Residents, Are You Trying Different Anesthetics?

[jetproppilot]

Residency, as we are all aware, is overall a pain in the a ss.

Change your mindset though, from showing up to work, setting your room up the same, drawing up the same syringes.....

to TRYING DIFFERENT WAYS TO ACCOMPLISH THE SAME THING, and you'll 1) increase your interest level at work 2) turn your prison time into time spent varying anesthetics 3)see that the smile you lost from your face a year ago because of the grind you are enduring may RETURN since you'll be doing some COOLSHI T!!!

Turns out residency is the bomb for this kinda professional enlightenment since during the rest of your career it'll be harder for you to try new things, mostly because you won't have time....

YOU'RE IN YOUR RESIDENCY!! CHANGE IT UP A BIT FROM TIME TO TIME!!!!

Ask yourself "What'll happen if I do THIS?"

Then do it.

You'll benefit as an anesthesiologist.

Your appreciation of pharmacology will become very finely tuned.....in addition to providing some entertainment for yourself, like watching a nurse push 2 milligrams of midazolam/morphine/etc over several minutes and realizing she was taught to do something totally unneccessary....

Lemme reflect on some of my "variations" when I was a resident and some of the variations of my resident colleagues.

1) TOTALLY BADASS, VERY OLD SCHOOL NITROUS NARCOTIC TECHNIQUE: 70% N2O, 30%O2, your-opiod-of-choice, background volatile (like 2% Des, .2% iso, .5% sevo OR 1mg midaz per hour....the background gas or benzo is for amnesia), and your non-depolarizer of choice...

....remembering this is a "light" anesthesia technique so ya gotta pay alotta attention to paralysis....

My residency did a tonna those BIG anterior-posterior back cases....you know...5-7 hours....so I decided for a period of months I'd do them nitrous-narcotic. I would select an opiod, use it over and over and over for weeks on end...then I'd switch to another. I'd pick a non-depolarizer....say vecuronium....and use it for weeks...then swith to pancuronium....rocuronium....

My most memorable technique was MORPHINE CURARE.

Yep....I was using the paralytic that aboriginies used on their arrows to kill monkeys...

And whats cool about this technique is you'll frontload with doses that'll scare you at first.... I've done an induction on a big back case with 1mg/kg morphine, .5mg/kg curare, 5mg midaz....

I thought about my anesthetic goals, one big one being I've gotta keep the mean arterial pressure around 60 during this case...

hmmmmm....morphine and curare cause alotta histamine release, which causes hypotension....

so I exploited the pharmacologic "side effects" of morphine and curare to my advantage.... and it worked!

So you may frontload with 70mg morphine.... or 500ug sufenta... or a milligram of fentanyl....run an infusion of sufenta/fentanyl....turn off the infusion an hour before extubation....tap on dude's head after reversal at the end, and see him open his eyes!!!

Cool, cool stuff.

2) Jeff P., a resident colleague of mine (Noyac knows him), decided he wanted to see what would happen if he gave a buncha sufentanil before induction.
So he's pre-O2ing this dude who's healthy and totally buzzed/amnestic on midazolam and he pushes 100ug sufenta....and waits...

...needless to say Jeff experienced for himself the rigid chest phenomenon.....no problem...sux-tube.....

3) VARIATION FROM THE NORM OF PREOPERATIVE SEDATION will allow you to learn what you can do, and what you cant..

You're in a controlled environment....on the OR table...monitors....airway stuff....how many times have you sat there with your thumb up your a ss waiting for a surgeon or an anesthesia attending?

MAKE USE OF YOUR TIME!!
....what happens if you slam in 5mg midazolam?
....50mg propofol?
....20 mg propofol?
....5 mg morphine?
....10ug sufentanil?
....250ug fentanyl?

4) EVER DONE A KNEE SCOPE with just propofol, an LMA, gas, and toradol? How many (small) cases have you done with no opiod? You'd be surprised how overused opiods are for simple cases, and how many PACU HEADACHES (nausea, vomiting, oversedation) you can avoid by sometimes doing an anesthetic sans opiod.....another great one is if youre doing a TKA/THA under epidural, why give any opiod at all? Dudes numb as Steven Tyler-in-the-70s-singing-SWEET EMOTION, right? Propofol infusion during the case. No opiod. Try it.

Certainly wouldnt suggest varying from the norm as a CA-1...or if you're working with an uptight attending...

As a CA-2, though, CA3, you'll do cases with attendings that'll give you the ropes.

Nows the time to learn more about these drugs we use every day....to learn more than anything you'll read in a textbook...

Residency colleagues, now's the time to expand your horizons.

On techniques.

Doses.

Different combinations.

And...uhhh....do me a favor, huh?

Post your experiences.

Cuz we can all learn from your travels too.

---

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[videolectures]

excellent post as usual.

part that hurts most is having been on awesome outside rotations and learning completely different styles of providing anesthesia (that are rather institutional) and then coming back...being forced to conform to the original institutional way of anesthesia...almost like back to square one.

Residency is the time to try different modalities of providing anesthesia alternatives yet balanced with debating/arguing and fighting the attendings ways

 

[lvspro]

First 2 mo's were spent learning a single common technique. After I got that down pat, i started using just about everything else. We don't have access to things like precedex, remi, and other expensive Rx, but I make do with what we have. Today my combos now look nothing like when I started.

On another note, I'm in my 2nd month of ICU and am realizing that I'm gonna be all straight OR medicine.

 

[coprolalia]

part that hurts most is having been on awesome outside rotations and learning completely different styles of providing anesthesia (that are rather institutional) and then coming back...being forced to conform to the original institutional way of anesthesia...almost like back to square one.

I have to agree with this. Most attendings I've met become threatened when you suggest a different way of trying an anesthetic other than their already thought-out, self-perceived-as-superior, usual way of doing things. And, if they actually let you try something different, they wait to pounce on you if/when it doesn't go smoothly.

I have become so jaded in my PGY-4 year. It is a rare breed of clinician who doesn't feel threatened by a resident. Most don't want you to think, but just conform. They feel that you don't have the experience yet to have an independent thought, and that you should learn by copying them. Even small stylistic mistakes are not tolerated. I have a feeling that a large portion of my true learning is going to occur next year as I move into PP.

Right now, I'm just resigned to collecting additional data, doing what I'm told, and trying to get ready to pass the boards. I will wait to "try" my acquired knowledge in the real world.

-copro

 

[Planktonmd]

4) EVER DONE A KNEE SCOPE with just propofol, an LMA, gas, and toradol? How many (small) cases have you done with no opiod? You'd be surprised how overused opiods are for simple cases, and how many PACU HEADACHES (nausea, vomiting, oversedation) you can avoid by sometimes doing an anesthetic sans opiod.....

Absolutely!
In residency they teach that everyone needs narcotics and it becomes a reflex, you can't induce anesthesia without subconsciously reaching for the blue syringe, it takes years of deconditioning to realize that it is actually possible to do a perfect GA with little or no narcotics.

 

[Trisomy13]

does inadvertent neuroleptanalgesia with droperidol count?


good post jet. we have a few attendings who encourage us to try different anesthetics, and a few more who are ok with whatever we want to do, and then the usual bunch of cookbook academics.

fortunately we have easy access to most anything when it comes to drug selection, so there is a fair amount of remi, dex, etc infusions, along with the occasional ketamine for the experience.

 

[videolectures]

I have been noticing a change in perspective in myself.

Before when I would see elevated BP I would instinctly reach for the blue syringe...now I have been reaching for beta blockers

An attending woking in the ambulatory setting that I admire mentioned to me he treats resp rate with narcotics, and BP HR with beta blockers. I guess he can do this bec nearly all his patients are breathing spontaneous with LMA

 

[mille125]

I have to agree with this. Most attendings I've met become threatened when you suggest a different way of trying an anesthetic other than their already thought-out, self-perceived-as-superior, usual way of doing things. And, if they actually let you try something different, they wait to pounce on you if/when it doesn't go smoothly.

I have become so jaded in my PGY-4 year. It is a rare breed of clinician who doesn't feel threatened by a resident. Most don't want you to think, but just conform. They feel that you don't have the experience yet to have an independent thought, and that you should learn by copying them. Even small stylistic mistakes are not tolerated. I have a feeling that a large portion of my true learning is going to occur next year as I move into PP.

Right now, I'm just resigned to collecting additional data, doing what I'm told, and trying to get ready to pass the boards. I will wait to "try" my acquired knowledge in the real world.

-copro

this is sad but true. I hate to say it but I think that a lot of the academic attendings are either lazy or have other issues to worry about. If they let you "deviate from their protocol", it may mean that they need to be more available. dont worry CA3 year will pass quickly. learn what you can while you are there.

 

[tussionex]

My most memorable technique was MORPHINE CURARE.

where did you get curare?

very cool!

 

[Trisomy13]

for today's Whipple:

precedex and sufentanil infusions with half MAC Sevo, thoracic epidural for post-op.

not wildly different but a chance to play with sufenta...

 

[Monty Python]

where did you get curare?

very cool!

Some places still have d-tubo curarine.

 

[Mman]

I mix it up all the time.

When using volatile agents, one week I use nothing but Des, the next week Sevo, and the following week Iso. Keeps me from getting bored. Every now and then I'll go with TIVA for a while.

I also mix up muscle relaxants between Roc and Vec and Cis.

I got on a kick of using Fent/Lido/Ketamine/Prop for induction for a while. Got them nice and deep without much hypotension.

Sometimes I'll bust out the Dexmeditomidine for a few cases.



I could do Prop/Sux/Tube til the cows came home, but that would be kind of boring after a while.

 

[2ndyear]

Another cool thing is to try to max out pain receptors with premeds. Google some articles and do a lit search. Next time you're doing backs on chronic painers, feed them a gram of tylenol, handful of neurontin, and induce with some ketamine.

 

[lvspro]

Another cool thing is to try to max out pain receptors with premeds. Google some articles and do a lit search. Next time you're doing backs on chronic painers, feed them a gram of tylenol, handful of neurontin, and induce with some ketamine.

Care to elaborate on neurontin doses?

 

[tussionex]

Some places still have d-tubo curarine.

we don't. we're boring.

 

[042686]

Bump

 

[pushthesux]

Tried a new anesthetic today....rocuronium, tube, and a pulse ox.

Very smooth.

Didn't have to worry about drawing up all those other drugs.

Didn't have to worry about charting HR/BP's cause I wasn't monitoring them.

Think of how much money I saved.

Most importantly, the patient didn't move for her lap chole and the surgeons were happy.

 

[Monty Python]

....... I also mix up muscle relaxants between Roc and Vec and Cis.

.

If you want your older attending to smile, or the younger one to grimace, mix up a sux drip for your next 20 minute case where paralysis is preferred. Add a drop of indigo carmine or other dye to the bag, attach it to your mainline IV, and let 'er rip after the usual induction drugs and intubation. Turn it off about 5 minutes prior to waking up.

http://www.brooksidepress.org/Produ.../DATA/operationalmed/Meds/Succinylcholine.htm

Must keep in mind some of the peripheral consideration of sux, however: http://www.rxmed.com/b.main/b2.phar...hs/CPS- (General Monographs- A)/ANECTINE.html

For more fun, set up a modified Jackson-Rees nonrebreather:

http://www.harvardapparatus.com/web...1051_37415_-1_HAI_ProductDetail_N_37326_37345




.

 

[NUGasStud]

An older attending was telling me the other day about the times before the nondepolarizers. All they had was sux drips. They put indigo carmine in the bag to let people know that the bag was sux. Blue bag = Succinylcholine.

 

[Noyac]

Why the indigo carmine?

I think its so that you can see that it is actually infusing since the sux infusion is clear and also you can tell when it is has all cleared the tubing when you shut it off. I use propofol for this on clear drips like sufenta, remi, etc. Just mix a very small amount of prop in the bag or syringe just enough to cloud the solution up. Now I can tell that it is actually running.

 

[Noyac]

An older attending was telling me the other day about the times before the nondepolarizers. All they had was sux drips. They put indigo carmine in the bag to let people know that the bag was sux. Blue bag = Succinylcholine.

thats what the labels are for. but your probably more right than I.

 

[nutmegs]

Any suggestions for something fun for a neuromonitoring spine case tomorrow? They want you to max out at 0.5MAC of volatile. I was thinking remi/precedex, but open to suggestions.
(<- hasn't done neuro yet so this is still new)

 

[Noyac]

Any of you guys/gals ever masked a whole case instead of placing an LMA or even after paralyzing the pt? This teaches you more than just how to effectively mask someone. It also teaches you to chart with one hand, draw up drugs, etc.

 

[Fastrach]

Any of you guys/gals ever masked a whole case instead of placing an LMA or even after paralyzing the pt? This teaches you more than just how to effectively mask someone. It also teaches you to chart with one hand, draw up drugs, etc.

Yeah, once had a d*ckhead staff who made me do that as punishment for not getting an LMA in on the first dunk. What an a-hole.

 

[Monty Python]

An older attending was telling me the other day about the times before the nondepolarizers. All they had was sux drips. They put indigo carmine in the bag to let people know that the bag was sux. Blue bag = Succinylcholine.

Now you're talking.

Although I believe it was taken off the market several years ago, powdered sux was available in 500 mg amps, which you jammed directly into the additive port on a 250 cc bag of normal saline.

 

[Monty Python]

Any suggestions for something fun for a neuromonitoring spine case tomorrow? They want you to max out at 0.5MAC of volatile. I was thinking remi/precedex, but open to suggestions.
(<- hasn't done neuro yet so this is still new)

I moonlight at a Shriner's Hospital, where we do teenage scoliosis out the wazoo. Usually done with continuous infusions of esmolol and remi.

Double-check before giving any post-induction paralytic. And if you're using remi, don't forget another narcotic on board for post-op pain as you prepare to shut off the remi. Remi is almost like a light switch.

While my experience with precedex is limited to hearts/livers and MAC infusion for total joints, I could see it potentially having a place on your neuro case --- but don't take my word for it.

 

[Monty Python]

Any of you guys/gals ever masked a whole case instead of placing an LMA or even after paralyzing the pt? This teaches you more than just how to effectively mask someone. It also teaches you to chart with one hand, draw up drugs, etc.

Yeah, masking and/or bagging an entire case is really fun for those of us left-handers. Picture in your mind bagging with the right hand while writing with the left, with clipboard balanced on the left leg, or else on the anesthesia machine with left arm going under the right arm (which is bagging).

 

[ZA_Gasman]

Yeah, masking and/or bagging an entire case is really fun for those of us left-handers. Picture in your mind bagging with the right hand while writing with the left, with clipboard balanced on the left leg, or else on the anesthesia machine with left arm going under the right arm (which is bagging).

I feel your pain. Am also lefty, it gets tough. At one of the hospitals I trained at, we had a gynae emergency list - mainly D&C for incompletes with the odd ectopic for good measure. We often had 12-15 cases on a morning list. All first/early second trimester, all facemasked with the right hand, charted with the left. Didn't know what to do with the right hand if a student was holding the mask!

But at least, we're the only ones in our right minds......

 

[pushthesux]

Any suggestions for something fun for a neuromonitoring spine case tomorrow? They want you to max out at 0.5MAC of volatile. I was thinking remi/precedex, but open to suggestions.
(<- hasn't done neuro yet so this is still new)

Squirt 1mg of remi into your 100ml bottle of propofol. After induction, start the propofol around 100-150 m/k/m (.1 to .15 m/k/m remi). Run dex at 0.5-0.7 m/k/h instead of your gas for a TIVA. Or you can just run about a half MAC of des.

Once they are closing (and done monitoring), you can turn everything off but the dex and extubate with the dex running.

Or, if you are running gas you can turn everything off and turn the gas up to 0.8 MAC cause its easier to titrate.

If they are just doing SSEP's you can run relaxant and knock the anesthetic doses down a little.

Lots of options with neuro.

 

[Dejavu]

Care to elaborate on neurontin doses?

Since nobody answered you, I will.

As part of our Total Joint Regional Anesthesia protocol, we give Neurontin 600 mg (and Oxycontin 10-20 (age dependent) and Celebrex 400mg) to all of our total joint pts. I also do the same to many, many other types of cases.

The neurontin has been pretty well studied at 600 and 1200 mg doses preop. Some excess sedation with 1200 and no significant added benefit led us to use 600mg in our protocol.

Apparently the Neurontin will drop pain scores by 30-40% for two days after surgery, both ortho and general surgery.

There are equal results in multiple studies with the pre-incision use of Ketamine 0.1-0.15mg/kg IV. Also drops pain scores for a couple of days in these studies without significant side effects. I give just about all of my pts 10 mg IV Ketamine just after induction. And it is the first thing I order when I get the PACU call about the resp rate of 5 and pain of 9/10.

 

[Noyac]

Yeah, masking and/or bagging an entire case is really fun for those of us left-handers. Picture in your mind bagging with the right hand while writing with the left, with clipboard balanced on the left leg, or else on the anesthesia machine with left arm going under the right arm (which is bagging).

I didn't know they let lefties do anesthesia.

 

[dhb]

Intubating dose of remi

 

[Frank Rizzo]

used droperidol yesterday for preop sedation with placing lines.

 

[urge]

used droperidol yesterday for preop sedation with placing lines.

How much did you give? Was it "Push"?

I'm considering it for my fiberoptics.

 

[DET0897]

If you want your older attending to smile, or the younger one to grimace, mix up a sux drip for your next 20 minute case where paralysis is preferred. Add a drop of indigo carmine or other dye to the bag, attach it to your mainline IV, and let 'er rip after the usual induction drugs and intubation. Turn it off about 5 minutes prior to waking up.

http://www.brooksidepress.org/Produ.../DATA/operationalmed/Meds/Succinylcholine.htm

Must keep in mind some of the peripheral consideration of sux, however: http://www.rxmed.com/b.main/b2.phar...hs/CPS- (General Monographs- A)/ANECTINE.html

For more fun, set up a modified Jackson-Rees nonrebreather:

http://www.harvardapparatus.com/web...1051_37415_-1_HAI_ProductDetail_N_37326_37345




.

Was considering a sux gtt the other day for a diagnostic laparoscopy followed by big ass back whack with montioring. Didn't do it though. Question: I assume you monitor twitches throughout the drip. In longer cases, is there a way to predict when you could be near Phase II block before actually achieving it?

 

[dhb]

used droperidol yesterday for preop sedation with placing lines.

drop will give you sedation but no anxiolysis so i think it's a bad drug for procedural sedation.

 

[9french]

drop will give you sedation but no anxiolysis so i think it's a bad drug for procedural sedation.

Worse, it can actually cause dysphoria. You push the drug pre-op for sedation, and all of a sudden the patient develops a feeling of impending doom.

The surgeon will be very unhappy if he ever finds out the reason the patient all of sudden refused to go back, saying, " I don't want to go back, I think I'll die," was because of your anesthetic medication.

 

[Monty Python]

Worse, it can actually cause dysphoria. You push the drug pre-op for sedation, and all of a sudden the patient develops a feeling of impending doom.

The surgeon will be very unhappy if he ever finds out the reason the patient all of sudden refused to go back, saying, " I don't want to go back, I think I'll die," was because of your anesthetic medication.

A chief CRNA where I used to work was scheduled for a subaceous cyst removal on a Friday. Out of professional curiosity, and knowing the above facts, he intentionally wanted only preop droperidol -- no versed, no valium, nothing but drop.

His IV was started in the preop holding room, and he received the drop. About 10 minutes later he ripped out the IV and stormed out of the hospital, directly to his car with his wife following.

The next Monday when he returned to work, he apologized profusely to everyone including the surgeon. He said he had felt like the the world was about to come to a horrible ending after receiving the drop.

 

[Monty Python]

Was considering a sux gtt the other day for a diagnostic laparoscopy followed by big ass back whack with montioring. Didn't do it though. Question: I assume you monitor twitches throughout the drip. In longer cases, is there a way to predict when you could be near Phase II block before actually achieving it?

I'd rather quote the experts here:

The transition from Phase I to Phase II block has been reported in 7 of 7 patients studied under halothane anesthesia after an accumulated dose of 2 to 4 mg/kg succinylcholine (administered in repeated, divided doses).

In another study, using balanced anesthesia (N2O/O2/narcotic/thiopental) and succinylcholine infusion, the transition was less abrupt, with great individual variability in the dose of succinylcholine required to produce Phase II block. Of 32 patients studied, 24 developed Phase II block. Tachyphylaxis was not associated with the transition to Phase II block, and 50% of the patients who developed Phase II block experienced prolonged recovery.

For Long Surgical Procedures: The dosage of succinylcholine administered by infusion depends upon the duration of the surgical procedure and the need for muscle relaxation. The average rate for an adult ranges between 2.5 and 4.3 mg/min.

The more dilute solution (1 mg/mL) is probably preferable from the standpoint of ease of control of the rate of administration of the drug and hence, of relaxation. This i.v. solution containing 1 mg/mL may be administered at the rate of 0.5 mg (0.5 mL) to 10 mg (10 mL)/minute to obtain the required amount of relaxation. The amount required/minute will depend upon the individual response as well as the degree of relaxation required. Avoid overburdening the circulation with a large volume of fluid. It is recommended that neuromuscular function be carefully monitored with a peripheral nerve stimulator when using succinylcholine by infusion in order to avoid overdose, detect development of Phase II block, follow its rate of recovery, and assess the effects of reversing agents (see Precautions).

source: http://www.rxmed.com/b.main/b2.phar...hs/CPS- (General Monographs- A)/ANECTINE.html

 

[Planktonmd]

A chief CRNA where I used to work was scheduled for a subaceous cyst removal on a Friday. Out of professional curiosity, and knowing the above facts, he intentionally wanted only preop droperidol -- no versed, no valium, nothing but drop.

His IV was started in the preop holding room, and he received the drop. About 10 minutes later he ripped out the IV and stormed out of the hospital, directly to his car with his wife following.

The next Monday when he returned to work, he apologized profusely to everyone including the surgeon. He said he had felt like the the world was about to come to a horrible ending after receiving the drop.

This is what happens when you give an insufficient dose of Droperidol.
If you give enough they will feel that the " world is about to come to a horrible ending" but they won't have enough energy to do anything about it.
This is the beauty of anti Dopaminergic drugs.

 

[coprolalia]

This is what happens when you give an insufficient dose of Droperidol.
If you give enough they will feel that the " world is about to come to a horrible ending" but they won't have enough energy to do anything about it.
This is the beauty of anti Dopaminergic drugs.

-copro

 

[coprolalia]

Case in point - the following thread:

http://forums.studentdoctor.net/showthread.php?t=557462

How many attendings, if you said, "I want to use thiopental for this induction," would meet you with a similar sentiment described towards the bottom of that thread?

I can't tell you how many times I've heard similar mutterings from those who are attempting to teach me.

In general, there are a lot of different ways to skin a cat out there. We're not talking about dripping ether onto cotton balls here. But, drugs that are still in use and in practice that we don't get access to because attendings are uncomfortable with them, have never used them (I've had several attendings who've never used alfentanil, for example), or simply don't like them.

Find those who are willing to let you experiment with different techniques and, more importantly, learn from your own experience what works and what doesn't. I'm not talking about doing unsafe things, but instead about gaining the ability to have a diverse personal evidence base on which to draw your own conclusions.

It really saddens me that there are many of you out there who will make it your entire way through residency and have never done, for example, a Brevital or Pentothal or Midazolam/Fentanyl-only induction. I feel bad for you. I really do.



-copro

 

[jetproppilot]

It really saddens me that there are many of you out there who will make it your entire way through residency and have never done, for example, a Brevital or Pentothal or Midazolam/Fentanyl-only induction. I feel bad for you. I really do.



-copro

Cop's point is a good one.

Now is the time, resident colleagues, to MIX IT UP.

 

[dhb]

(I've had several attendings who've never used alfentanil, for example

Those damn FMG's

I feel bad for you. I really do.

I feel bad that you feel bad

ps you can only mix up what your pharmacy carries (they still make alfentanil??)

 

[urge]

I like the thread in general but I don't like the notion that as an attending you don't have "time" to try new techniques. So, what if your attendings don't let you use alfenta, pent..... Do it when you are your own attending. There is nothing preventing you from it.

 

[tussionex]

ps you can only mix up what your pharmacy carries (they still make alfentanil??)

yes, we carry both alfenta and sufenta. only one doc uses them. we dont carry any remi, though.
everyone else carries a fent/versed/morphine...maybe some ketamine.

 

[OB1🤙]

Many firsts this past week.

Wednesday did my first ever subclavian line- doesn't count as mixing it up I guess, but it was the first time an attending was willing to let me do one.

Thursday busted out a sufenta induction with mini squirts of propofol. Very smooth, worth the funny looks pharmacy gave me when I asked for it. Finally lost my sufenta virginity.

Today played around with an iso/nitrous mix at the behest of an attending who thinks that sevo is terrible and should never be used outside of mask inductions. Hadn't used iso yet in residency. The wakeups were very smooth, I gotta say.

Last week was playing with a "6/2/2" mix one of the guys who does a lot of eyes came up with- 6ccs propofol, 2ccs (1000mcg alfenta), 2ccs 1% lidocaine for a retrobulbar block. Usually about 4-6 ccs of this mix makes the retrobulbar block nice and smooth.

Fun all around. Obviously nothing earth-shattering, but for this CA-1, it's been fun.

 

[Monty Python]

Thursday busted out a sufenta induction with mini squirts of propofol. Very smooth.

This was my sufenta technique when the second year residents were doing the four-five hour abdominal hysts at a teaching hospital.

Induce with total of 50 mics (1 cc) of sufenta, broken up in thirds given over about 90 seconds. Perhaps 5 cc of propofol to get them completely over the edge. Paralyze, ETT, vent, very low % of forane.

Take the other 1 cc of sufenta remaining and mix it IVPB, infusing continuously about 15 mic/hr, started when they were reaching for the skin scalpel. The trick when using a sufenta drip is knowing when to turn it off. With residents, it's when the abdominal retractors come out. In private practice, it's when the target organ is removed.

Once the sufenta is off, I'd give 25-50 mg of demerol IM.

You will be amazed how smoothly and comfortably the sufenta pts wake up, no bucking, and moving themselves to the gurney.

 

[Mofeen]

Anyone care to chime in with a TIVA recipe for your run of the mill abdominal case? Thinking about busting out some Sufenta tomorrow.

 

[Green912]

ENT cases w/certain staff: Propofol, Remi, Nitrous

For cases >2hrs we're supposed to use a Sufenta infusion instead of Remi. Gotta remember to turn if off much sooner than remi.

Used a Dexmetatomidine gtt for a MAC case last week. Worked a bit better with the occasional 0.5mg of Midaz. I was hoping the med would be much better than a propofol gtt but wasn't blown away.