• Please review the updated member agreement. Included is a new statement supporting the scientific method and evidence-based medicine. Claims or statements about disease processes should reference widely accepted scientific resources. Theoretical medical speculation is encouraged as part of the overall scientific process. However, unscientific statements that promote unfounded ideological positions or agendas may be removed.

GaseousClay

:)
5+ Year Member
Oct 23, 2013
366
323
USA
Status
Resident [Any Field]
How are you doing these cases at your institution? I have only done this once a couple years ago and I believe we kept him just sedated but able to phonate for the surgeon. Not done very often here so just hoping to gain some insight from y'alls. thanks!
 

sublimaze

7+ Year Member
Feb 26, 2011
9
8
Status
Attending Physician
versed 2 mg, precedex load over 10 minutes (1 mcg/kg), followed by infusion (titrate to drowsy but cooperative), generous local infiltration by surgeon, 30 mg toradol, 1 gm apap.
pt was able to tolerate nasal fiberoptic laryngoscopy and entire procedure without any narcotics, cooperated/able to phonate entire case.
a lot of this case is explaining to the patient what to expect before even stepping into the OR, then titrating sedation to maintain spontaneous ventilation (ppl here sometimes use remi for fast on/off).
also not a bad idea to cover the patients eyes with a towel.
most importantly, having a good fast surgeon helps as well.
 

Ronin786

7+ Year Member
Mar 27, 2011
1,640
1,596
Status
Attending Physician
Did one of these last month

4mg versed upfront (2 in preop, 2 in the room), load with dexmedetomidine and keep a low dose remi gtt (~.075 mcg/kg/min) on for the first part. Nasal cannula on and patient spontaneously ventilating but asleep. Turn off the remi gtt ~10 minutes before you need the patient to talk then turn it back on when they're closing. Goes very smoothly as long as patient is cooperative like sublimaze mentioned.
 
  • Like
Reactions: GaseousClay

PonyUp

5+ Year Member
Jul 15, 2012
163
49
USA
Status
Attending Physician
versed 2 mg, precedex load over 10 minutes (1 mcg/kg), followed by infusion (titrate to drowsy but cooperative), generous local infiltration by surgeon, 30 mg toradol, 1 gm apap.
pt was able to tolerate nasal fiberoptic laryngoscopy and entire procedure without any narcotics, cooperated/able to phonate entire case.
a lot of this case is explaining to the patient what to expect before even stepping into the OR, then titrating sedation to maintain spontaneous ventilation (ppl here sometimes use remi for fast on/off).
also not a bad idea to cover the patients eyes with a towel.
most importantly, having a good fast surgeon helps as well.
Did at least one of these every Thursday Oct-Dec of last year. Used the same setup - precedex bolused in preop +/- the versed you mentioned depending on the patient.
The surgeon would insist on decadron in the awake patient in preop as well - I was always scared of the anal pruritus associated but never really happened especially with that precedex on board.
Little bits of fentanyl intraop if the patient was feeling too much, but our surgeon was fantastic with his local so it ended up being 25-75mcg per case. Never gave toradol [surgeon request], but would have given ofirmev instead of fentanyl if the patients had OSA.
Patient's whole face was prepped out so it was towel over eyes + drape. Our surgeon wanted the patient awake the whole time and able to sing happy birthday/phonate on command.

These are some of my favorite cases. Regarding expectations, the surgeon was forward with the patients from when he saw them in preop clinic that the only way he could accomplish what he needed to was if they were fully awake, so the patients came to us mentally prepared.
 
About the Ads