soorg

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Which do you use for induction? Our hospital uses pentothal, which I hate. Doesn't get 'em as deep as propofol, plus is classified as Class C pregnancy category, vs. propofol which is Class B. They both cross the placenta, so why not use propofol instead?
 

urge

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Pent, sux, tube.


Need I say more?

:confused:
 

urge

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Are you a crna?

That's a crna concern.
 

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is heavy marcaine an option? we had a spirited debate last year about sleeping parturients...that was fun.

use either drug, you will see more hypotension with propofol and the baby MAY be more affected than with pentothal.

i wouldnt worry about pregnancy class when the baby is coming out in 5 minutes.
 

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Which do you use for induction? Our hospital uses pentothal, which I hate. Doesn't get 'em as deep as propofol, plus is classified as Class C pregnancy category, vs. propofol which is Class B. They both cross the placenta, so why not use propofol instead?
Why? do not know how to cook it? ;)
 
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jwk

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It's an academic debate nowadays - plenty of people use propofol, plenty use pentothal. We use both, although with the pentothal shortage a few months back, everyone was using propofol. It's just not a big deal anymore. Remember that pentothal was the standard years ago because it was the ONLY drug available. It was never "approved" for OB use.

Pentothal not as deep as propofol? What planet are you from? Are you giving 50 of pentothal vs 200 of propofol or what?
 

urge

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Pentothal not as deep as propofol? What planet are you from? Are you giving 50 of pentothal vs 200 of propofol or what?

I had a "pretty good" attending during residency who was doing a "propofol allergic" patient with me. I told her " this is the perfect case for thiopental". You know what we ended up using? Etomidate. She would not do pent. She was scared shtless of thiopental.

The OP is scared of it too.

It is more common than you think.
 

hoyden

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I had a "pretty good" attending during residency who was doing a "propofol allergic" patient with me. I told her " this is the perfect case for thiopental". You know what we ended up using? Etomidate. She would not do pent. She was scared shtless of thiopental.

The OP is scared of it too.

It is more common than you think.


Do you have any explanation for that? Where is the stigma coming from?
 

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im at a loss for why i should be scared of pentothal, i agree its not ideal for every situation but its a perfectly valid choice
 

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Which do you use for induction? Our hospital uses pentothal, which I hate. Doesn't get 'em as deep as propofol, plus is classified as Class C pregnancy category, vs. propofol which is Class B. They both cross the placenta, so why not use propofol instead?
Doesnt matter.
 

jetproppilot

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I had a "pretty good" attending during residency who was doing a "propofol allergic" patient with me. I told her " this is the perfect case for thiopental". You know what we ended up using? Etomidate. She would not do pent. She was scared shtless of thiopental.

The OP is scared of it too.

It is more common than you think.
There exists a plethora of information we all learn in an academic environment that, in the real world, has no effect on patient outcome.

So we all, at least early in our careers: follow certain rules, use certain drugs, avoid certain drugs, cancel cases needlessly based on lab values that don't affect outcome, insert invasive lines that are actually deleterious, etc.

Got about forty eight straight hours?

I could bore you for about that long with anesthesia dogmas I had to actively forget.

With the help of real world anesthesiologists who do cases all day, every day.

In private practice.

Alot of what we learn in residency makes us astute anesthesiologists.

Alot of what we learn in residency also hinders us.

Needlessly.
 

rsgillmd

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Which do you use for induction? Our hospital uses pentothal, which I hate. Doesn't get 'em as deep as propofol, plus is classified as Class C pregnancy category, vs. propofol which is Class B. They both cross the placenta, so why not use propofol instead?
I like Propofol for the severe preeclamptics. I think think it does a better job of blunting the sympathetic response to laryngoscopy than Pentothal.

That having been said, there is probably no real difference. I never used Pentothal in residency for C/S because it was a pain in the neck to get it from the Pyxis and draw it up in an emergency. It must much easier to just use Propofol. I never had any problems with it.

Where I work now Pentothal is locked in the cart, not in the Omnicell (like a Pyxis). The CRNAs I work with are comfortable using it, and so am I. I have had no problem with it other than with the severe preeclamptics.

It was funny to see their jaws basically drop when they first heard me say "Draw up Propofol" for a patient who was being wheeled back for an emergent C/S.

As others have said, who cares about pregnancy class when the baby is going to be out in a matter of minutes.
 

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baby should be out in 90 secs.. 5 minutes is too long. tell your OBs to learn how to operate...

I used to use pentothal, but primarily it's propofol now. Whatever. Doesnt matter. the only reason I used pentothal was that we had it in the twist and shake syringes. Twist it in, shake it up, shoot it in. Easy. Fast. Now it's in a separate vial; pain to draw up... forget about it... Propofol it is

drccw
 

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A number of studies have described the use during cesarean section of propofol, a hypnotic agent used for the IV induction and maintenance of anesthesia (1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19 and 20). Apparently, the drug has not been used during the 1st and 2nd trimesters in humans. Reproduction studies in rats and rabbits at doses 6 times the recommended human induction dose revealed no evidence of impaired fertility or fetal harm (21).

The pharmacokinetics of propofol in women undergoing cesarean section was reported in 1990 (1). Propofol rapidly crosses the placenta and distributes in the fetus (2,3,4,5,6,7,8,9,10,11 and 12). The fetal:maternal (umbilical vein:maternal vein) ratio is approximately 0.7. Doses were administered either by IV bolus, by continuous infusion, or by both methods.

Several studies have examined the effect of maternal propofol anesthesia on infant Apgar scores, time to sustained spontaneous respiration, and Neurologic and Adaptative Capacity Score (NACS) or Early Neonatal Neurobehavioural Scale (ENNS) (1,2,4,5,7,8,11,12,13,14,15,16,17 and 18). Most investigators reported no difference in the Apgar scores of infants exposed to propofol either alone or when compared with other general anesthesia techniques, such as thiopental with enflurane or isoflurane (2,5,7,8,14,15,16,17 and 18). Moreover, no correlation was found between the Apgar scores and umbilical arterial or venous concentration of propofol (2,5,8,11,15).
 

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The real question is how safe Propofol is for a Cerclage procedure. Here you have a developing fetus (as oposed to the usual full term at c section) and a drug known to cross the placenta.

But, my bet is propofol is used everyday across the world for a cerclage under GA.
 

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Surprised nobody has pointed out yet that you can keep pentothal drawn up ready to go for a crash c-section for 24 hours, whereas with propofol you obviously cannot do that. That's the only advantage in this situation.

In my academic institution, however, we usually have a number of anesthesia residents showing up to crashes so there's usually one person available to draw up propofol while somebody else is throwing on monitors, a third is preoxygenating, etc, so we usually end up doing that instead. That way, nobody has to go through "all the trouble" of mixing up pentothal again. Nobody is afraid to use pentothal...just a bit lazy. :)
 

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More dogma. It always killed me when I saw a C/S room all setup for the crash case. Drugs just sitting there all drawn up and ready to be pushed. I don't get this.

It's about as stupid as drawing up every emergency drug in the world for every case and having it on your back cart. Why?
 

soorg

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No, definitely NOT afraid of pentothal, just that it doesn't seem to blunt airway reflexes as well as propofol. And yes, to all the wise guys (& gals), I am using the appropriate dose.

I do agree that pregnancy class shouldn't matter if the baby is coming out 1 minute after induction.

Good. I got my answer. Thanks to all.
 

drccw

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More dogma. It always killed me when I saw a C/S room all setup for the crash case. Drugs just sitting there all drawn up and ready to be pushed. I don't get this.

It's about as stupid as drawing up every emergency drug in the world for every case and having it on your back cart. Why?
I agree... in my general practice (mix of ortho/vascular/gen surg/ gyn/ thoracic)
I give ephedrine maybe twice a week.
Phenylephrine maybe twice a month
atropine? I can't remember the last time I gave it

Yet there are people that draw up everything up.. ridiculous..
waste of time and money....There are a lot of drugs wasted...
money and waste...

though on L&D I do make sure I have 2 syringes ready to draw the drugs into
drccw
 

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we have vials and labeled syringes in a clear mini-"crash cart" set up on the side of the Bluebell, reassures everyone to see and easy to notice when it isnt set up
 

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No, definitely NOT afraid of pentothal, just that it doesn't seem to blunt airway reflexes as well as propofol. And yes, to all the wise guys (& gals), I am using the appropriate dose.
.
Immediately after the parturient is unconscious from whatever induction agent given, you rapidly administer succinylcholine.

The succinylcholine removes worries about the induction agent's inability to blunt airway reflexes.

Succinylcholine blunts airway reflexes.

Extremely well.
 

fakin' the funk

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So we all, at least early in our careers: follow certain rules, use certain drugs, avoid certain drugs, cancel cases needlessly based on lab values that don't affect outcome, insert invasive lines that are actually deleterious, etc.
I'm playing devil's advocate here. What interventions that anesthesiologists do -- or what aspects of anesthesiology training -- DO affect outcome?
 

fakin' the funk

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More dogma. It always killed me when I saw a C/S room all setup for the crash case. Drugs just sitting there all drawn up and ready to be pushed. I don't get this.

It's about as stupid as drawing up every emergency drug in the world for every case and having it on your back cart. Why?
Just to clarify, you're saying...you don't need 10 drugs drawn up even in an emergency...you can draw up the 1-2 drugs that you'll need in 30 seconds and slam 'em in?
 

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Just to clarify, you're saying...you don't need 10 drugs drawn up even in an emergency...you can draw up the 1-2 drugs that you'll need in 30 seconds and slam 'em in?
Not exactly. What I'm saying is that I don't like the idea of drawing up a bunch of drugs and leaving them on the anesthesia cart in the OB room just in case there is a crash section.

In an emergency, I usually know what drugs I am going to need and I will draw them up as the case dictates usually b/4 the case gets started if I have the time. I don't know anyone that draws up a bunch of meds for the "possible" emergency case that may come through he door. Not talking about the c/s's here.
 

SleepIsGood

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Hey guys...the answer was in the Hall review book.

I dont have the book in front of me. But it was shown that in parturients there's a HIGHER incidence of cardiac arrthymias (aystole) with sux and propofol. Someone can check the reference.

On the explanation section they stated that this was not the case with pentothal and sux. I'm sure the fact that you can draw up pentothal and keep it there on the anesth machine also is a reason why it's preferred.
 

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If I remember correctly there are some reports about prolonged QT and torsade after Propofol.
I have to confess though that in the past 10 years I have used Propofol exclusively as the induction agent for all the C sections I did under GA and I never saw one single arrhythmia.




Hey guys...the answer was in the Hall review book.

I dont have the book in front of me. But it was shown that in parturients there's a HIGHER incidence of cardiac arrthymias (aystole) with sux and propofol. Someone can check the reference.

On the explanation section they stated that this was not the case with pentothal and sux. I'm sure the fact that you can draw up pentothal and keep it there on the anesth machine also is a reason why it's preferred.
 

urge

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I agree... in my general practice (mix of ortho/vascular/gen surg/ gyn/ thoracic)
I give ephedrine maybe twice a week.
Phenylephrine maybe twice a month
atropine? I can't remember the last time I gave it
Wut?!!!

I use neo drip 40mcg/ml for fluid maintenance. 4-2-1 rule.

What kind of patients do you have?

PS: Are you running a meth lab?
 

Noyac

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Wut?!!!

I use neo drip 40mcg/ml for fluid maintenance. 4-2-1 rule.

What kind of patients do you have?

PS: Are you running a meth lab?
:laugh:
I agree totally.

I had a day last week were I didn't give any neo to any pts all day. That was the first time I can remember this happening in 5 yrs.
 

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The more i advance the less pressors i use (less narcs too btw)
 

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The more i advance the less pressors i use (less narcs too btw)
and the less inhalation agent...although i sometimes use more narcs and less gas
 

jwk

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baby should be out in 90 secs.. 5 minutes is too long. tell your OBs to learn how to operate...
It's always amazing to me that, even in private practice, some guys doing crash C-Sections take 5min+ to get the baby out (and bovie bleeders on the way in) and others can get the baby out in 20 sec once I say go.

Surprised nobody has pointed out yet that you can keep pentothal drawn up ready to go for a crash c-section for 24 hours, whereas with propofol you obviously cannot do that. That's the only advantage in this situation.
We used to keep pre-mixed pentothal on our carts for up to 30 days. Our pharmacy is incredibly anal, but they never found any literature saying that was bad practice, and supposedly years ago did cultures to assure themselves that nothing evil was going to happen.

More dogma. It always killed me when I saw a C/S room all setup for the crash case. Drugs just sitting there all drawn up and ready to be pushed. I don't get this.
We get several pre-filled syringes from our pharmacy, including sux and lidocaine. We kept our C/S drugs out on the carts for years with no hassles from DEA, JCAHO, or the CMS inspectors. We changed this just recently because an outside contracted "mock surveyor nurse" claimed it was a big no-no, and you know how nurses are with their rules. This was about the same time that pentothal was in short supply for a few months, so now everyone has made the jump to propofol, and it's not drawn up ahead of time (takes about 1.4 seconds to draw up using one of those plastic spikes).

Anyway, for the occasional crash C/S, or a trauma or cardiac OR that is used pretty regularly, I don't see why you wouldn't have some meds ready to go. I definitely don't see the need to do it as a matter of routine for every case, and actually scold my students if I come in the room and their are 10 drugs drawn up (and 3 tubes, 2 blades, tape pre-torn, etc.)
 

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It's always amazing to me that, even in private practice, some guys doing crash C-Sections take 5min+ to get the baby out (and bovie bleeders on the way in) and others can get the baby out in 20 sec once I say go.


We used to keep pre-mixed pentothal on our carts for up to 30 days. Our pharmacy is incredibly anal, but they never found any literature saying that was bad practice, and supposedly years ago did cultures to assure themselves that nothing evil was going to happen.



We get several pre-filled syringes from our pharmacy, including sux and lidocaine. We kept our C/S drugs out on the carts for years with no hassles from DEA, JCAHO, or the CMS inspectors. We changed this just recently because an outside contracted "mock surveyor nurse" claimed it was a big no-no, and you know how nurses are with their rules. This was about the same time that pentothal was in short supply for a few months, so now everyone has made the jump to propofol, and it's not drawn up ahead of time (takes about 1.4 seconds to draw up using one of those plastic spikes).

Anyway, for the occasional crash C/S, or a trauma or cardiac OR that is used pretty regularly, I don't see why you wouldn't have some meds ready to go. I definitely don't see the need to do it as a matter of routine for every case, and actually scold my students if I come in the room and their are 10 drugs drawn up (and 3 tubes, 2 blades, tape pre-torn, etc.)
Agree with this...all these tubes, blades, etc is likely overkill.

I do think that if you are at a BUSY ob place where crashes can happen. It's probably a good idea to have some predrawn up stuff or at the least prelabeled syringes in an anesthesia cart (locked). We're lucky, we have the already labelled syringes with meds at our institution now. I still like to have a 'set' ready to go in the top drawer. Sometimes drugs run out during the day and pharmacy doesnt refil it. If you have stuff ready to go somewhere, atleast you know you have something at 1AM for that crash that comes in.
 

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Immediately after the parturient is unconscious from whatever induction agent given, you rapidly administer succinylcholine.

The succinylcholine removes worries about the induction agent's inability to blunt airway reflexes.

Succinylcholine blunts airway reflexes.

Extremely well.
Man, this is exactly what I wish other attendings/residents would get. In a regular case (lap chole,ob case, etc)..there's almost NO reason to ever give a full 2 mg/kg of propofol or whatever. ALMOST always in this country for adults we give mx relaxants IMMEDIATELY with the induction agents. Typically with just 1 mg/kg of prop, the fentanyl, the lido, and the midaz you have given the pt will be unconscious. Then you are typically giving mx relaxnt.

More propfol (or more any induction agent) just causes unnecessary hypotension (yes typically to no sequalae...except sometimes in a very fragile, catecholamine depleted pt).
 

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there's almost NO reason to ever give a full 2 mg/kg of propofol or whatever....Typically with just 1 mg/kg of prop, the fentanyl, the lido, and the midaz you have given the pt will be unconscious.
More propfol (or more any induction agent) just causes unnecessary hypotension (yes typically to no sequalae...except sometimes in a very fragile, catecholamine depleted pt).
I agree. My induction doses are comprable to yours, and I avoid iatrogenic hypotension. It galls me to see our "experienced" CRNA's push whole sticks (20ml) of propofol then 10mL (200mg) of sux and always have resultant hypotension. The sux I put in just to illustrate their regimen of over-dosing. 200mg of sux irrespective of pt weight?!?!?