Remifentanil wake-ups

[GassYous]

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I'm sure, but there are 15 private hospitals in my city and the neuromonitoring guys I talk to say that they only regularly work at 3 of them. I like those odds.

Would you like me to start using remi for TKA's and penile prosthetics?

It would give new meaning to opioid induced rigidity

 

[abolt18]

+1 for drop. Wish we still had it.

Anyone use precedex to prevent emergence delirium and agitation in this population? I haven’t used it enough to form an impression.

How were you dosing droperidol? What scenarios were you using it for exactly? We just added it back to our formulary and it's part of our "ponv prophylaxis/treatment algorithm" that the pharmacists made... It's given in a baby dose, like 2.5mg up to 2 times. I haven't used it yet.

 

[deleted87051]

How were you dosing droperidol? What scenarios were you using it for exactly? We just added it back to our formulary and it's part of our "ponv prophylaxis/treatment algorithm" that the pharmacists made... It's given in a baby dose, like 2.5mg up to 2 times. I haven't used it yet.

That’s a lot. The patients will definitely not be complaining of nausea because they’ll be asleep. Standard dose for nausea was 0.625mg. I’d use 2.5mg to chill them out.

 

[abolt18]

That’s a lot. The patients will definitely not be complaining of nausea because they’ll be asleep. Standard dose for nausea was 0.625mg. I’d use 2.5mg to chill them out.

Maybe that's the dose... 0.625. It's brand new, haven't looked at the protocols/algorithms very closely.

 

[deleted87051]

Maybe that's the dose... 0.625. It's brand new, haven't looked at the protocols/algorithms very closely.

Also fwiw, there used to be a medication marketed as Innovar for neuroleptanesthesia. It was a combination of fentanyl and droperidol. It was taken off the market before I started but my attendings used to tell me about it when I was a resident.

 

[Hork Bajir]

From this old school paper about innovar:

“Although the technique described Iacked the flexibility of Inhalation anaesthesia certain advantages deserve further consideration. Among them; the possibility to intubate the patient without loss of reflexes and Without relaxants, the lack of circulatory depression, the possible benefit of a mild adrenergic bloekade, the rapid return of responsiveness, and the calm postoperative period with reduced drug requirements were particularly noticed.”

Sounds pretty damn good, TBH.

The paper is interesting to skim if anyone is trying to kill a few minutes (I find super old school anesthesia papers so interesting):

https://link.springer.com/content/pdf/10.1007%2FBF03004423.pdf

 

[zizzer]

I don't understand the animosity towards neuromonitoring techs. It might make your job easier, but if it's necessary for the surgeon to safely fix the patient's problem, why does everybody complain? It seems akin to a surgeon complaining about us taking the time to preoxygenate fully or something like that because it makes his day longer. Besides, if you guys already aren't already running people on low volatile, you should give it a try anyway. I agree that dealing with MEPs can make things more challenging sometimes though.

 

[GassYous]

I don't understand the animosity towards neuromonitoring techs. It might make your job easier, but if it's necessary for the surgeon to safely fix the patient's problem, why does everybody complain? It seems akin to a surgeon complaining about us taking the time to preoxygenate fully or something like that because it makes his day longer. Besides, if you guys already aren't already running people on low volatile, you should give it a try anyway. I agree that dealing with MEPs can make things more challenging sometimes though.

I don't have any animosity towards them. But I do think that it is silly that the patient is charged tens of thousands for something that I'm not convinced actually helps. Then again I'm not the surgeon or the patient so I generally keep my opinions to myself.

 

[abolt18]

I don't have any animosity towards them. But I do think that it is silly that the patient is charged tens of thousands for something that I'm not convinced actually helps. Then again I'm not the surgeon or the patient so I generally keep my opinions to myself.

How many times have you seen the surgeon change what they're doing based on "decreased signals"?

 

[Mehd School]

I don't understand the animosity towards neuromonitoring techs. It might make your job easier, but if it's necessary for the surgeon to safely fix the patient's problem, why does everybody complain? It seems akin to a surgeon complaining about us taking the time to preoxygenate fully or something like that because it makes his day longer. Besides, if you guys already aren't already running people on low volatile, you should give it a try anyway. I agree that dealing with MEPs can make things more challenging sometimes though.

Is it necessary for the surgeon? I don't know. The data out there that justifies it's existence isn't very strong. Meanwhile, it significantly increases the cost to the patient as well as puts them at higher risk of having lighter anesthesia and/or moving during a critical portion of the case.

 

[GassYous]

How many times have you seen the surgeon change what they're doing based on "decreased signals"?

I don't recall it happening. Usually they say "hey I just advanced the screw how are the signals" and the signals are fine. I remember one time the signals on one side were worse than the other side and apparently it was like that the whole time but surgeon didn't understand when they told him. Surgeon was mad after the tech switched and it was explained but patient was fine postop so...

 

[Mehd School]

How many times have you seen the surgeon change what they're doing based on "decreased signals"?

Almost never. Decreased signals are almost unanimously blamed on pt's MAP even if I'm telling them we're at their goal of >85 (which again the data isn't good for this).

 

[woopedazz]

How were you dosing droperidol? What scenarios were you using it for exactly? We just added it back to our formulary and it's part of our "ponv prophylaxis/treatment algorithm" that the pharmacists made... It's given in a baby dose, like 2.5mg up to 2 times. I haven't used it yet.

Big dose! Probably 0.5mg BD is the PONV protocol. That's what we do at ours.
I use it pretty frequently intra-op for those who can't receive dexamethasone/other antiemetic(s).
I also use it with ergometrine 100% of the time to good effect.

 

[pgg]

How were you dosing droperidol? What scenarios were you using it for exactly? We just added it back to our formulary and it's part of our "ponv prophylaxis/treatment algorithm" that the pharmacists made... It's given in a baby dose, like 2.5mg up to 2 times. I haven't used it yet.

I always used a single 0.625 mg dose.

 

[abolt18]

I always used a single 0.625 mg dose.

I just double-checked and this is the dose that they recommended for us. 0.625-1.25mg.