Nitrous and T and A's

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MErc44

MErc44

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Who uses it for maintenance? Also, completely unrelated, does anyone know where to get a handbook that goes over the units for each type of surgery and anesthesia related procedure?
 
If you use it for mask induction you might as well use it for maintenance.
The concern about increasing the pressure in the middle ear is theoretically eliminated when tubes are inserted in the ears, and these are usually short cases so the difference is only few more minutes of N2O exposure.
 
I'm not a fan of nitrous in airway cases. Airway surgeries frequently use oxygen and nitrous oxide to ventilate and anesthetize patients, respectively. Both gases support combustion, and both reduce the amount of energy (e.g., current, heat, friction) needed to ignite flammable substances. Moreover, during airway surgery, these gases leak around the tracheal tube, its cuff, or packing, creating an oxygen enriched environment in the oropharynx. Some fuels that will not burn in the 21% concentration of oxygen found in room air will burn vigorously in an Oxygen enriched environment.
 
ssmallz said:
I use it on all my T&As helps me use less sevo and wake em up quicker
Click to expand...

Another way to use less sevo is to turn the blue vaporizer on instead. Give in ... use desflurane ... you know you want to. 🙂



I use nitrous for GA c-sections, pediatric mask inductions, and essentially nothing else. If I take over a case for someone who was using it, the first thing I do is turn it off.
 
MErc44 said:
Who uses it for maintenance? Also, completely unrelated, does anyone know where to get a handbook that goes over the units for each type of surgery and anesthesia related procedure?
Click to expand...

Boo nitrous.

Also you can get the abeo coder iPhone app that has surgical and anesthetic cpt plus crosswalk info and units for anesthetic cpts. Now that I have to do some coding I find it pretty slick.


On the iPhone
 
pgg said:
Another way to use less sevo is to turn the blue vaporizer on instead. Give in ... use desflurane ... you know you want to. 🙂



I use nitrous for GA c-sections, pediatric mask inductions, and essentially nothing else. If I take over a case for someone who was using it, the first thing I do is turn it off.
Click to expand...

I'd love to but they don't have any des at my new hospital😡. In residency we did it all the time
 
For those of you using Des for peds cases, have you noticed any increase in emergence delirium? Our children's hospital trialed Des a few years back and ended up getting rid of it because they saw their emergence delirium rates go way up.
 
So, this was my first week as an attending. I was at a surgery center the other day and we did 4 cases from 9 AM till noon. Three of those were T and A's and two of those kids had their iv's placed pre op. how do you guys induce a 10 year old with an IV in place for a15 min procedure. My choice was not very slick.
 
dhb said:
What about when you factor in the absorbent?
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Judging by the few online shopping carts I can find, soda lime appears to be about $2-3/pound ($4-6/kg), unless you're buying proprietary pre-filled canisters for specific machines. Low flows will consume absorbent faster since more CO2 will get absorbed vs sent out the scavenger as gas volume is replaced by higher flows, but is this really a significant issue?

To tell the truth I haven't kept track of how often it needs replacement, but I'm skeptical that it's a major cost. If I do a full day's cases using nothing but desflurane at ~0.6 LPM fresh gas flows, I don't have to replace the absorbent. So I can't imagine it adding more than $1-2 per patient, worst case.


I know some places are using the somewhat higher priced Amsorb to enable low flow sevoflurane use. In those circumstances, if you decide the minimum 2L/min flows from the stupid package insert don't apply, I can see sevoflurane being cheaper than desflurane.


But then as an overall cost issue ... are we really going to get excited about a $10/case difference in cost when OR time, PACU time, implant cost, etc are orders of magnitude higher?
 
Agree with plank except I don't use Midaz. Personally, I don't use Midaz in kids bc it seems as tho they wake up more confused and agitated.

Which brings me to the emergence delirium. I like to give a small dose of propofol to kids right before extubation so that they wake up smoothly. With this it doesn't matter which gas I use. Some of my partners give precedex for this. It think the two work equally well.
 
Planktonmd said:
Midazolam IV pre-op then Propofol + Lidocaine + Fentanyl ----> tube, no relaxant.
A 10 Y/O with an IV is like an adult with an IV.
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Agree. Muscle relaxant is highly overrated in kids, I never use it unless it's necessary for the surgery
 
I don't use nmb for the majority of peds cases either but I had to use close to 4 mg/kg of propofol to establish adequate intubating conditions. The bed was turned away for the surgery and back to me in 10 min and it took more time than I would like for pt to wake up. I think in the future i will use an inhalation induction even with an iv in place.
 
MErc44 said:
I don't use nmb for the majority of peds cases either but I had to use close to 4 mg/kg of propofol to establish adequate intubating conditions. The bed was turned away for the surgery and back to me in 10 min and it took more time than I would like for pt to wake up. I think in the future i will use an inhalation induction even with an iv in place.
Click to expand...

Use sevo and fent and 1/kg of prop. Wham, bam, tube, done.
Or just extubate deep.
 
IlDestriero said:
0.5 mcg/kg slow push at the end.👍
Click to expand...

I thougt they were using 0.25mcg/kg. but I'd have to check to be sure. I asked the pacu nurses if their pts were waking up better than mine and they unanimously said mine still wake up better. It may be because I extubate deep but most of my partners will do this from time to time as well.

I also find that mixing the precedex and wasting the left over is just such a PITA. Propofol is just so easy.
 
Noyac said:
I thougt they were using 0.25mcg/kg. but I'd have to check to be sure. I asked the pacu nurses if their pts were waking up better than mine and they unanimously said mine still wake up better. It may be because I extubate deep but most of my partners will do this from time to time as well.

I also find that mixing the precedex and wasting the left over is just such a PITA. Propofol is just so easy.
Click to expand...

I tried this one day. They had less emergence delirium...but they were sleepy for hours in the pacu.
 
Noyac said:
I thougt they were using 0.25mcg/kg. but I'd have to check to be sure. I asked the pacu nurses if their pts were waking up better than mine and they unanimously said mine still wake up better. It may be because I extubate deep but most of my partners will do this from time to time as well.

I also find that mixing the precedex and wasting the left over is just such a PITA. Propofol is just so easy.
Click to expand...

It would be interesting if 0.25mcg is an effective dose.
 
None of our peds guys regulary use dex, but about half of them will use clonidine IV 1-2mcg/kg routinely. I have been asking the PACU nurses if they think it makes a difference, and the consensus is that kids who get clonidine + some narcotic wake up nicely. They say clonidine without narcotic doesn't do anything (Here all kids are taken intubated to the PACU and extubated by the PACU nurses). They also said that the clonidine does not extend PACU times.
 
SaltyDog said:
extubated by the PACU nurses
Click to expand...

I've never seen a PACU I'd trust to do this, not even the peds hospitals where deep extubations / emergence in the PACU was routinely and safely done.

At my current hospitals, all of my patients are awake before they leave the OR, unless they're going to the ICU on a vent.
 
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