Propofol dosing for TIVA

[deleted162650]

Remi is a horrible contributor to PONV.

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[POW16]

Dang now we'll never find out in which country he is training.

 

[deleted162650]

Dang now we'll never find out in which country he is training.

I’m pretty sure he’s mentioned it before.

 

[POW16]

I’m pretty sure he’s mentioned it before.

You are correct

 

[Psai]

At least I understand your posts.

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.


You are right about that.


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.

Tiva is more expensive than gas. It's an especially big difference if you're running low flow iso.

 

[dhb]

Tiva is more expensive than gas. It's an especially big difference if you're running low flow iso.

I think our 50ml 2% propofol is 6€ so it's probably more expensive that iso but i wouldn't be so sure about the other gases.

 

[projectpat]

Remi is a horrible contributor to PONV.

Its effects are gone so fast though. It's a much smaller culprit than fentanyl or hydromorphone

 

[Psai]

Its effects are gone so fast though. It's a much smaller culprit than fentanyl or hydromorphone

For analgesia maybe but not hyperalgesia

 

[deleted171991]

Nobody does that.

Nobody NEEDS that. Just the amateurs across the pond.

And feeling bad after inhalational anesthesia means just a bad provider (or poor facilities). I regularly use inhalational GA even on my PONV patients and guess what? No PONV. One doesn't need propofol to make a patient feel good. What one needs is as little anesthetic as possible, just not too little, plus knowing which drugs to use and in what doses.

 

[deleted171991]

Its effects are gone so fast though. It's a much smaller culprit than fentanyl or hydromorphone

My patients seldom get PONV from my intraop fentanyl or hydromorphone use. Why is that?

People should stop blaming medications and start blaming providers. In the wrong hands (and mostly just in those), aspirin causes GI bleed and droperidol torsades.

 

[coffeebythelake]

Nobody NEEDS that. Just the amateurs across the pond.

And feeling bad after inhalational anesthesia means just a bad provider (or poor facilities). I regularly use inhalational GA even on my PONV patients and guess what? No PONV. One doesn't need propofol to make a patient feel good. What one needs is as little anesthetic as possible, just not too little, plus knowing which drugs to use and in what doses.

and when you have that occasional patient that gets nauseated every time they get anesthesia, even with MAC cases, would you still do inhalational GA? i don't do TIVA often but i think there's definitely a place for TIVA + the works for those deemed highest risk.

 

[BeatriZZ]

Well it's obvious we are not nearly as good at our jobs as you are FFP. You are just better, bask in your glory

Seriously why blame "providers"? Instead be helpful and offer advice rather than criticism..you pissant

My patients seldom get PONV from my intraop fentanyl or hydromorphone use. Why is that?

People should stop blaming medications and start blaming providers. In the wrong hands (and mostly just in those), aspirin causes GI bleed and droperidol torsades.

 

[deleted171991]

and when you have that occasional patient that gets nauseated every time they get anesthesia, even with MAC cases, would you still do inhalational GA? i don't do TIVA often but i think there's definitely a place for TIVA + the works for those deemed highest risk.

Especially in MAC cases, it's a provider issue.

Usually, these are people who get nauseous even from being shown the opiate vial. Yes, there is always a place for TIVA, although it has been diminishing in my practice. A scopolamine patch coupled with minimalism tends to work wonders.

 

[drmwvr]

Especially in MAC cases, it's a provider issue.

Usually, these are people who get nauseous even from being shown the opiate vial. Yes, there is always a place for TIVA, although it has been diminishing in my practice. A scopolamine patch coupled with minimalism tends to work wonders.

What? For what cases? Gall bladder or thoracotomy? Breast biopsy or open AAA? Really?

 

[deleted171991]

What? For what cases? Gall bladder or thoracotomy? Breast biopsy or open AAA? Really?

I don't understand the questions. Really.

If you mean that PONV after certain high-risk surgeries in high-risk patients is not necessarily provider-dependent, I will not disagree. But I was talking about PONV after MAC, not GA, in the post you had quoted. Seriously, why even bother using anything else than propofol for MAC, in a patient with h/o PONV?

I used to do mostly TIVA in all my patients with h/o PONV. Except that, where I work now, most people still use gas and the patients do well. Which has convinced me that it's not the gas. There is another thing they do: they tend to minimize opiates.

I tend to agree with this (despite it being a crappy meta-analysis): Evidence-based analysis of risk factors for postoperative nausea and vomiting. - PubMed - NCBI, but I would replace duration of anesthesia with volatile anesthetics with dose of volatile anesthetics. But that's just one factor, the same way female gender etc. are.

The most reliable independent predictors of PONV were female gender, history of PONV or motion sickness, non-smoker, younger age, duration of anaesthesia with volatile anaesthetics, and postoperative opioids. There is no or insufficient evidence for a number of commonly held factors, such as preoperative fasting, menstrual cycle, and surgery type, and using these factors may be counterproductive in assessing a patient's risk for PONV.

 

[Twiggidy]

My patients seldom get PONV from my intraop fentanyl or hydromorphone use. Why is that?

People should stop blaming medications and start blaming providers. In the wrong hands (and mostly just in those), aspirin causes GI bleed and droperidol torsades.

Disagree. If I turn my Sevon on at 2% and my colleague turns his on at 2% except his patient gets PONV, that doesn't mean he stinks as a provider. I blame the patient more than anything.

 

[Twiggidy]

Remi is a horrible contributor to PONV.

I love my Remi. I haven't had any PONV with it but I use it with propofol like all the time so maybe the anti-nausea effects of the propofol are fighting it. If I use gas I don't use Remi.

 

[deleted171991]

Disagree. If I turn my Sevon on at 2% and my colleague turns his on at 2% except his patient gets PONV, that doesn't mean he stinks as a provider. I blame the patient more than anything.

Neither of you should need 2% sevo for most of the case, not in 2018 when there are many other options. It's called balanced anesthesia for a reason.

But I agree that patients matter a lot. Today I saw PONV after a propofol MAC for the first time. Nothing else, just propofol infusion for an hour for a minor procedure, in an elderly male patient. He ended up needing haldol. There goes the myth of TIVA.

 

[Psai]

Neither of you should need 2% sevo for most of the case, not in 2018 when there are many other options. It's called balanced anesthesia for a reason.

But I agree that patients matter a lot. Today I saw PONV after a propofol MAC for the first time. Nothing else, just propofol infusion for an hour for a minor procedure, in an elderly male patient. He ended up needing haldol. There goes the myth of TIVA.

Maybe the nausea was a coincidence. I feel nauseous right now without even having had any propofol.

 

[Twiggidy]

Maybe the nausea was a coincidence. I feel nauseous right now without even having had any propofol.

agree

 

[deleted171991]

70 y/o with CKD in my other room. He gets 2 of versed from an experienced CRNA for an LMA case without asking, of course. Plus high gas and pressors. I wonder WTH is my patient so groggy at the end of case. Then I see the junk in the chart.

These are the moments when I love solo anesthesia.

 

[Twiggidy]

70 y/o with CKD in my other room. He gets 2 of versed from an experienced CRNA for an LMA case without asking, of course. Plus high gas and pressors. I wonder WTH is my patient so groggy at the end of case. Then I see the junk in the chart.

These are the moments when I love solo anesthesia.

Ive learned to not use versed, especially for GA cases. It's unnecessary. Definitely not needed for people say over 65. People think versed is this wonderful thing (mostly non anesthesiologist becasue its all they can give to make someone close their eyes) In many cases its the wrong drug.

 

[dhb]

Ive learned to not use versed, especially for GA cases. It's unnecessary. Definitely not needed for people say over 65. People think versed is this wonderful thing (mostly non anesthesiologist becasue its call the can give to male someone close their eyes) In many cases its the wrong drug.

Almost as bad a remi

 

[deleted162650]

Almost as bad a remi

If you tell me you’re gonna do a versed/remi anesthetic I’m gonna kick you in the balls.

 

[Twiggidy]

Almost as bad a remi

 

[Ronin786]

Ive learned to not use versed, especially for GA cases. It's unnecessary. Definitely not needed for people say over 65. People think versed is this wonderful thing (mostly non anesthesiologist becasue its call the can give to male someone close their eyes) In many cases its the wrong drug.

Agreed. Unless you're a terribly anxious female or kid, it's not the end of the world to roll into an operating room and remember moving over to the bed. The grogginess and cognitive dysfunction in the elderly definitely outweigh it.

 

[coffeebythelake]

Agreed. Unless you're a terribly anxious female or kid, it's not the end of the world to roll into an operating room and remember moving over to the bed. The grogginess and cognitive dysfunction in the elderly definitely outweigh it.

you know how many 70+ year old patients are out there popping benzos at home?


hint: A LOT

 

[San Marzano]

you know how many 70+ year old patients are out there popping benzos at home?


hint: A LOT

I see this so often it doesn’t even surprise me anymore.

 

[Twiggidy]

you know how many 70+ year old patients are out there popping benzos at home?


hint: A LOT

It's nothing a syringe of propofol (or etomidate if someone is real frail) can't handle

 

[projectpat]

Few minutes after filling specimen cup, containing a stopcock, with Isoflurane.

(it's in pieces now)

Put that in your lungs

 

[deleted162650]

Few minutes after filling specimen cup, containing a stopcock, with Isoflurane.

(it's in pieces now)

Put that in your lungs

Uh yeah, the volatiles are organic solvents. Not really a news flash. On the bright side, they’re excellent for cleaning just about anything. Just make sure to use in a well ventilated area