Induction and patient age

[coccygodynia]

This is meant to be a generic question regarding induction doses and patient age for the experienced providers on the board. At what age do you start to be a bit more ginger with your induction doses of propofol/STP? I know to focus more on the physical age of the patient rather than the chronological and that with additional comorbidities, they may need a more cardiac stable induction agent ... but how about for those grandpa's with only a lap chole in their history and no CV disease?

I've been dosing my propofol around 50mg at a time for those over 70 and waiting for loss of lash reflex (usually takes about a minute with only 100mg total). Is this too cautious? In the beginning, I'd have to fight a post-induction slump with the full dose and felt like I was chasing the BP for the first part of the case. What do you guys/gals practice?

---

Members don't see this ad.

 

[Aislin]

That's a good method. If you allow the opioid to act before intubation you should be able to prevent the reflex. As for the BP, considering a patient with good cv function, you can hydrate him first (consider infusing a quarter to half the total volume to compensate for the npo period) and that would minimize the effect of induction drugs.

 

[jetproppilot]

This is meant to be a generic question regarding induction doses and patient age for the experienced providers on the board. At what age do you start to be a bit more ginger with your induction doses of propofol/STP? I know to focus more on the physical age of the patient rather than the chronological and that with additional comorbidities, they may need a more cardiac stable induction agent ... but how about for those grandpa's with only a lap chole in their history and no CV disease?

I've been dosing my propofol around 50mg at a time for those over 70 and waiting for loss of lash reflex (usually takes about a minute with only 100mg total). Is this too cautious? In the beginning, I'd have to fight a post-induction slump with the full dose and felt like I was chasing the BP for the first part of the case. What do you guys/gals practice?

Just about anyone can handle 100mg propofol. That being said, your method may be a little over cautious, but thats ok. Better to air on the cautious side. Heres a couple other considerations:

1)Watch the BIS when you are inducing...not really needed, but its interesting. Give 100mg propofol to a healthy dude, and you'll see the BIS slide into the 40s most times. Shows we probably are too generous with induction agents, at least when used concominantly with a muscle relaxant. If you're messing with the airway without muscle relaxant (LMA) you'll need more.

2) Use your pre-op meds (midaz) as a sensitivity guide on young and old alike. If you give 2mg midaz and the pt gets very sleepy, you know they are relatively to the left on the dose-response curve. Then you'd cut back your induction dose accordingly.
On the flip side, if you give 2mg midaz and they're still talking about last night's football game, you give 2mg more and they're still talking, you know you'll have to beef up your induction dose.

Remember there is no correct induction dose. The doses we memorize are starting places, and you have to adjust accordingly. I think giving pre-op meds and seeing how the pt reacts is very useful...helps you taylor your anesthetic to that individual patient.

 

[militarymd]

Different ways to skin that old cat.

I almost never give preop meds. Straight to induction agent....I adjust based on my "best guess" on how they will respond.

 

[jetproppilot]

Different ways to skin that old cat.

I almost never give preop meds. Straight to induction agent....I adjust based on my "best guess" on how they will respond.

WOHHHHHH, Jedi, Versed good drug...most patients dont wanna remember the OR, and most sugeons/anesthesiologists dont want them to remember it either...also lessens awareness potential which is a huge litiginous topic these days. Its happy hour with versed when I'm bartending.

 

[militarymd]

WOHHHHHH, Jedi, Versed good drug...most patients dont wanna remember the OR, and most sugeons/anesthesiologists dont want them to remember it either...also lessens awareness potential which is a huge litiginous topic these days. Its happy hour with versed when I'm bartending.

Here's what I believe. I think Versed actually INCREASES the likelihood of patients complaining about recall.

Now, I say "complaining" of recall...not actual recall.

Although benzodiazepines do stop the formation of memories in most patients, it is not guaranteed.

If a patient forms a vague recollection of the OR (while under Versed), they may confuse that with awareness under anesthesia....especially if they had pain prior to surgery.

In my preop assessment and counselling, I inform my patients of what they WILL remember.....trip back to the OR, monitors being applied, face mask, followed by possible discomfort in the IV as propofol goes in....followed by emergence sometime after surgery is over.

My patients have a very clear demarcation in when they lose consciousness, and they fine with it....my surgical colleagues are ok with this also.

In patients who truly require anxiolysis, I give them anxiolytics, but that happens for me maybe once or twice a month.

 

[coccygodynia]

I agree Jet - when I'm dosing the first 50mg I look to see how they respond with awareness ... if they're still spontaneously breathing around the 30sec mark, I give the next 50mg and it's usually lights out (for the elders, that is). It's saved me a couple of times from some severe HOTN post-induction (especially if I have to wait several minutes for some surgial stimulation). Thanks for the advice all.

 

[VentdependenT]

Well hot damn.

On my first surgery I appreciated the versed before going for my surg. It was a major head rush and it knocked most of the fear out of me. I did remember some things but mainly I remember being warm and fuzzy.

On a recent orbital fx surgery I received no preop drugs and I was scared $hitless on that cold damn ride to the OR. I remember laying on a friggen cold table listening to the surgeons laugh over some recent oyster dinner story while looking at my friggen x ray. Some noname techs hooked me up to all the monitors. Then the anesthesiologist strolled in and pumped in some propofol without telling me and next thing I remember is vomiting in the PACU. At least a nurse held my friggen hand attached to my strapped down arm before I was smited with propofol.

I always give versed. I do not tape peoples arms anymore before induction if I can help it. I always tell pts what to expect in an OR before they hit it. I always explain why I'm applying each little stickey cold goobery thing as I do it.

 

[militarymd]

I remember laying on a friggen cold table listening to the surgeons laugh over some recent oyster dinner story while looking at my friggen x ray. Some noname techs hooked me up to all the monitors. Then the anesthesiologist strolled in and pumped in some propofol without telling me and next thing I remember is vomiting in the PACU. At least a nurse held my friggen had attached to my strapped down arm before I was smited with propofol.

Differences in hospitals.

Our surgeons don't come into the OR until the patient is asleep. Prior to induction, our ORs are kept fairly quiet.

Our OR team (OR nurse + anesthesia team) brings the patient into the room together, and prepares the patient together.

I am in attendance during this process nearly 100% of the time.

I use to tell my residents "Versed is a poor substitute for good bedside manner".

Having said that, my colleagues all drug up their patients before going to the OR.

Having said THAT, I get a lot of requests to provide anesthesia care from repeat customers.

 

[VentdependenT]

I hear you on the bedside manner.

 

[Laryngospasm]

I think premedication is especially important in the pt with severe cardiovascular dz, where stress and changes in hemodynamic parameters can be disasterous.

 

[militarymd]

I think premedication is especially important in the pt with severe cardiovascular dz, where stress and changes in hemodynamic parameters can be disasterous.

so mental stress is more "disasterous" than clamping an aorta or 2 liters of blood loss???

 

[Laryngospasm]

so mental stress is more "disasterous" than clamping an aorta or 2 liters of blood loss???

That is more of a controlled disaster, healthy premedication can help prevent anxiety, tachycardia, stress MI, and coronary vasospasm. Studies have shown a decreased hypertensive response on narcotic induction as well when premedicated with lorazepam. I will respectfully disagree with you, I will not be convinced that tachycardia and hypertension in a pt. with ischemia, valvular disease, or aortic dissection or aneurysm or all three is a good thing.

 

[militarymd]

That is more of a controlled disaster, healthy premedication can help prevent anxiety, tachycardia, stress MI, and coronary vasospasm. Studies have shown a decreased hypertensive response on narcotic induction as well when premedicated with lorazepam. I will respectfully disagree with you, I will not be convinced that tachycardia and hypertension in a pt. with ischemia, valvular disease, or aortic dissection or aneurysm or all three is a good thing.

Ahhhh....the much talked about surrogate endpoints.

 

[jetproppilot]

Ahhhh....the much talked about surrogate endpoints.

throwing the surrogate endpoints aside, I wouldnt attribute your repeat customers to the fact that you dont like premedication. I'd attribute it to, probably, your personality, compassion, and astute clinical skills, which it sounds like alot of your partners lack.

Read Venty's post...I think thats a fairly common feeling with patients...and if polled, I'll bet most of them would prefer, if possible, to remember your smiling face in day surgery/holding pushing the orange-labeled syringe of medicine into their IV, remembering the PACU nurse in recovery asking them if they have any complaints, and nothing in between.
I agree midazolam offers no amnestic guarantees, but from JCHO standards, and more importantly from a clinician's standpoint, there is no doubt it lessens the possibility of intraoperative recall.

 

[militarymd]

throwing the surrogate endpoints aside, I wouldnt attribute your repeat customers to the fact that you dont like premedication. I'd attribute it to, probably, your personality, compassion, and astute clinical skills, which it sounds like alot of your partners lack.

Read Venty's post...I think thats a fairly common feeling with patients...and if polled, I'll bet most of them would prefer, if possible, to remember your smiling face in day surgery/holding pushing the orange-labeled syringe of medicine into their IV, remembering the PACU nurse in recovery asking them if they have any complaints, and nothing in between.
I agree midazolam offers no amnestic guarantees, but from JCHO standards, and more importantly from a clinician's standpoint, there is no doubt it lessens the possibility of intraoperative recall.

Alright...I guess we have a difference in opinion on pre-op medication..but that is a good thing....That's what makes medicine fun

 

[jetproppilot]

Alright...I guess we have a difference in opinion on pre-op medication..but that is a good thing....That's what makes medicine fun

Agreed, this would be boring if we agreed on everything!

 

[VentdependenT]

C'mon MMD you know you love the cookie cutter approach you big bastard.

 

[mustangsally65]

Read Venty's post...I think thats a fairly common feeling with patients...and if polled, I'll bet most of them would prefer, if possible, to remember your smiling face in day surgery/holding pushing the orange-labeled syringe of medicine into their IV, remembering the PACU nurse in recovery asking them if they have any complaints, and nothing in between.

I love coming to this forum because there are always interesting discussions going on. And anesthesia is interesting to me anyway. I think my interest was sparked by the anesthesiologist at my first surgery. He was so personable and nice and easy to talk to. This made a big difference, because it made me feel safe. The surgeon is often a bit stand-offish, because you don't see much of him/her. The nurses tend to be a little too much in-your-face because they're doing all the pre-op stuff and with you most of the time. In my experience, the anesthesiologist made my experience as pleasant as any hernia repair surgery could be.

I don't know what meds I had pre-op, if any, but I do remember having no fears at all because the anesthesiologist had the best bedside manner. And it seems like you guys on here are very caring about your patients as well, which is great to see.

The only thing that irritated me pre-op was the nurse holding my hand after I"d been taken to the OR. I guess for some people it is comforting, but to me it was annoying. I hope I wasn't rude or anything.

Are patients ever rude to you guys while they are between consciousness and unconsciousness? Do they say weird things? I've got to shadow an anesthesiologist one of these days. . .

I'm a class of 2010 hopeful, by the way.

 

[Noyac]

I gotta agree with Military on this, especially in the elderly. I hardly ever give versed. It can delay recovery in the elderly, costs money for a high that you erase as soon as they go to sleep, requires additional nursing in some facilities (monitoring with pulse ox) which is more $$, etc, etc. If it is needed great if not, why give it. Most patients anxiety can be treated with a little conversation, humor, reassurance before surgery. I really get peaved when someone pushes versed just before the white stuff. What the ****

 

[jetproppilot]

I really get peaved when someone pushes versed just before the white stuff. What the ****

Totally agree with that.

 

[VentdependenT]

That does seem pointless. What would be the reasoning for adding versed to your induction regimine? Decreased recall in the face of all the other meds your administering?

I'm gettin into a little slop fest on the General Residency forum. Looks like I picked up a bit of Jet's fire.

 

[jetproppilot]

That does seem pointless. What would be the reasoning for adding versed to your induction regimine? Decreased recall in the face of all the other meds your administering?

I'm gettin into a little slop fest on the General Residency forum. Looks like I picked up a bit of Jet's fire.

Go gettem Venty...