Induction with sevoflurane and propofol

[Dr-Junior]

Hello,

I have observed that when using Propofol and fentanyl/sufentanyl the blood pressure drops really low. I've heard that, especially for old patients, inducing with mainly sevoflurane and a lower dose of propofol can get a much more stable blood pressure.

Now my question is which one is better to start with sevoflurane or Propofol?

Thanks in advance

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[medking]

Are you a medical student?

 

[Dr-Junior]

I am a junior resident

 

[getdown]

You didn't tell us if the prop/fent induction you saw were given at full doses. You could potentially give more fentanyl early and titrate the propofol slowly to effect so you're not slugging the elderly with a full 1mg/kg dose thereby avoiding the drop in BP.

Also, people usually don't like the smell of sevo so doing a mask induction with sevo first before giving them propofol seems suboptimal to me but I've never heard of this technique before.

 

[IlDestriero]

It's all in the dosing. You can titrate propofol in after a heavy fentanyl dose in pre op and have very stable VS.
In kids I usually do a mask induction with Sevo and a small 1/kg prop bolus +/- 1/kg fent for intubation. Works fine as long as you don't leave them at 8% sevo. I don't think that's a good plan for most adults though.

 

[Urzuz]

Also, people usually don't like the smell of sevo so doing a mask induction with sevo first before giving them propofol seems suboptimal to me but I've never heard of this technique before.

I don't necessarily agree with this. I can see a situation in which you want to mask induce them for whatever reason (keep them spontaneously ventilating, stable hemodynamics, etc), and then right before laryngoscopy or any sort of stimulus you want to deepen them a bit more with a touch of propofol. Not saying it is necessarily what I would do, but every situation is unique and different and I can see this being a viable technique in certain circumstances. The smell of sevoflurane is oftentimes the least of peoples' concerns when you are choosing to mask induce a patient, especially in the adult setting.

 

[BLADEMDA]

Background The induction of general anaesthesia is associated with the greatest cardiovascular changes in elderly patients. Induction can be performed either intravenously or with gaseous induction. Sevoflurane has advantages over propofol for induction of anaesthesia in the elderly, since the lower reduction in mean arterial pressure with sevoflurane is both statistically and clinically significant. This prospective randomized controlled trial investigated the cardiovascular benefits of co-induction of anaesthesia with 0.75 mg/kg of propofol and 8% sevoflurane, when compared with 8% sevoflurane alone in patients requiring surgery for fractured neck of femur.
Method In total, 38 patients aged 75 or over were allocated into the two groups, receiving either 0.75 mg/kg of propofol followed by 8% sevoflurane or 8% sevoflurane alone. Vital signs were recorded until successful insertion of a laryngeal mask. Induction times, induction events and patient satisfaction scores were also recorded.
Results Results showed that there were no differences in the cardiovascular parameters between the two groups. Induction times were faster in the propofol and sevoflurane group (62 vs. 81 s; P = 0.028). The postoperative questionnaire showed that the majority of patients in both groups were satisfied with the induction process.
Conclusions We concluded that 0.75 mg/kg of propofol followed by sevoflurane induction is an acceptable alternative to sevoflurane induction. It is associated with similar haemodynamic variables, faster induction times and is very well tolerated.


http://www.ncbi.nlm.nih.gov/pubmed/17888191

 

[BLADEMDA]

http://forums.studentdoctor.net/threads/phenylephrine-and-propofol.877455/#post-11940363

A thread to read

 

[RK.md]

0.75 mg/kg of propofol followed by sevoflurane induction

Works like a (predictable) charm after some fentanyl up front.

 

[fakin' the funk]

I have observed that when using Propofol and fentanyl/sufentanyl the blood pressure drops really low. I've heard that, especially for old patients, inducing with mainly sevoflurane and a lower dose of propofol can get a much more stable blood pressure.

What's the fentanyl for?

 

[teeva]

For old patients, typically I induce with 0.5-0.75mg/kg propofol, push non-depolarizer, a little fentanyl, and ventilate with 1% sevo on the dial to keep end tidal sevo around 0.5% and then intubate. Provides much better BP stability than using any larger dose of propofol regardless of baseline BP. For LMA usually that's enough propofol to insert the LMA and I don't wait to ventilate.

Not sure why I'd subject a pt to sevo inhalation induction and then push propofol. The former defeats the need for the latter.