Propofol or gas..

[RxBoy]

---

Members do not see this ad.

6 hour cranie. Mix of propofol and 0.5 mac gas (sevo/iso) running throughout case. Case begins to wind down, need to start planning for smooth extubation. 20 minutes from skin closure to mayfield to wrapping.

Do you turn off gas and let the propofol run, or do you turn off the propofol and leave the gas on?

 

[proman]

Turn off everything. Crani = 1 MAC.

It's also why I like nitrous/iso combo for these cases. 50% nitrous, 0.5 iso, turn off iso when the dura is closed, go to 70% nitrous, 7L/3L oxygen. Reverse when the Mayfield is released and turn off the nitrous. <5 minute wakeups practically 100% of the time.

 

[Lightwand]

Turn off everything. Crani = 1 MAC.

It's also why I like nitrous/iso combo for these cases. 50% nitrous, 0.5 iso, turn off iso when the dura is closed, go to 70% nitrous, 7L/3L oxygen. Reverse when the Mayfield is released and turn off the nitrous. <5 minute wakeups practically 100% of the time.

Agree. This is my exact recipe + remi/su/alfenta infusion, turned off at the appropriate time (5/25/10 min prior to emergence).

Crani=free amnesia.

 

[BLADEMDA]

Turn off everything. Crani = 1 MAC.

It's also why I like nitrous/iso combo for these cases. 50% nitrous, 0.5 iso, turn off iso when the dura is closed, go to 70% nitrous, 7L/3L oxygen. Reverse when the Mayfield is released and turn off the nitrous. <5 minute wakeups practically 100% of the time.

Damn. Been doing it that way for 20 years. Also, I load up front with Fentanyl or run a Sufenta drip (turn it off 30 minutes before the end).

Loading up front with Fentanyl is much easier and once they work on the brain the need for narcotics seems to diminish.

 

[proman]

I don't care what anyone says, nothing gives the crisp, fast, reliable wakeup of nitrous. Maybe xenon will but that's a long way from reality. I usually don't go heavy on narcotics but I know many do. I typically give a total of 250 of fentanyl, 150 by the time the incision is made, nothing during the case, 50 mcg as the skin is closed and another 50 after the wakeup. All that changes when I can do a scalp block. Of course, I don't do much neuro now.

 

[Idiopathic]

why use propofol at all?

 

[proman]

why use propofol at all?

At my current place, I've encountered a lot of "the brain was so tight I had to switch to propofol". It's something I hadn't ever encountered before and I think it's related to when the mannitol is given. I was accustomed to giving 1gm/kg of mannitol around incision time over 15-30 minutes. The surgeons here ask for 0.5gm/kg when they start drilling the bone, which I don't think is long enough. I wonder how much variation there is in mannitol timing. While hypertonic saline is better, is anyone actually using it in place of mannitol?

 

[RxBoy]

why use propofol at all?

We usually use it here to aid in the anesthetic for SSEP and/or MEP monitoring. Remi would be more ideal but our department are real sticklers with the nicer drugs, I still use it if attendings are accepting. Anyways the electrophysiology techs always want the gas less than <0.6 mac. I have never tried N2O on SSEP monitored patient as a supplement. Im not sure if it interacts, but if it doesn't I will try it next time.

 

[DrBeaker]

90% of the time, if they are planning on doing SSEP's or MEP's, the patient gets a TIVA with prop and remi/sufent. Remi flows like water here, 6mg is in our drug box.

 

[btbam]

We usually use it here to aid in the anesthetic for SSEP and/or MEP monitoring. Remi would be more ideal but our department are real sticklers with the nicer drugs, I still use it if attendings are accepting. Anyways the electrophysiology techs always want the gas less than <0.6 mac. I have never tried N2O on SSEP monitored patient as a supplement. Im not sure if it interacts, but if it doesn't I will try it next time.

I've always been told N2O has no effect on SSEPs, so I either go 0.5 MAC iso w/ N20 or prop at 75-100 mcg/kg/min, don't really notice a difference between the two. Slap a BIS on if you feel so inclined.

 

[Arch Guillotti]

Turn off everything. Crani = 1 MAC.

It's also why I like nitrous/iso combo for these cases. 50% nitrous, 0.5 iso, turn off iso when the dura is closed, go to 70% nitrous, 7L/3L oxygen. Reverse when the Mayfield is released and turn off the nitrous. <5 minute wakeups practically 100% of the time.

Agree, great combo.

 

[C.P.]

Turn off everything. Crani = 1 MAC.

It's also why I like nitrous/iso combo for these cases. 50% nitrous, 0.5 iso, turn off iso when the dura is closed, go to 70% nitrous, 7L/3L oxygen. Reverse when the Mayfield is released and turn off the nitrous. <5 minute wakeups practically 100% of the time.

I do something similar too, but wanted to point out an extremely important detail you mentioned.

having a "light" patient with a Mayfield on can be catastrophic if they decided to wiggle. They can shred their head or snap their neck as their body tried to go one way and their head stays in place.
Never seen it happen, but never want to either.

A quick, smooth wake-up is important and nice to achieve, but respect the Mayfield.

 

[proman]

I do something similar too, but wanted to point out an extremely important detail you mentioned.

having a "light" patient with a Mayfield on can be catastrophic if they decided to wiggle. They can shred their head or snap their neck as their body tried to go one way and their head stays in place.
Never seen it happen, but never want to either.

A quick, smooth wake-up is important and nice to achieve, but respect the Mayfield.

FYI there's never been a single documented case of cervical spine injury from moving in the Mayfield. The "shred their head" has happened, tearing of the scalp and bleeding. No one will get paralyzed from the Mayfield. But the point is still valid. I was taught "relaxed but reversible", so 1-2 twitches while in the Mayfield. I find paralytic infusions to be the easiest way of achieving that. I also give 50 mcg of fentanyl around the time they are on the final layer of skin (and minimal narcotic before). A lot of my peers give a lot more narcotic though. Control hemodynamics with labetalol as the volatile anesthetic wears off.

 

[fakin' the funk]

Turn off everything. Crani = 1 MAC.

It's also why I like nitrous/iso combo for these cases. 50% nitrous, 0.5 iso, turn off iso when the dura is closed, go to 70% nitrous, 7L/3L oxygen. Reverse when the Mayfield is released and turn off the nitrous. <5 minute wakeups practically 100% of the time.

+1

Crani's are one of the only cases where you can do a (nearly) pure nitrous/narcotic anesthetic since you get free amnesia. Where I am at we do a narcotic load up front, <0.5 MAC volatile/propofol/1-2 twitch neuromuscular blockade until they start closing up, then 70% nitrous only until ready to reverse and wake up, most of the time the emergence is totally cough/buck free and the pt is following commands prior to extubation and nearly lucid in the PACU.