Tips for fast turnover/start of cases

[interleukin2]

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Any thoughts on what are some good habits and routines to efficiently go about starting, finishing, and turning over a case? I am interested in workflow patterns you may have found useful. Thanks!

 

[Endee]

Any thoughts on what are some good habits and routines to efficiently go about starting, finishing, and turning over a case? I am interested in workflow patterns you may have found useful. Thanks!

Some efficiency observations I made during school:

One thing I was taught was to take a baseline BP measurement and start preoxygenating as soon as the patient enters the room, since these steps take some time to complete/cycle. While thats going, you put the other monitors on and by the time the BP is ready and the sat probe and EKG leads are on, it has been a few minutes on the Pre-O2. Of course, sicker or special needs patients might obviate doing it that way.

Another was right after induction, in the few minutes that usually exist between you being finished with your things and waiting for prep and drape to start, thats when you immediately set up airway and drugs for the next case.

I've heard people talk about mixing all of the induction drugs into one syringe too, but I've never tried that or seen anyone do that, so I'm weary.

One wakeup technique I've seen is to turn off the gas relatively early, go on 70/30 N2O/O2, and let the gas blow off with the nitrous keeping them asleep. Stimulation has to be low at this point or the patient will move. But it seemed like wakeups were pretty smooth.

One anesthesiologist who taught me a lot about efficiency in the OR had "Work in parallel, not in series" as his mantra. I find myself telling myself that when I'm setting up a room or doing almost any other task..

 

[epidural man]

Any thoughts on what are some good habits and routines to efficiently go about starting, finishing, and turning over a case? I am interested in workflow patterns you may have found useful. Thanks!

Do a lot of cases! You will figure it out.

I think one thing - while starting a case - is use the mask to strap on the face. That should be the first thing you do. This does several things - one, by the time you get your monitors on, the patient is preoxygenated. Two, it totaly frees you up to do things with both hands, move about, etc. Did you remember you were going to use some lidocaine with your induction but forgot to draw it up? Or you wanted to put a BIS probe on awake before induction to watch it drop with each med? No problem if the mask is strapped on - you just go do it while the patient continues to preoxygenate. just turn around and do the stuff you need to. If you are holding the mask, you are stuck there.

I love having the mask strapped on. When doing cases by myself, I often will not prepare to the extent I did as a resident - and I am always forgetting stuff like having the pink tape right there - or whatever - silly stupid stuff like that. (comes from not doing anesthesia day in / day out).

A good drill - that one of my attendings would have me do - is pretend that this simple, healthy person, case (like a knee scope on a 35 y/o) is an emergent case. My self-imposed goal was to see if I could have the tube in withing 5 minutes from coming through the door. This is a difficult task since sometimes it takes 5 minutes just to get the person from the gurney to the OR table.

 

[pgg]

I love having the mask strapped on.

I hate the strap, I think it freaks patients out. 🙂

We have good OR nurses though, whose sole job upon entering the room is to help us. I just have the OR nurse hold the mask in place.

 

[Consigliere]

Meh, let the CRNA worry about fast turnover. Just sign the damn chart; chances are you won't be doing your own cases anyway.

 

[DreamLover]

Meh, let the CRNA worry about fast turnover. Just sign the damn chart; chances are you won't be doing your own cases anyway.

Not true...not yet anyways...especially in the western half of the country...lots of MD only or mixed...I'm sure they will eventually move the way of more care team model....but not yet

 

[saratoga733]

my 2 cents: sure it's always a good idea to be prepared and efficient... but after working in private practice for a few years now... working like a demon and trying to save a few minutes is just not worth it (obviously we're talking about elective cases w/ healthy pts). mistakes always tend to happen when we rush! besides, personally i feel it made me look mechanical and unpolished. i've come to appreciate establishing a welcoming atmosphere once the pt enters the or, ie chatting up (aka distracting) the patient... instills more confidence from surgeons/nurses rather than slapping that facemask on the second they lie down.

 

[jwk]

my 2 cents: sure it's always a good idea to be prepared and efficient... but after working in private practice for a few years now... working like a demon and trying to save a few minutes is just not worth it (obviously we're talking about elective cases w/ healthy pts). mistakes always tend to happen when we rush! besides, personally i feel it made me look mechanical and unpolished. i've come to appreciate establishing a welcoming atmosphere once the pt enters the or, ie chatting up (aka distracting) the patient... instills more confidence from surgeons/nurses rather than slapping that facemask on the second they lie down.

You can be efficient without rushing.

 

[Monty Python]

Any thoughts on what are some good habits and routines to efficiently go about starting, finishing, and turning over a case? I am interested in workflow patterns you may have found useful. Thanks!

Generally the pulse-ox is the first monitor on as I then reach for the mask. Will tell you both HR and baseline room-air SaO2. It's also the last one I remove.

 

[epidural man]

I hate the strap, I think it freaks patients out. 🙂

We have good OR nurses though, whose sole job upon entering the room is to help us. I just have the OR nurse hold the mask in place.

I always hear people say this...I haven't yet found that to be true.

I always tell them before we go back - "The first thing I am going to do is strap a mask on - this fills your lungs and tissues with oxygen..." And I usually ask if they think they will be bothered by this. I haven't had anyone yet tell me that a mask on the face might bother them. I find versed a wonderful mask-tolerating drug. 🙂

They always try to tell me something through the mask. I always answer their questions with propofol.

 

[Bertelman]

I always hear people say this...I haven't yet found that to be true.

I always tell them before we go back - "The first thing I am going to do is strap a mask on - this fills your lungs and tissues with oxygen..." And I usually ask if they think they will be bothered by this. I haven't had anyone yet tell me that a mask on the face might bother them. I find versed a wonderful mask-tolerating drug. 🙂

They always try to tell me something through the mask. I always answer their questions with propofol.

They're telling you that mask strap is f*ng uncomfortable and bordering on torture.







You're "listening" with propofol.

 

[iwumd07]

.

 

[iwumd07]

They're telling you that mask strap is f*ng uncomfortable and bordering on torture.







You're "listening" with propofol.

Lulz!!

Actually I've had the mask with straps a couple times. I actually prefer it. It's quite comfortable. Better than someone's arm/hand in my face and them pushing the darn thing into my cheeks.

 

[Bertelman]

Just use the tube holder metal bracket thing. If you know how to set the circuit tubing on it, the mask just gently rests on their face. Hands-free.

 

[baller71457]

Just use the tube holder metal bracket thing. If you know how to set the circuit tubing on it, the mask just gently rests on their face. Hands-free.

Yup

 

[TrustMe]

I second the tube holder. Lightly rests the mask on their face and gives you two free hands. Even works for people that tell me they can't tolerate the mask. Versed helps a lot of people tolerate a lot of things (colonoscopy, EGD for example).

 

[RxBoy]

Just use the tube holder metal bracket thing. If you know how to set the circuit tubing on it, the mask just gently rests on their face. Hands-free.

Agreed. This is always my approach. Straps are not only terrifying (forcing the pt to look like Darth Vader), but always gets in the way of eye tape, talking, ect. Just rest it on their face with propped up metal bracket as you do your thing. Just be sure to tell them that its only going to rest on their face, it doesn't need to be on tightly or completely covering the face.

Standard GETA on healthy patient:
My order: pulse ox-O2- (opposing arm board if needed when those circulators love being lazy)-bp cuff letting it cook-leads (the longest and most annoying part)- induction drug syringes one side patient-Airway equipment in kidney basin on other side - tube on chest-call attending for induction-load only the essential syringes (Prop/sux) push the others (fent/lido/ect)-then use hand to give tighter seal and tell them to take deep breathes. Take a glace at end tidal O2 to see how well preoxygenated. By the time attending in, induce and tube. Process takes me no more than 3 to 4 minutes depending on how prepared the room was before the start. The second tube is in/confirmed/secured, drop the bed and tell circulators \ ok to position/prep/foley ect.

If I have a co-resident help me take the patient back, we can get it done in 2 minutes flat. Too bad our circulators are so incompetent.

At our ambulatory center, its so much nicer. Patient comes in with Leads already attached (just need to insert the connector), BP cuff already on (just need to connect tubing). When case is done, we just disconnect the way they came in.

 

[WholeLottaGame7]

They're telling you that mask strap is f*ng uncomfortable and bordering on torture.







You're "listening" with propofol.

Personally, I find that Mr. Propofol is great at answering questions. For awhile I used to take the mask off the patients' face if they were asking questions, but I've realized 3 things: 1) the vast majority of the time the question is something like "how long will the surgery last?" (newsflash, you should know this by now), 2) it slows me down, 3) they're just re-nitrogenating their lungs.

 

[BobBarker]

Tape the patients eyes shut in holding.

 

[pjl]

The key to efficiency is good help. I am incredibly spoiled. Obviously this is rarely the case in residency.

Our anesthesia techs get the room set to our preferences, so I can walk in and be ready to start the case in about 3 minutes of prep in the morning, same during the day between cases, although I spend most of those minutes during the prior case. When I get to the room all I have to do is a final check of the machine.

The patients have monitors placed in preop so all that is needed is to hook them up to the OR.
The patient enters the room, and from that point until patient is intubated I have the undivided attention of the circulating nurse and frequently another person. Because I work at a friendly hospital this second person is often the surgeon. I never would have dreamed of having the surgeon put on a moniter, start a second IV, set up the warmer during residency, but it is awesome.

The circulating nurse can hook the monitors up as I talk to the patient, and grab my preinduction drugs, and place the mask in the tube holder so it gently sits on their face. BP cuff first. "Deep, easy breaths" as BP cuff runs.
Time to fall asleep.

If I do an art line the techs have set up a tray exactly like I like it. If I do a central line they set up the tray ahead of time, and scrub in with me, handing me what I want when I want it.

The only downside of this set up is that your wife will start to wonder why you are so lazy and ask her to get you things that are on the counter right next to you.

Edit: I forgot to mention one thing I feel really adds to efficiency. Once you start a task, take the appropriate amount of time to do it right. Rush set up if needed, but never rush once the needle hits the skin. Time saved on performing a single attempt slowly is much greater than 2 or 3 attempts fast, and you look much better to patients and other staff.

 

[dhb]

Tape the patients eyes shut in holding.

 

[Bertelman]

Personally, I find that Mr. Propofol is great at answering questions. For awhile I used to take the mask off the patients' face if they were asking questions, but I've realized 3 things: 1) the vast majority of the time the question is something like "how long will the surgery last?" (newsflash, you should know this by now), 2) it slows me down, 3) they're just re-nitrogenating their lungs.

I've got nothing against pushing propofol in that situation, but I had to take that shot. The setup was too easy. Epidural man would have expected nothing less from me. Believe me, I will push propofol with the best of them to silence a rambling patient.

I actually prefer to acknowledge the question being asked, though, because it frequently produces a few laughs from the staff in the room.

I really, really love my job.

 

[RT2MD]

The key to efficiency is good help. I am incredibly spoiled. Obviously this is rarely the case in residency.

Our anesthesia techs get the room set to our preferences, so I can walk in and be ready to start the case in about 3 minutes of prep in the morning, same during the day between cases, although I spend most of those minutes during the prior case. When I get to the room all I have to do is a final check of the machine.

The patients have monitors placed in preop so all that is needed is to hook them up to the OR.
The patient enters the room, and from that point until patient is intubated I have the undivided attention of the circulating nurse and frequently another person. Because I work at a friendly hospital this second person is often the surgeon. I never would have dreamed of having the surgeon put on a moniter, start a second IV, set up the warmer during residency, but it is awesome.

The circulating nurse can hook the monitors up as I talk to the patient, and grab my preinduction drugs, and place the mask in the tube holder so it gently sits on their face. BP cuff first. "Deep, easy breaths" as BP cuff runs.
Time to fall asleep.

If I do an art line the techs have set up a tray exactly like I like it. If I do a central line they set up the tray ahead of time, and scrub in with me, handing me what I want when I want it.

The only downside of this set up is that your wife will start to wonder why you are so lazy and ask her to get you things that are on the counter right next to you.

Edit: I forgot to mention one thing I feel really adds to efficiency. Once you start a task, take the appropriate amount of time to do it right. Rush set up if needed, but never rush once the needle hits the skin. Time saved on performing a single attempt slowly is much greater than 2 or 3 attempts fast, and you look much better to patients and other staff.

Awesome.

 

[PMPMD]

Edit: I forgot to mention one thing I feel really adds to efficiency. Once you start a task, take the appropriate amount of time to do it right. Rush set up if needed, but never rush once the needle hits the skin. Time saved on performing a single attempt slowly is much greater than 2 or 3 attempts fast, and you look much better to patients and other staff.

👍 I heard this first from one of our speed demon surgeons. OK, the only speed demon in our academic hospital.

 

[epidural man]

They're telling you that mask strap is f*ng uncomfortable and bordering on torture.







You're "listening" with propofol.

HAHAHAHAHAHA!

Love it.

Propofol helps calm the sheer terror in their eyes. I don't post op my patients for this very reason - I'm scared they'll hit me.

 

[RxBoy]

Tape the patients eyes shut in holding.

Now that's someone serious about turnover...
Drastic times calls for drastic measures.

 

[NotAMD]

i just use a regular closed FM as soon as i enter, bp next, then ekg, pulse ox, induce with them breathing on FM - upon apnea switch to circuit and mask ...

heres a ? for you all, i know that the whole concept of proving you can ventilate before pushing paralytic is controversial nowadays,

but for those who do practice by ventilating before pushing, this is the time i find a 2nd pair of hands most useful - just the physical pushing of the relaxant as im masking, i usually have to just stop masking and push it then remask no biggie .. better way?

 

[jwk]

Just use the tube holder metal bracket thing. If you know how to set the circuit tubing on it, the mask just gently rests on their face. Hands-free.

👍👍👍

Strapping the mask on is overkill, just like tying the patient's arms to the arm boards before induction. You're just not in that much of a friggin hurry, and if you are, you need to pay more attention to the patient's needs rather than your efficiency ratings. For those you feel like you really need a good seal, I'd prefer to hold the mask on and be focusing my attention on the patient and monitors rather than fumbling around getting everything else ready that should already be ready.

 

[Bertelman]

For the record, sometimes in my "efficiency" I actually choose to turn on the O2 after placing the facemask. Sometimes not. If I don't it's a nice test of their FRC, or at least that's what I tell myself.

Point is, if you are trying to work on efficiency, I would suggest developing a distinct pattern, and justify that pattern however you wish. If you work with a proscribed order of events, you are far less likely to deviate and miss a step.

 

[cfdavid]

Some efficiency observations I made during school:

One thing I was taught was to take a baseline BP measurement and start preoxygenating as soon as the patient enters the room, since these steps take some time to complete/cycle. While thats going, you put the other monitors on and by the time the BP is ready and the sat probe and EKG leads are on, it has been a few minutes on the Pre-O2. Of course, sicker or special needs patients might obviate doing it that way.

Another was right after induction, in the few minutes that usually exist between you being finished with your things and waiting for prep and drape to start, thats when you immediately set up airway and drugs for the next case.

I've heard people talk about mixing all of the induction drugs into one syringe too, but I've never tried that or seen anyone do that, so I'm weary.

One wakeup technique I've seen is to turn off the gas relatively early, go on 70/30 N2O/O2, and let the gas blow off with the nitrous keeping them asleep. Stimulation has to be low at this point or the patient will move. But it seemed like wakeups were pretty smooth.

One anesthesiologist who taught me a lot about efficiency in the OR had "Work in parallel, not in series" as his mantra. I find myself telling myself that when I'm setting up a room or doing almost any other task..

Just the other day I was told by an attending (I think she's in the minority on this one), that it's o.k. to turn off the volatile agent rather quickly since you can always give propofol if it's too early.

I can see some controversy in this (my impression was that she meant WELL in advance), but like you stated, there's often very little surgical stimulation at the end of the case, so with a little N2O on board, I guess it would be o.k. It's always a judgement call and every attending has their own preference even w/r/t when to DC the monitors. Some are early, and some much more conservative. My experience is that those whom do a lot of hearts tend to be more conservative about ripping off monitors (EKG and BP cuff) too soon. Others are much more cavalier.

It's a fine line as you don't want them jumping off the table while the drapes are still up.....

 

[hoyden]

i

but for those who do practice by ventilating before pushing, this is the time i find a 2nd pair of hands most useful - just the physical pushing of the relaxant as im masking, i usually have to just stop masking and push it then remask no biggie .. better way?

Tape the IV stopcock to the bed, push paralytic by one hand, masking by the other ( I use straps, but after they are unconscious), switch the stopcock, IV flowing; use your hand for the bag again ( takes 5 seconds to push the paralytic)... nothing special... why do you need a second pair of hands?

 

[JSBMD]

Yes, it's a fine line indeed, but in my opinion what impresses those around you (surgeons, nurses, etc) that you are "good" isn't nearly as much related to how fast you have someone asleep as much as how fast you have someone awake after a case.

Scrambling in a frantic mess at the beginning of a case may save you 1 or 2 minutes. Waking a patient up fast after a case can save you 10 minutes or more compared to your slower colleagues. Want to impresss the crowd? Wake your patients fast. This does mean turning off volatile agents as soon as you know case is winding down, and running the patient on something (N2O/oxygen for me) easily d/c'd at the end. I do this probably 15 minutes before drapes come down, but then I really know my regular surgeons' habits like the back of my hand. This doesn't work if you are a "sit down reader", this requires that I stand and watch the case progress like a hawk. And yes, occasionally this means a small bolus of proposal to give me a couple more minutes of anesthesia.

Still, nothing like the feeling of bringing a patient to the PACU 2-3 minutes after the case ends, surgeon still dictating, while the patient is asking "Is it over?".

THAT is a very good way to shine in the eyes of those around you.

 

[JSBMD]

Arrgghhh!!

Can't edit my above post!

Obviously meant "propofol" but iPad keeps spell-checking into "proposal"

You guys hopefully get my meaning.

 

[Monty Python]

:

Strapping the mask on is overkill, just like tying the patient's arms to the arm boards before induction. .

A personal suggestion, passed to me by others with more experience in the VA system and Defense Dept. hopsital system. Do not fasten the armboard restraint straps on a former prisoner of war, nor someone with PTSD, until after they're asleep.


.

 

[NotAMD]

Yes, it's a fine line indeed, but in my opinion what impresses those around you (surgeons, nurses, etc) that you are "good" isn't nearly as much related to how fast you have someone asleep as much as how fast you have someone awake after a case.

Scrambling in a frantic mess at the beginning of a case may save you 1 or 2 minutes. Waking a patient up fast after a case can save you 10 minutes or more compared to your slower colleagues. Want to impresss the crowd? Wake your patients fast. This does mean turning off volatile agents as soon as you know case is winding down, and running the patient on something (N2O/oxygen for me) easily d/c'd at the end. I do this probably 15 minutes before drapes come down, but then I really know my regular surgeons' habits like the back of my hand. This doesn't work if you are a "sit down reader", this requires that I stand and watch the case progress like a hawk. And yes, occasionally this means a small bolus of proposal to give me a couple more minutes of anesthesia.

Still, nothing like the feeling of bringing a patient to the PACU 2-3 minutes after the case ends, surgeon still dictating, while the patient is asking "Is it over?".

THAT is a very good way to shine in the eyes of those around you.

id just say caution for awareness with the n20/o2 wakeup - you dont want 0.0%et inhalational for 15 minutes as unpleasant/scary things are still happening to the patient - maintain 0.2-0.3 mac inhalational

 

[pgg]

id just say caution for awareness with the n20/o2 wakeup - you dont want 0.0%et inhalational for 15 minutes as unpleasant/scary things are still happening to the patient - maintain 0.2-0.3 mac inhalational

Agreed, 2-3% desflurane comes off quick enough, I don't find that nitrous really adds anything. I admit a perhaps irrational anti-nitrous bias though, and almost never use it.

The trick is getting them down to 2-3% des a solid 5-10 min early so the tissue depot starts dumping. Desflurane wakeups are so fast easy and predictable it makes it feel like cheating.

 

[proman]

id just say caution for awareness with the n20/o2 wakeup - you dont want 0.0%et inhalational for 15 minutes as unpleasant/scary things are still happening to the patient - maintain 0.2-0.3 mac inhalational

I don't have any concerns with 70% nitrous and recall. Patients are usually not paralyzed at that point so they could always move if they experienced something unpleasant.

 

[DreamLover]

For me...I was never a strap user during residency-no one used it where I trained. We just rested the mask on balanced by the Christmas tree. Now forward to graduation and new job and EVERYONE uses the strap here. Pros are that it is more stable and falls off face less but it's definitely a much tighter fit and I can see how pts may not love it.

As for wake up...I'm a low flow Anesthesia girl myself. As long as I have a nice ventilator with no leaks and some fresh exorbant...I can wake up someone with .8-1 MAC on in no time! I rarely use nitrous at the end of my cases, but I think it's fine in the right person.

 

[dhb]

Yes, it's a fine line indeed, but in my opinion what impresses those around you (surgeons, nurses, etc) that you are "good" isn't nearly as much related to how fast you have someone asleep as much as how fast you have someone awake after a case.

Fast wake ups will gain you a lot of time over a day.
However (and this isn't a personal attack on you) if you need multiple agents / nitrous / propofol boluses for a predictable wake up you are doing something wrong (except if you're using iso which i never have).

I've never used the nitrous technique or given propofol boluses with the intent of timing the wake up. The key IMHO is to get the patient in SV and titrate narcotics while dialing down the volatile. With that done wake up is just a formality.

 

[dhb]

As for wake up...I'm a low flow Anesthesia girl myself. As long as I have a nice ventilator with no leaks and some fresh exorbant...I can wake up someone with .8-1 MAC on in no time!

👍

 

[Arch Guillotti]

I don't have any concerns with 70% nitrous and recall. Patients are usually not paralyzed at that point so they could always move if they experienced something unpleasant.

agree, recall isn't really a concern for me either

 

[Arch Guillotti]

Fast wake ups will gain you a lot of time over a day.
However (and this isn't a personal attack on you) if you need multiple agents / nitrous / propofol boluses for a predictable wake up you are doing something wrong (except if you're using iso which i never have).

I've never used the nitrous technique or given propofol boluses with the intent of timing the wake up. The key IMHO is to get the patient in SV and titrate narcotics while dialing down the volatile. With that done wake up is just a formality.

Yeah but according to your other post you use des all the time. Long cases with sevo/iso are completely different.

There are many cases where you can't just get them breathing and titrate in the narcotics.

 

[Bertelman]

Yeah but according to your other post you use des all the time. Long cases with sevo/iso are completely different.

There are many cases where you can't just get them breathing and titrate in the narcotics.

Beat me to it.

 

[Consigliere]

Please see post #5.

 

[Arch Guillotti]

Meh, let the CRNA worry about fast turnover. Just sign the damn chart; chances are you won't be doing your own cases anyway.

yeah but there are things we can do like having all the preops done and any issues addressed before it is time to start the case

 

[Consigliere]

yeah but there are things we can do like having all the preops done and any issues addressed before it is time to start the case

We see 100% of our pts. prior to surgery (except cataracts) in our pre-op clinic. I troubleshoot throughout the day and am an integral part of "running the board" to ensure fast throughput through the OR. The lazy, hospital-employed CRNAs could care less about efficiency. We also do all central lines, nerve blocks and catheters and fiberoptic intubations. That and intervene multiple times throughout the day to prevent catastrophes. And to think that the CMS wants to remove our burdensome presence....

 

[chocomorsel]

The key to efficiency is good help. I am incredibly spoiled. Obviously this is rarely the case in residency.

Our anesthesia techs get the room set to our preferences, so I can walk in and be ready to start the case in about 3 minutes of prep in the morning, same during the day between cases, although I spend most of those minutes during the prior case. When I get to the room all I have to do is a final check of the machine.

The patients have monitors placed in preop so all that is needed is to hook them up to the OR.
The patient enters the room, and from that point until patient is intubated I have the undivided attention of the circulating nurse and frequently another person. Because I work at a friendly hospital this second person is often the surgeon. I never would have dreamed of having the surgeon put on a moniter, start a second IV, set up the warmer during residency, but it is awesome.

The circulating nurse can hook the monitors up as I talk to the patient, and grab my preinduction drugs, and place the mask in the tube holder so it gently sits on their face. BP cuff first. "Deep, easy breaths" as BP cuff runs.
Time to fall asleep.

If I do an art line the techs have set up a tray exactly like I like it. If I do a central line they set up the tray ahead of time, and scrub in with me, handing me what I want when I want it.

The only downside of this set up is that your wife will start to wonder why you are so lazy and ask her to get you things that are on the counter right next to you.

Edit: I forgot to mention one thing I feel really adds to efficiency. Once you start a task, take the appropriate amount of time to do it right. Rush set up if needed, but never rush once the needle hits the skin. Time saved on performing a single attempt slowly is much greater than 2 or 3 attempts fast, and you look much better to patients and other staff.

Wow, I want to work here. Are they hiring? Where are you located? Sounds lovely.

 

[JSBMD]

You are right to be worried about recall. That said, I haven't seen it. Moreover, I urge you residents to start checking patients in PACU if you have time. You'll be shocked to see that a patient will be awake and talking for a good 10 minutes before they lay down any real memories. Yet they are there talking to you (repeating themselves, because they don't recall already saying whatever profound thing it is they just said). I did however have a colleague with a recall issue once, a few years back. Colleague was a bit flaky though, so I don't know exactly what was going on there.

And no, I don't routinely need to give propofol at the end of the case. Maybe once every 200-300 cases.

Don't underestimate the difficulty of doing this well, though. Our specialty is at times more "art" than science. And I'll bet that if you put 10 of us on the same case, you'd see 10 different anesthetics. So long as you get a patient safely through, then you are OK. Beyond that lies "good".

And, I'll stand by what I said earlier: if you want to look good in the eyes of those watching you, wake up your patients faster than your competition, I mean colleages.

 

[dhb]

And no, I don't routinely need to give propofol at the end of the case. Maybe once every 200-300 cases.

Ok i can understnad that.

Arch it's true that i use a lot of Des but even with Sevo you can acheive the same thing. I extubate deep so i don't need to wait for the patient to wake up / be orientated before leaving the room.
I often found that it was easier to wake up patients after very long cases (6h+) than for cases of intermediate duration...

 

[Gimlet]

You are right to be worried about recall. That said, I haven't seen it. Moreover, I urge you residents to start checking patients in PACU if you have time. You'll be shocked to see that a patient will be awake and talking for a good 10 minutes before they lay down any real memories. Yet they are there talking to you (repeating themselves, because they don't recall already saying whatever profound thing it is they just said).

I routinely ask my patients about this on my postop checks, and I would say more than half of them don't even remember the hour they spent in the PACU. Usually when I ask them to tell me the first thing they remember after surgery they say "oh, being up here in my hospital room and my wife was sitting next to me."