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Hey everyone,
I'm a first year Anaesthesia resident in Singapore, with only a month of anaesthesia under my belt, so please bear with my ignorance, but I'm truly interested in your opinions regarding techniques for smooth induction and emergence.
This is how a "typical" GA+ETT induction for an ASA 1 60kg male patient goes over here:
- preoxygenate
- 20mg lidocaine
- 100mcg fentanyl
- 100 - 120mg propofol
- atracurium
- ventilate with "overpressure" of volatile agents, typically desfurane at 10%, for 2-3 minutes waiting for atracurium to work
- intubate
The problem I noticed with this approach is the rollercoaster ride that is the hemodynamics. The propofol tends to cause significant hypotension while we are waiting for the relaxant to work. 20mg lidocaine + 100mcg fent doesn't seem to blunt the laryngeal reflexes much, so the BP+HR goes sky high with during intubation. After that, there is typically a long period of little stimulation where the surgeons are cleaning + draping, etc, and the BP usually falls again. This is generally followed by boluses of phenylephrine to keep BP up. Most of us anticipate the surgical incision, so we dose fentanyl + crank up the gas, but occasionally we underestimate things and the BP goes sky high again.
One attending (who was trained in Canada) uses 200-300mcg fentanyl with ~80mg propofol + 0.9mg/kg roc. He claims that the effects of all the meds peak around 1 minute, which is when he intubates. From my observation, his method results in much less hemodynamic swings, but he is truly the minority here. I'll be truly interested to know what I can do in my own practice to achieve smooth and stable induction.
Just thought I'll start a discussion here where everyone can share their secret tips on smooth inductions / emergence.
I'm a first year Anaesthesia resident in Singapore, with only a month of anaesthesia under my belt, so please bear with my ignorance, but I'm truly interested in your opinions regarding techniques for smooth induction and emergence.
This is how a "typical" GA+ETT induction for an ASA 1 60kg male patient goes over here:
- preoxygenate
- 20mg lidocaine
- 100mcg fentanyl
- 100 - 120mg propofol
- atracurium
- ventilate with "overpressure" of volatile agents, typically desfurane at 10%, for 2-3 minutes waiting for atracurium to work
- intubate
The problem I noticed with this approach is the rollercoaster ride that is the hemodynamics. The propofol tends to cause significant hypotension while we are waiting for the relaxant to work. 20mg lidocaine + 100mcg fent doesn't seem to blunt the laryngeal reflexes much, so the BP+HR goes sky high with during intubation. After that, there is typically a long period of little stimulation where the surgeons are cleaning + draping, etc, and the BP usually falls again. This is generally followed by boluses of phenylephrine to keep BP up. Most of us anticipate the surgical incision, so we dose fentanyl + crank up the gas, but occasionally we underestimate things and the BP goes sky high again.
One attending (who was trained in Canada) uses 200-300mcg fentanyl with ~80mg propofol + 0.9mg/kg roc. He claims that the effects of all the meds peak around 1 minute, which is when he intubates. From my observation, his method results in much less hemodynamic swings, but he is truly the minority here. I'll be truly interested to know what I can do in my own practice to achieve smooth and stable induction.
Just thought I'll start a discussion here where everyone can share their secret tips on smooth inductions / emergence.