BobBarker

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Anybody do this? I have heard of someone filling up a 50ml NS bag up with the induction agents and dripping it in as they apply monitors and preox.
 

pgg

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Why on earth would someone want to do that? To save 20 seconds, at the expense of not getting a set of pre-induction vitals?
 

urge

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Anybody do this? I have heard of someone filling up a 50ml NS bag up with the induction agents and dripping it in as they apply monitors and preox.
Yes, but not like that. Big syringe with all sorts of stuff inside.
 

nimbus

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30 ml syringe with prop/roc/xylo. Been doing it for years. Works great.
 

G0S2

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Some military docs where I trained taught me the 100 cc propofol with 250 fent and 100 ketamine. Pt hits room run at 300 mcg/kg/min propofol. By the time monitors on, intubated. Cut down to 200 and run case at 150.
 

chmd

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The silver bullet is a 3cc syringe with 2cc of 50mg/cc ketamine and 1cc of 5mg/cc midazolam. That is then used to mix 10mg of vec.
 

Idiopathic

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we take care of different patients, you and i

edit: i mean obviously not true, but i take induction pretty seriously. i still make my residents mask ventilate, etc.

the closest thing to this that I do is push roc before propofol in my RSI
 

pgg

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One syringe with all your induction meds, sure. But I can't for the life of me figure out why anyone would deliberately start a drip-drip-drip induction before the patient has monitors on. What's the benefit?

This is like populating an island with cloned dinosaurs, lots of talk about if it could be done but not whether it should be done.
 

G0S2

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One syringe with all your induction meds, sure. But I can't for the life of me figure out why anyone would deliberately start a drip-drip-drip induction before the patient has monitors on. What's the benefit?

This is like populating an island with cloned dinosaurs, lots of talk about if it could be done but not whether it should be done.

The benefits of TIVA and time to reach steady state. I love it.
 

Idiopathic

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ive induced with drips before, in residency. you really have to do it right, it is pretty awful watching someone slowly go through the stages of anesthesia right in front of you, begging you to put them to sleep.

im sure i did it wrong, but i saw zero value in it
 

Mman

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you can concoct more than a hundred ways to induce anesthesia in somebody, but nearly all of them are merely a thought exercise that you probably would be best not using on actual patients because there is a better way to do it.
 

Idiopathic

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I know it's rare for the IV to blow between meds. But it does happen...
yeah i usually scope out the IV landscape in these patients because it is my one worry, also, i can get someone induced with volatile & nitrous pretty quickly if i have to. always important to remember this.
 

Jay K

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When I first started private practice I tried an induction mixture of 50mg lidocaine, 110mg propofol, 2mg midazolam and 100mcg fentanyl in a 20mL syringe, but that has subsequently evolved "back" to individual dosing schemes.

I've found more benefit for my adult patients to be able to give midazolam slightly ahead of pre-oxygenation and monitors, and then allowing the fentanyl a little time to work its way in as well, prior to induction which immediately follows my first set of vitals; We're talking about routine uncomplicated cases of course.

There are numerous ways to skin the cat safely, but like many others, I don't see the benefit-outweighing-risk in the "50mL NS bag drip technique," as there are too many variables that could throw a wrench in the works with that type of induction if you're doing a wide variety of cases on a wide variety of patient types.
 

sevoflurane

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Here is a good one your patients will appreciate. It will get you fast intubating conditions in the longer upper extremity cases that need to be tubed.
Since the BP cuff will go on the same side as the IV in these cases, try this one out and see if you like it.

1) Depending on the patient, start with 1-2mg of dilaudid in pre-op (depending on the patient).
2) After the patient is in the room, put on the BP cuff as soon as possible. Cycle it and while it's up, dump in 5 ccs of 2% lido while pre-oxygenating. This will keep the Lido in the distal upper extremity giving those veins a mini bier block. (ROC and PROPY both can hurt! :eek:)
3) Once the BP cuff takes it's measurement and blood flow is reestablished, hit 'em with some prop (1.5-3 mg/kg) and roc (1.5 mg/kg) +/- some alfenta all in the same syringe. By this point, dilaudid will be kicking in and alfenta will help smooth things out as the tube goes in. Hemodynamics stay pretty solid and the patients go to sleep very peacefully with minimal to no vein irritation. Intubating conditions are lightning fast. :sneaky:

Of course, every patient needs to be treated with respect and this formula is not for everyone... especially the oldies. In the healthy 30-50 y/o, it works like magic.
 

chmd

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Here is a good one your patients will appreciate. It will get you fast intubating conditions in the longer upper extremity cases that need to be tubed.
Since the BP cuff will go on the same side as the IV in these cases, try this one out and see if you like it.

1) Depending on the patient, start with 1-2mg of dilaudid in pre-op (depending on the patient).
2) After the patient is in the room, put on the BP cuff as soon as possible. Cycle it and while it's up, dump in 5 ccs of 2% lido while pre-oxygenating. This will keep the Lido in the distal upper extremity giving those veins a mini bier block. (ROC and PROPY both can hurt! :eek:)
3) Once the BP cuff takes it's measurement and blood flow is reestablished, hit 'em with some prop (1.5-3 mg/kg) and roc (1.5 mg/kg) +/- some alfenta all in the same syringe. By this point, dilaudid will be kicking in and alfenta will help smooth things out as the tube goes in. Hemodynamics stay pretty solid and the patients go to sleep very peacefully with minimal to no vein irritation. Intubating conditions are lightning fast. :sneaky:

Of course, every patient needs to be treated with respect and this formula is not for everyone... especially the oldies. In the healthy 30-50 y/o, it works like magic.
I don't understand 3mg/kg of propofol in adult patients. It seems like 50% too much and it would probably require a second syringe/bottle for most adults.
 

sevoflurane

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I gave a range. 1.5-3mg/kg of propofol because most UE patients don't get tubed. I also am talking 'bout healthy 30-50 y/o.

Most fall on the lower side of that range, but some don't. It's all an ongoing assessment of how the patient responds to your IV meds.

Real story example:

35 y/o AA military type male shows up for testicular surgery of some kind. Dude is big. He's cut and he's probably on roids. He-man type.
He gets 2mg of dilaudid in pre-op. In the room he's wide awake with no visible signs of sedation. Another 150 mcgs of fent. goes in.

Yeah.... I got this.

2mg/kg of prop on top of that. Sevo up to 1.0 mac. #5 LMA slipped in with ease. He picks up his breathing almost immediately.

Incision....

He-man, then proceeds to break through both of his arm straps, sits up and pulls out his LMA. Still deeply sedated to the point of amnesia, but making comprehensible sentences.

I rarely go 3mg/kg, but if they are not responding to my sedatives I will give 'em 200mg, reassess and then maybe drop in another 100mg or so.

If you have 1.5 mg/kg of roc on board, you likely don't need 3mg/kg of prop.
 

pgg

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Yeah, no kidding. I start with 3 mg/kg for those catecholamine charged young military male types. I usually don't give them any opiate before the LMA but I run them deep on the volatile. Can be amazing how much it takes to put and keep those guys down.