Propofol dosing for TIVA

[deleted875186]

I’m curious how low people go on their propofol dosing for TIVA, especially in cases where you can’t put a BIS on and your not paralyzed. Lowest Ive ever gone with a continuous sufenta infusion was 90 mcg in an older guy that was somewhat sicker, but the guy did move once towards the end of the surgery.

Also, where do people usually start their propofol dosing for TIVAs?

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[CUBR]

Depends what else you got on board and how long the shenanigan has been going on. Some more academic residents have done sufenta, dex, ketamine and prop. After an hour they're on 50mcg of prop.

 

[coffeebythelake]

Patients will respond to nociception (and hence move) if u are doing a straight propofol anesthetic. 90 mcg/kg/min is probably enough to ensure lack of awareness for a sickly older patient

 

[coffeebythelake]

I would do 50 mcg/kg/min minimum for propofol, along with other adjuncts

 

[deleted697535]

Why not just one one of the tci algorithms on your phone?

 

[deleted59964]

Why not just one one of the tci algorithms on your phone?

you guys don’t have syringe pumps with tci built in ? we just program the pump and set a target concentration in plasma or at the effect site

 

[parcus]

you guys don’t have syringe pumps with tci built in ? we just program the pump and set a target concentration in plasma or at the effect site

I keep hearing that in the US they can't do that for some legal reason (but they can for example program tci algorithms into their infusion pumps), will find out the veracity of this in a couple of months. Anyways, I wonder if there is better data today to make a dose adjustment algorithm for obese/elderly/frail pts... Or maybe BIS would be best for those?

 

[deleted162650]

you guys don’t have syringe pumps with tci built in ?

Nope.

 

[parcus]

Truth be told though, that TCI concentration probably becomes so inaccurate when you start mixing propofol with other stuff that programing your own infusion is more "honest".

 

[deleted697535]

you guys don’t have syringe pumps with tci built in ? we just program the pump and set a target concentration in plasma or at the effect site

I used to in Europe.
I thought no one in North America used them?

 

[deleted59964]

Nope.

That’s surprising ... it’s not like healthcare in the US is short of a dollar.

 

[deleted162650]

That’s surprising ... it’s not like healthcare in the US is short of a dollar.

Us lowly anesthesiologists never get the cool expensive toys. Instead we just have to rely on clinical experience and skill.

 

[deleted59964]

Truth be told though, that TCI concentration probably becomes so inaccurate when you start mixing propofol with other stuff that programing your own infusion is more "honest".

It doesn’t become inaccurate ... it’s a pharmacokinetic model that aims to predict propofol concentration at the target site ... and adjusts rate to maintain it at a steady state given redistribution to other compartments... the concentration of propofol is unaffected by whether you give opioid.

Sure the depth of Anaesthesia will be different if you add other stuff.

Saying it’s inaccurate if you add other stuff is like saying end tidal control of volatile gets inaccurate if you add other stuff (opioid etc). It doesn’t ... it only tells you the end tidal.

Don’t get me wrong ... TCI is just a tool, and has limitations it’ll happily tell you the predicted effect site concentration even if your propofol is disconnected and pooling on the floor and your patient is awake.

 

[epidural man]

Why not just one one of the tci algorithms on your phone?

Tell me more!

 

[epidural man]

I’m curious how low people go on their propofol dosing for TIVA, especially in cases where you can’t put a BIS on and your not paralyzed. Lowest Ive ever gone with a continuous sufenta infusion was 90 mcg in an older guy that was somewhat sicker, but the guy did move once towards the end of the surgery.

Also, where do people usually start their propofol dosing for TIVAs?

I have started doing TIVA's on almost every case I do. If I take over a case, I turn off the gas and turn on the propofol.

As a senior resident told me long ago..."people on propofol wake up happy, hungry, and horny."

People feel crappy on gas...people feel great on propofol. Why wouldn't I not want that for my patients.

Did you know propofol tends to erase sleep deficit, and gas adds to the deficit? Why the hell wouldn't I want that for all my patients.

My dose -

Mix 2000mcg Alfentanil in 100ml of propofol.

Start at 180mcg/kg/min - Titrate down but usually not much lower than 100 unless getting really close to the end.

Often I will use ketamine.

Patients move on any dose.

 

[Ronin786]

The Roberts Method is a pretty decent method. The concentrations are a little wonky since they're in mg/kg/hour. I'm used to mcg/kg/min

"A 1.5 mg/kg loading dose is followed by an infusion of 10 mg/kg/hour that is reduced to rates of 8 and 6 mg/kg/hr at ten minute intervals. An overall mean blood propofol concentration of 3.67 μg/ml was achieved within 2 minutes and maintained stable for the subsequent 80–90 minutes of surgery."

https://onlinelibrary.wiley.com/doi/epdf/10.1111/j.1365-2044.1988.tb09061.x

For those interested, that correlates to 167mcg/kg/min then 133 then 100.

 

[DrOwnage]

If I told my attending I wanted to add 2000 mcg of alfentanil to my 100ml vial of prop and run it as an infusion at 180 they would probably shoot me in the forehead with a 50 cal.

 

[CUBR]

There was just recently some article looking at the separation of drugs in an infusion syringe and the concentrations vary a bit, so I'm not a fan of mixing into a syringe. I've never had luck even with the lido and propofol trick. Our spine guys are routinely doing 300-400 min cases, we turn off everything for the last hour or so.

 

[deleted697535]

I have started doing TIVA's on almost every case I do. If I take over a case, I turn off the gas and turn on the propofol.

As a senior resident told me long ago..."people on propofol wake up happy, hungry, and horny."

People feel crappy on gas...people feel great on propofol. Why wouldn't I not want that for my patients.

Did you know propofol tends to erase sleep deficit, and gas adds to the deficit? Why the hell wouldn't I want that for all my patients.

My dose -

Mix 2000mcg Alfentanil in 100ml of propofol.

Start at 180mcg/kg/min - Titrate down but usually not much lower than 100 unless getting really close to the end.

Often I will use ketamine.

Patients move on any dose.

'Feel crappy'? What do you mean? How.many other variables are there to control for before you decide it's the gas?

Gas is easy, has it's own built in monitoring and recording method.

And what about awareness? With your method you've not given a bolus

There's flaws with everything, sounds like your way works well for you though...

There are many apps available for phones that run the various March Schneider and minto tci algorithms. You just select one and enter the details and leave your phone close to the pump. It beeps when you need to make a change

 

[anbuitachi]

I'm sure you can go lower than 90...
I do 100 mcg/kg/min on young healthy patients + opioid. Older sicker dood, just tirate to effect. Put on a bis, it's probably lower than you expect

 

[projectpat]

I have started doing TIVA's on almost every case I do. If I take over a case, I turn off the gas and turn on the propofol.

As a senior resident told me long ago..."people on propofol wake up happy, hungry, and horny."

People feel crappy on gas...people feel great on propofol. Why wouldn't I not want that for my patients.

Did you know propofol tends to erase sleep deficit, and gas adds to the deficit? Why the hell wouldn't I want that for all my patients.

My dose -

Mix 2000mcg Alfentanil in 100ml of propofol.

Start at 180mcg/kg/min - Titrate down but usually not much lower than 100 unless getting really close to the end.

Often I will use ketamine.

Patients move on any dose.

Agreed. TIVA > gas. TIVA is king here. What would you personally want - TIVA or gas?

To OP, if using only prop, then typically not lower than 100, unless old and sick. But it's almost never just prop. Different story with other adjuncts involved. i.e. Large initial fentanyl load and prop requirement will be reduced. With remifentanil added, the prop requirement is further reduced, 75 mcg prop, maybe down to 60. With remi/nitrous, the prop is almost homeopathic at 25-35 mcg (in this techniqiue, prop is not the primary anesthetic). We do an interesting ERAS, minimal narcotic TIVA here that includes prop, precedex, and ketamine; patients are sleepier for emergence and in PACU but great post op analgesia, minimal PONV and according to surgical colleagues, quicker discharges. However I don't see this triple infusion ERAS thing flying in private practice due to $$$.

*mcg/kg/min for above values

 

[ambiturner]

I would occasionally run prop at 50 on older people having hip replacements under spinal if they didn't mind remembering things and just wanted to sleep. They would usually open their eyes when the saw started and occasionally remember the sound. This would suggest 50 is probably too low for healthy old people. Sick ones maybe you'd be ok.

 

[epidural man]

'Feel crappy'? What do you mean? How.many other variables are there to control for before you decide it's the gas?

Good questions...and I don't really have a great answer.

I started thinking about this as a resident though - after doing anesthesia for one of my attending who had a lumbar fusion. I did a TIVA for him (per their request). He later said that he felt really great the first 24 hours after surgery, but after that, felt horrible for a few days. He thought that was probably from the effects of propofol wearing off after the first day.

I thought that was a really interesting thought - and so have been paying attention ever since. If you you start to listen to patients in the PACU, you will start to see that people don't like Gas. Let me back up. I teach my residents NEVER to ask in the PACU - "Are you in Pain?" I tell them to ask an open ended question....Is something bothering you? (much better question...and IF they are in pain, they will arrive at this conclusion).

Anyway, when I ask this, I often hear patients say..."YES, I CAN'T WAKE UP". That was always curious to me. And you can say - "Just go to sleep"...but they can't. They are left in this state of feeling groggy with severe brain fog...want to wake up...but can't because they are getting a constant infusion of low dose gas coming out of the fat. This elution of gas from the fat - I think happens in a low dose over several hours. To demonstrate this, when taking over a case and starting the TIVA, i'll have the resident mark the time when the gas is turned off to when it is completely unreadable by the machine. It always takes 90 minutes or more.

Comparing that to propofol, people don't have that same experience at all. It looks different, and looks like it feels completely different. I have never heard someone say they were bothered by the sleepiness on propofol.

I have also tried to read a lot about the EEG and sleep effects of GAS. Interesting, most are taught that anesthesia messes with sleep cycles for days after exposure. But when you get in the weeds, that is mostly referring to volatile exposure. The data about propofol and exposure is completely the opposite (but granted...there is very little data).

So long answer...but all i can say is start paying attention and I think you will also start to agree with me that there seems to be huge differences in how people feel hours after their anesthetic. I don't know if you call your patients the next day, but it is really eye-opening getting some of that feedback.

What about recall? Great question...TIVA is on the risk factor list for sure. That is why I almost always use midazolam (great antiemetic), and 0.5mg/kg of ketamine on induction and some boluses throughout. I use a BIS a lot. I don't keep paralyzed if I don't have to (they are supposed to move first, right?)

I started doing TIVA after I had to go to an exercise with the Marines. We set up our field tents and to do anesthesia, we had a syringe pump with lots of propofol and a portable IMPAX ventilator. At the time, I was thinking....I hope I don't have to do anesthesia for real like this...beause I realized how uncomfortable I was doing TIVA due to a complete lack of experience. All anesthesiologists need to feel 100% comfortable doing TIVA...so that was an ey opener for me and I thought, "I'm going to get super comfortable doing TIVA" and now it is mostly all I do. I wanted to be proficient, but also wanted residents to know also. I started on the journey with them...telling them I had no idea how to "come in for landing" on TIVA's but I was going to figure it out.

 

[epidural man]

And yes...I am completely aware that BIS doesn't protect me against awareness.

I am not using it as an awareness prevention tool.

I am using it as an anesthetic depth monitor. It absolutely works most of the time for measuring relative anesthetic depth. I have yet to see someone who doesn't get a drop in BIS with a bolus of propofol, or increase dose of propofol. I have yet to see someone who has an increasing dose of anesthetic who didn't have a corresponding lowering of the BIS value. It is an excellent trend monitor for anesthetic depth.

 

[deleted875186]

BIS does not take into account the effects of opioids. Dex and ketamine, and nitrous I think, will increase the BIS value. So if I’m using them I usually think putting a BIS on is just more dangerous for me, since I’ll be inclined to give more prop to treat the BIS.

And yes...I am completely aware that BIS doesn't protect me against awareness.

I am not using it as an awareness prevention tool.

I am using it as an anesthetic depth monitor. It absolutely works most of the time for measuring relative anesthetic depth. I have yet to see someone who doesn't get a drop in BIS with a bolus of propofol, or increase dose of propofol. I have yet to see someone who has an increasing dose of anesthetic who didn't have a corresponding lowering of the BIS value. It is an excellent trend monitor for anesthetic depth.

 

[deleted162650]

So one of my former partners had a few shoulder surgeries. One with Sevo and one with prop based TIVA. He reported feeling way more awake after sevo. It was the prop that left him groggy for hours. Prop gtts linger - for a long time- sometimes.

And 90 mins to get a reading of 0.00 EtAgent????

I routinely extubate people with the monitor reading 0.00 and the gas has been off waaaayy less than 90mins. What the hell are you guys doing over there??

 

[dhb]

I feel like patient variabilty is key: some people are very awake very fast after a gas based GA and some not.
I had a GA; 99% sure it was sevo and was sleepy for a couple of hours (don't remember PACU) but had no pb with discharge late in the afternoon and didn't have sleeping problems after.

 

[epidural man]

So one of my former partners had a few shoulder surgeries. One with Sevo and one with prop based TIVA. He reported feeling way more awake after sevo. It was the prop that left him groggy for hours. Prop gtts linger - for a long time- sometimes.

And 90 mins to get a reading of 0.00 EtAgent????

I routinely extubate people with the monitor reading 0.00 and the gas has been off waaaayy less than 90mins. What the hell are you guys doing over there??

Is he fat or skinny?

I bet that has something to do with it to.

I'm sure there are a lot of moving parts to this equation...

I could be wrong. Maybe gas is better.

someone should study it...

 

[deleted162650]

I'm sure there are a lot of moving parts to this equation...

I think that is 100% true. So much interpatient variability to make blanket statement like “Prop is better.”

Reminds me of Billy Madison:

Shampoo is better
No conditioner is better!

 

[parcus]

It doesn’t become inaccurate ... it’s a pharmacokinetic model that aims to predict propofol concentration at the target site ... and adjusts rate to maintain it at a steady state given redistribution to other compartments... the concentration of propofol is unaffected by whether you give opioid.

Sure the depth of Anaesthesia will be different if you add other stuff.

Saying it’s inaccurate if you add other stuff is like saying end tidal control of volatile gets inaccurate if you add other stuff (opioid etc). It doesn’t ... it only tells you the end tidal.

This is incorrect, opioids do raise propofol concentration and vice versa.

Anyhow, I think the key to understanding TIVA is that it does not work like gas at all. With TIVA you need to mix things for it too work well, gas can often be used with minimal amounts of other stuff on board. Opioids reduce the MAC by at most 60%, when it comes to propofol, a tiny little bit of fentanyl reduces the cp50 by more than 60%. If you go too high on either propofol or opioids your patient is going to take too long to wake up, which is why I think remifentanyl is the best for TIVA. Miller's has a great table illustrating the doses that theoretically yield the fastest recovery (somewhere in chapter 30). Even though it was never validated clinically, the remifentanyl mix works well in my experience. When it comes to TIVA I find very little in terms of hard data anyways. I tried the fentanyl mix twice and it was a **** show in terms of hemodynamics/delayed extubation, maybe I will try it again to make sure it really sucks and wasn't just bad luck.

As for sedation, I believe I read some study saying at 2.3 nl/ml people 50% would not respond to verbal stimulation, and the concentration for patients not recalling stuff was slightly lower. So whenever the attending lets me I just dilute 200-400 mg of prop into a 500 cc RL bag and adjust the drip until patient looses response to verbal stimulus. We call it salinefol, works pretty well, no need to waste time setting a pump. And if my theory is correct (which I don't know if it is), patient should not recall stuff as long as they are unresponsive to verbal command.

Agreed. TIVA > gas. TIVA is king here. What would you personally want - TIVA or gas?
We do an interesting ERAS, minimal narcotic TIVA here that includes prop, precedex, and ketamine; patients are sleepier for emergence and in PACU but great post op analgesia, minimal PONV and according to surgical colleagues, quicker discharges. However I don't see this triple infusion ERAS thing flying in private practice due to $$$.

*mcg/kg/min for above values

I read somewhere about an anesthesia with 66% NO and a little bit of benzos + propofol. Dunno why it doesn't seem very popular, but I guess it would be a nice "opioid free" alternative. Maybe if you put ketamine and minimal amounts of opioids you can reduce that NO and the propofol dose and still acchieve something comparable to opioid free.

Also curious as to which study says TIVA is a risk factor for awakening, the chinese one comparing BIS and random TIVAs that "proved" BIS superiority seems so bad.

 

[Psai]

It takes 2 seconds to program a pump. wtf is salinefol
remi sucks for tiva, causes a lot of hyperalgesia. there's no hell like dealing with a chronic pain spine patient who had remi
the trick with tiva is figuring out when to turn things off so that the wakeup comes out well. bis helps with that

 

[deleted59964]

This is incorrect, opioids do raise propofol concentration and vice versa.

.

oh really - i’m on the edge of my seat waiting for an explanation of that.

please - enlighten me

 

[epidural man]

someone mentioned it - but I think a recent article showed that remifentanyl mixed with prop - is not mixed at all. The remi all sits at the bottom or top of the bottle (can't remember which).

 

[deleted875186]

Correct, even lidocaine at higher doses mixed with propofol starts to become insoluble.

I’ll never understand why people mix medicines. I prefer to know exactly how much of each drug and IV fluid I’m giving someone.

someone mentioned it - but I think a recent article showed that remifentanyl mixed with prop - is not mixed at all. The remi all sits at the bottom or top of the bottle (can't remember which).

 

[anbuitachi]

And yes...I am completely aware that BIS doesn't protect me against awareness.

I am not using it as an awareness prevention tool.

I am using it as an anesthetic depth monitor. It absolutely works most of the time for measuring relative anesthetic depth. I have yet to see someone who doesn't get a drop in BIS with a bolus of propofol, or increase dose of propofol. I have yet to see someone who has an increasing dose of anesthetic who didn't have a corresponding lowering of the BIS value. It is an excellent trend monitor for anesthetic depth.

With ketamine, or nitrous, Bis value goes to crap. Easily have BIS of 70s due to either effect of nitrous / ketamine.

 

[timgasman]

I’m curious how low people go on their propofol dosing for TIVA, especially in cases where you can’t put a BIS on and your not paralyzed. Lowest Ive ever gone with a continuous sufenta infusion was 90 mcg in an older guy that was somewhat sicker, but the guy did move once towards the end of the surgery.

Also, where do people usually start their propofol dosing for TIVAs?

It depends on what you are looking to do. If it is a big spine case where they are using motors, I may run as high as 200 mcg/kg/min. I could also use adjuncts such as remifentanil or precedex

 

[deleted9493]

I use TIVA all the time in the pediatric world. Emergence delirium? Psshh.

Amazing how many seem to think that performing a TIVA is stressful or so much more labor intensive. As has been said, I think this stems from lack of follow-up and therefore a lack of reflection on how to mitigate PONV, dysphoria, cognitive dysfunction, etc.

 

[parcus]

It takes 2 seconds to program a pump. wtf is salinefol
remi sucks for tiva, causes a lot of hyperalgesia. there's no hell like dealing with a chronic pain spine patient who had remi
the trick with tiva is figuring out when to turn things off so that the wakeup comes out well. bis helps with that

Well, if I tried to set up a pump here for sedation with propofol my attendings would look at me funny. There is a few more $$ I would spend for the line or the syringe to set up a pump, and people are very proud of spending the minimum amount necessary. Different culture here. Anyways, there is no need to know exactly how much propofol you are giving if your goal is only to have them unresponsive to verbal stimulation. Remi causes hyperalgesia mainly in high doses, at 0.1-0.2, which is generally where it is at for lap choles here, it doesn't seem to cause it.

Also it varies in different settings and is apparently less or nonexistent if combined with propofol instead of sevo or desflurane. Here I almost always give my patients something to inhibit COX-2 before I start my remi infusion, which apparently helps too. I haven't done many spinal cases, but people usually do them with TIVA here, and post op pain doesn't seem too crazy for these.

someone mentioned it - but I think a recent article showed that remifentanyl mixed with prop - is not mixed at all. The remi all sits at the bottom or top of the bottle (can't remember which).

I might have left the impression that I mix those; I don't like to. I hate it when my attendings do it in a 50cc syringe with 2% propofol, 2mg of remi, results in too much hypotension, too little propofol imo. When I said remi-prop mix I meant the combination in 2 different pumps.

 

[vector2]

Well, if I tried to set up a pump here for sedation with propofol my attendings would look at me funny. There is a few more $$ I would spend for the line or the syringe to set up a pump, and people are very proud of spending the minimum amount necessary. Different culture here. Anyways, there is no need to know exactly how much propofol you are giving if your goal is only to have them unresponsive to verbal stimulation. Remi causes hyperalgesia mainly in high doses, at 0.1-0.2, which is generally where it is at for lap choles here, it doesn't seem to cause it.

Also it varies in different settings and is apparently less or nonexistent if combined with propofol instead of sevo or desflurane. Here I almost always give my patients something to inhibit COX-2 before I start my remi infusion, which apparently helps too. I haven't done many spinal cases, but people usually do them with TIVA here, and post op pain doesn't seem too crazy for these.

Remi for lap choles? Do you guys light 100 dollar bills on fire to celebrate the completion of the case?

 

[parcus]

Remi for lap choles? Do you guys light 100 dollar bills on fire to celebrate the completion of the case?

People like it, hospital doesn't seem to complain. I feel as if I don't have enough information to compare sevo vs TIVA in terms of costs. Hospitals too often do not disclose how much they really pay for stuff. The prices out there are simply misleading around here. But I agree, it is probably more costly than sevo.

 

[pgg]

One of the things I love most about this about this forum is reading about the odd stuff that's normal practice in other parts of the world.

 

[Psai]

Can't afford lines and syringes. Runs remi for lap choles

 

[parcus]

One of the things I love most about this about this forum is reading about the odd stuff that's normal practice in other parts of the world.

And the odd stuff that's normal practice in the US. Keeping your phone near the pump adjusting it every few minutes.... ain't nobody got time for that.

 

[deleted162650]

And the odd stuff that's normal practice in the US. Keeping your phone near the pump adjusting it every few minutes.... ain't nobody got time for that.

Nobody does that.

 

[Psai]

And the odd stuff that's normal practice in the US. Keeping your phone near the pump adjusting it every few minutes.... ain't nobody got time for that.

I gotta be honest, I don't understand any of your posts

 

[deleted59964]

Can't afford lines and syringes. Runs remi for lap choles

agreed something here is not quite right

 

[anbuitachi]

Well, if I tried to set up a pump here for sedation with propofol my attendings would look at me funny. There is a few more $$ I would spend for the line or the syringe to set up a pump, and people are very proud of spending the minimum amount necessary. Different culture here. Anyways, there is no need to know exactly how much propofol you are giving if your goal is only to have them unresponsive to verbal stimulation. Remi causes hyperalgesia mainly in high doses, at 0.1-0.2, which is generally where it is at for lap choles here, it doesn't seem to cause it.

Also it varies in different settings and is apparently less or nonexistent if combined with propofol instead of sevo or desflurane. Here I almost always give my patients something to inhibit COX-2 before I start my remi infusion, which apparently helps too. I haven't done many spinal cases, but people usually do them with TIVA here, and post op pain doesn't seem too crazy for these.


I might have left the impression that I mix those; I don't like to. I hate it when my attendings do it in a 50cc syringe with 2% propofol, 2mg of remi, results in too much hypotension, too little propofol imo. When I said remi-prop mix I meant the combination in 2 different pumps.

Thats pretty cool, ive never actually seen 2% propofol here. we only use 1%.

Dont really see remi causing hyperalgesia much in spines cause the cases you use remi for are usually short. We dont use remi for 12 hr spine cases in patients on chronic pain killers

 

[deleted59964]

This is incorrect, opioids do raise propofol concentration and vice versa
....

Even though it was never validated clinically, the remifentanyl mix works well in my experience.

...

I tried the fentanyl mix twice and it was a **** show in terms of hemodynamics/delayed extubation, maybe I will try it again to make sure it really sucks and wasn't just bad luck.

still waiting for an explanation of how propofol concentration is raised by opioid use... and how I am "incorrect".

what exactly is "your experience"? from your previous posts you're a first (or 2nd?) year resident?
you've used fentanyl with TIVA ... twice???

you say you are expected to be economical with healthcare costs but you use remifentanil for lap chole's

and you refer to "your country"? where is that exactly?
in which country are you training?

 

[parcus]

I gotta be honest, I don't understand any of your posts

At least I understand your posts.

Can't afford lines and syringes. Runs remi for lap choles

Quick search and It seems remi costs about 4x in the US compared to here. 1300 dollars per 10 2mg vials. I dunno, I'd need access to real prices here before I could convince myself gas is absolutely cheaper than TIVA with remi, also loads of other variable to take into account when making this calculation, like people overutilizing fresh gas flow during their anesthesia. Whatever the case TIVA with remi works well for lap choles, people are happy with it here, that's what matters. At least it decreases PONV.

Thats pretty cool, ive never actually seen 2% propofol here. we only use 1%.

Dont really see remi causing hyperalgesia much in spines cause the cases you use remi for are usually short. We dont use remi for 12 hr spine cases in patients on chronic pain killers

You are right about that.

still waiting for an explanation of how propofol concentration is raised by opioid use... and how I am "incorrect".

what exactly is "your experience"? from your previous posts you're a first (or 2nd?) year resident?
you've used fentanyl with TIVA ... twice???

you say you are expected to be economical with healthcare costs but you use remifentanil for lap chole's

and you refer to "your country"? where is that exactly?
in which country are you training?

Ok, fine. Mixed-effects modeling of the influence of alfentanil on propofol pharmacokinetics. - PubMed - NCBI. As a bonus here is another one showing similar things about midazolam and propofol. Mixed-effects modeling of the influence of midazolam on propofol pharmacokinetics. - PubMed - NCBI.

I'm a 2nd year resident... and? I will not disclose anymore online. Also, no I have used fent + prop plenty of times, but only twice I tried to follow those cp50 doses in Millers, and it didn't work very well, that's all. It takes a lot of convincing to try different stuff.

 

[deleted59964]

Mixed-effects modeling of the influence of alfentanil on propofol pharmacokinetics. - PubMed - NCBI. As a bonus here is another one showing similar things about midazolam and propofol. Mixed-effects modeling of the influence of midazolam on propofol pharmacokinetics. - PubMed - NCBI.

Academically interesting, clinically irrelevant