jetproppilot

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Since the kids are bathed, dinners over, girlfriends at work (different one than previous, great girl, Noyac has met her),

I'm bored.

Boredom seems good for me since it spikes creativity. I'll use "creativity" loosely since some of my literary ideas are great and some of them, well, suck.:laugh:

I think I'm gonna post a TIP OF THE DAY.

Every day I log on I'll start a new post with the title Jetpearl.

Inside will be a random tip I've found useful over the span of my career.

No rhyme nor reason. No pattern of the tips. Just something that comes to mind that I'll share.

A quick tip. some just a sentence. Some, maybe a brief explanation.

I'm sure alotta you will know this stuff. You can agree or disagree which is good since the fact we all do things different opens up discussion. My hope is I can pass on some neat tips to the residents in an effort to make their lives a little easier. Or at least spark a useful discussion about our trade.

HERES Jetpearl Number One:

For an LMA induction, try propofol only. The patient will begin to breathe quicker than if you give fentanyl simultaneously. Once spontaneous respiration has returned, judiciously slide in your opioid. Realize more propofol will be required sans opioid. For run of the mill knee scope et al on the non elderly, give the whole stick.
 

doctor712

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You need to remind me why I'm not up at your pad sharing two chilled Boddington's shooting the JetPearlSh i t!!!??? Otherwise, I'm hoppin' on 595 and headin' up tout de SWEET.

You rawk.

Doc.

D712
 

Noyac

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Good tip Jet but I like to do it a little differently. I give 50 mcg of fent as they are moving over to the bed. Then I cut my prop dose down slightly to 16-18 cc. Then mask them for maybe a minute with sevo at 3.0. I like to save some propofol for the end of the case. I insert the LMA partially inflated (the disposable ones I just insert without pulling out any air out) Then give an easy breath to test the seal. THey usually breath about 10 bpm at this point.

Not disagreeing with you, just posting a different way.

BTW, I can vouch for the GF, she's great (read: hot). ANd I must say that I'm much more comfortable with you calling her your girlfriend than your SO.
 

ProRealDoc

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Since the kids are bathed, dinners over, girlfriends at work (different one than previous, great girl, Noyac has met her),

I'm bored.

Boredom seems good for me since it spikes creativity. I'll use "creativity" loosely since some of my literary ideas are great and some of them, well, suck.:laugh:

I think I'm gonna post a TIP OF THE DAY.

Every day I log on I'll start a new post with the title Jetpearl.

Inside will be a random tip I've found useful over the span of my career.

No rhyme nor reason. No pattern of the tips. Just something that comes to mind that I'll share.

A quick tip. some just a sentence. Some, maybe a brief explanation.

I'm sure alotta you will know this stuff. You can agree or disagree which is good since the fact we all do things different opens up discussion. My hope is I can pass on some neat tips to the residents in an effort to make their lives a little easier. Or at least spark a useful discussion about our trade.

HERES Jetpearl Number One:

For an LMA induction, try propofol only. The patient will begin to breathe quicker than if you give fentanyl simultaneously. Once spontaneous respiration has returned, judiciously slide in your opioid. Realize more propofol will be required sans opioid. For run of the mill knee scope et al on the non elderly, give the whole stick.
if you're bored, why not liven things up a bit




If you want to liven things up a bit and put some hair on your chest then...

 
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drccw

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30/70 O2/N20 and 8% sevo is what I have been playing with for my LMA insertions...

I see no reason not to do mask inductions in appropriately sized adults....
It's easy, it's still pretty quick.
 

IlDestriero

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30/70 O2/N20 and 8% sevo is what I have been playing with for my LMA insertions...

I see no reason not to do mask inductions in appropriately sized adults....
It's easy, it's still pretty quick.
I'm not sure what "appropriately sized adults" is, but when your nurse gets slammed by a 20 something amateur body builder when he gets disinhibited and freaks out during the mask induction, you may change your thinking on that. Laryngospasm without an IV is also loads of fun.:(
 

aredoubleyou

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30/70 O2/N20 and 8% sevo is what I have been playing with for my LMA insertions...

I see no reason not to do mask inductions in appropriately sized adults....
It's easy, it's still pretty quick.
Yea, thats pretty clearly two sigma dude.
 

ProRealDoc

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30/70 O2/N20 and 8% sevo is what I have been playing with for my LMA insertions...

I see no reason not to do mask inductions in appropriately sized adults....
It's easy, it's still pretty quick.

I've only done a mask induction on a adult once during residency. All others have been kiddos.
 

sevoflurane

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20mcgs of precedex as they hit the room + 25 mcgs of fent, sevo at 5ish as the propofol takes over.
 

jetproppilot

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Good tip Jet but I like to do it a little differently. I give 50 mcg of fent as they are moving over to the bed. Then I cut my prop dose down slightly to 16-18 cc. Then mask them for maybe a minute with sevo at 3.0. I like to save some propofol for the end of the case. I insert the LMA partially inflated (the disposable ones I just insert without pulling out any air out) Then give an easy breath to test the seal. THey usually breath about 10 bpm at this point.

Not disagreeing with you, just posting a different way.

BTW, I can vouch for the GF, she's great (read: hot). ANd I must say that I'm much more comfortable with you calling her your girlfriend than your SO.
Nice, Noy!
 

drccw

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I'm not sure what "appropriately sized adults" is, but when your nurse gets slammed by a 20 something amateur body builder when he gets disinhibited and freaks out during the mask induction, you may change your thinking on that. Laryngospasm without an IV is also loads of fun.:(
I never said there wasn't an IV... plus I'm not doing this on the amateur body builder (they get more like 300 mg of propofol). It's mainly for our quick outpatient GYN (and not the whales)
and I truly believe that mask inducing an adult is an important skill to learn...
as well as the mask anesthetic...

Did you guys ever have a propofol shortage? We never did; though I really did cut down on my propofol use. It's easy these days when propofol is pretty darn cheap; but imagine if you had to ration it; if the other options were thiopental (also a shortage), etomidate (ever try to put a LMA in with that) or etc....

drccw
 

BDanes

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I agree with jet. In my experience it is easiest to give no fentanyl until they resume spontaneous ventilation. I do, however, always give versed prior. And I will also usually give some lidocaine.

Another thing I've been doing lately as well is to place them on the vent making sure peak pressures are around 18 or less until they start to breathe again. I find this allows me to get them to a nice plane of anesthesia faster so I dnt have to hear the nurses and surgeons tell me the patients light when they prep.

Of course they are light! It cracks me up how they have no comprehension
how anesthesia works!
 

Mman

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My LMA inductions are mostly similar to previous posts in the thread.

Usually a moderate dose of propofol and then crank up the sevo and ventilate to get them deep enough for LMA placement. I never give narcs until the propofol has redistributed enough for them to start spontaneously breathing again.

I used to do just propofol without the gas but I found that I'd have to give such a relatively big dose of propofol that it would still take them a little bit to start breathing again (1-3 minutes). By cutting back on the propofol and using more Sevo, they tend to be breathing spontaneously very shortly after LMA placement.

I've also done plenty of gas inductions on adults, but I only do it on ones that are up for it. Generally start them out with 70% nitrous for about 60 seconds before slowly dialing up the Sevo. If you start out with 8% Sevo (with or without Nitrous) they will hate the smell. If you have a little mask strap, you can start the nitrous while hooking up your monitors and it saves time. The best part about the gas induction for the LMA is that you can place the LMA in the patient who is still spontaneously ventilating and just let them keep going.
 

rsgillmd

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........
HERES Jetpearl Number One:

For an LMA induction, try propofol only. The patient will begin to breathe quicker than if you give fentanyl simultaneously. Once spontaneous respiration has returned, judiciously slide in your opioid. Realize more propofol will be required sans opioid. For run of the mill knee scope et al on the non elderly, give the whole stick.
I completely agree with you on this one Jet. One of my attendings in residency taught me this, and I love it. They usually came back breathing within about a minute or so. It really helps for the quick GYN cases.

:thumbup::thumbup:
 

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wow some of you really try to make things difficult. i'm with jet. no narcotic. give some versed, a stick of propofol, and slide tha LMA in. easy as can be. sometimes i wonder what the hell people are doing when i walk in their room and they have 27 vials of meds half empty on the machine. come on people, you don't need to reinvent the wheel (precedex?????) every time you slide an LMA or put a tube in. this stuff is easy!
 

sevoflurane

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What's wrong with precedex? Been using it routinely on all my ortho cases for about 3 months now. One vial for 10 patients. Definately not a cost issue and definately not that difficult or complex. In fact, easier than midazolam or fentanyl as it comes pre-filled with my narc box from pharmacy. Reach in, grab it, use it. Simple.

Cuts down on my opiods and inhaled agents and keeps my patients spontaneoulsy breathing throughout the case. Apnea time is about 1 minute or less as I rarely use all 20cc of propofol. Rarely do I have to assist ventilation. Try it sometime. It's not at all a big deal or "difficult" IMHO. Just another way.;)
 

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I like the propofol only at first & titrate in narcs technique.

Why do so many use sevo? Why not des - afraid of laryngospasm with it?
 

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I'm just glad to have one our veterans back...... JET!!!!!!!!
 

jetproppilot

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I'm just glad to have one our veterans back...... JET!!!!!!!!
Thanks Dude.

Noyac The Near Professional Snowboarder Who Appeared In A Cult Favorite Helicopter-Drop-On-Top-Of-A-Ridiculously-High, Steep-Mountain Snowboarder Video

is posting!!! Nice to see you again, Noy. Btw for those of you who don't know Noy, picture a handsomer Tommy Lee with shorter hair. Long, yeah, but above the shoulders. Wedding gown white teeth. Shades so cool I don't think they're available in the US. Lean, muscular dude wearing cool west coast clothes and shoes. Think Deniro without the attitude. Definite swagger, just not arrogant. He lives with the coolest dog on earth whose focus on ball catching became an internet sensation long ago.

Only thing that needs to happen now is for Wax-On-Wax-Off-Famous-Asian-MMD to rear his intellectual, resourceful head, and for Zippy to pop in every once in a while to remind us how he rode off into the sunset at the conclusion of his residency, lounging shotgun aside his uncle-on-disability, smoking a fatt bone, chilled whiskey awaiting him on the floorboard of their fleeing hooptie.
 

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My recipe for knee scopes, assuming a normal airway and reasonable health

50 mcgs of fentanyl when they walk through the door, have them breath 50:50 nitrous and give em 20 of propofol. Crack the des flip on the vent and PCV 12mmhg w/a rate of 8. Get em deep like 1.3 mac before the surgeon makes incision, keep the CO2 around 40-45 and once they're deep enough flip off the vent and get em back breathing. Usually they start breathing on their own real quick but occasionally they need a lil apnea. Once the surgeon starts taking the scope out, kill the des, crank up the flows and once the bandage starts to go on, turn off the nitrous. By the time the bed is in the room the pt is wide awake and ready to move themselves over w/out my help. This leaves me free to turn over the room before dropping the pt off and pick up the next one
 

Noyac

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Thanks Dude.

Noyac The Near Professional Snowboarder Who Appeared In A Cult Favorite Helicopter-Drop-On-Top-Of-A-Ridiculously-High, Steep-Mountain Snowboarder Video

is posting!!! Nice to see you again, Noy. Btw for those of you who don't know Noy, picture a handsomer Tommy Lee with shorter hair. Long, yeah, but above the shoulders. Wedding gown white teeth. Shades so cool I don't think they're available in the US. Lean, muscular dude wearing cool west coast clothes and shoes. Think Deniro without the attitude. Definite swagger, just not arrogant. He lives with the coolest dog on earth whose focus on ball catching became an internet sensation long ago.

Only thing that needs to happen now is for Wax-On-Wax-Off-Famous-Asian-MMD to rear his intellectual, resourceful head, and for Zippy to pop in every once in a while to remind us how he rode off into the sunset at the conclusion of his residency, lounging shotgun aside his uncle-on-disability, smoking a fatt bone, chilled whiskey awaiting him on the floorboard of their fleeing hooptie.

THanks Jet but I have to disagree with one thing, the professional snowboarder part is a bit of a stretch. I'm just a weekend warrior fighting to hold onto my youth. Sevo can vouch for my snowboarding skills, they are just average. But I like it steep.

The rest I can't comment on since they are just impressions.;)

I would love to see some more of the older guys return as you say.

My only description of you for others who haven't met you but wonder what you might look like is sort of a Howie Long with more personality. That's the best I can do.
 

Noyac

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My recipe for knee scopes, assuming a normal airway and reasonable health

50 mcgs of fentanyl when they walk through the door, have them breath 50:50 nitrous and give em 20 of propofol. Crack the des flip on the vent and PCV 12mmhg w/a rate of 8. Get em deep like 1.3 mac before the surgeon makes incision, keep the CO2 around 40-45 and once they're deep enough flip off the vent and get em back breathing. Usually they start breathing on their own real quick but occasionally they need a lil apnea. Once the surgeon starts taking the scope out, kill the des, crank up the flows and once the bandage starts to go on, turn off the nitrous. By the time the bed is in the room the pt is wide awake and ready to move themselves over w/out my help. This leaves me free to turn over the room before dropping the pt off and pick up the next one
This is critical. Everyone appreciates it. You look like a star (had a nurse tell me just yesterday "you are definitely doing my next anesthetic if I need one"). It just makes everything easier on everyone and with our current anesthesia drugs it is easy to do.
 

Jay K

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This thread simply shows that there are multiple ways to skin the cat, and it's hard to argue that one way's better than the other - which is great because I like having multiple ways to accomplish the same goal.

As an aside, I've also mask-induced adults. Last one which was memorable to me was one of our typical state psychiatric hospital folks who presented fully clothed and in a vest restraint during his preop admission and was still lashing out w/ his free foot. Rather than trying to ketamine dart the poor fellow who also had schizophrenia and visual hallucinations (can you imagine the poor recovery RN w/ this hallucinating guy s/p ketamine too?), we just wheeled him in with his vest. Circulating RN got on top. Masked him down in a few breaths. He did just fine. Mask-inducing adults is also a good option for those patients who would like a mask induction and then PIV placed in the OR just like a peds patient. If I can make a patient happy w/o compromising their care, then it's fine by me. The vasodilation from mask induction can also be beneficial in adults w/ difficult IV starts who have been "tortured" in preop by staff unable to obtain IV access.
 

Noyac

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This thread simply shows that there are multiple ways to skin the cat, and it's hard to argue that one way's better than the other - which is great because I like having multiple ways to accomplish the same goal.

As an aside, I've also mask-induced adults. Last one which was memorable to me was one of our typical state psychiatric hospital folks who presented fully clothed and in a vest restraint during his preop admission and was still lashing out w/ his free foot. Rather than trying to ketamine dart the poor fellow who also had schizophrenia and visual hallucinations (can you imagine the poor recovery RN w/ this hallucinating guy s/p ketamine too?), we just wheeled him in with his vest. Circulating RN got on top. Masked him down in a few breaths. He did just fine. Mask-inducing adults is also a good option for those patients who would like a mask induction and then PIV placed in the OR just like a peds patient. If I can make a patient happy w/o compromising their care, then it's fine by me. The vasodilation from mask induction can also be beneficial in adults w/ difficult IV starts who have been "tortured" in preop by staff unable to obtain IV access.
They don't hallucinate after the ketamine has worn off.
 

sevoflurane

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Sevo can vouch for my snowboarding skills, they are just average. But I like it steep.
You are an animal. A day of Purg, hockey game, then Silverton? I will agree with Jet.... You are a rockstar home-E. Humble, kind, smart, chill and crazy sick riding a T.rice 159" on a 120" base with 20" of fresh pow. :cool: That was a hard day.

Noy is definately one cool ANESTHESIOLOGIST. A super stud we should feel proud to have in our camp. :thumbup:
 

Noyac

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You are an animal. A day of Purg, hockey game, then Silverton? I will agree with Jet.... You are a rockstar home-E. Humble, kind, smart, chill and crazy sick riding a T.rice 159" on a 120" base with 20" of fresh pow. :cool: That was a hard day.

Noy is definately one cool ANESTHESIOLOGIST. A super stud we should feel proud to have in our camp. :thumbup:
:laugh:

Well, it's just what people do around here.

BTW, I haven't met many people from your neck of the woods that can even attempt Silverton, so well done both of you.
 
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