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redrroc said:
Anesthesia resident CA1 here . I have a question based on my experience in OR for last year. , in this scenario , when she wasn’t receiving any propofol her vitals should be reflecting that. Does it mean the CRNA / whoever was in this case was really negligent not paying attention to vitals ?
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if a patient is on a beta blocker they might not have the same change in vitals to awareness you would otherwise expect, but yes usually going to say vitals change.
 
redrroc said:
Anesthesia resident CA1 here . I have a question based on my experience in OR for last year. , in this scenario , when she wasn’t receiving any propofol her vitals should be reflecting that. Does it mean the CRNA / whoever was in this case was really negligent not paying attention to vitals ?
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Using vitals alone to determine depth of anesthesia is not very sensitive or specific. As mman said, certain medications can blunt the sympathetic surge that you might expect from a patient who is awake, paralyzed, freaking out and feeling pain.
 
redrroc said:
Anesthesia resident CA1 here . I have a question based on my experience in OR for last year. , in this scenario , when she wasn’t receiving any propofol her vitals should be reflecting that. Does it mean the CRNA / whoever was in this case was really negligent not paying attention to vitals ?
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What are you going to see? Hypertension, tachycardia, maybe sweating, dilated pupil if you looked. Patient is paralyzed so no movement or respiratory effort. The hypertension or tachycardia could be mistaken for nociception from surgical incision, but in general, yes this should have prompted the CRNA to increase the depth. As noted above, a BIS could have addressed this early, but probably would not have avoided the error.
 
coffeebythelake said:
I use tiva <5% of my GAs. Probably <2%. Pt with hx of bad PONV? Check. Aside from ponv concerns, I think there are some aspects of tiva that are nicer than gas anesthetic. I think patients wake up a lot smoother on propofol and recovery seems to be faster with less persistent grogginess.
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I think recovery from prop compared to sevo is only faster in very short cases, otherwise I actually think sevo is quicker recovery so long as you get the gas off early.
 
Sometime during residency I looked into TCI techniques and practiced with it for some time. I think there is a benefit for using gas to prevent awareness and ensure amnesia, as stated by someone prior. That is approximately a quarter mac. To make up the majority of the rest of the anesthetic, I run propofol because the experience is better for the patient after they wake up - which takes no longer than inhaled alone. Takes a little more work, but ultimately I never deal with staging, delirium, or nausea. When I supervise, I deal with those problems more frequently.
 
Micropannus said:
Takes a little more work, but ultimately I never deal with staging, delirium, or nausea.
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never?????

Come on man. I've done anesthetics with no gas, no narcotic, and every antiemetic you can find and still seen nausea postop. It's rare, but there are some patients you just look at funny and they are getting sick/
 
dipriMAN said:
What are you going to see? Hypertension, tachycardia, maybe sweating, dilated pupil if you looked. Patient is paralyzed so no movement or respiratory effort. The hypertension or tachycardia could be mistaken for nociception from surgical incision, but in general, yes this should have prompted the CRNA to increase the depth. As noted above, a BIS could have addressed this early, but probably would not have avoided the error.
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Would BIS help in a densely paralyzed patient? Usually when I’ve used bis, the number goes up after the vital signs change or the patient moves. In my experience, it’s not an early indicator but lags the other signs of too light anesthesia.
 
Mman said:
Come on man. I've done anesthetics with no gas, no narcotic, and every antiemetic you can find and still seen nausea postop. It's rare, but there are some patients you just look at funny and they are getting sick/
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Exceedingly rare. Once a migraine patient a several months ago. Another time I remember a TIVA patient went home and then was nauseous (came back for some reason). I will say though that if I supervise and don’t have the time to argue, I see a lot emesis bags.
nimbus said:
Would BIS help in a densely paralyzed patient? Usually when I’ve used bis, the number goes up after the vital signs change or the patient moves. In my experience, it’s not an early indicator but lags the other signs of too light anesthesia.
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Regardless of the number, the waveform almost certainly would have been high frequency, low amplitude. Sometimes I feel like the number should be taped over.
 
nimbus said:
Would BIS help in a densely paralyzed patient? Usually when I’ve used bis, the number goes up after the vital signs change or the patient moves. In my experience, it’s not an early indicator but lags the other signs of too light anesthesia.
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Response of bispectral index to neuromuscular block in awake volunteers†
I don't trust BIS when paralytic is on board. The BIS algorithm requires detection of muscle activity to generate the value to indicate the patient is awake. Also it has a delay in computation up to 4 minutes so your experience is spot on.
 
Using BIS just based on an algorithm-derived number for aware or not aware is every bit as ridiculous as replacing our telemetry with an automated readout that says NSR, SVT, or whatever instead of the waveform. The fact that we're all not trained how to read some basic EEG waveform for depth of anesthesia purposes is pretty pathetic considering how easy it is to learn. One can learn it in under an hour of youtube, so it should definitely be part of residency training and testing in my opinion.

By the way, Massimo's SedLine monitor is much better than BIS. It sticks to the forehead better, is bilateral, has better raw EEG display, and charts the characteristic frequencies over time, which is very helpful for interpretation. I usually run about 0.6-0.7 MAC or a little less if I have a stable opioid plasma concentration with repeated hydromorphone bolus or a remifentanil gtt. I run it lower at the end of the case. Somebody pointed out that avoiding NMB when not needed is not a "clean" anesthetic. I disagree completely and think that NMB is part of a balanced anesthetic that allows less volatile anesthetic, resulting in better outcomes.
 
dipriMAN said:
I think recovery from prop compared to sevo is only faster in very short cases, otherwise I actually think sevo is quicker recovery so long as you get the gas off early.
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Totally agree.

Leave the vent on and keep the patient paralyzed until the very end. Get the sevo down to 0.7 - 0.8% expired while they're closing. When they pick up the stapler or finish up the last suture, sevo off flows up sugammadex in. They'll be awake in less than a minute, and they'll breathe when they're awake unless you OD'd the opioids.

Desflurane is every bit as fast to come off as propofol, and it's a hell of a lot easier to time/titrate in longer procedures and morbidly obese people for the simple reason that there's an end tidal des number in bright blue right there on the monitor. It's so fast, that a lot of people will criticize it for causing "emergence delirium" because they're used to underdosing opioids with their sevo and iso anesthetics, because iso and even sevo stick around long enough after emergence in analgesic quantities. By the time the sevo/iso patients offgas the rest of the volatile we've walked away in the PACU and the RN is standing there with some fentanyl or hydromorphone.

Rapid emergence is not a reason to do a TIVA.
 
LineAndBerry said:
My chairman at Mercy Hospital of Pittsburgh, Ephraim Siker (president of the ASA at the time), started APSF. I remember having some worries about the potential unintended legal consequences of an ever-expanding list of "guidelines".
"An EEG-based monitor of unconsciousness (depth of an anesthesia monitor) is required to reduce the likelihood of awareness whenever total intravenous anesthesia is combined with the administration of neuromuscular blocking agents,” the APSF recommended.
So, in effect, the APSF has established a criterion for lawyers to sue and win any time a patient experiences awareness under TIVA. I don't think that awareness should ever occur with competent anesthesia, but perhaps they are correct in saying this. This is the double-edged sword of organisations like APSF.
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And there are a lot of organizations these days. Lots of guidelines to keep up with 😂
 
DrOwnage said:
I usually won't run a TIVA unless I have remifentanil available. The potency of remi pretty much ensures adequate amnesia when paired with prop. If someone has PONV they get a block if possible, scop patch, dex, zofran, and possibly prochlorperizine near the end of the case. Although I'm pretty anal about this. Even if an inpatient comes down with a 2 day old IV, ill have the nurses put in a fresh one, or do it myself to attach the TIVA to. Having the infusion connected also helps.
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Why not just turn the gas on? I dont get it. I would rather have ponv then awareness.. I feel CRNAs are doing a lot of TIVAs because they dont know how to wake patients up on gas. Its a stormier emergence. Requires much more skill. i NEVER to TIVA and I do my own cases and I do all cases, bowel, cancer, etc . I even use gas with NITROUS>
 
pgg said:
Totally agree.

Leave the vent on and keep the patient paralyzed until the very end. Get the sevo down to 0.7 - 0.8% expired while they're closing. When they pick up the stapler or finish up the last suture, sevo off flows up sugammadex in. They'll be awake in less than a minute, and they'll breathe when they're awake unless you OD'd the opioids.

Desflurane is every bit as fast to come off as propofol, and it's a hell of a lot easier to time/titrate in longer procedures and morbidly obese people for the simple reason that there's an end tidal des number in bright blue right there on the monitor. It's so fast, that a lot of people will criticize it for causing "emergence delirium" because they're used to underdosing opioids with their sevo and iso anesthetics, because iso and even sevo stick around long enough after emergence in analgesic quantities. By the time the sevo/iso patients offgas the rest of the volatile we've walked away in the PACU and the RN is standing there with some fentanyl or hydromorphone.

Rapid emergence is not a reason to do a TIVA.
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^^^^ This is how the pros do it.
 
dipriMAN said:
I think recovery from prop compared to sevo is only faster in very short cases, otherwise I actually think sevo is quicker recovery so long as you get the gas off early.
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Thoughts on pacu course? My anecdotal experience is that patients with propofol based anesthetic tend to be more alert upon emergence, reading newspaper in RR, some even feel great with that dopamine release... while those with gas anesthetic tend to be more groggy and take longer to recover.
 
coffeebythelake said:
Thoughts on pacu course? My anecdotal experience is that patients with propofol based anesthetic tend to be more alert upon emergence, reading newspaper in RR, some even feel great with that dopamine release... while those with gas anesthetic tend to be more groggy and take longer to recover.
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Propofol anesthesia is superior to Sevo/Des in terms of quality of recovery. I know this from my decades of practice as well as personal experiences. But, for long cases I find that that blending propofol with low dose inhalational agent to be much more practical in terms of managing the case; that said, I have personally performed many pure TIVA cases exceeding 6 hours in duration but I still prefer to add some low dose inhalational agent to my propofol when there are no contraindications for doing so.
 
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For really short cases TIVA with propofol is just fine and I use it frequently with patients who have a strong history of postop N/V DESPITE prophylaxis.

Background: Sevoflurane has a low blood-gas partition coefficient resulting in a rapid recovery. Few studies have examined the maintenance and recovery characteristics of sevoflurane compared with propofol in a standardized outpatient population.

Methods: The study was a multicentre study performed in 10 centres. One hundred and sixty-nine elective outpatients due for knee-arthroscopy received 100 mg diclofenac rectally as pain prophylaxis prior to induction of general anaesthesia with fentanyl 1.0–1.5 μg/kg+propofol 2.0–2.5 mg/kg iv. Anaesthesia was maintained with 60% nitrous oxide in oxygen through a laryngeal mask and continuous administration of either: sevoflurane (group S) or propofol infusion (group P) in order to maintain stable haemodynamics. Data of postoperative function and side-effects were collected in a double-blind design, including a patient interview after 24 h.

Results: The sevoflurane patients had a significantly faster emergence from anaesthesia, with response to commands at 6.9±0.4 min versus 8.2±0.4 min in the propofol group (P < 0.05, mean±SD). At 15 min after surgery, group S had a better score in the digit symbol substitution test and felt less confused in a visual analogue scale test compared with group P (P<0.05). Peroperative bradycardia, nausea and vomiting and late postoperative dizziness were more common in group S. In the sevoflurane group, 32% had nausea or vomiting in the 24 h observation period compared with 18% for propofol (P < 0.05). There was no difference between group S and group P in postoperative pain, eligibility for recovery room discharge (75±12 versus 70±11 min) or home-readiness (155±12 versus 143±11 min).

Conclusion: Maintenance of anaesthesia with sevoflurane results in a more rapid emergence, but a higher incidence of nausea and vomiting compared with propofol. The side-effects were minor in our study, and did not result in any difference in time to discharge from the recovery ward or the hospital.


 
coffeebythelake said:
Thoughts on pacu course? My anecdotal experience is that patients with propofol based anesthetic tend to be more alert upon emergence, reading newspaper in RR, some even feel great with that dopamine release... while those with gas anesthetic tend to be more groggy and take longer to recover.
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I too think patients “look better” immediately upon extubation with prop, there is less hyperactive delirium, better for nausea, but I think once the patient is in PACU for 30 mins I am not sure there is a big difference. Patients don’t remember extubation, so I’m not sure this is really that meaningful to justify doing a TIVA.
 
Im surprised this has not been shared yet:


Also I agree that the Sedline monitor is much better than BIS. Still get some garbage numbers(psa which is like the BIS number), but can see EEG and spectral array (especially good) and interpret it. Sadly, they only have BIS where I am at now.
 
pgg said:
Totally agree.

Leave the vent on and keep the patient paralyzed until the very end. Get the sevo down to 0.7 - 0.8% expired while they're closing. When they pick up the stapler or finish up the last suture, sevo off flows up sugammadex in. They'll be awake in less than a minute, and they'll breathe when they're awake unless you OD'd the opioids.

Desflurane is every bit as fast to come off as propofol, and it's a hell of a lot easier to time/titrate in longer procedures and morbidly obese people for the simple reason that there's an end tidal des number in bright blue right there on the monitor. It's so fast, that a lot of people will criticize it for causing "emergence delirium" because they're used to underdosing opioids with their sevo and iso anesthetics, because iso and even sevo stick around long enough after emergence in analgesic quantities. By the time the sevo/iso patients offgas the rest of the volatile we've walked away in the PACU and the RN is standing there with some fentanyl or hydromorphone.

Rapid emergence is not a reason to do a TIVA.
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For nonpainful procedures like TAVRs and EP ablations, I do them with sevo+roc and no versed or fentanyl. Even the 90yo’s are conversant within 5min. No nausea. In GI, I use single agent propofol infusion and get similar wakeups but the procedures are usually much shorter. I think people wake up faster and clearer from single agent sevo anesthesia than even propofol. If you start adding benzos and opioids, it’s much less predictable.
 
nimbus said:
For nonpainful procedures like TAVRs and EP ablations, I do them with sevo+roc and no versed or fentanyl. Even the 90yo’s are conversant within 5min. No nausea. In GI, I use single agent propofol infusion and get similar wakeups but the procedures are usually much shorter. I think people wake up faster and clearer from single agent sevo anesthesia than even propofol. If you start adding benzos and opioids, it’s much less predictable.
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I have had them both for short procedures (no versed) and I prefer the straight Propofol. I had zero post op N/V with the SEVO and didn't mind it at all but still prefer propofol. I agree the wake-up time is actually faster with sevo than propofol iv as well. I just liked how I felt post propofol than post SEVO.

So, my personal experiences line up with the literature and the comments. Unless there is an issue with postop N/V you don't need to bother much with TIVA (except for neuro monitoring cases). But, for those patients with a significant history of postop Nausea despite prophylaxis with everything the use of a TIVA with propofol IV makes sense (avoid opioids as well).
 
What are everyone’s thoughts on when surgeons request/demand TIVA? We have one who acts very self-righteous and implies that his patients are special, so he wants propofol. I just run some background propofol and ignore him. If he would ask me I would probably feel better about accommodating his request because the experience is typically better for the patient. But it really rubs me the wrong way when plastic surgeons act like their patients deserve a higher standard of care than other sub specialties.

Guess this was more of a tangential rant than a question
 
The Duck Knows said:
What are everyone’s thoughts on when surgeons request/demand TIVA? We have one who acts very self-righteous and implies that his patients are special, so he wants propofol. I just run some background propofol and ignore him. If he would ask me I would probably feel better about accommodating his request because the experience is typically better for the patient. But it really rubs me the wrong way when plastic surgeons act like their patients deserve a higher standard of care than other sub specialties.

Guess this was more of a tangential rant than a question
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Plastic surgeons are some of the biggest prima donnas out there so I'm not surprised
 
The Duck Knows said:
What are everyone’s thoughts on when surgeons request/demand TIVA? We have one who acts very self-righteous and implies that his patients are special, so he wants propofol. I just run some background propofol and ignore him. If he would ask me I would probably feel better about accommodating his request because the experience is typically better for the patient. But it really rubs me the wrong way when plastic surgeons act like their patients deserve a higher standard of care than other sub specialties.

Guess this was more of a tangential rant than a question
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If there is no contraindication and your day is going to run smoother by accommodating a prissy surgeon then go for it. I’m still using some sevo if it’s a long case, though.
 
The Duck Knows said:
What are everyone’s thoughts on when surgeons request/demand TIVA? We have one who acts very self-righteous and implies that his patients are special, so he wants propofol. I just run some background propofol and ignore him. If he would ask me I would probably feel better about accommodating his request because the experience is typically better for the patient. But it really rubs me the wrong way when plastic surgeons act like their patients deserve a higher standard of care than other sub specialties.

Guess this was more of a tangential rant than a question
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If they ask me to run propofol I run it unless there's a good reason not to. But like you I'm running mostly gas and then just a splash of propofol for optics / voodoo PONV ppx. It won't hurt the patient and if the surgeon thinks it'll help somehow then sure why not (it'll help the surgeon's mental state at least).
 
dipriMAN said:
I think recovery from prop compared to sevo is only faster in very short cases, otherwise I actually think sevo is quicker recovery so long as you get the gas off early.
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Way to hedge your bet there. Could just say if you time it right, emergence is quick.
If you get the gas off early, sevo is quick.
If you titrate down the prop infusion, propofol recovery is quick.

I’m sure you do that and I’m just being snarky, but the wording made me stop as I scrolled on by.
 
BLADEMDA said:
A human study of the propofol induction dose required to achieve a bispectral index (BIS) <60 in self-reported cannabis users showed that they required significantly higher induction doses of propofol when compared to self-reported cannabis nonusers.59 Another small study showed that administration of Sativex, a synthetic THC and CBD analogue in a 1:1 ratio, resulted in an increase in BIS even when controlling for minimum alveolar concentration of volatile anesthetics.60 It was unclear whether this represented a shallower depth of anesthesia or cannabinoid-induced increase in electroencephalogram (EEG) activity. In addition, most users utilize high-THC, minimal-CBD strains of cannabis, whereas this study utilized strains with an equal THC:CBD ratio, and it is unclear whether the CBD in this study would have a differential effect compared with THC alone. Though chronic cannabis users develop tolerance to the neurocognitive effects of the drug, it is unclear whether cross-tolerance exists between cannabis and anesthetic agents. One human study showed a lack of cross-tolerance of such effects with alcohol in heavy cannabis users.61

Thus, experimental and anecdotal data support the view that cannabis users require higher induction doses of propofol. Less is known about the maintenance phase of anesthesia. Each cannabinoid has differential effects on the body, and there are simply insufficient studies to draw firm conclusions on their individual or summated effects on anesthetic maintenance. Cannabinoid-induced elevations in EEG activity may render BIS a less reliable marker of anesthetic depth of anesthesia in this population. Further studies are needed to determine whether BIS is an effective guide in monitoring depth of anesthesia for this population. Anecdotal data would suggest that, as with induction doses, higher doses of volatile agents are required to achieve adequate maintenance.

There are no specific data regarding intraoperative analgesic use in cannabis users, but recent studies have shown that cannabis users report higher pain scores, have worse sleep, and require more rescue analgesics in the immediate postoperative phase of care.62–64 It is possible that this population may require greater analgesic use in the intraoperative phase, but there are no data to support or refute this view. Nevertheless, the use of a multimodal perioperative analgesic approach utilizing acetaminophen and a nonsteroidal anti-inflammatory drug or a cyclooxygenase-2-specific inhibitor combined with a local or regional analgesia technique, if possible, would be beneficial.65,66

A review of the anesthetic implications of marijuana use - PMC

Marijuana, derived from plants of the genus Cannabis, is the most commonly used illicit drug in the United States. Marijuana is illegal at the federal level and remains a Drug Enforcement Agency Schedule 1 substance. Nevertheless, most states have ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
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Agree anecdotally as well in emergency situations, I have given huge doses of propofol to patients with a cannabinoid tolerance, sometimes exceeding 2-3 mg/kg for conscious sedation
 
coffeebythelake said:
With inhaled agents I consider their responses within the realm of normal population variability. So while some people may claim that all anesthesia requirements of Marijuana users is higher, which may or may not be true (even the articles posted by blade say that much), the only situation where I find a significant clinical difference (and hence change my practice routinely) is with heavy Marijuana users and propofol.

Personally I like to keep patients reasonably muscle relaxed until near case end (from 0 to 2 twitches on TOF) because I use less anesthetic to keep them still. That and judicious use of opioids. You call muscle relaxant use not clean, I actually think jt is a more elegant balanced anesthetic.

And yes it really depends on how you define a "successful anesthetic". Lack of awareness under general anesthesia score big points in my mind.
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Muscle relaxants have no amnestic properties. So if you’re keeping your inhaled agents low, by default the likelihood of recall goes up.
 
redrroc said:
Anesthesia resident CA1 here . I have a question based on my experience in OR for last year. , in this scenario , when she wasn’t receiving any propofol her vitals should be reflecting that. Does it mean the CRNA / whoever was in this case was really negligent not paying attention to vitals ?
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Probably.
 
redrroc said:
Anesthesia resident CA1 here . I have a question based on my experience in OR for last year. , in this scenario , when she wasn’t receiving any propofol her vitals should be reflecting that. Does it mean the CRNA / whoever was in this case was really negligent not paying attention to vitals ?
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If you look at the ASA closed claims database for cases of awareness, the data is pretty clear that vital signs are NOT a sensitive predictor for awareness (which is to say that in the majority of cases where awareness documented, retrospective review of the vital signs did not reveal HTN/tachycardia/etc). The hypothesis to explain this is that in the cases where the patient became tachycardia or whatever, the anesthesia provider noticed and deepened the anesthetic…. So yes, awareness can manifest with VS changes, but the lack of VS changes should not reassure you that awareness is not taking place.

Obviously the above is a general statement based on the closed claims data, not a commentary on what did or did not happen with any one specific case. As good as it can feel to bash CRNAs and automatically assume the worst of them in an anonymous online forum, this sort of thing could theoretically happen to anyone. To err is human
 
neutro said:
Muscle relaxants have no amnestic properties. So if you’re keeping your inhaled agents low, by default the likelihood of recall goes up.
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That really depends on what you mean by inhaled agents "low". I never said that. I said I use muscle relaxant so I don't have to rely on the inhaled agents to prevent patient movement. So instead of a whopper dose like 1.2 MAC, i use "less" anesthetic like 0.7 MAC. Big distinction.
 
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Hork Bajir said:
If you look at the ASA closed claims database for cases of awareness, the data is pretty clear that vital signs are NOT a sensitive predictor for awareness (which is to say that in the majority of cases where awareness documented, retrospective review of the vital signs did not reveal HTN/tachycardia/etc). The hypothesis to explain this is that in the cases where the patient became tachycardia or whatever, the anesthesia provider noticed and deepened the anesthetic…. So yes, awareness can manifest with VS changes, but the lack of VS changes should not reassure you that awareness is not taking place.

Obviously the above is a general statement based on the closed claims data, not a commentary on what did or did not happen with any one specific case. As good as it can feel to bash CRNAs and automatically assume the worst of them in an anonymous online forum, this sort of thing could theoretically happen to anyone. To err is human
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Completely paralyzed, healthy woman awake and being operated on. Likely someone wasn’t paying attention to the vitals. The reason that the close claims don’t reflect this is that paper charts are mostly fiction….
 
dannyboy1 said:
Completely paralyzed, healthy woman awake and being operated on. Likely someone wasn’t paying attention to the vitals. The reason that the close claims don’t reflect this is that paper charts are mostly fiction….
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I’m aware, and agree this patient was likely hypertensive/tachycardic- but I wasn’t commenting about this specific case. My response was directed at the CA-1 who was asking the question- residents should be taught that while awareness is certainly on the differential for intra-op hypertension and tachycardia, LACK of vital sign changes are not especially reassuring that awareness is not taking place.
 
coffeebythelake said:
That really depends on what you mean by inhaled agents "low". I never said that. I said I use muscle relaxant so I don't have to rely on the inhaled agents to prevent patient movement. So instead of a whopper dose like 1.2 MAC, i use "less" anesthetic like 0.7 MAC. Big distinction.
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1.2 Mac is not a whopper dose by any means for many outpatient surgeries. We often have a higher concentration than that for lmas
 
neutro said:
1.2 Mac is not a whopper dose by any means for many outpatient surgeries. We often have a higher concentration than that for lmas
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Again.. Context matters. You are saying that "low" dose anesthetic increases risk for recall. I said my gas anesthetic is targeting amnesia rather than a dose meant to prevent patient movement. I use rocuronium judiciously so i dont need 1.2 MAC. Using that depth of anesthesia IS a whopper dose if you are targeting amnesia with a dose meant to prevent patient movement. You might be misinterpreting the context in your previous 2 comments. Get it?
 
being aware doesnt mean in a lot of pain. vitals may be elevated but may not be super elevated for you to suspect awareness. just because propofol infusion wasnt started doesnt mean shes just a patient who only received roc. i dont know the details of this case. but usually when i do tiva, i still give fentanyl , and often midaz, lidocaine for induction. and i may bolus fentanyl during the case as well
 
coffeebythelake said:
Again.. Context matters. You are saying that "low" dose anesthetic increases risk for recall. I said my gas anesthetic is targeting amnesia rather than a dose meant to prevent patient movement. I use rocuronium judiciously so i dont need 1.2 MAC. Using that depth of anesthesia IS a whopper dose if you are targeting amnesia with a dose meant to prevent patient movement. You might be misinterpreting the context in your previous 2 comments. Get it?
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Sorry I don’t get that you’re saying 1.2 mac of inhaled agent is a whopper dose…I disagree with that.

I’m surprised that you’d say that - outpatient surgeries extubate healthy patients deep with more than that…allows for a very comfortable wake up

As you know, Classically deep extubation for tonsils is done at 2% isoflurane - that’s way more than 0.7 Mac

If you’re including muscle relaxants as part of Balanced anesthetic then sure…outside of initial paralysis for intubation open belly and laparoscopy, heart procedures and certain ortho cases, practice seems to be moving away from routine muscle relaxant usage as a first line…of course we use it when needed

Advantages of not using paralysis as you know:
- don’t have to reverse it
- don’t have to monitor twitches
- don’t need to over-Medicate or complicate your anesthetic unless needed
- risk of recall is much higher esp when you’re running inhaled agents low while using nmbs
- no confounding factor if patient is light and doesn’t move because they’re paralyzed but don’t have enough analgesia or amnesia on board…
 
neutro said:
1.2 Mac is not a whopper dose by any means for many outpatient surgeries. We often have a higher concentration than that for lmas
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I very rarely use 1.2 MAC for anyone, it is a whopper dose, it’s a very deep plane of inhalational anesthesia where you probably don’t need muscle relaxants to cause immobility. In adults … I don’t do peds.
 
dipriMAN said:
I very rarely use 1.2 MAC for anyone, it is a whopper dose, it’s a very deep plane of inhalational anesthesia where you probably don’t need muscle relaxants to cause immobility. In adults … I don’t do peds.
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Not at all. Especially quick surgeries with LMA’s where you want them deep. I run sevo at >3% all the time.
 
dannyboy1 said:
Not at all. Especially quick surgeries with LMA’s where you want them deep. I run sevo at >3% all the time.
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What surgery are you even describing that needs such a deep plane but is so fast? Maybe a DL bronch in a kid or something?
 
dipriMAN said:
What surgery are you even describing that needs such a deep plane but is so fast? Maybe a DL bronch in a kid or something?
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Let's rein this in guys. We got off topic talking about wha6 constitutes whopper doses, when all I said was that 1.2 MAC is unnecessary when you have rocuronium on board. That's it.
 
dannyboy1 said:
Not at all. Especially quick surgeries with LMA’s where you want them deep. I run sevo at >3% all the time.
Click to expand...

And I used to do inhalational inductions with 8% sevo. But I would never run a patient on 8% sevo maintenance. You run the sevo at 3% for short cases without muscle relaxant but the brain partial pressure might never reach that dose.. So Again.. context...
 
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