Lets do it...DESFLURANE AND THE LMA

[VentdependenT]

---

Members do not see this ad.

Who uses it with LMA's? If ya do, do you have problems with airway irritation? Laryngospasm frequency increased? Whats YOUR optimum technique?

In addition, I'm using des more and more frequently. HOWEVER I friggen can't stand that annyoing sympathetic discharge? tips and tricks?

 

[militarymd]

Who uses it with LMA's? If ya do, do you have problems with airway irritation? Laryngospasm frequency increased? Whats YOUR optimum technique?

In addition, I'm using des more and more frequently. HOWEVER I friggen can't stand that annyoing sympathetic discharge? tips and tricks?

Who cares? It's self limiting.

 

[CremeSickle]

Did a Des / LMA the other day.

The only problem i have with des is how quickly they wake up and start coughing with it. I like sevo better.

Just personal preference tho. The sympathetic discharge supposedly reverses at 5-7 minutes per Dr. Egar.

 

[VolatileAgent]

do this all the time... never had a problem... what's the issue again? 😕

 

[dhb]

what's the issue again? 😕

Airway irritation on mask induction not maintenance of anesthesia... i think

 

[OldManDave]

Have used this many times myself without major issues. However, I never use Des in anyone who smokes or has RAD/Asthma/COPD. Regarding sympathetic discharge, big deal. It is rarely clinically significant.

For me though, I am an Iso/N2O dude. Works everytime for pennies/case & once you gain "the feel" of working the combo, you rarely, if ever, have prolonged wake ups. Besides, I think the relatively long tail of Iso is a nice touch to have your clientele snooze the rest of their post-op day away only to awake refreshed & complimentary of their anesthesia provider the next day.

I hear the next question forming..."what about that 13% increased N/V?" The studies that assoc N2O with PONV pretty clearly demonstrate that to occur focally in child-bearing age ladies, esp those having the classi puke-indicing procedures: breast, int female reproductive organs & anything that send a lot of blood into the gut. So, I am more aggressive in my PONV prophylaxis & very very rarely have PONV.

More than one way to skin the old cat!

 

[VolatileAgent]

Airway irritation on mask induction not maintenance of anesthesia... i think

well, no one i know uses des for mask induction. that's what sweet sevo is for. and, apparently back in the day when halothane was still used here in the good ole u. s. of a., that was the D.O.C. for mask induction. the old timers tell me that nothing was prettier than a halothane mask induction...

 

[Intubate]

I use des with LMAs all the time, often with 50% nitrous. If you avoid cranking the agent to above 8%, they rarely get tachy/HTN. If they cough, give em a bump of propofol, that gives you enough time to deepen them and stop the coughing. The desflurane rep said to give fentanyl before placing the LMA to prevent coughing, but in my experience, that also prevents breathing.

 

[VentdependenT]

Who cares? It's self limiting.

Its just something else to deal with on induction. I don't like hearing the HR go to 120's and the pressure go UP after I friggen induce grandma.

Supposedly if you go up slowly with the agent then you can avoid this. But if I have to SLOWLY titrate in desflurane then it defeats the purpose of using the stuff for short cases all together.

For OMD. Interesting tip on the ISO. I only use that stuff for the frequent liver transplants we do. Most, if not all our machines now, don't have vaporizers for it anymore.

 

[VentdependenT]

do this all the time... never had a problem... what's the issue again? 😕

interesting. I am just starting to use it more and I thought this may be a concern in clinical practice. Most of the attendings, and residents, downtown use sevo.

 

[objdoc]

You probably have seen this...

 

[Noyac]

I use it all the time. Here is my technique:

Propofol induction with 50 mcg fentanyl (given occasionally).

Sometimes I use suxx for LMA placement but lets talk about the times I don't.

as soon as the LMA is in I turn the O2 flow down to 1 LPM. I crank the DES to 12%. The pt breathes spontaneously and I can't remember the last time someone coughed. I saw it somewhere once that as long as you keep the sum of the carrier (O2/air/ N2O) gas flow times the DES % below 24 you won't see any irritation. My conc is 12 (1 lpm O2 X 12% DES = 12)

 

[VentdependenT]

Thanks Noy.

So you run em deep with the des for LMA cases? You pull em deep too?

 

[Noyac]

Thanks Noy.

So you run em deep with the des for LMA cases? You pull em deep too?

Sorry I didn't go much beyond the induction and the start of the case. I find that with DES 1MAC is plenty as opposed to sevo. Just think of all the times you have had someone at 1 - 2 MAC sevo and the surgeon makes incision and the pt moves. Well i don't see this with DES which is why I like it so much.

So I have them breathing 12%Des until they get up to around 7% ET Des. Then I start coming down on the vaporizer. i keep them at around 1 MAC for the first 30 minutes or so and then start weaning the DES as I see fit. I keep their resp rate around 12 with narcs.

At the end of the case I get them down to around 3 - 4 % ET DES. I pull the LMA deep while the sutures are going in and let them breath 100% O2 by mask and some chin lift if necessary. Move the stretch next to the bed and say "Hey Joe, wake up and move to the bed next to you". If they move slowly or open their eyes slowly we move them (about 1/2 the time) and the movement usually wakes them up plenty.

Hope that is more clear.

ASk your attendings, I'm sure they know how this is done.



I'm just pokin fun. I'm sure hey know how.

THere are some great residents coming out and someone must be training them. THey can't be learning everything from SDN.

 

[jetproppilot]

For me though, I am an Iso/N2O dude. Works everytime for pennies/case & once you gain "the feel" of working the combo, you rarely, if ever, have prolonged wake ups.
More than one way to skin the old cat!

Doubt you'll be using iso in private practice, dude. Maybe on hearts/ELAPs that are going intubated to the ICU...but thats even a stretch since we're trying to extubate CABGs ASAP.

Some old tricks are great.

I don't believe an iso/N2O-combo is one of them.

 

[jetproppilot]

Sorry I didn't go much beyond the induction and the start of the case. I find that with DES 1MAC is plenty as opposed to sevo. Just think of all the times you have had someone at 1 - 2 MAC sevo and the surgeon makes incision and the pt moves. Well i don't see this with DES which is why I like it so much.

So I have them breathing 12%Des until they get up to around 7% ET Des. Then I start coming down on the vaporizer. i keep them at around 1 MAC for the first 30 minutes or so and then start weaning the DES as I see fit. I keep their resp rate around 12 with narcs.

At the end of the case I get them down to around 3 - 4 % ET DES. I pull the LMA deep while the sutures are going in and let them breath 100% O2 by mask and some chin lift if necessary. Move the stretch next to the bed and say "Hey Joe, wake up and move to the bed next to you". If they move slowly or open their eyes slowly we move them (about 1/2 the time) and the movement usually wakes them up plenty.

Hope that is more clear.

ASk your attendings, I'm sure they know how this is done.



I'm just pokin fun. I'm sure hey know how.

THere are some great residents coming out and someone must be training them. THey can't be learning everything from SDN.

Nice technique, bro.

BTW, hope your old team isnt intimidated by the new Yankee ROCKET.

Lookin forward to a GUARANTEED low ERA from the old dude. Heck, better be for 28 mil......

SEE NOY?

SHOULDDA STUCK WITH BASEBALL!

Man, I'd love to have that kinda negotiating power...

ROCKET: "George, here's how it is. I'll pitch for you. But I want a cool mil-a-week. And if I'm not scheduled to pitch, I'm gonna stay at my crib with my hot wife and kidlets. But I'll agree to watch the game on TV."

"OK?"

George: "OK, Rocket. Whatever you want. If a mil-a-week isnt enough, and you need more spare 500k-each engines for your jet, please call me."

Try that with your administrator:

Noy: Mr. Slim-Administrator, I'll agree to do the anesthesia here for six-hundred-large. But Only from nine-to-five. If I have to come out after five, or on weekends/holidays, I get two-large an hour."

"Additionally, I'd like eggs benedict each morning, cooked fresh on my arrival by a chef."

"I'd like this excuse you have as a doctors lounge totally revamped. Double the size. Adourn it with oversize couches, two 70 inch plasma TVs tuned to ESPN only, WIFI, three laptops with 2 gig of RAM, two DVD players, at least three Top Gun DVDs, a refrigerator stocked with strawberry yogurt, Mountain Dew, and Hungry Man frozen dinners."

"OK?"

Mr. Slim-Administrator: "Noy, ya gotta stop doin' that con-bud. Yeah, it totally contributes to your snowboard-fakies. And I agree with you. It makes TOOL sound even better. But...uhhhhh....you've lost rationality in this office."

Uhhhh....sorry Mike.

I mislead you.

Guess we ain't got Da Rocket's arm.

So forgettabout goin' to the CEO with my proposal.

 

[Noyac]

Nice technique, bro.

BTW, hope your old team isnt intimidated by the new Yankee ROCKET.

Lookin forward to a GUARANTEED low ERA from the old dude. Heck, better be for 28 mil......

SEE NOY?

SHOULDDA STUCK WITH BASEBALL!

Man, I'd love to have that kinda negotiating power...

ROCKET: "George, here's how it is. I'll pitch for you. But I want a cool mil-a-week. And if I'm not scheduled to pitch, I'm gonna stay at my crib with my hot wife and kidlets. But I'll agree to watch the game on TV."

"OK?"

George: "OK, Rocket. Whatever you want. If a mil-a-week isnt enough, and you need more spare 500k-each engines for your jet, please call me."

Try that with your administrator:

Noy: Mr. Slim-Administrator, I'll agree to do the anesthesia here for six-hundred-large. But Only from nine-to-five. If I have to come out after five, or on weekends/holidays, I get two-large an hour."

"Additionally, I'd like eggs benedict each morning, cooked fresh on my arrival by a chef."

"I'd like this excuse you have as a doctors lounge totally revamped. Double the size. Adourn it with oversize couches, two 70 inch plasma TVs tuned to ESPN only, WIFI, three laptops with 2 gig of RAM, two DVD players, at least three Top Gun DVDs, a refrigerator stocked with strawberry yogurt, Mountain Dew, and Hungry Man frozen dinners."

"OK?"

Mr. Slim-Administrator: "Noy, ya gotta stop doin' that con-bud. Yeah, it totally contributes to your snowboard-fakies. And I agree with you. It makes TOOL sound even better. But...uhhhhh....you've lost rationality in this office."

Uhhhh....sorry Mike.

I mislead you.

Guess we ain't got Da Rocket's arm.

So forgettabout goin' to the CEO with my proposal.

Yeah, it ain't that easy dealing with the administrators. I just finished negotiating my contract with the CEO and CFO. I got 3 more years here pretty easily but the raise is more difficult. Nothing this year but we agreed to discuss it next year. The date is even set.

AS far as the Rocket goes. He better learn to hit as well if he is going to make any impact on the Yankees. And they use the DH which makes this very unlikely. The Yankees are going to be lucky just to get a wildcard spot.

 

[jetproppilot]

Yeah, it ain't that easy dealing with the administrators. I just finished negotiating my contract with the CEO and CFO. I got 3 more years here pretty easily but the raise is more difficult. Nothing this year but we agreed to discuss it next year. The date is even set.

AS far as the Rocket goes. He better learn to hit as well if he is going to make any impact on the Yankees. And they use the DH which makes this very unlikely. The Yankees are going to be lucky just to get a wildcard spot.

Uhhhhh, Mike,

ARE YOU BEING SERIOUS???


YA REALLY THINK HE'S GOTTA HIT TO MAKE AN IMPACT??????

HAHAHHAHAHAHHAHHAHAHHAHAHAHAHAHHAA

uhhhhhh.....what is THE UNIT'S batting average????

 

[Noyac]

Uhhhhh, Mike,

ARE YOU BEING SERIOUS???


YA REALLY THINK HE'S GOTTA HIT TO MAKE AN IMPACT??????

It's really just a joke but what I'm getting at is that the Yankees can't hit (we all know that these guys can hit but they just aren't hitting yet) so Roger will need to bring some more than just his pitching to the team.

But Roger does bring more than just pitching. He brings enthusiasm, experience and a bulldog attitude (I like this).

But even if he doesn't turn them around. Its a business move as much as anything for George. Yeah, he's paying a buttload to Roger. but don't think he isn't making a buttload from signing him. It probably a wash or close to it for George.

 

[jetproppilot]

It's really just a joke but what I'm getting at is that the Yankees can't hit (we all know that these guys can hit but they just aren't hitting yet) so Roger will need to bring some more than just his pitching to the team.

But Roger does bring more than just pitching. He brings enthusiasm, experience and a bulldog attitude (I like this).

But even if he doesn't turn them around. Its a business move as much as anything for George. Yeah, he's paying a buttload to Roger. but don't think he isn't making a buttload from signing him. It probably a wash or close to it for George.

An opinion from the True, Knowing Professional that you are. 👍

 

[Pooh & Annie]

It's really just a joke but what I'm getting at is that the Yankees can't hit (we all know that these guys can hit but they just aren't hitting yet) so Roger will need to bring some more than just his pitching to the team.

But Roger does bring more than just pitching. He brings enthusiasm, experience and a bulldog attitude (I like this).

But even if he doesn't turn them around. Its a business move as much as anything for George. Yeah, he's paying a buttload to Roger. but don't think he isn't making a buttload from signing him. It probably a wash or close to it for George.

And he, like all decent Yankee pitchers, will be on the DL within a month of starting. (My guess is a torn flactoid). And that's perfectly fine with me!

 

[Noyac]

And he, like all decent Yankee pitchers, will be on the DL within a month of starting. (My guess is a torn flactoid). And that's perfectly fine with me!

i don't know. Roger doesn't usually spend much time on the DL. The guy is a machine when it comes to pitching.

 

[Pooh & Annie]

i don't know. Roger doesn't usually spend much time on the DL. The guy is a machine when it comes to pitching.

As an octogenarian his chances are high...

By the way, anybody know anything about baseball cards? I've got some Bonds graded cards that I wanna toss on ebay, and if I should wait till he beats the record or do it now while everybody's watching him. I personally hate the dude, and have no desire to keep them. I don't collect cards but got them cheap at a repo auction (those places are SWEET)

 

[2ndyear]

[/QUOTE]Interesting tip on the ISO. I only use that stuff for the frequent liver transplants we do. Most, if not all our machines now, don't have vaporizers for it anymore.[/QUOTE]

Interesting how institutions differ. Our cost for Sevo is $226/bottle, Des is $180. Iso....$11/bottle. Again, that's the cost to my department, probably not yours. Iso is dirt cheap and potent though. Of course many things go into cost of inhaled agents. At one hospital we routinely use Iso/N20 at flows of 3L/min total, sometimes 2, but generally for an everyday whatever case you're around there. At another place Sevo and Des rules, some machines have only a Sevo and Des vaporizer. But they're all Draeger Apollo's and calculate the lowest acceptable flow for a case. I haven't done the math, but even though the MAC is higher I'm not burning through much Des at 500 mL/min. Could I do a lower flow at the first place? Sure and I do. But that's not how it's done there usually. Lots of Iso in the scavenger.

 

[jetproppilot]

Interesting tip on the ISO. I only use that stuff for the frequent liver transplants we do. Most, if not all our machines now, don't have vaporizers for it anymore.[/QUOTE]

Interesting how institutions differ. Our cost for Sevo is $226/bottle, Des is $180. Iso....$11/bottle. Again, that's the cost to my department, probably not yours. Iso is dirt cheap and potent though. Of course many things go into cost of inhaled agents. At one hospital we routinely use Iso/N20 at flows of 3L/min total, sometimes 2, but generally for an everyday whatever case you're around there. At another place Sevo and Des rules, some machines have only a Sevo and Des vaporizer. But they're all Draeger Apollo's and calculate the lowest acceptable flow for a case. I haven't done the math, but even though the MAC is higher I'm not burning through much Des at 500 mL/min. Could I do a lower flow at the first place? Sure and I do. But that's not how it's done there usually. Lots of Iso in the scavenger.[/QUOTE]

Don't get lost on volatile agent cost.....

Walk it all the way through to the PACU.

What do you think the PACU time is gonna be for a 2 hour case using iso vs des/sevo?

Assume a day surgery case....pt going home.

If the iso has in fact doubled or tripled PACU time, then the $ 11 dollar iso vs $ 180 des is no longer relevant.

 

[Intubate]

You probably have seen this...

removed

 

[CremeSickle]

Don't get lost on volatile agent cost.....

Walk it all the way through to the PACU.

What do you think the PACU time is gonna be for a 2 hour case using iso vs des/sevo?

Assume a day surgery case....pt going home.

If the iso has in fact doubled or tripled PACU time, then the $ 11 dollar iso vs $ 180 des is no longer relevant.

Thats a common argument for Des. I would submit that a good clinician can time the Iso off to have the same PACU times. I think Des is so easy it can make you a lazy clinician. I do alot of cases where i use Iso/N2O and end the ISO early using only N2O. Good wakeups and PACU exit times.

 

[Arch Guillotti]

Thats a common argument for Des. I would submit that a good clinician can time the Iso off to have the same PACU times. I think Des is so easy it can make you a lazy clinician. I do alot of cases where i use Iso/N2O and end the ISO early using only N2O. Good wakeups and PACU exit times.

I agree with this as well. I like the iso/N2O combo as well. good wakeups that are pretty easy to time.

 

[Noyac]

In academics it probably isn't really important b/c the pacu times don't change much b/w pts. In the ambulatory setting it does, however. You do a case that ends a little after 5:00. Everyone wants to go home. The investors want everyone to go home so they don't have to pay overtime. With DES you can wake them up lickity split and take them to phase 2 bypassing pacu. Give them some juice and out the door. Not usually with Iso. Yes in the right hands it is possible with Iso but not as reliable.

 

[fval28]

In academics it probably isn't really important b/c the pacu times don't change much b/w pts. In the ambulatory setting it does, however. You do a case that ends a little after 5:00. Everyone wants to go home. The investors want everyone to go home so they don't have to pay overtime. With DES you can wake them up lickity split and take them to phase 2 bypassing pacu. Give them some juice and out the door. Not usually with Iso. Yes in the right hands it is possible with Iso but not as reliable.

Agree- with Des they return to their pre-anesthetized state faster with very few patients looking "hungover" like with iso. Also I have found that for old folks the des is particularly forgiving - had an 80 yo old dude on friday for a lap ccy that went a LOT longer than expected d/t bleeding and equipment issues (total time ~2 hours). dude woke up in the or, moved himself to the stretcher, stayed in pacu for 30 min and then d/c- scored me some big points with the or/pacu staff for getting them out of there on time for the long holiday weekend- patient was happy too😀

 

[epidural man]

Did a Des / LMA the other day.

The only problem i have with des is how quickly they wake up and start coughing with it. I like sevo better.

Just personal preference tho. The sympathetic discharge supposedly reverses at 5-7 minutes per Dr. Egar.

Des with droperidol for PONV - a perfect combination. The drop smoothes out the Des wakeup.

 

[CremeSickle]

have to try that!