Propofol Shortage - How do you run your spine cases?

[Soparklion]

I'd usually infuse propofol as the main anesthetic, supplemented by remi and some desflurane. Now I've got no propofol and the neuromonitoring guys aren't too keen on accepting poor signals with more des.

What is your institution doing?

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[Surfer]

Sevo with fentanyl.

 

[nimbus]

I run a prop/remi/ketamine TIVA....with propofol no higher than 50mcg/kg/min, ketamine @5mcg/kg/min, and remi at 0.1mcg/kg/min. The neurophysiologists love this. You could probably just run ketamine/remi with des or sevo at 1/4 to 1/2 MAC. The key is ketamine which actually enhances the signals.

 

[BobBarker]

Precedex, Des, Remi

 

[somedumbDO]

Precedex, Des, Remi

You run a half mac of ANY gas plus, narcotic of choice. This works for ALL adults with good baseline signals. For the pedi spines 1-3yr old range you will need another IV agent precedex, ketamine, clonidine... whatever. The neuromonitoring peeps are comparing the baseline to intraop. so as long as baselines are good and you arent playing anesthesia rollercoaster you will be fine.

 

[btbam]

I was always under the impression that ketamine boluses affect ssep's much more than an infusion. We occasionally run ketamine instead of prop on spines in kids with mitochondrial disorders.

 

[seinfeld]

Precedex, Des, Remi

2nd that

 

[Trisomy13]

Precedex, Des, Remi

this

 

[cchoukal]

Precedex, Des, Remi

This, where remi = su.

 

[deleted9493]

Is anyone concerned about generating false negative findings while running Ketamine? Wake-up test on Ketamine?

My own preference in kids is .5 MAC isoflurane, .3mg/kg methadone with IV placement, dex. infusion. A morphine load up front is nice to smooth the hypertension that would otherwise be seen on first incision (owing to histamine release) and its hemodynamic effect is generally gone before the bony hemorrhage begins. Diazepam and titrated methadone at end of case.

 

[sevoflurane]

Is anyone concerned about generating false negative findings while running Ketamine? Wake-up test on Ketamine?

No to the first, especially with a continuous low dose infusion. Ketafol is my preference for these cases and it works great as an anesthetic, analgesic and as propofol sparing delivery of a balanced anesthetic + good for neuromonitoring. It's also dirt cheap.
No to ketamine if you are doing a wake up test (or real low dose)... that's just about one of the worst K-holes I can imagine.

 

[sevoflurane]

I also throw in 4 gms of magnesium, precedex, 1-2 mg of remi +.3 Mac low flow DES. Good narc load up front. I try to keep my remifentanyl really light as it adds nothing towards the end of the case and is associated with opioid induced hyperalgesia (I often just use 1mg or none at all).

Turn off ketafol 45 minutes before we are out the door and titrate in a little narcotic.

 

[sevoflurane]

Ketamine is a great analgesic + has a long 1/2 life. Most of these patients are tolerant to opiods but not to their side effects... Ketamine makes great sense IMHO.

 

[deleted9493]

Ketamine is a great analgesic + has a long 1/2 life. Most of these patients are tolerant to opiods but not to their side effects... Ketamine makes great sense IMHO.

Agreed. I have just never done a wake up test on a child getting a low dose infusion so was curious. Were I not subject to the institutional norms of fellowship, I'd be giving most of my spine patients low dose ketamine, a pregabalin premed and avoiding potent opioid infusions, as possible.

 

[TrustMe]

Maybe I'm not smart enough to understand all of this, but some of this sounds like too much for an adult spine case. If they are just doing SSEP's, 0.6 MAC of sevo, fentanyl 1-2mcg/kg/hr, +/- low dose propofol and keep them still (1-2 twitches, use a vec infusion if you want, but I think that is overkill as well). Keep it simple. I do love ketamine though and think it is great in the chronic pain patient having surgery. Peds spine whacks are a whole other beast. Won't get into that now. I hate remi for a case where they will wake up and actually have incisional pain. Use something that will actually help the patient.

 

[btbam]

Why is everyone using remi and des on cases that are 3 hours minimum? I just turn off the fent infusion when they start closing and work in longer acting stuff once they come back breathing.

 

[sevoflurane]

What's your beef with Des?

 

[Precedex]

iso + fent

 

[jwk]

Why is everyone using remi and des on cases that are 3 hours minimum? I just turn off the fent infusion when they start closing and work in longer acting stuff once they come back breathing.

We do a boatload of spines. We don't even have remi on formulary. I prefer des for just about any case. Why would it be a problem for long cases? I'd much rather use it than sevo, especially for obese patients.

 

[deleted162650]

What's the ratio on your ketafol mix?

 

[pgg]

What's your beef with Des?

I love yellow-gas snobs.


Desflurane is superior in every way that counts, except inhalation inductions. There, I said it.

 

[cchoukal]

I love yellow-gas snobs.


Desflurane is superior in every way that counts, except inhalation inductions. There, I said it.

And possibly cost, depending on your flow. There was also an interesting article in AnA in 2010 by Susan Ryan demonstrating that desflurane had a much higher tendency to form greenhouse gas than the other volatiles.

But back to the question. I also recall doing a couple of (smaller) backs with sevo + methdone.

 

[dhb]

Desflurane is superior in every way that counts, except inhalation inductions. There, I said it.

That's what i though i one point but clinically it's not true.

 

[btbam]

I like Des just fine! It just seems to have greater utility in those quick cases where you don't have time to blow off sevo or iso.

 

[OB1🤙]

Desflurane is superior in every way that counts, except inhalation inductions. There, I said it.

This.

 

[KCBarbarossa]

I did a TIVA for a C-spine case with monitoring yesterday (SSEP, TcMEP, EMG). Ran the ketamine at 5mcg/kg/min. It was a bit overkill but I also ran propofol, dex, and remi (i know i know). No hypotension issues at all, but I turned the ketamine infusion off about 30 minutes prior to attempting to extubate the patient. I ended up taking him to the PACU on a Jackson-Rees (i know i know....lol). Patient was responsive just still too sleepy to pull the tube and I didn't want to push it since he was then in a C-collar and wasn't a super easy intubation to begin with.

This was the first time I ran a ketamine infusion and it's not at all common at my institution, so it was a learning curve.

According to Miller, a dose of 15-45 mcg/kg/min for maintenance WITH 50% N20 is quoted.

Looking at context-sensitive 1/2 lives, Ketamine infusions approximate propofol infusions, so I don't know why this guy was so slow to wake up.

I'm interested in more experiences with ketamine infusions. Also, the case only ran about 2.5 hours and I started it at the very start (just after induction) of the case, but it's not as if it ran for 4 hours.

Again, not sure why it took so long for the patient to wake up. Admittedly, I had the guy on a hefty dose of propofol (100-150) as well, so it may have been that. But the propofol had been off for about 30 minutes as well (as were the other drips). No narcotics btw......

Any input is appreciated. My attending wasn't too helpful on this one since we normally don't run ketamine infusions at my place.

Again, this was TIVA with zero VA on board and zero paralytics.

 

[dhb]

Assuming a 75kg patient that's 56mg of K over 2.5h which obviously is not a huge dose but everybody is different and the more drugs you use: precedex, prop, K the more synergy there is.


Or maybe it was the 2mg of midaz from holding

 

[proman]

I would do spines the way I always did them:

0.5% iso, 50% nitrous

My monitoring guys don't even care if I run volatile anesthestic during EEG. That's one time I think TIVA makes a difference.

 

[sevoflurane]

Drop 200 mg of ketamine into 100 ml of prop. *Run your mixture on a prop plate/medfusion pump @ 150 mcg/kg/min for 10 min. Then start dropping it to achieve 50 mcg/kg/min. *Add mag as its synergistic (1+1=3) with both prop and ketamine and ketamine is synergistic with propofol decreasing your amounts of both. *Mag also has analgesic properties + bronchodilation, muscle relaxation and a little cardiac protection. *

Turn off your infusion 45 minutes before the last stitch is thrown. *Get them breathing prone and use small boluses of propofol if they get a little wiggly (40-50mg @ a time). *Works every time.

http://m.bja.oxfordjournals.org/content/100/3/397.abstract

"Conclusions I.V. magnesium sulphate during TIVA reduced rocuronium requirement and improved the quality of postoperative analgesia."

http://m.anesthesia-analgesia.org/content/92/5/1173.short

"Implications: Ketamine and Mg2+inhibit functioning of recombinantly expressed NR1/NR2A and NR1/NR2B glutamate receptors, and combinations of the compounds act in a super-additive manner. These findings may explain, in part, why combinations of ketamine and Mg2+are more effective analgesics than either compound alone."

As a side note, I think Nitrous is dirty. *I never use it unless I'm in the pedi room and even then its just for mask inductions.*

 

[sevoflurane]

I love yellow-gas snobs.


Desflurane is superior in every way that counts, except inhalation inductions. There, I said it.

Yep. I was a young medical student when I picked my user name...

It's cheaper @ low flows though. There, I said it.

We don't even have Iso. Haven't used it since my last day of residency.

 

[sevoflurane]

I'll only say this once:

DES>>>>>>>SEVO

 

[IlDestriero]

I mix 1mg ketamine/cc propofol when I use it.
I usually run the ketamine as a separate infusion though at 0.1 mg/kg/hr as part of a TIVA for my peds spines. Most use remi but a few use fentanyl. We also give a dose of methadone (0.1 mg/kg up to 10 mg) for post op pain control.

 

[gasattack3]

Drop 200 mg of ketamine into 100 ml of prop. *Run your mixture on a prop plate/medfusion pump @ 150 mcg/kg/min for 10 min. Then start dropping it to achieve 50 mcg/kg/min. *Add mag as its synergistic (1+1=3) with both prop and ketamine and ketamine is synergistic with propofol decreasing your amounts of both. *Mag also has analgesic properties + bronchodilation, muscle relaxation and a little cardiac protection. *

Turn off your infusion 45 minutes before the last stitch is thrown. *Get them breathing prone and use small boluses of propofol if they get a little wiggly (40-50mg @ a time). *Works every time.

http://m.bja.oxfordjournals.org/content/100/3/397.abstract

"Conclusions I.V. magnesium sulphate during TIVA reduced rocuronium requirement and improved the quality of postoperative analgesia."

http://m.anesthesia-analgesia.org/content/92/5/1173.short

"Implications: Ketamine and Mg2+inhibit functioning of recombinantly expressed NR1/NR2A and NR1/NR2B glutamate receptors, and combinations of the compounds act in a super-additive manner. These findings may explain, in part, why combinations of ketamine and Mg2+are more effective analgesics than either compound alone."

As a side note, I think Nitrous is dirty. *I never use it unless I'm in the pedi room and even then its just for mask inductions.*

Very nice. Is this what you do for scoliosis cases? Or any spine with monitoring?

How do you reconcile needing to turn the ketamine (or ketamine mixture) off 45 min ahead of last stitch when the context-sensitive half life seems to approximate that of propofol? It seems like a lot of time, BUT with my n=1 experience with a ketamine infusion, I probably didn't turn it off early enough. Thoughts?

 

[leaverus]

I'd usually infuse propofol as the main anesthetic, supplemented by remi and some desflurane. Now I've got no propofol and the neuromonitoring guys aren't too keen on accepting poor signals with more des.

What is your institution doing?

i dont get it. it's very rare that i use a propofol infusion for a spine case. usually just halogenated agent + narcotic infusion and nmb if no MEPs and i've had the neuromonitoring guy tell me on a few occasions that signals were attenuated but that's more exception than the rule. the textbooks say more important than the specific agents used is maintenance of a steady state condition. even in residency it was unusual for anyone to add a propofol gtt to their regimen. what gives?

 

[deleted9493]

Very nice. Is this what you do for scoliosis cases? Or any spine with monitoring?

How do you reconcile needing to turn the ketamine (or ketamine mixture) off 45 min ahead of last stitch when the context-sensitive half life seems to approximate that of propofol? It seems like a lot of time, BUT with my n=1 experience with a ketamine infusion, I probably didn't turn it off early enough. Thoughts?

It is important to bear in mind how significant the pain stimulus will be at surgery's end; all else being equal, a patient having T2 to sacral fusion will emerge differently (read: faster) than a patient having cervical work alone. Perhaps it goes without saying but nociceptive input is just as important a consideration as pharmacokinetics when it comes to timing emergence.

 

[dhb]

It is important to bear in mind how significant the pain stimulus will be at surgery's end; all else being equal, a patient having T2 to sacral fusion will emerge differently (read: faster) than a patient having cervical work alone. Perhaps it goes without saying but nociceptive input is just as important a consideration as pharmacokinetics when it comes to timing emergence.

If i understand correctly what you're saying i completely disagree.

 

[deleted9493]

If i understand correctly what you're saying i completely disagree.

I am suggesting that for two identical patients having surgery of equal duration and equal anesthetic dosing, the patient with the more painful procedure will tend to emerge more quickly (e.g. have EEG tracing and BIS values consistent with an awake state, earlier).

 

[dhb]

I am suggesting that for two identical patients having surgery of equal duration and equal anesthetic dosing, the patient with the more painful procedure will tend to emerge more quickly (e.g. have EEG tracing and BIS values consistent with an awake state, earlier).

I agree in theory but what you say is very hypothetical because if the procedure is more painful then you would be giving more anti-nociceptive drugs to that patient thus your two anesthetics not being equal.
I think inter-patient variability plays a bigger role as to how quickly one will emerge.