Residents, Are You Trying Different Anesthetics?

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For a while I tried Sufenta infusions with prop and a little gas, usually for back cases with monitoring. I would occasionally bolus the Sufenta (5-10 mcg) for rising blood pressure, only to see a steady and sustained drop to uncomfortable levels that did not reverse easily about 15-20 minutes later. Perhaps I was just bolusing to much Sufenta, or maybe my infusion was too low a rate, but this kind of put me off the drug. I prefer running Remi and titrating it, then bolusing 0.5-2 mg Dilaudid near the end of the case.

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The doc I was with in December did a lot of backs with monitoring which required .5 mac. Always used Precedex. 100mcg put in a 50 CC NS bag. Gave 10 mcg during induction with the drip set up for between 8-14 ml's hour depending on his mood. Induction with 170 or so mg propofol, succ with a nibble of roc beforehand, 2mg versed, and some fentanyl. Doc had been doing neuro cases long enough that he would know when the surgeon was about to advance to a more painful/stimulating part of the case, and he would slip a biscuit of versed, fentanyl, and maybe some roc. Very light with the roc as not to mess up the monitoring, but enough to make him feel comfortable the patient wasn't going to move as the surgeon is swimming through the cauda equina. Patients would always extubate smoothly, snore being pushed to recovery, but answer questions/follow orders as needed. Sometimes we would use precedex drip with propofol/ketamine infusion with the same result. To correct low BP, we had premixed a 100cc bag with a cc of phenylephrine. Filled up a 10cc syringe for the case. Keep the rest for next patient. BP start to drop, slip a cc or two in. Dude was a jedi.
 
The doc I was with in December did a lot of backs with monitoring which required .5 mac. Always used Precedex. 100mcg put in a 50 CC NS bag. Gave 10 mcg during induction with the drip set up for between 8-14 ml's hour depending on his mood. Induction with 170 or so mg propofol, succ with a nibble of roc beforehand, 2mg versed, and some fentanyl. Doc had been doing neuro cases long enough that he would know when the surgeon was about to advance to a more painful/stimulating part of the case, and he would slip a biscuit of versed, fentanyl, and maybe some roc. Very light with the roc as not to mess up the monitoring, but enough to make him feel comfortable the patient wasn't going to move as the surgeon is swimming through the cauda equina. Patients would always extubate smoothly, snore being pushed to recovery, but answer questions/follow orders as needed. Sometimes we would use precedex drip with propofol/ketamine infusion with the same result. To correct low BP, we had premixed a 100cc bag with a cc of phenylephrine. Filled up a 10cc syringe for the case. Keep the rest for next patient. BP start to drop, slip a cc or two in. Dude was a jedi.


If that's a jedi, I'm doing something right.

Looks like a pretty typical anesthetic for a back case, and nothing special. 1/2 MAC Sevo, remi/sufenta infusion, +/- propofol/precedex. Bolus for the pinning and the painful parts (which take all of about 10 cases to figure out). Neo for pressure. Yay, I'm a jedi!

One could argue that the rocuronium is wholly unnecessary and if anything, contraindicated due to the monitoring. I'm not sure trying to dose rocuronium to "not mess up the monitoring, but enough to make him feel comfortable" is anything but a homeopathic approach.
 
If that's a jedi, I'm doing something right.

Looks like a pretty typical anesthetic for a back case, and nothing special. 1/2 MAC Sevo, remi/sufenta infusion, +/- propofol/precedex. Bolus for the pinning and the painful parts (which take all of about 10 cases to figure out). Neo for pressure. Yay, I'm a jedi!

One could argue that the rocuronium is wholly unnecessary and if anything, contraindicated due to the monitoring. I'm not sure trying to dose rocuronium to "not mess up the monitoring, but enough to make him feel comfortable" is anything but a homeopathic approach.

Funny how there are so many ways to do the same case. My normal is for backs is a $5 anesthetic: 0.5 ET% iso, 50% nitrous and hydromorphone at the end. Monitoring: SSEPs = full relaxation, MEPs = vec infusion for 3 twitches or no relaxation. I couldn't use Precedex if I wanted to (P&T committee has it locked up in the safe next to the gold bullion).
 
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