Stage 2 with propofol infusion?

[icecoldstar]

Resident here. Can you theoretically go through stage 2 with propofol infusion or do those stages only apply to volatiles? Thanks!

---

Members don't see this ad.

 

[coffeebythelake]

Resident here. Can you theoretically go through stage 2 with propofol infusion or do those stages only apply to volatiles? Thanks!

Not the classic stage 2 as described in textbooks

 

[nimbus]

Aspiration +- laryngospasm can look a lot like stage2.

 

[coffeebythelake]

yeah i can imagine this sort of scenario:
lightening propofol anesthetic, increasing secretions pooling in oropharynx, aspiration or tickling the glottic opening, laryngospasm

 

[BLADEMDA]

IMHO, you need to be very unlucky to get laryngospasm with propofol. It only takes about 0.5 mg/kg bolus of propofol to block laryngeal reflexes. That means running an infusion of propofol even at 60-70 ug/kg/min should be sufficient to blunt laryngeal reflexes to most people (exceptions for drug users, marijuana, etc). I extubate all the time with spontaneously breathing patients running propofol IV all the time without incident.

Until you get the hang of it you can just extubate when the gag reflex returns but that takes longer in most patients than using Sevo.

 

[BLADEMDA]

The major finding of this study was that the outcome of primary outcome apnea with laryngospasm occurred more frequently in patients anesthetized with sevoflurane and that this difference was more marked between the study groups when the longer lasting events (> 10 s) rather than short lasting events (> 5 s) were considered. Therefore, although laryngospasms of various durations occurred in patients anesthetized with either drug, the proportion of longer lasting events, which is of special interest from a clinical point of view, was greater in children anesthetized with sevoflurane.

Respiratory Reflex Responses of the Larynx Differ between Sevoflurane and Propofol in Pediatric Patients

Background. The effects of anesthetics on airway protective reflexes have not been extensively characterized in children. The aim of this study was to compare the laryngeal reflex responses in children anesthetized with either sevoflurane or propofol under two levels of hypnosis using the...

pubs.asahq.org

 

[BLADEMDA]

Conclusion​

We conclude that intravenous administration of small dose of propofol or midazolam before tracheal extubation decreases the incidence and severity of laryngospasm and coughing in adult patients undergoing oropharyngeal surgeries.

Effect of small dose propofol or midazolam to prevent laryngospasm and coughing following oropharyngeal surgeries: Randomized controlled trial

To compare the effectiveness of small dose of propofol or midazolam in treating laryngospasm following extubation in adult patients undergoing orophar…

www.sciencedirect.com

 

[zizzer]

So Blade, they're suggesting to have the patient emerging from volatile agent, spontaneously breathing and following commands, then give 0.8mg/kg propofol and extubate?

 

[BLADEMDA]

So Blade, they're suggesting to have the patient emerging from volatile agent, spontaneously breathing and following commands, then give 0.8mg/kg propofol and extubate?

There are cases where the surgeon will tell you "no bucking" on wake-up. Whether it is an abdominoplasty or free flap or just a hernia repair by administrating a dose of propofol IV at the end of the case immediately prior to extubation almost ensures your patient won't spasm or buck. Yes, you can extubate deep on Sevo or ISO but a deep extubation with propofol is very smooth and you titrate the vapor to 0.2 or 0.3 MAC just prior to the extubation.

For a typical case there is no reason to give propofol IV at the end of the case where you were using volatile agent.

 

[GassYous]

There are cases where the surgeon will tell you "no bucking" on wake-up. Whether it is an abdominoplasty or free flap or just a hernia repair by administrating a dose of propofol IV at the end of the case immediately prior to extubation almost ensures your patient won't spasm or buck. Yes, you can extubate deep on Sevo or ISO but a deep extubation with propofol is very smooth and you titrate the vapor to 0.2 or 0.3 MAC just prior to the extubation.

For a typical case there is no reason to give propofol IV at the end of the case where you were using volatile agent.

Sometimes it is tough. Smokers seem to cough no matter what

 

[coffeebythelake]

Sometimes it is tough. Smokers seem to cough no matter what

Precedex or remifentanil for those cases.
Lidocaine helps
Propofol isn't as effective to prevent bucking compared to these others

Blade mentioned some situations where pt seem more prone to Laryngospasm. I would like to add, anecdotally, patients who had covid even with minimal symptoms also seem to be more likely to laryngospasm