Nerve Monitoring Cases

[GassYous]

What do you guys like to do in outpatient ent where they don't want paralysis due to nerve monitoring? I've had a few cases where I'm running a mac of gas and propofol at like 125. There's no remi and I don't want to give too much opioids that would delay the wakeup but their monitoring machine still beeps and they complain about the patient being light. I've just started adding nitrous but I'm trying to avoid it due to environmental impact and I don't actually think the patient is light.

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[DrOwnage]

How long are these cases? Most of the cases I did in residency were around 2-3 hours probably for a mastoidectomy, ect. With the young peeps who are getting those cases I do LTA with intubation, induction with 0.5mg/kg of ketamine and propofol, 1mg of dilaudid up front, run them deep at around 1.2-1.3 MAC of sevo. I think you should be fine with that if the case is around 2 hours. If its shorter I usually nix the ketamine.

 

[secretasianman]

I honestly don’t do anything special. I do like to give precedex boluses though if I need more opioids than usual. Precedex is life.

 

[GassYous]

Thanks guys. I used to run prop/remi tiva only and I think it was a serious crutch.

 

[JiPo]

You can do prop/sufenta. You can titrate sufenta the same way you titrate down prop. Turn it off whenever you turn off prop.

 

[deleted697127]

Where are you doing these procedures? I don’t see it as a crutch. If it’s a free standing surgery center, find out who orders drugs and have them order remi. You are improving operating conditions for the surgeon. If you don’t have it in the outpatient surgery center at your hospital, use your legs and go grab it wherever they do keep it.

 

[GassYous]

Surgery center. I think the problem is that they are penny wise and don't want to shell out for better medications like remi or sugammadex if they can avoid it.

 

[deleted59964]

how is remi a crutch?
is sevo a crutch
is propofol

maybe we should be giving thio and iso ? (or ether)

i think the patients would disagree

 

[deleted697127]

Surgery center. I think the problem is that they are penny wise and don't want to shell out for better medications like remi or sugammadex if they can avoid it.

Who doesn’t want it? Sounds like the surgeon wants it.

 

[JiPo]

Surgery center. I think the problem is that they are penny wise and don't want to shell out for better medications like remi or sugammadex if they can avoid it.

From what I understand, sufentanil is much cheaper than remifentanil. At my shop, for long TIVA cases, we are strongly encouraged to use sufentanil over remifentanil due to cost.

 

[Ronin786]

I've run into this issue because of how hard it is to get Remi. Propofol infusion and crank up the gas. Ketamine boluses.

 

[GassYous]

I agree with you guys. Probably the administrators are responsible but I don't know exactly who makes the decisions for which medications are available. The cases are about 2 hours long. As an aside, for multilevel spines I dropped remi in favor of fentanyl drips because I noticed patients were in significant pain in pacu.

What do you guys run sufent at? I have used it a few times in residency but only as boluses.

 

[JiPo]

I agree with you guys. Probably the administrators are responsible but I don't know exactly who makes the decisions for which medications are available. The cases are about 2 hours long. As an aside, for multilevel spines I dropped remi in favor of fentanyl drips because I noticed patients were in significant pain in pacu.

What do you guys run sufent at? I have used it a few times in residency but only as boluses.

I run it at 0.2mcg/kg/hr along with prop at 100-150mcg/kg/min

 

[kidthor]

Weird - you're running a decently deep anesthetic. Maybe you just need more opioid up front? Does the surgeon put in much local? Usually I do these with about a MAC of gas, propofol gtt at around 100ish (maybe less), and some fentanyl up front - maybe 200mcg or so. Our surgeons put in a fair amount of local up front too. Sometimes they move a little bit but not often...

 

[AdmiralChz]

I used to have the SAME thing happen all the damn time in residency. I’d run super deep with infusions whatever patient would still move. Drove me nuts and made me think I sucked at my job. Surgeons were nasty about it too. Doesn’t happen to me now at all, strangely and it’s not a change in anesthetic. I think if the surgeons push hard on the trachea it is exceptionally stimulating, so different techniques make an impact there.

I agree with the above - just deepen the anesthetic. More fent, gas, prop whatever. Run a neo drip if you’re hypotensive, sort of how it goes.

Many surgery centers have no remi (expensive) and very few have sufenta (very cheap, but why would it routinely be needed for outpatient surgery?) so I feel your pain.

 

[coffeebythelake]

I agree with you guys. Probably the administrators are responsible but I don't know exactly who makes the decisions for which medications are available. The cases are about 2 hours long. As an aside, for multilevel spines I dropped remi in favor of fentanyl drips because I noticed patients were in significant pain in pacu.

What do you guys run sufent at? I have used it a few times in residency but only as boluses.

Well of course running remi means more pain than fentanyl drip. Fentanyl gtt actually sticks around better than sufenta or dilaudid when u run an infusion over hours. As for sufenta, bolus it then 0.2 to 0.5 mcg/kg/hr

 

[deleted162650]

how is remi a crutch?
is sevo a crutch
is propofol

Prop - No
Sevo - No
Remi - Yes (actually it’s more like one of those wheelchairs you blow into to make it go)

Remi is Satans’s semen itself.

Oh, and please change back to your old avatar. I miss the bouncing track star.

And only us Americans are allowed to call ourselves idiots.

 

[HalO'Thane]

What do you guys like to do in outpatient ent where they don't want paralysis due to nerve monitoring? I've had a few cases where I'm running a mac of gas and propofol at like 125. There's no remi and I don't want to give too much opioids that would delay the wakeup but their monitoring machine still beeps and they complain about the patient being light. I've just started adding nitrous but I'm trying to avoid it due to environmental impact and I don't actually think the patient is light.

Nitrous? For Middle Ear Surgery? I always thought that was supposed to be a No-No; at least in academia where I was taught.

 

[CodeBlu]

Geeze... I love remi. Don't take it away from me... please?

 

[Maverikk]

Remi is a great drug, relatively very expensive, if you're at a place that does a lot of ENT/nerve monitoring it would be worthwhile inquiring into availability but you can do the cases without it. I would want pharmacy to make up pre-made syringes, the 2mg vial I have is a lot if you have to use a new vial for each case. Nerve monitoring ENT and carotids are the only cases I think the benefits outweigh the costs and even carotids I mostly do without.
To answer your question: if the cases are at least an hour I'd give some ketamine (30-50) upfront

I think some good eduation (for me too): for people who use alfentanil, what do you usually bolus/infusion, what's the clinical offset time for infusions (long v. short infusions)?