes. But... then close them again.
Brought her intubated to PACU. She slept for another 2 hours comfortably on PS8/5. Then woke up.

I’m no TIVA expert... but, I find that even with “short” context sensitive half time drugs like sufentanil etc.... sometimes that stuff adds up over time.

Anyways, she didn’t have any nausea/vomiting which was the main reason for the TIVA. So that was a win.


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[woopedazz]

My logbook says I've done 86 TIVAs in the past 5 months.
I'm a trainee who does about 0.5 in theatre and 0.5 consults/clinic/ward/codes/pain/other.

 

[Psai]

Did a TIVA the other day for what was supposed to be a 3 hour lap gyne case... turned into an 8 hour open gyne case. Running propofol and a sufentanil infusion at 0.2mcg/kg/hr.... turned sufentanil off 2 hours before “emergence”... prop off as they start to close fascia. This lady took her sweet sweet time waking up.

Breathing was fine.... would open her eyes. But... then close them again.
Brought her intubated to PACU. She slept for another 2 hours comfortably on PS8/5. Then woke up.

I’m no TIVA expert... but, I find that even with “short” context sensitive half time drugs like sufentanil etc.... sometimes that stuff adds up over time.

Anyways, she didn’t have any nausea/vomiting which was the main reason for the TIVA. So that was a win.


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It was probably the prop

 

[deleted162650]

Alfentanil with propofol seems to work perfect

Why alfenta? Sufenta has a much better context sensitive half-life. Man I miss that drug (haven't had it on formulary since residency).

 

[deleted162650]

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 am a certified, card-carrying Remi hater. But that being said, I don't think the problem is with the drug itself, but rather how that evil temptress encourages you to use her. People run it at silly doses 'cuz hey - it goes away right? It's not all that potent really. We had a discussion about this not too long ago, and the consensus was that it's maybe 2x as potent as fentanyl. Yet people have no problem blowing through a 2mg vial during a case. If I told you I was planning to give 4mg of fentanyl during the case you'd look at me like I had 3 heads. No wonder the patient ends up nauseous and going through acute withdrawals.

 

[deleted162650]

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.

The worst offender for this is Precedex. I know several staff anesthesiologist who had dex infusions as part of clinical studies on its effects on neuromonitoring. They all hated it because it F'd up their sleep cycles for 3-4 days post infusion.

I also know people who have had both Sevo and PPF based TIVA's. They reported feeling much more awake after Sevo.

 

[pgg]

I am a certified, card-carrying Remi hater.

It's got its uses. I like propofol-remifentanil TIVAs for EBUS. Smooth and easy.

The worst offender for this is Precedex. I know several staff anesthesiologist who had dex infusions as part of clinical studies on its effects on neuromonitoring. They all hated it because it F'd up their sleep cycles for 3-4 days post infusion.

I didn't know that, but it makes sense. I've never been a really big fan of Precedex for procedural sedation - though I admit that might be partly because I haven't used it enough to get good at it. It's always struck me as a drug that was good for sedating people who don't need to be sedated.

 

[deleted162650]

It's got its uses. I like propofol-remifentanil TIVAs for EBUS. Smooth and easy.

I’ve used it successfully for MAC laryngoplasties as well. It has its uses but routine GA’s and spines aren’t one of them.

It’s a great drug for people that aren’t great at anesthesia.

 

[epidural man]

Why alfenta? Sufenta has a much better context sensitive half-life. Man I miss that drug (haven't had it on formulary since residency).

Depends on your goal I guess. The line is flatter with algebra up than with sufenta, but it does last longer. I used to do sufenta more as a resident.

 

[epidural man]

I’ve used it successfully for MAC laryngoplasties as well. It has its uses but routine GA’s and spines aren’t one of them.

It’s a great drug for people that aren’t great at anesthesia.

Just curious, why not?

It is a great way to decrease total mac requirements, it has analgesic properties, and slows heart rate. I rarely do infusion but 20mcg bonuses can be very effective I think.

 

[deleted162650]

Just curious, why not?

It is a great way to decrease total mac requirements, it has analgesic properties, and slows heart rate. I rarely do infusion but 20mcg bonuses can be very effective I think.

Earlier you said using remi was like standing in a canoe and now you say you use regularly??

 

[psychbender]

I think there is some confusion. Epidural man was talking about precedex, SaltyDog and PGG were discussing remi.

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[deleted162650]

I think there is some confusion. Epidural man was talking about precedex, SaltyDog and PGG were discussing remi.

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Ah. Makes sense. Thanks for clearing that up.

 

[rakotomazoto]

We had an elective CA-3 rotation in China, I didn't make it over there but according to everyone that went, every single case is TIVA.

They also do all of their central lines without ultrasound, A-lines with no wires. Lines placed pre-induction with no local and *somehow* the patients survive. I imagine that using anatomical landmarks is easier when most people are regular sized, not USA jumbo-sized. Apparently, one time a patient with a BMI of 32 showed up and everyone started losing their minds, discussing what special precautions should be undertaken to do the case safely.

 

[deleted162650]

They also do all of their central lines without ultrasound, A-lines with no wires. Lines placed pre-induction with no local and *somehow* the patients survive.

Some people in my class did a trip to SE Asia. They came back with video of doing parasthesia technique nerve blocks on 7yo kids with no sedation and the kids just laid there and took it like a champ. We’re such p*ssies here.

 

[Psai]

Some people in my class did a trip to SE Asia. They came back with video of doing parasthesia technique nerve blocks on 7yo kids with no sedation and the kids just laid there and took it like a champ. We’re such p*ssies here.

Kills me when Iv drug users with a million tattoos lose their goddamn minds when you come at them wih a 24

 

[Drwine]

The most recent comments are a reminder that not all patients are created the same and studies need to be taken with a whole box of salt.
I am old enough to remember when fentanyl was new. The drug was developed in Belgium and the earliest US studies were done in Salt Lake City. A patient population who consumes a ton of alcohol contrasted with patients who consume no alcohol and no other mood altering substances. I do remember doing TIVA cases giving 4-6 mg fentanyl when the prevaling thought was that inhalation agents were poison for patients with cardiac disease. They ended up going to ICU and were extubated the next morning.

I would suggest to learn to use different drugs and figure out where best to employ each.
For example, our structural heart program has mushroomed and we have found that low dose remi and Precedex are great at "stunning" 90 year olds for TAVR with rapid recovery and fast turnover. Another good use for Precedex is doing awake fiberoptic intubations when I do not have skilled helpers to watch the patient closely while my attention is on the procedure itself.

 

[Psai]

I actually like narcotic heavy anesthesia for cardiac patients. Don't see why people are in such a rush to get them extubated. And you don't need to "stun" 90 year olds with remi.

 

[pgg]

We had an elective CA-3 rotation in China, I didn't make it over there but according to everyone that went, every single case is TIVA.

They also do all of their central lines without ultrasound, A-lines with no wires. Lines placed pre-induction with no local and *somehow* the patients survive. I imagine that using anatomical landmarks is easier when most people are regular sized, not USA jumbo-sized. Apparently, one time a patient with a BMI of 32 showed up and everyone started losing their minds, discussing what special precautions should be undertaken to do the case safely.

Well

Obviously I don't know where in China your classmates were or the overall quality of the institution. But I'd be careful with accepting the way they make do with less as some kind of evidence that good care can/should be provided their way.

I spent some time practicing at a public hospital in SE Asia last year. Circumstances and culture lead to some major differences in the way they practice.

They did do a lot of TIVAs ... mainly because they didn't have a gas scavenging system or end-tidal monitors. They also did a very high percentage of their cases under spinal because 1.5 mL of local, a needle, and a couple of cotton balls in a bowl of betadine is a really cheap anesthetic. Major abdominal surgery ain't always pretty under spinal but it's possible.

They did most blocks without ultrasound, using landmark techniques. I'd guess at least 1/4 to 1/3 failed outright or were deficient in ways that would lead us to classify them as failures. The patients were incredibly stoic however, so a marginal or even a failed block rarely stopped surgery. A bit of ketamine often helped them limp through ... though more than once I saw a patient's howls during surgery dismissed as merely a ketamine reaction.

They were very, very skilled at placing lines. I'd look at a patient and think, man, where would I find a spot for a 20g in this person, and a minute later they'd have a 2" 16g taped into a forearm. They were very proficient with arterial lines too. Lots of awake nasal intubations for patients with c-spine injuries, and they were slick.

But overall very much a technician mentality there, good with mechanical skills and following a recipe, but NOT good at anticipating and avoiding complications, or handling unexpected events. Poor depth of knowledge. It's how I imagine a US hospital would run if SRNAs were pushed out the door halfway through training and just ran the show for the rest of their careers with no one tracking complications.

And it wasn't because people were dumb or lazy. The physicians (especially the ones under age 50 or so) were brilliant. Incredibly hard workers who'd outcompeted legions of their peers, in a coldly objective meritocracy that the USA hasn't seen in decades, to snag a relative bare handful of positions available. I think their growth was stunted by the oppressive hierarchical culture, and overall lack of good instruction, educational supplies, access to native-language literature on par with English materials.

*somehow* the patients survive

Unless they don't. M&M was through the roof. I witnessed a couple of egregious intraoperative clean kills, a number of near misses, and perioperative mortality was pretty high.

Protocols were outdated and sometimes harmful (ubiquitous use of hetastarch fluids, poor sterility, poor antibiotic use).

They very carefully avoid noticing and tabulating M&M because nobody wants to look bad, and there's a horribly malignant blame culture. Very hierarchical - senior people don't get questioned or stopped even when multiple people there know that the wrong thing is being done. It's the classic Asian stereotype, given wings and steroids ... the elders are gods.


Anyway, the point of this long rambling post is simple - don't let the way they apparently get away with doing certain things sway you to the opinion that those things are OK. I can assure you they get away with a lot less than they let on to foreigners ...

 

[propadope]

I love remi/prop/nitrous/precedex for office based dental. I use it to decrease chances of MH, PONV, emergence delirium and to smooth the emergence. I try to keep my propofol infusion reasonably low by using the other medications to hasten recovery