Propofol infusion at end of case for fast wake up

[CharleyVCU1988]

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Has anyone ever heard of this technique? One of my co-residents is trying this out, and I saw a couple of CRNAs trying this on general cases. I stalked the EMR to see when exactly they deployed and then stopped the propofol infusion but I can't remember now off the top of my head.

What is everyone's thoughts on this?

 

[Chloroform4Life]

Has anyone ever heard of this technique? One of my co-residents is trying this out, and I saw a couple of CRNAs trying this on general cases. I stalked the EMR to see when exactly they deployed and then stopped the propofol infusion but I can't remember now off the top of my head.

What is everyone's thoughts on this?

Sounds unnecessary.

Just turn down your gas when they are closing with goal ET gas around 0.5 mac, lower for old folks, higher for young ones. Pt should be breathing spontaneously if possible. Titrate opioid to respiratory rate and you can give boluses of propofol if you think pt might move. No need for a gtt imo.

Once last stitches are done, turn off gas, ramp up flow. By the time they clean up and drape comes down, pt should be extubatable.

 

[Mman]

One of many ways to wake somebody up at the end of a case. You can accomplish the same thing by turning on nitrous while getting the volatile gas out of them.

 

[PainDrain]

This seems like a completely unnecessary way of doing things. Here is a thought, learn how to titrate your gas and your drugs so people will wake up. This can easily be achieved with nitrous (I prefer other methods typically due to ponv) or low gas flow techniques.

 

[Chloroform4Life]

Since when do anesthesiologists take advice from crnas?

If your training program teaches you nothing else, learn this: never develop your habit based on how crnas practice.

Sure, they may be well meaning and some of what they tell you may be right. But a lot of what they tell you is garbage. As a trainee, you don't have the experience to know what is garbage and what isn't just yet. So remember, when they try to teach you, its mostly anecdotal and not based on reality.

 

[Temeraire]

I once had a very rigid attending who trained at ucsf swear up and down that this was the smoothest way to wake patients up. She did a lot of neuro cases and said that the propofol wake-up was particularly useful for this population because it reduced bucking on the tube and PONV. I'm a med student so I didn't argue, but now I'd like to know how valid this is.

Edit: now that I remember, I think she also combined the propofol with a remi infusion and titrated the propofol down first, followed by the remi. This is was not a TIVA case btw.

 

[Planktonmd]

Just another way to skin the cat!

 

[Twiggidy]

Agree with Plank...in this field there are 1000 maybe more ways to skin the cat. Do whatever way works for you and doesn't hurt the patient

I think she also combined the propofol with a remi infusion and titrated the propofol down first, followed by the remi. This is was not a TIVA case btw.

This is a very typical "go to" technique for neuro anesthesia and I tend to use it now for any patients that mentions of hint of "i get sick after anesthesia". As others have said, you just have to know when to turn off your drugs but that comes with experience and getting to know your surgeon's technique.

 

[ambiturner]

I do this when I have leftover propofol, if you're doing a long case and need some time to blow off the gas either this or nitrous is a good way to go, especially in academics when you have no idea how long the fellow/resident/med student is going to take to close.

You also don't need an infusion, you can hand bolus with some rounded off numbers. If you want 100 mcg/kg/min and assume your pt is 100 kg, 100 x 100 = 10000 mcg/min = 10 mg/min = 1 cc of propofol per minute that you need to push. This saves the trouble of setting up the pump and the cost of the tubing. Just be careful to stop bolusing a few minutes before they finish or else you'll have to deal with both the gas AND the propofol tails.

 

[OB1🤙]

Use des!

 

[Robotic Wis-Hipple]

Get your gas off early, spontaneous breathing, then propofol boluses to cover skin closure. Prop infusion is overkill, wastes infusion line and a 50cc bottle (unless you have syringe pumps or just spike a 20cc I guess). As others have said, nitrous or des do the same thing but I agree that propofol wake ups are smoother and may even get you some antiemetic benefits.

 

[criticalelement]

Actually the technique borders on unsafe practice.

Answer this question.. when you are waking someone up, why on earth would you start a drug that puts people to sleep? Just doesnt make sense..
Eventually you will get burned very badly with this technique. i am not at all surprised that some crnas told you about this.. i would rather the patient buck then start propofol as i a waking someon up

 

[pgg]

Actually the technique borders on unsafe practice.

Answer this question.. when you are waking someone up, why on earth would you start a drug that puts people to sleep? Just doesnt make sense..
Eventually you will get burned very badly with this technique. i am not at all surprised that some crnas told you about this.. i would rather the patient buck then start propofol as i a waking someon up

If there's anything nurselike in this thread, it's declaring this common technique to be unsafe because you're unfamiliar with it or don't use it.

 

[deleted643396]

Nitrous (or Des, if available...a lot of hospitals are restricting it). Squirts of propofol if the resident or PA is doing a plastics closure (although a timely use of patient bucking helps speed things along if the PA is chatting instead of closing). Get the patient breathing spontaneously as soon as you can and titrate narcotics.

 

[chfo]

I found that the fastest way to wake someone up is to turn off the gas.

 

[deleted59964]

I'm surprised by the simplistic answers to this question.

for long cases -- e.g. 6+ hours, it takes a long time for the volatile to diffuse out (servo worse than des).
just turning off the volatile early can of course work just fine, but the exponential washout curve for volatile means it's a long time at low mac before wake up. during this time at low mac - can you be sure you won't get awareness / recall?

by turning off the vapour and switching to propofol TCI for the last hour or so, you can blow off the volatile and then get a crisp wake up when you stop the propofol. all the more so if you use remi.

like many things in anesthetics, it's a good technique -- sometimes, if you do it right, for the right indication.

 

[amyl]

I agree drip is totally unnecessary. this is how I do quick smooth wakeups -- get them spontaneous and extubate deep if pt characteristics allow, if not gas off nitrous on and a stick of propofol for little bits if you feel like you need it while titrating narcs to respiratory rate. lido down the tube to help the coughing and emergence HTN/tachy response. even in a longer case or if I use iso does this not work for drapes down-tube out

 

[Twiggidy]

Actually the technique borders on unsafe practice.

Answer this question.. when you are waking someone up, why on earth would you start a drug that puts people to sleep? Just doesnt make sense..
Eventually you will get burned very badly with this technique. i am not at all surprised that some crnas told you about this.. i would rather the patient buck then start propofol as i a waking someon up

This response is borderline trolling.....

 

[deleted643396]

If you work at a hospital where the OR nurses are unionized and get paid by the hour then they get mad at you for quick wake ups. You won't be a very popular anesthesiologist. They much prefer CRNAs who waste another 20 minutes waking up a patient after drapes are down.

 

[criticalelement]

This response is borderline trolling.....

YOu are not a borderline arse..

 

[dhb]

I'm surprised by the simplistic answers to this question.

for long cases -- e.g. 6+ hours, it takes a long time for the volatile to diffuse out (servo worse than des).

I have found that my faster wake ups (people talking in the or) were cases that lasted less than 30min or long cases 4h+

 

[DocFocker]

Actually the technique borders on unsafe practice.

Answer this question.. when you are waking someone up, why on earth would you start a drug that puts people to sleep? Just doesnt make sense..
Eventually you will get burned very badly with this technique. i am not at all surprised that some crnas told you about this.. i would rather the patient buck then start propofol as i a waking someon up

This is the dumbest thing I have ever heard.

 

[gasp]

Actually the technique borders on unsafe practice.

Answer this question.. when you are waking someone up, why on earth would you start a drug that puts people to sleep? Just doesnt make sense..
Eventually you will get burned very badly with this technique. i am not at all surprised that some crnas told you about this.. i would rather the patient buck then start propofol as i a waking someon up

Whoa! Take it easy .. Whats up with all the critisizing of this simple question the op asked?? OP didn't mean to give them a drug to "put them back to sleep", he most likely just meant to switch from gas to propofol as a transition before the end of a case and titrate that down to wake them up and wants to know others thoughts.

OP, there are many way to skin a cat as you may already have heard thousands of times. Try the technique yourself and see if you like it better than gas wake up. There are people who are better with either technique so you do which ever one works best and most efficient for you. Personally, I don't like switching over to propofol and titrating that to effect and waking them up because I have noticed it takes me longer to do it that way and the pt's are more confused when waking up. We have DES at our institution and that makes my choice simple but to each their own.. G luck.

 

[deleted162650]

Okay, first you need to make the distinction between a fast wake-up and a smooth wake-up.

If you want fast then just turn the gas off earlier and give less narcotic.

If you want smooth then you need to:
a) Get rid of the damn near all the volatile
b) Have enough narcotic on board (or a well enough topicalized trachea) so that the pt will tolerate the ETT
c) Not F with the pt was they're waking up

As stated earlier, there's as many ways to do that as there are anesthesiologists (a propofol gtt is just one particularly cumbersome way of doing it).

Now a fast and smooth wake-up is a Jedi level anesthetic skill.

 

[criticalelement]

Whoa! Take it easy .. Whats up with all the critisizing of this simple question the op asked?? OP didn't mean to give them a drug to "put them back to sleep", he most likely just meant to switch from gas to propofol as a transition before the end of a case and titrate that down to wake them up and wants to know others thoughts.

OP, there are many way to skin a cat as you may already have heard thousands of times. Try the technique yourself and see if you like it better than gas wake up. There are people who are better with either technique so you do which ever one works best and most efficient for you. Personally, I don't like switching over to propofol and titrating that to effect and waking them up because I have noticed it takes me longer to do it that way and the pt's are more confused when waking up. We have DES at our institution and that makes my choice simple but to each their own.. G luck.

It is NOT appropriate using propofol at the end of the case. Amateur status.

 

[pgg]

It is NOT appropriate using propofol at the end of the case. Amateur status.

Is it possible that the reason you hate your life so much and can't find a tolerable job is because you're not as good as you think you are?

 

[deleted162650]

Is it possible that the reason you hate your life so much and can't find a tolerable job is because you're not as good as you think you are?

Or perhaps the problem is that he's SOOOO good no quality practice will hire him for the fear of making everybody else look bad 🙄🙄😉

 

[sevoflurane]

Gaaawwd... seriously?
A propofol bump at the end of a case is something I do often. I actually think it protects me from potential laryngospasm.

 

[pjl]

Gaaawwd... seriously?
A propofol bump at the end of a case is something I do often. I actually think it protects me from potential laryngospasm.

Amateur.

Actually, I'm a fan of doing anesthesia in whatever way works for you, without compromising patient safely. I see nothing inherently unsafe about a propofol infusion at the end of a case. Seems more complex than needed, but not unsafe.
Bumps of propofol are useful if a closure is unexpectedly delayed (someone starts a good story or dancing rather than sewing)

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[criticalelement]

Amateurs.

 

[PainDrain]

So let's make a distinction here shall we. Giving 20-30 mg propofol bolus as the skin is closed is one thing, but starting a patient on TIVA dosing of propofol at the end of the case and turning off the gas is another. I think the first example is fine and it does make for a smooth wake up, the latter makes no sense at all. Like tits on a bull.

 

[sevoflurane]

Amateur.

Actually, I'm a fan of doing anesthesia in whatever way works for you, without compromising patient safely. I see nothing inherently unsafe about a propofol infusion at the end of a case. Seems more complex than needed, but not unsafe.
Bumps of propofol are useful if a closure is unexpectedly delayed (someone starts a good story or dancing rather than sewing)

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You do any prone brain tumor resections in pins? I blow off nearly all my agent towards the end of the case prone, give a bit of propofol that is left over from induction so the patient doesn't buck while we flip and the pins are still on.
By then time we flip and the pins are out I have a spontaneously ventilating patient with almost no inhaled agent on board. They can be pretty darn responsive after my bolus wears off and that is exactly what you want after a crani. At the very least, respiratory mechanics tend to be excellent shortly after the flip.

What do you do? Wait 'till you flip to start blowing off the agent, run a remi or precedex drip, use the force?

Listen, amateurs, it's not the drug you use, it's how you use it. To be so closed minded as to other ways to do anesthesia out of your little box is just being blind.

 

[vector2]

just turning off the volatile early can of course work just fine, but the exponential washout curve for volatile means it's a long time at low mac before wake up. during this time at low mac - can you be sure you won't get awareness / recall?

Has anyone here ever experienced problems with awareness/recall doing this? I've had some long cases where I've turned off iso (still with low flows) a couple minutes before surgeon even began closing fascia and where the skin was sutured instead of stapled, and I've never heard of a patient complaining about this (granted, I don't go around the PACU asking them if they remembered the tube being in 20 minutes ago). Obviously if there's any movement or I hear the HR ticking up emergence-style I'll bump some propofol and/or turn on some nitrous, but I've never really thought about awareness in this situation unless I'm using des.

 

[criticalelement]

,giving propofol at the end of the case makes no sense at all. Like tits on a bull.

exactamundo

 

[caveat87]

I agree with volatile off early. For people i expect to buck i may run a lidocaine infusion and keep it running until the patient is extubated. For teenagers, a good propofol bolus or precedex hit makes for a less aggressive wakeup.

I would think a propofol infusion would increase time until wakeup

 

[PainDrain]

You do any prone brain tumor resections in pins? I blow off nearly all my agent towards the end of the case prone, give a bit of propofol that is left over from induction so the patient doesn't buck while we flip and the pins are still on.
By then time we flip and the pins are out I have a spontaneously ventilating patient with almost no inhaled agent on board. They can be pretty darn responsive after my bolus wears off and that is exactly what you want after a crani. At the very least, respiratory mechanics tend to be excellent shortly after the flip.

What do you do? Wait 'till you flip to start blowing off the agent, run a remi or precedex drip, use the force?

Listen, amateurs, it's not the drug you use, it's how you use it. To be so closed minded as to other ways to do anesthesia out of your little box is just being blind.

I did a lot of these in residency and done a lot of prone spine cases. A combination of gas, remi and precedex makes for an amazing wake up. You can throw propofol in also to decrease the gas or go all TIVA.

 

[deleted171991]

I don't wake up people on propofol, but one thing I like about anesthesiology is that the right way is the one that gets you from point A to point B. It can be straight or it can be a labyrinth, pick your poison. In the end, what matters most is the outcome, meaning happy patient and happy surgeon. Whatever takes you there... fine by me.

For me, unless one proves that doing X is better than doing Y , there is no right way or wrong way, just a matter of personal preference and experience.

Some people are masters of propofol; they even know the secret dose that's better for wake up than coffee.

 

[ArMed]

A nice alternate that I'm surprised hasn't been suggested. Try giving like 0.3mcg/kg Precedex 1 hr before case ends, or shortly before a deep extubation (pt should be spontaneous). Be conservative with narc's until pt is extubated.

 

[deleted171991]

A nice alternate that I'm surprised hasn't been suggested. Try giving like 0.3mcg/kg Precedex 1 hr before case ends, or shortly before a deep extubation (pt should be spontaneous). Be conservative with narc's until pt is extubated.

I'll tell you why not.

If you follow JCAHO requirements of using a separate vial of substance for every patient, that's one very expensive wake up.

 

[pjl]

You do any prone brain tumor resections in pins? I blow off nearly all my agent towards the end of the case prone, give a bit of propofol that is left over from induction so the patient doesn't buck while we flip and the pins are still on.
By then time we flip and the pins are out I have a spontaneously ventilating patient with almost no inhaled agent on board. They can be pretty darn responsive after my bolus wears off and that is exactly what you want after a crani. At the very least, respiratory mechanics tend to be excellent shortly after the flip.

What do you do? Wait 'till you flip to start blowing off the agent, run a remi or precedex drip, use the force?

Listen, amateurs, it's not the drug you use, it's how you use it. To be so closed minded as to other ways to do anesthesia out of your little box is just being blind.

I forgot whatever the sarcastic face emoji is.
I do what you do.


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[sevoflurane]

I forgot whatever the sarcastic face emoji is.
I do what you do.


Sent from my iPad using SDN mobile app

👍

 

[deleted643396]

Since we are talking about multiple ways to skin the cat, how about rocuronium, esmolol drip, and then sugammadex as they are putting the last stitches in? Awareness might be an issue, but it would be a fast "wakeup."

(insert sarcasm emoji here)

 

[pgg]

Since we are talking about multiple ways to skin the cat, how about rocuronium, esmolol drip, and then sugammadex as they are putting the last stitches in? Awareness might be an issue, but it would be a fast "wakeup."

(insert sarcasm emoji here)

The volume overload from the gallons of esmolol needed might be a problem. I recommend adding a Nipride drip.

 

[Chloroform4Life]

Since we are talking about multiple ways to skin the cat, how about rocuronium, esmolol drip, and then sugammadex as they are putting the last stitches in? Awareness might be an issue, but it would be a fast "wakeup."

(insert sarcasm emoji here)

Actually, an esmolol gtt has analgesic properties, so your idea is not too farfetched. Just need 0.4 mac or so on board for amnesia.

 

[deleted162650]

That's actually my anesthetic of choice for convicted child molesters.

 

[fakin' the funk]

Has anyone here ever experienced problems with awareness/recall doing this? I've had some long cases where I've turned off iso (still with low flows) a couple minutes before surgeon even began closing fascia and where the skin was sutured instead of stapled, and I've never heard of a patient complaining about this (granted, I don't go around the PACU asking them if they remembered the tube being in 20 minutes ago). Obviously if there's any movement or I hear the HR ticking up emergence-style I'll bump some propofol and/or turn on some nitrous, but I've never really thought about awareness in this situation unless I'm using des.

I suspect that with iso you could go high flows, iso off, at the start of fascial closure in a medium/long case and still have a 0% incidence of recall

 

[RxBoy]

Has anyone ever heard of this technique? One of my co-residents is trying this out, and I saw a couple of CRNAs trying this on general cases. I stalked the EMR to see when exactly they deployed and then stopped the propofol infusion but I can't remember now off the top of my head.

What is everyone's thoughts on this?

This is a well known technique for wakeups sometimes called the "propofol sandwich" (propofol in the beginning and at the end). Works beautifully IMHO.

However like all techniques, it has its time and place. This works best for cases >2 hrs, with longer acting volatiles (Iso, sevo), and need for fast turnover. The goal is start the infusion 30 min before extubation and dial the volatile to zero (the transition). Your goal is for the Et volatile to say 0.0 and propofol running 100-150 mcg/kg/min. Propofol can then be turned off within a couple minutes of expected extubation. Wakeups are as smooth as can be. This strategy avoids extra narcotics and has a profound anti emetic effect.

Its not very effective for less than 2 hour cases because blowing off the gas is pretty quick process that's easy to time. Its also not effective if youre planning on running the infusion longer than 30 minutes. Its effective because youre taking advantage of the pharmacokinetics of 2 different drugs. Blowing off the volatile will be a slow process, whereas reaching an effective propofol plasma concentration is a very quick process. Eliminating the propofol will be just as rapid as long as fat tissue does not become saturated. The shorter the infusion the faster the clearance (read about pharmacokinetics of propofol). With a short infusion, patients will go from a deep sleep to wide awake in minutes. Its a nice technique to master.

 

[Laryngophed]

I agree with volatile off early. For people i expect to buck i may run a lidocaine infusion and keep it running until the patient is extubated. For teenagers, a good propofol bolus or precedex hit makes for a less aggressive wakeup.

I would think a propofol infusion would increase time until wakeup

I just repeat the intubating dose of lidocaine right before I shut off the gas. A little bit of narcotic (as appropriate) and that + des makes for some fast, smooth wake-ups.

feelsgoodman.jpg

 

[sigrhoillusion]

Since we are talking about multiple ways to skin the cat, how about rocuronium, esmolol drip, and then sugammadex as they are putting the last stitches in? Awareness might be an issue, but it would be a fast "wakeup."

(insert sarcasm emoji here)

You forgot to slam in the 1mg of Narcan and Flumazenil to avoid any lingering effects of the opioids and benzos... 😉