Obvious

[IveGotTwins]

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22 yo male ASA 1 coming to OR for lap bilateral inguinal hernia repair. 2 mg versed in pre-op, roll back, hooked to monitors, induced with 60 mg 1% lidocaine, 100 mg propofol, 100 mcg fentanyl, 5 mg vec. Easy airway, 8.0 tube in. As my staff is walking out he says no more muscle relaxants or narcotics just keep him deep. So I get the ET des% to 1.4. BP and HR are normal.

20 min later the surgeons are inserting the ports and the patient gets tachy (120s) and hypertensive (MAP 100s) and begins bucking the vent. So against the instructions of my staff I give 100 mcg of fentanyl and 5 mg of vec. This seems completely reasonable to me given the situation (which isn't even a situation). Staff returns 40 mins later to check in and sees that I gave more vec and fentanyl. He is angry. I tell him what happened and he says I should have given a beta blocker and further deepen with gas. I ask why and he says that narcotics are addictive.

I think my actions were completely normal, logical and defensible and his plan is crazy.

I am a CA1 so forgive me if I'm missing something obvious.

 

[leaverus]

22 yo male ASA 1 coming to OR for lap bilateral inguinal hernia repair. 2 mg versed in pre-op, roll back, hooked to monitors, induced with 60 mg 1% lidocaine, 100 mg propofol, 100 mcg fentanyl, 5 mg vec. Easy airway, 8.0 tube in. As my staff is walking out he says no more muscle relaxants or narcotics just keep him deep. So I get the ET des% to 1.4. BP and HR are normal.

20 min later the surgeons are inserting the ports and the patient gets tachy (120s) and hypertensive (MAP 100s) and begins bucking the vent. So against the instructions of my staff I give 100 mcg of fentanyl and 5 mg of vec. This seems completely reasonable to me given the situation (which isn't even a situation). Staff returns 40 mins later to check in and sees that I gave more vec and fentanyl. He is angry. I tell him what happened and he says I should have given a beta blocker and further deepen with gas. I ask why and he says that narcotics are addictive.

I think my actions were completely normal, logical and defensible and his plan is crazy.

I am a CA1 so forgive me if I'm missing something obvious.

The obvious is that you probably should have just listened to your "staff" and done what he wanted simply because you don't want to get on an attending's bad side this early in your residency - or you could have called him in; academic attendings love to show their usefulness. Technically, neither of you is wrong (except for the nonsense about intraoperative narcotics being addictive - wtf is that?? he's spewing that out the wrong orifice); there are many ways to "deepen" an anesthestic and i personally believe that as long as you maintain stable hemodynamics, facilitate surgery, and are able to extubate the patient safely at the end of surgery it doesn't really matter what the heck you give. Having said that, it seems to me that for a young healthy 22 year old guy, 100mg propofol and 5mg vec for induction are very chintzy doses - you guys having a major shortage problem or something?

 

[IveGotTwins]

If I were in charge of the induction doses I would have given 8 of vec, 200 of fentanyl and 150 of propofol.

The surgeons could not get all the ports in bc he was bucking/coughing/responding so much. In my mind the surgery was not be facilitated under those conditions so I gave the relaxant and narcotic. At the time he was already at 1.4 MAC of des which is pretty deep, right?

I agree with the sentiment regarding intra-op narcotics and addiction.

 

[urge]

22 yo male ASA 1 coming to OR for lap bilateral inguinal hernia repair. 2 mg versed in pre-op, roll back, hooked to monitors, induced with 60 mg 1% lidocaine, 100 mg propofol, 100 mcg fentanyl, 5 mg vec. Easy airway, 8.0 tube in. As my staff is walking out he says no more muscle relaxants or narcotics just keep him deep. So I get the ET des% to 1.4. BP and HR are normal.

Need I say more?


Besides, what is 60mg 1% Lido?

 

[IveGotTwins]

I meant MAC 1.4, ET% 7.6. Sorry.

1% lidocaine.

 

[urge]

I imagine your attending has been burned on wake ups. Whether or not he was right, now you have someone who thinks you cannot follow instructions. If you keep making friends like that you will have a horrible residency. Why not just give a big slug of propofol?

 

[IveGotTwins]

I understand that giving too much narcotic and muscle relaxant can delay wake ups. I just don't think 200 mcg of fentanyl and 10 of vec is too much considering we're 3.5 hrs into the case not even halfway done.

Propofol probably would have been a better choice. I could have given that and given my staff time to get to the room to see if he might agree with more narcs and muscle relaxant.

Thanks for the responses thus far.

 

[Sonny Crocket]

What you did was fine clinically other than going against the advice of your attending. I recommend always Having some extra propofol handy should those situations arise. If the patient bucks just flip to manual ventilation and bolus some propofol while you figure out what to.

In residency my thinking was "when in Rome ...." Meaning just try and run things the way the attending wants unless you think it is unsafe. This allows you to coast through without problems. When you graduate you can do things the way YOU want which is liberating. Damn some attendings drove me crazy with their dogma during residency.

 

[imfrankie]

I feel for your situation, you're in the hot seat with the surgeons breathing and "the patient's bucking." But my advice is, next time the Attending says do/don't just find another way. Big dose of proposal and gas up then give a ring. You could really hurt yourself interpersonally. Plus...it's important to learn to solve the problem other ways, so in defense of your attending, sometimes it's good to say, "I want you to work the problem with these tools only." I'd recommend you hunt the guy/gal down and eat a lot of humble pie explaining you are really sorry you didn't follow directions, you were under the gun and lost your cool and it won't happen again. Really, I think you should apologize and ask for forgiveness.

 

[cincincyreds]

22 yo male ASA 1 coming to OR for lap bilateral inguinal hernia repair. 2 mg versed in pre-op, roll back, hooked to monitors, induced with 60 mg 1% lidocaine, 100 mg propofol, 100 mcg fentanyl, 5 mg vec. Easy airway, 8.0 tube in. As my staff is walking out he says no more muscle relaxants or narcotics just keep him deep. So I get the ET des% to 1.4. BP and HR are normal.

20 min later the surgeons are inserting the ports and the patient gets tachy (120s) and hypertensive (MAP 100s) and begins bucking the vent. So against the instructions of my staff I give 100 mcg of fentanyl and 5 mg of vec. This seems completely reasonable to me given the situation (which isn't even a situation). Staff returns 40 mins later to check in and sees that I gave more vec and fentanyl. He is angry. I tell him what happened and he says I should have given a beta blocker and further deepen with gas. I ask why and he says that narcotics are addictive.

I think my actions were completely normal, logical and defensible and his plan is crazy.

I am a CA1 so forgive me if I'm missing something obvious.

The issue here is the patient was not deep enough with ET Desflurane of 1.4%. You have to understand that after you intubate the patient, it takes time for the desflurane concentration to build up. The way to make this go faster is to keep your flows higher for the first few minutes.

The second the patient started bucking, you should have immediately taken this patient off of the vent. Possibly the patient could have an irritated airway from smoking or something like that which was worsened by the fact this patient was not deep enough.

So if the patient is not deep enough, the treatent is to increase your depth of anesthia. I would have gone up on the desflurane, increased my flows, and if needed given a small dose of propofol. I would have also taken the patient off of the vent for 10 seconds or so to decrease the irritation on the airway which could have caused the bucking until the patient had achieved a higher anesthetic depth. This was not an issue of more muscle relaxant.

Also you need to go to your attending and apologize for not following directions. If there is one thing that drives me nuts, it is the resident not following my directions. If we are doing controlled hypotension and I tell you to keep the BP systolic at 80, do as I say. Don't start telling me that it is not safe for end organ perfusion, yada yada yada.

 

[IveGotTwins]

Again, I misspoke when I said ET of 1.4. What I meant was MAC of 1.4. ET was 7+.

 

[leaverus]

If there is one thing that drives me nuts, it is the resident not following my directions. If we are doing controlled hypotension and I tell you to keep the BP systolic at 80, do as I say. Don't start telling me that it is not safe for end organ perfusion, yada yada yada.

I certainly hope I'm misunderstanding your intent here. I thought you academic guys were supposed to TEACH? If you're using a certain scenario - induced hypotension - as a teaching point and explaining why it's used, why you want the BP at a certain level, etc. and actually having a discussion with your trainee, that's one thing. But if you mean that you give them orders, end of story, then what good are you?

I would like to think ivegottwins' attending was using this as a teaching/thinking opportunity as well, but if he's telling 'em stuff like addictive potential of intraop opioids, then he's likely not bright enough for that to have been his intent.

 

[Somnus Tuto]

22 yo male ASA 1 coming to OR for lap bilateral inguinal hernia repair. 2 mg versed in pre-op, roll back, hooked to monitors, induced with 60 mg 1% lidocaine, 100 mg propofol, 100 mcg fentanyl, 5 mg vec. Easy airway, 8.0 tube in. As my staff is walking out he says no more muscle relaxants or narcotics just keep him deep. So I get the ET des% to 1.4. BP and HR are normal.

20 min later the surgeons are inserting the ports and the patient gets tachy (120s) and hypertensive (MAP 100s) and begins bucking the vent. So against the instructions of my staff I give 100 mcg of fentanyl and 5 mg of vec. This seems completely reasonable to me given the situation (which isn't even a situation). Staff returns 40 mins later to check in and sees that I gave more vec and fentanyl. He is angry. I tell him what happened and he says I should have given a beta blocker and further deepen with gas. I ask why and he says that narcotics are addictive.

I think my actions were completely normal, logical and defensible and his plan is crazy.

I am a CA1 so forgive me if I'm missing something obvious.

😱

1. this is ultimately his (your attending's) case and so while you would do things differently if you were in charge...you're not. He bears ultimate responsibility for the case and gets to bill for it.
2. As far as you're concerned, particularly as a CA-1 resident, the attending knows best. Debate is mostly encouraged prior to or after a case or during PBLD/case discussions in conference.

Prop then deepen would have been just fine. The way I see it, you treated the symptoms, not the problem.
If the problem was primarily pain, bucking might not have been an issue.
the problem was insufficient depth, which could have been properly addressed with more Des and some prop (fentanyl would help but not without your attending's go ahead)
Prop is efficient at blunting aw reflexes

 

[Somnus Tuto]

that being said, MAC 1.4 is quite high.
makes you wonder what this guy does recreationally

reminds me of a case I did where I kept pumelling this patient with narcs to no avail
she stayed deep but tachy and hypertensive throughout the case, awoke in 2 secs after we turned off sevo (slight exaggeration here) but was screaming in pain all the way to Post-Anesthesia unit
and for two hours after

spent two hours trying to treat this pt's pain but even after 1g (yes, that's 1000mcg fentanyl), she was still screaming and cussing.

I took a pretty detailed preop history so I couldn't figure out what the heck was going out
about 2.5 hours into our failed attempts to treat her pain, she reveals:
"I'm on F$%king Suboxone, you *****s, fentanyl isn't going to do s&%t for me"

shoulda known.
2am deltoid abscess drainage...of course

well, you shoulda said so earlier, lady...

 

[Idiopathic]

some lessons here. your attending shouldnt have to come back in the room to find out that you determined to change clinical course, right or wrong. to you its innocuous enough, but when the attendings major influence in this case (i.e. the plan) is overridden, they should get to know about it when it happens. there are multiple ways to handle an in-room crisis, which this was (of sorts), so i am not here to play monday morning QB. you did what you thought was best, if someone at that time thinks there is a flaw in your knowledge base or management plan then they should work to educate you. this is part of learning.

the cardinal sin here is not telling him when it happened. i think most of us around here are reasonable people and would have been upset at that, but also most of us probably did this at one time in our career and again, this is part of learning.

 

[Idiopathic]

I certainly hope I'm misunderstanding your intent here. I thought you academic guys were supposed to TEACH? If you're using a certain scenario - induced hypotension - as a teaching point and explaining why it's used, why you want the BP at a certain level, etc. and actually having a discussion with your trainee, that's one thing. But if you mean that you give them orders, end of story, then what good are you?

I would like to think ivegottwins' attending was using this as a teaching/thinking opportunity as well, but if he's telling 'em stuff like addictive potential of intraop opioids, then he's likely not bright enough for that to have been his intent.

teaching happens in the context of the plan. if i have a plan that includes certain things, the resident should expect to be taught those reasons, and may offer an alternative perspective, with the understanding that my plan is THE plan. it has to be that way.

 

[Idiopathic]

Again, I misspoke when I said ET of 1.4. What I meant was MAC of 1.4. ET was 7+.

honestly this probably close to 1 MAC in this age group. 1.4 MAC of des is probably closer to 9.5-10% you were closer to 1 MAC, where, as we know, its a coin flip as far as response to surgical stimulus goes..

 

[jwk]

that being said, MAC 1.4 is quite high.

It is? Why?

The recent studies comparing BIS vs ET agent in comparing "awareness" used a MAC of 1.4 as I recall.

Remember that 1 MAC is just an ED50, and 1.4 MAC is an ED95. Granted, the various drugs we use alter that significantly, but in the end, everything we give is titrated to effect. Some need no narcotics/NMB's, some need a lot.

 

[Somnus Tuto]

It is? Why?

The recent studies comparing BIS vs ET agent in comparing "awareness" used a MAC of 1.4 as I recall.

Remember that 1 MAC is just an ED50, and 1.4 MAC is an ED95. Granted, the various drugs we use alter that significantly, but in the end, everything we give is titrated to effect. Some need no narcotics/NMB's, some need a lot.

MAC 1 is the MAC at which 50% of patients will not respond to surgical stimulus
MAC 1.3 is the MAC at which 99.7% of patients will not respond...3 SDs from the mean
this is high, using your standard deviation bell curve

MAC 1.4, then should, at least theoretically, capture all comers (all other factors being equal)

ED measures are slightly different

 

[Somnus Tuto]

It is? Why?

The recent studies comparing BIS vs ET agent in comparing "awareness" used a MAC of 1.4 as I recall.

Remember that 1 MAC is just an ED50, and 1.4 MAC is an ED95. Granted, the various drugs we use alter that significantly, but in the end, everything we give is titrated to effect. Some need no narcotics/NMB's, some need a lot.

Furthermore, in the main study to which you are referring from Wash U in St Louis, MAC ranges from 0.7 to 1.3 were used with audible alarms from MAC <0.7 or >1.3

 

[pgg]

we're 3.5 hrs into the case not even halfway done.

This is the real crime here. Did they have a CA1 doing the surgery too?


Just keep your attendings in the loop when you do something outside their plans.

 

[IveGotTwins]

Two board certified general surgeons who are both completing MIS fellowships.

So lesson 1: Don't go directly against an attending's wishes. In this particular situation I should have given propofol and called rather than giving the meds. Understood. I don't make it a habit of directly disobeying. This was literally the first time I have done it actually.

I disagree with propofol treating the problem. I think the problem was pain from incision and the temporary effect of propofol would have not lasted long enough even if the case was short. I think the starting doses of fentanyl and vec were too small or the time between induction and incision was too long.

Regardless of the length of case or the risk of delayed wake up, does anyone think that limiting intra-op narcotics based only on "they are addicting" is a normal/rational/sound train of thought? This was the only reason I was given.

 

[urge]

Regardless of the length of case or the risk of delayed wake up, does anyone think that limiting intra-op narcotics based only on "they are addicting" is a normal/rational/sound train of thought? This was the only reason I was given.

I wouldn't say addicting is the proper word. Hyperalgesia is probably what your attending was concerned. Why don't you read on that?

 

[Idiopathic]

Two board certified general surgeons who are both completing MIS fellowships.

So lesson 1: Don't go directly against an attending's wishes. In this particular situation I should have given propofol and called rather than giving the meds. Understood. I don't make it a habit of directly disobeying. This was literally the first time I have done it actually.

my lesson is actually to do what the patient needs when they need it, but let the attending know when it happens. i think propofol is always the best choice when the patient needs to be put down RIGHT THEN. vec takes 3 minutes, minimum, and doesnt get to the root of the problem, you wont be able to get someone deeper with volatile when you cant ventilate them, and narcotics probably wont give you the bang for your buck since they provide very little in the way of sedation. i always recommend my residents keep the leftover propofol capped and out in case of this very situation, whether its near wakeup or incision, etc.

what you did wasnt wrong, but many roads lead to Rome.

 

[Bertelman]

I disagree with propofol treating the problem. I think the problem was pain from incision and the temporary effect of propofol would have not lasted long enough even if the case was short. I think the starting doses of fentanyl and vec were too small or the time between induction and incision was too long.

Was it truly the incision, or was it the trocar introduction? Or, more likely, insufflation?

You'll find that patients have one of two responses with abd insufflation: pressure tanks, or pressure shoots up. You got the latter.

As for this young man's recreational habits, it is hard for me to believe he can be DL'd and easily intubated with 100 mcg, 100 mg and a sad excuse of a vec dose, yet somehow ET des 7.5% is insufficient to maintain a case.

You likely would have been fine with another 100 mg prop and maybe 50 fent.

 

[amyl]

you will see, propofol works for everything but hypotension. bucking. pruritis, nausea. disorientation. emergence delirium. shivering.

 

[IlDestriero]

The fastest way to get your ass handed to you is to deliberately disregard the stated plan of the attending physician, questionable or not. And then not to call and come clean? Wow. Seriously, don't do that again without calling first. There was no reason to push either of those drugs in that situation, and bucking isn't a plan changing emergency. Stop the stimulation, 1mg/kg propofol, manual vent, 14% des, wait a minute or two, and back to it. That's how residents get some probation time. More importantly when the recommendation letters go out in another 18 months or so they lack the usual expected hyperbole.
If you have a problem with the plan, the time to discuss it is at the time that it is formulated.
And that's an obscenely long time for a hernia repair.

 

[hoyden]

if i were in charge of the induction doses i would have given 8 of vec, 200 of fentanyl and 150 of propofol.

the surgeons could not get all the ports in bc he was bucking/coughing/responding so much. In my mind the surgery was not be facilitated under those conditions so i gave the relaxant and narcotic. At the time he was already at 1.4 mac of des which is pretty deep, right?

I agree with the sentiment regarding intra-op narcotics and addiction.

wow

 

[DannyB]

wow

What's wrong with that?

 

[Idiopathic]

What's wrong with that?

agreed

 

[hoyden]

What's wrong with that?

Too much fentanyl. And forgetting a better drug for the induction instead.


One more thing - learn your ventilator. It has modes which will help you titrate the narcs and avoid bucking at the same time.

 

[leaverus]

Too much fentanyl. And forgetting a better drug for the induction instead.


One more thing - learn your ventilator. It has modes which will help you titrate the narcs and avoid bucking at the same time.

Cmon, seriously - too much? How so? It's a young, healthy 22-year old guy undergoing an apparently 3.5+hr surgery. The only thing we know for certain is that patient was light for incision/trocar - perhaps 200mcg would have been the perfect amount? If you're gonna take that route, please cite me RCT findings that show specific induction doses affect outcomes.

 

[hoyden]

Cmon, seriously - too much? How so? It's a young, healthy 22-year old guy undergoing an apparently 3.5+hr surgery. The only thing we know for certain is that patient was light for incision/trocar - perhaps 200mcg would have been the perfect amount? If you're gonna take that route, please cite me RCT findings that show specific induction doses affect outcomes.

He is talking about induction. not intraoperstive narcotics. You do not need fentanyl for induction in that amount unless you are afraid of rupturing the intracranial aneurysm, which is not an issue in this case. Blunting the aw reflexes is well done by lidocaine and propofol and I would sVe fentanyl for exactly before incision , however the timing might be a problem for a fresh CA1.

If you are deep enough you do not need to overnarcotize. If you start with 200 for induction you will get too much at the very end even with 3 hour hernia surgery. It is not a nitrous-narcotics technique anymore ( nothing wrong with it ))))

I am not even touching the issue of subordination at all, though instinctively I trust the attending's judgement more than fresh resident's.

 

[DannyB]

Too much fentanyl. And forgetting a better drug for the induction instead.


One more thing - learn your ventilator. It has modes which will help you titrate the narcs and avoid bucking at the same time.

3-5 mcg/kg for induction

you may like lidocaine better but certainly not worth a "wow"

 

[IveGotTwins]

Alright. I'll agree that 200 mcg of fentanyl is generous for simply blunting airway reflexes for intubation.

I've already apologized profusely for insubordination. We have no hard feelings that I can appreciate.

My issue was that I wasn't supposed to give any additional narcs for multiple abdominal incisions. This is the root of my question. Does anyone think that 100 mcg of fentanyl is enough for blunting of airway reflexes and for pain control for trocar insertion/insufflation? Perhaps if they were simultaneous. In this case there was 15 minutes or so between intubation and incision. My opinion then and now was that it was insufficient. He was at 1.4 MAC of des. Propofol plus a phone clearly is the consensus answer here.

By the way, when I asked my attending after the case (after I apologized) what he would have done differently he said propofol bolus, increase gas (past 1.4 MAC) and control HR/HTN with metoprolol. All to avoid giving more than 100 mcg of fentanyl. Anyone have opinions about that?

 

[hoyden]

3-5 mcg/kg for induction

you may like lidocaine better but certainly not worth a "wow"

it is worth a wow because it is way too much for induction - it is not narcotic induction only

 

[Idiopathic]

Alright. I'll agree that 200 mcg of fentanyl is generous for simply blunting airway reflexes for intubation.

you will? what is the optimal amount?

My issue was that I wasn't supposed to give any additional narcs for multiple abdominal incisions. This is the root of my question. Does anyone think that 100 mcg of fentanyl is enough for blunting of airway reflexes and for pain control for trocar insertion/insufflation? Perhaps if they were simultaneous. In this case there was 15 minutes or so between intubation and incision. My opinion then and now was that it was insufficient. He was at 1.4 MAC of des. Propofol plus a phone clearly is the consensus answer here.

By the way, when I asked my attending after the case (after I apologized) what he would have done differently he said propofol bolus, increase gas (past 1.4 MAC) and control HR/HTN with metoprolol. All to avoid giving more than 100 mcg of fentanyl. Anyone have opinions about that?

you had a patient get light on incision, happens every day to experienced providers. ill reiterate that i dont think your gas was at "1.4 MAC", i believe your fentanyl effect was close to washed out, and that you werent chemically paralyzed, hence - bucking and hemodynamic changes with incision is probably a coin flip. his way is not wrong. there are different ways to deliver anesthesia. thats probably the best way to say it.

 

[hoyden]

Alright. I'll agree that 200 mcg of fentanyl is generous for simply blunting airway reflexes for intubation.

I've already apologized profusely for insubordination. We have no hard feelings that I can appreciate.

My issue was that I wasn't supposed to give any additional narcs for multiple abdominal incisions. This is the root of my question. Does anyone think that 100 mcg of fentanyl is enough for blunting of airway reflexes and for pain control for trocar insertion/insufflation? Perhaps if they were simultaneous. In this case there was 15 minutes or so between intubation and incision. My opinion then and now was that it was insufficient. He was at 1.4 MAC of des. Propofol plus a phone clearly is the consensus answer here.

By the way, when I asked my attending after the case (after I apologized) what he would have done differently he said propofol bolus, increase gas (past 1.4 MAC) and control HR/HTN with metoprolol. All to avoid giving more than 100 mcg of fentanyl. Anyone have opinions about that?

You did the right thing apologizing.

The answer is - it depends. If they are deep enough you might not need more at all.

I tend to give less, because of the turnover times and your attending was thinking about the same. And propofol is your best friend. If you fear the BP drop, you can always give phenylephrine.
Learn the ventilator - it will help you give much less narcotics, than you expect solely by pharmacodynamics.

 

[IveGotTwins]

Some have stated that they believe 200 mcg is too much simply for intubation. That's fine, different strokes I suppose. I've read and been told that 3-5 per kg is a standard induction dose. So based on that alone 225 mcg is a minimum. I'm agreeing simply to move past the point of what dose was sufficient for only intubation/blunting airway reflexes.

Would anyone abandon narcotics to treat pain at incision and treat the resulting HTN/HR with a beta blocker when the total amount of narcotic given is only 100 mcg of fentanyl? And if you would is your reason because narcotics are addictive?

 

[periopdoc]

In opiate naive patients I routinely do lap choles and hernia with no more than 100 mcg of fent. Sometimes you need a little something extra if the gall bladder is significantly inflamed and/ or the surgeon does extensive cautery of the liver. Of course my surgeons don't take 3 hours to do these surgeries.
- pod

 

[hoyden]

In opiate naive patients I routinely do lap choles and hernia with no more than 100 mcg of fent. Sometimes you need a little something extra if the gall bladder is significantly inflamed and/ or the surgeon does extensive cautery of the liver. Of course my surgeons don't take 3 hours to do these surgeries.
- pod

I agree with the dose( 100 mcg) for lap chole/hernias in private practice
But even for 3 hour hernia repair one does not need more than150 mcg of the fentanyl for the WHOLE operation at all - most of it will be embroidering the skin by the students at the end, which is not stimulatory at all

 

[hoyden]

Some have stated that they believe 200 mcg is too much simply for intubation. That's fine, different strokes I suppose. I've read and been told that 3-5 per kg is a standard induction dose. So based on that alone 225 mcg is a minimum. I'm agreeing simply to move past the point of what dose was sufficient for only intubation/blunting airway reflexes.

Would anyone abandon narcotics to treat pain at incision and treat the resulting HTN/HR with a beta blocker when the total amount of narcotic given is only 100 mcg of fentanyl? And if you would is your reason because narcotics are addictive?

I think you are running the same circle again and again and again. Nobody is talking about the nil narcotics for incision, but 200 mcg is way too much for incision as well. Make them deeper and you will see wonders.

 

[periopdoc]

Would anyone abandon narcotics to treat pain at incision and treat the resulting HTN/HR with a beta blocker when the total amount of narcotic given is only 100 mcg of fentanyl? And if you would is your reason because narcotics are addictive?

Patients do not experience pain under anesthesia, and major surgeries can be successfully carried out with no opiate given until the very end of the case. Beta blockers are helpful in this scenario. As long as adequate opiate is given at the time of awakening, the patient will not experience any difference in pain. (This is may not be entirely true if you believe that pre-emptive analgesia decreases the risk of long term chronic pain, but fentanyl would not be the drug of choice for this). What opiates will give you is synergy with your anesthetic agents resulting in blunting of airway reflexes and reducing the sympathetic response to stimuli which gives you a smoother anesthetic.

I agree that narcotics are addictive (to the anesthesiologist giving them to the patient). Because it is so easy to do a smooth anesthesia with opiate (the more the smoother) it is easy to get too reliant on them instead of trying to dose them optimally for pain control on awakening while ignoring other methods of making your anesthetic run smoothly. The ultimate result, especially as a new trainee, is that you will become reliant on them to provide a smooth anesthetic because it is the only tool you have in your toolbox. You will also have more folks who end up excessively narcotized in PACU.

I am not taking your side or his. The way that you present the interaction, he sounds like a bit of a dick who may not be the most confident anesthesiologist in the world. But, there are two sides to every story. Perhaps there is some history we don't know about. Then again, perhaps he may have just been trying to teach you to think outside the box and he was disappointed that you couldn't/ didn't.

- pod

 

[rsgillmd]

Plenty of great points posted already. I just thought I'd chime in to say I don't think 200 mcg is necessarily too much either. Maybe I missed it, but we don't know this guy's weight.

I tend to give 2-3 mcg/kg with induction (one of my attendings was a believer in the 3-5 mcg/kg dosing), and any additional as needed. I haven't had any major problems with it. A 70 kg male, no other concerns, would probably get 150 mcg Fentanyl from me. I've given that dose plenty of times to patients having lap choles and lap hernias and woken them up 45-60 minutes later without significant difficulty.

For the CA-1: one of the best pieces of advice I got from an attending was to get used to thinking in terms of weight basis early on. Makes a lot of things easier. Everyone eventually develops their own style. But as already stated by many others, don't go against your attending's plan intraop without notifying him. Taking a patient off the vent works very well. As amyl said, propofol is a wonder drug.

Also you don't necessarily need non-depolarizers for laparoscopic surgery. There are many ways to skin a cat. We have a shortage of neostigmine in my hospital. Partly out of conservation efforts (but not really, because it is a multi-dose vial), and mainly out of a desire to do something different, we did two lap excision of ruptured ectopics last night without any non-depolarizers. The only paralytic we used was sux for intubation. I wasn't there for the extubation of the first case (busy doing other things so I left the CRNA alone), but I can vouch that there was no delay in extubation for the second case.

 

[gasp]

22 yo male ASA 1 coming to OR for lap bilateral inguinal hernia repair. 2 mg versed in pre-op, roll back, hooked to monitors, induced with 60 mg 1% lidocaine, 100 mg propofol, 100 mcg fentanyl, 5 mg vec. Easy airway, 8.0 tube in. As my staff is walking out he says no more muscle relaxants or narcotics just keep him deep. So I get the ET des% to 1.4. BP and HR are normal.

20 min later the surgeons are inserting the ports and the patient gets tachy (120s) and hypertensive (MAP 100s) and begins bucking the vent. So against the instructions of my staff I give 100 mcg of fentanyl and 5 mg of vec. This seems completely reasonable to me given the situation (which isn't even a situation). Staff returns 40 mins later to check in and sees that I gave more vec and fentanyl. He is angry. I tell him what happened and he says I should have given a beta blocker and further deepen with gas. I ask why and he says that narcotics are addictive.

I think my actions were completely normal, logical and defensible and his plan is crazy.

I am a CA1 so forgive me if I'm missing something obvious.

Ok, your a CA-1 and I remember those days cause it was only 2 years ago. I remember lots of times when the staff told me the same thing and it would make me angry since I thought the patient obviously needed more narcotics/paralytic. You will one day come to realize that it is your staff's right to tell you these things because it is ultimately his/her licence on the line so always listen to them. If he told you not to give anything else, then just page/call him when this happened and let him guide you on how to fix it. He may very well do exactly as you did but that is his prerogative. Now let me give you some pointers.

1. Yes, >6% Des should be enough to prevent all that from happening when incision was made but you will see that everyone is different and people always surprise you. So what you could have done and what I would have done is use Propofol. It is your best friend so always have some handy and just push some depending on how much he took to be induced (usually about 50mcg right before cut does the trick to prevent whatever craziness happened in your case).

2. After you have given the propofol and the pt is again calm and doing fine, now you have some time to think about what you want to do next. Just paralyzing the pt some more only makes them not move but they will still feel pain and you will see that with catecholamine release leading to hypertention/tachycardia. Fentanyl would have been my choice after the propofol but next time call your staff and let them know before giving the fentanyl. Also, 50mcg at a time is better than 100mcg at a time.

3. Giving Vec when the pt starts bucking/moving is really not efficient. First of all, it takes a good 90 seconds to start working so it doesn't help you at that moment that you need it. I would just have checked twitches after giving the propofol and fentanyl (in that order) and based my vec on twitches.

**Propofol is always your friend and staff NEVER mind that you gave that to prevent chaos (unless you overdo it)**

 

[dhb]

Patients do not experience pain under anesthesia, and major surgeries can be successfully carried out with no opiate given until the very end of the case. Beta blockers are helpful in this scenario. As long as adequate opiate is given at the time of awakening, the patient will not experience any difference in pain. (This is may not be entirely true if you believe that pre-emptive analgesia decreases the risk of long term chronic pain, but fentanyl would not be the drug of choice for this). What opiates will give you is synergy with your anesthetic agents resulting in blunting of airway reflexes and reducing the sympathetic response to stimuli which gives you a smoother anesthetic.

I agree that narcotics are addictive (to the anesthesiologist giving them to the patient). Because it is so easy to do a smooth anesthesia with opiate (the more the smoother) it is easy to get too reliant on them instead of trying to dose them optimally for pain control on awakening while ignoring other methods of making your anesthetic run smoothly. The ultimate result, especially as a new trainee, is that you will become reliant on them to provide a smooth anesthetic because it is the only tool you have in your toolbox. You will also have more folks who end up excessively narcotized in PACU.

I am not taking your side or his. The way that you present the interaction, he sounds like a bit of a dick who may not be the most confident anesthesiologist in the world. But, there are two sides to every story. Perhaps there is some history we don't know about. Then again, perhaps he may have just been trying to teach you to think outside the box and he was disappointed that you couldn't/ didn't.

- pod

 

[pgg]

Esmolol is a pretty good drug for "blunting the sympathetic effect of laryngoscopy" ... better than lidocaine and fentanyl, anyway.

 

[Oggg]

In residency, many of my attendings advocated 5-7mcg/kg because sometimes you still get a brief HTN tachy with 3-5 during DL. I use so much less in PP.

Btw it sounds like you were still light. I agree with gas and PPF. I think beta blockers are lame if they aren't sick. And a heavy drinking, norco-gobbling, drug smoking 22yo football player is going to need fresh paralysis right before incision. What did your twitch monitor show?

 

[hoyden]

Plenty of great points posted already. I just thought I'd chime in to say I don't think 200 mcg is necessarily too much either. Maybe I missed it, but we don't know this guy's weight.

looking at the other drug dosing it should be ~ 80 kg

Also you don't necessarily need non-depolarizers for laparoscopic surgery. There are many ways to skin a cat. We have a shortage of neostigmine in my hospital. Partly out of conservation efforts (but not really, because it is a multi-dose vial), and mainly out of a desire to do something different, we did two lap excision of ruptured ectopics last night without any non-depolarizers. The only paralytic we used was sux for intubation. I wasn't there for the extubation of the first case (busy doing other things so I left the CRNA alone), but I can vouch that there was no delay in extubation for the second case.

I tend to not use non-depolarizer at all, if I have to it is cisatracurium ( not available everywhere). You can do lap chole without paralyzing them even for intubation ( have had several cases with MG). teaching point is here - there are many ways to provide anesthesia and it is a part of the fun to learn to do it in different combinations.

 

[IveGotTwins]

Pt was 75 kg. He didn't appear to be a recreational drug user but looks can be deceiving.