Arch Guillotti
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Tips for fast turnover/start of cases
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I've heard this before. Maybe I'm just not thinking about this the right way, but how exactly does low-flow anesthesia speed emergence?
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I am curious also.
Emergence is all about minute ventilation, and reducing etGAS early enough so that the tissue concentration can equilibrate with the newly-lowered blood concentration.
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I feel like I'm in the minority here...no one knows not how to use LFA let Aline how it works-
Low Flow Anesthesia (LFA) has been variously defined as an inhalation technique in which a circle system with absorbent is used with a fresh gas inflow of :
- less than the patients alveolar minute volume
- less than 1-1.5 l/min
- 3 l/min or less
- 0.5 2 l/min
- less than 4 l/min
- 500 1000 ml/min
- 0.5 1 l/min
Closed System Anesthesia is a form of LFA in which the FGF = uptake of anesthetic gases and oxygen by the patient and gas sampling. No gas is vented by the APL valve.
If you have a good understanding of how gas flows work in a circle system then there are several advantages to LFA from temp regulation all the way down to cost...
There are always disadvantages bit you just have to choose the right situation!
Plus...it's fun to do and in my opinion, less PONV
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Yes agreed, but I don't follow how emergence benefits from low flows. I don't think it does (and I use 0.5 Lpm fresh gas flows for the majority of my cases).
Edit to add ...
Less PONV?
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Essentially, you're running a fine balance of gas concentration. You're running enough flow for anesthesia but not enough to cause volatile to be stored in various compartments (fat, muscle etc) so when wake up time is here...once you turn up your flows and turn off your gas.. It takes no time to blow off any remaining volatile = wake up fast...even in high BMIs
I find (by conjecture) less PONV because the pt was exposed to a significant less amt of volatile...
I could be wrong in all of my reasoning-but it works for me and the ETT is coming out when the curtain is coming down...I never need nitrous and my PONV occurrence is lower...maybe not for everyone but it works for me I'm comfortable with it and I really like it
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I don't mean to be a smartass 😀 well maybe I do, but that's not congruent with my understanding of physics.
The tissue depot is a function of time and agent blood concentration ... nothing else (OK, temperature - but that's not likely to be clinically relevant).
You're probably just good at turning the vaporizer off early enough, which I think is a tough skill to consistently get right. 👍
I learned low-flow anesthesia from Harry Lowe (look him up, he invented it). I was taught by the man himself that LFA was less wasteful, which appealed to his inner cheapskate. He made it clear, however, that the actual concentration of volatile agent INSIDE the patient was the same with high- vs low-flow anesthesia. So, not clear how this results in any difference in PONV.
Also, Lowe worked out a patient's O2 consumption with a silly slide rule-like thing and put exactly that much O2 into the circuit. Typically 225-275ml/min. Not 300-1500, as that would be "wasteful". Bellows would always look like they were collapsing. We could deduce how much gas sampling systems used when they were introduced by how much O2 was needed above the calculated amount. Still not above 450ml/min total including gas sampling.
I think you were taught a "modified LFA" as compared to mine. We didn't see any difference in wake ups (time or PONV-wise). Gas, though, was turned completely off after first few minutes of the case starting, levels stayed high 'til the end and gas flows were increased. This saved a TON of agent and bottled O2. You can see how this might fly today as it relates to the greenhouse effect discussed elsewhere in the forum.
Also, Lowe worked out a patient's O2 consumption with a silly slide rule-like thing and put exactly that much O2 into the circuit. Typically 225-275ml/min. Not 300-1500, as that would be "wasteful". Bellows would always look like they were collapsing. We could deduce how much gas sampling systems used when they were introduced by how much O2 was needed above the calculated amount. Still not above 450ml/min total including gas sampling.
I think you were taught a "modified LFA" as compared to mine. We didn't see any difference in wake ups (time or PONV-wise). Gas, though, was turned completely off after first few minutes of the case starting, levels stayed high 'til the end and gas flows were increased. This saved a TON of agent and bottled O2. You can see how this might fly today as it relates to the greenhouse effect discussed elsewhere in the forum.
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I'm glad I wasn't the only one who doesn't get it. The way it was explained to me, when you shut off the vaporizer at low flow, the stored volatile returns to the blood compartment and keeps the patient (sort of) anesthetized. Since you aren't adding to the system, the total body content of volatile decreases which would speed up emergence. I think this technique would work well during minimal stimulation, like skin closure. I'll personally stick to nitrous because I like that additional 0.7MAC and nothing compares to the smoothness and control of a nitrous/opioid/no detectable VA wakeup (not even des).
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I didn't say either way was wrong. If you prefer to use Nitrous, then for the right patient, I don't have any issues with it. I just find that for me, I don't need it. Who knows, we all do anesthesia differently. My combo of Gas/Opiods/NSAIDs/Regional etc works for me so yeah, if I turn off the volatile and my flows are low, the volatile will fill/remain in the blood compartment, keeping my pt asleep and this has been successful for me, and yes, then does allow for a speedy wake up
But If for some reason I had used higher flows/or a narcotic infusion etc and my pt was still deep...I too am a fan of deep extubations for the right patient population as well. That's why anesthesia is fun...you can do the same thing a million ways and they can all be right
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My biggest mistake as a CA-1: Reversing early and letting patients SV by letting CO2 build up. This is the mother of all long/ugly wakeups.
-I never use des or N20, I hate them. Iso or sevo, most of the time Iso.
-If I Titrate opiates, I do it early. Near the start of slow skin closure (or when I think I have 10 or so minutes left), I use EtCO2 to assess how deep someone is, in that I keep it constant (32-34) as I wash out gas with agent off and high flows until they buck (I always make sure I have at least 1 good twitch). Most of the time its around a ET of 0.3ish (true reading using low flow).
-I use mech ventilation as long as possible. Only when the case truly is at the very end I reverse and switch to SV.
-Immediately get the patient in a good position, head up, suctioned.
-"Open your eyes", "squeeze my finger", pulling good TV. Extubate.
Most rookie residents think the goal is getting them to SV any means necessary. The true goal is get off as much gas as possible before extubation, especially with ISO. Here and there in I might push a some prop or fent if they get a little out of control, but this is rare because I can time it pretty precise.
I avoid this strategy for any procedure less than 2 hours or the kids/young adults (who always wake up swinging).
-I never use des or N20, I hate them. Iso or sevo, most of the time Iso.
-If I Titrate opiates, I do it early. Near the start of slow skin closure (or when I think I have 10 or so minutes left), I use EtCO2 to assess how deep someone is, in that I keep it constant (32-34) as I wash out gas with agent off and high flows until they buck (I always make sure I have at least 1 good twitch). Most of the time its around a ET of 0.3ish (true reading using low flow).
-I use mech ventilation as long as possible. Only when the case truly is at the very end I reverse and switch to SV.
-Immediately get the patient in a good position, head up, suctioned.
-"Open your eyes", "squeeze my finger", pulling good TV. Extubate.
Most rookie residents think the goal is getting them to SV any means necessary. The true goal is get off as much gas as possible before extubation, especially with ISO. Here and there in I might push a some prop or fent if they get a little out of control, but this is rare because I can time it pretty precise.
I avoid this strategy for any procedure less than 2 hours or the kids/young adults (who always wake up swinging).
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Arch Guillotti
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It doesn't have to be ugly, sometimes it can work quite well.
A few of the nurses I work with ALWAYS flip the vent over to manual at the end of the case. Then we wait around a while for the patient to start breathing, then we wait for the patient to wake up. yes, it is ugly.
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Sorry didn't mean to offend you. I get how the low flow technique might lead to a fast wakeup. I don't get how running 0.2 MAC doesn't risk awareness. Are your patients relaxed during that period?
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The pt is not at .2 MAC-with low enough flows-they are easily at .6 Mac or more until I turn my flows up...at low flows-eventually the inspired and expired volatile percentage equals out and although they may be at .6 or .7 MAC, it disappears at 10L O2 flow in no time...and nope-most are breathing and I've titrated in my opioid by that time...once they don't need to be relaxed anymore, I tend to reverse and get a nice normal SV breathing pattern and titrate my opioid of choice...I can push a bolus of propofol if needed but it usually just isn't...plus-if they're a candidate for a deep extubation...when surgery is done, I can extubate and head to PACU
I think we got a bit off track of the original intent/question posed in this thread (and I am guilty of helping derail the thread).
To the original poster: I think you can see that there are MANY ways to wake someone up quickly and get them out of the OR in a timely fashion. And as has been said, all of them are the right answer so long as they are effective and safe. Take your pick of style and/or technique. More likely, though, you are being led to a different strategy every day by a different attending (namely, his or her own strategy). Don't get confused because the answer seems to change every day, this is just what we're seeing here on this thread.
However, as I said in my first post here, the REAL way to facilitate OR turnover is to wake patients up quickly. Sure, spend some time streamlining your case starts; you will save a minute or two as you get more efficient with experience. But the way to save big chunks of time when you have 4,5 or 6 cases in a day is to get the patient awake and out of the OR fast time and time again. Repeatability is the most difficult part of this. This will take more practice than you will probably get during a 3 year residency. Sorry, it's true.
Still, keep working on quick and repeatable wakeups. You will get it right more often the more you focus on this aspect of our craft. You will get it wrong often, but just try to learn from it when you do. Whatever you do, don't compromise safety for the sake of speed. You are learning, you are expected to be slow, therefore no one will hang you if you take a bit longer occasionally.
To the original poster: I think you can see that there are MANY ways to wake someone up quickly and get them out of the OR in a timely fashion. And as has been said, all of them are the right answer so long as they are effective and safe. Take your pick of style and/or technique. More likely, though, you are being led to a different strategy every day by a different attending (namely, his or her own strategy). Don't get confused because the answer seems to change every day, this is just what we're seeing here on this thread.
However, as I said in my first post here, the REAL way to facilitate OR turnover is to wake patients up quickly. Sure, spend some time streamlining your case starts; you will save a minute or two as you get more efficient with experience. But the way to save big chunks of time when you have 4,5 or 6 cases in a day is to get the patient awake and out of the OR fast time and time again. Repeatability is the most difficult part of this. This will take more practice than you will probably get during a 3 year residency. Sorry, it's true.
Still, keep working on quick and repeatable wakeups. You will get it right more often the more you focus on this aspect of our craft. You will get it wrong often, but just try to learn from it when you do. Whatever you do, don't compromise safety for the sake of speed. You are learning, you are expected to be slow, therefore no one will hang you if you take a bit longer occasionally.
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Do the PACU nurses start an iv when the patient is in holding? Do you put the iv in the OR? it saves you a couple of minutes when you have an iv before entering the room...
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I'm probably reading this statement too literally, but I don't think bucking on emergence is something you should wait for, or even intend to happen. Indeed, "bucking" on emergence is often something to be avoided. If my patient starts bucking, then I've lost control of the emergence, and I'm reacting to him rather than bringing him on home. You should have days in your practice when not a single patient bucks on emergence, or at least only during extubation.
With your technique of waiting until the end of the case, then blowing off gas in a mad race for the finish line, it's speeding their emergence, and in my experience is more likely to lead to this bucking. Emergence is no different than induction- a smooth, steady induction/emergence just looks better.
Try weaning their gas off a little earlier in the case. If there is sufficient narcotic on board, they should be able to tolerate the closing on less than 1 MAC. By the time they are on skin, you can be on 1/2 MAC or less. They can be reversed as soon as the last layer of fascia is closed. Do stimulating things like sucking out the oropharynx and removing OG tubes before they are reversed. The surgeon should have put in local, so the skin closure is usually a pretty low stimulus. Control the FGF at this point to control their speed of emergence, with the vaporizer off or very low. Look for signs they are waking up, like swallowing. That's usually an earlier indicator. Once you start to see lid reflex or eyebrows raise, gently whisper their name in an ear. Eyes open? You're ready to extubate. By the time you graduate, you should be able to do this with some frequency before the drapes come down.
Here's a side benefit of having them lighter on closing: if they start to wiggle, the surgeon often gets the hint and speeds up closing, or better yet kicks the slow med student to the curb and makes the resident finish. More often than not, I've found that having a patient buck, etc. has as much to do with the closing team doing stimulating things like bovie some ridiculously tiny skin bleeder when the gas is at 0.2, or the scrub attacks the abdomen with a wet towel to abrade the last bit of prep off the skin. Can't do anything for that.
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d
Yeah I didn't mean that violent bucking, fighting the vent ect. I meant the small buck, where your peak pressure alarm goes off as they try to intiate a small breath over the vent or simply a rebreathing ETCO2 waveform (not technically bucking). At that point I flip the switch and do a full reversal. If they are partially paralyzed they wont buck violently specially if you avoid stimulation at all costs Emergence truly is an art, everyone has a preference. To the OP try different ways and see what works for you.
My rationale is that I want to get them from stage 3 to stage 1 fast as possible. If you let them SV fully reversed as they blow gas off their MV is at most half of what I can deliver with Mech Vent meaning it will take twice as long to wake up, and more of that stage 2ish craziness. I find if they can initial breaths at a lower EtCO2, then the gas has pretty much washed out because their CO2 responsiveness is closer to normal.
If I want a really smooth wake up, I actually start to work in medium dose infusion of propofol much earlier as I wash out all the gas. Then I go down to a lower dose toward the end, then finally shut it off at the end. These patients wake up F/C instantly.
If I want a super smooth wake up, then I just do it deep extubation if possible.
Yeah I didn't mean that violent bucking, fighting the vent ect. I meant the small buck, where your peak pressure alarm goes off as they try to intiate a small breath over the vent or simply a rebreathing ETCO2 waveform (not technically bucking). At that point I flip the switch and do a full reversal. If they are partially paralyzed they wont buck violently specially if you avoid stimulation at all costs Emergence truly is an art, everyone has a preference. To the OP try different ways and see what works for you.
My rationale is that I want to get them from stage 3 to stage 1 fast as possible. If you let them SV fully reversed as they blow gas off their MV is at most half of what I can deliver with Mech Vent meaning it will take twice as long to wake up, and more of that stage 2ish craziness. I find if they can initial breaths at a lower EtCO2, then the gas has pretty much washed out because their CO2 responsiveness is closer to normal.
If I want a really smooth wake up, I actually start to work in medium dose infusion of propofol much earlier as I wash out all the gas. Then I go down to a lower dose toward the end, then finally shut it off at the end. These patients wake up F/C instantly.
If I want a super smooth wake up, then I just do it deep extubation if possible.
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I'm with Bertelman - this would not be recognized as the "art of emergence" in private practice. Maybe in academia where the closure may take 45 minutes - but when you go from open abdomen to dressings going on in 5 minutes, it won't look that great. Neostigmine takes 15+ minutes to peak effect - if I'm waiting until the patient is spontaneously ventilating before I reverse, I'm way behind.
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In fast turnover rooms I would never use my strategy.
One of the hospitals we rotate at has private practice surgeons, a standard lap chole in 20 minutes. With these quick cases (less than 2 hours like I mentioned) I use a whole different strategy (Particularly less gas, and no paralytic relying more so on IV meds).
As for the reversal, neostigmine takes 10-11 minutes for peak effect (according to big miller). Another thing to consider NMB are potentiated by acidosis, hypothermia, and volatiles themselves. Keeping the PaCO2 down, decreasing the gas quick (which will also raise pt temp) will help augment NMB duration. These in turns speeds up the reversal's action because of a less dense block.
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So. First you say NMBDs are potentiated by acidosis, but then keeping PaCO2 low (alkalosis) will augment NMBD duration.
I'm also admittedly not familiar with how increasing the rate of blowing off a gas, presumably by increasing FGF, a known heat dissipator, can increase body temp.
To be quite honest, I'm impressed with what appears to be your level of understanding of the words in Ronald Miller's seminal textbook, but I'm doubtful very much of the above translates into meaningful differences in clinical practice for your average lap chole.
Arch Guillotti
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I have to agree. I don't think any of what you are describing (particularly for a 20 minute lap chole) makes a difference.
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Correct, not 15+ minutes.
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I give reversal pretty early for this exact reason (yeah, closer to 10 min per others and Miller). Also, what about SIMV as a means of allowing for adequate RR for blowing off the gas, but not having the patient buck the vent while SV'ing? I do this often. I like to "titrate" the RR in SIMV also, as the patient's SV ramps up I decrease the RR on SIMV (provided the patient is producing decent Vt's.)
Also, I've rethought the use of propofol in covering your bases during unpredictable (i.e. they let the med student do the subcuticular suturing) closures, and I think it's o.k. since the patient likely still has some narcotic on board, as well as skin isn't really all that stimulating. So, if you cut the gas off too early, I see no real problem in giving some propofol if you find you are too early.
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Let me rephrase:
My original Statement:
JWK stated that this is nonesense in a quick case. So my response was that I totally agree and that's why I originally said >2 hour case. Let me reiterate, I would NOT use this strategy in a 20 min lap chole.
Bertelman was right (its a typo). Should read:
"Another thing to consider NMB are potentiated by acidosis, hypothermia, and volatiles themselves. Keeping the PaCO2 down, decreasing the gas quick (which will also raise pt temp) will help REDUCE NMB duration. These in turns speeds up the reversal's action because of a less dense block."
Example: Recently did a 5 hour hepatic lobe resection (complicated patient with a complicated liver). Sparing the details, the patient was breathing iso near 0.8 mac balanced with liberal opiate use for 5 hours (no epidural due to orthopedic hardware). Decision was made to attempt extubation at the end of case if feasible.
As the surgeon began to close the peritoneum, my TOF=1 strong with 1 weak. At this point loaded the patient with 150 mcg of fentanyl, I dialed the gas way down to nothing and turned up the flows above MV (propofol loaded on the stop cock in case I felt the patient was getting light). Within 15 minutes Et MAC was near 0.3, EtCO2 was 34 TOF at 2 strong twitches. Turned the flow down to 1 L/min (so patient rebreathed their exhaled iso) because BIS started to creep in the 60's until they got to skin. As they stapled, I increased flow again to >MV to insure no rebreathing. TOF now at 3 strong twitches. Never took the patient off the vent Et iso mac at about 0.2. As they applied dressing, put the patient in rtberg, the patient began to start breathing over the vent at an EtCO2 of 34. Pushed reversal, suctioned mouth, switched to SV. As surgeon dictating case, I gently ask the patient to open their eyes... they do. I ask the patient to squeeze my fingers... they do. Patient pulling 500s at a rate in the teens. I do a quick clinical leak test, extubate, switch over to simple mask, move to stretcher, put HOB up, move over lines, SpO2 still 99%, out of the room within 5 minutes of last dressing applied. Never had to push propofol. Patient VAS=0, wide awake in recovery.
My original Statement:
JWK stated that this is nonesense in a quick case. So my response was that I totally agree and that's why I originally said >2 hour case. Let me reiterate, I would NOT use this strategy in a 20 min lap chole.
Bertelman was right (its a typo). Should read:
"Another thing to consider NMB are potentiated by acidosis, hypothermia, and volatiles themselves. Keeping the PaCO2 down, decreasing the gas quick (which will also raise pt temp) will help REDUCE NMB duration. These in turns speeds up the reversal's action because of a less dense block."
Example: Recently did a 5 hour hepatic lobe resection (complicated patient with a complicated liver). Sparing the details, the patient was breathing iso near 0.8 mac balanced with liberal opiate use for 5 hours (no epidural due to orthopedic hardware). Decision was made to attempt extubation at the end of case if feasible.
As the surgeon began to close the peritoneum, my TOF=1 strong with 1 weak. At this point loaded the patient with 150 mcg of fentanyl, I dialed the gas way down to nothing and turned up the flows above MV (propofol loaded on the stop cock in case I felt the patient was getting light). Within 15 minutes Et MAC was near 0.3, EtCO2 was 34 TOF at 2 strong twitches. Turned the flow down to 1 L/min (so patient rebreathed their exhaled iso) because BIS started to creep in the 60's until they got to skin. As they stapled, I increased flow again to >MV to insure no rebreathing. TOF now at 3 strong twitches. Never took the patient off the vent Et iso mac at about 0.2. As they applied dressing, put the patient in rtberg, the patient began to start breathing over the vent at an EtCO2 of 34. Pushed reversal, suctioned mouth, switched to SV. As surgeon dictating case, I gently ask the patient to open their eyes... they do. I ask the patient to squeeze my fingers... they do. Patient pulling 500s at a rate in the teens. I do a quick clinical leak test, extubate, switch over to simple mask, move to stretcher, put HOB up, move over lines, SpO2 still 99%, out of the room within 5 minutes of last dressing applied. Never had to push propofol. Patient VAS=0, wide awake in recovery.
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I'm no expert on the matter, and the attendings on this board (bertelman/arch/JWK) dwarf my experience points which is why I enjoy this forum. I love criticism because it sparks debate in which I learn. I can only defend my stance.
But my thoughts of SIMV is that yeah its nice to not worry about bucking but the CO2 still builds up too fast meaning they will breath on their own quicker yes, but they won't expel gas fast enough for me because MV is still on the lower end. I remember as a CA1 when I had a patient on SIMV but the pt completely SV with an ET ISO mac of 0.7 toward the end of the case (prolly 15 min to go). I thought wow this is great. My attending walked in, pushed small dose of propofol until the pt was apenic and turned on the vent with high flow VC. He breathed the patient down for 10 minutes getting the EtCO2 in the lower 30s with vaporizer off. When they were done closing, he turned off the vent, patient began to breath almost instantly and low and behold the patient quickly woke up immediately after. It was almost like a magic trick because I never understood why he would do something I thought was so foolish. Now it makes sense.
Bottomline: If my machine had AC, I would use it all the time but SIMV is not my favorite specially since you have to reverse extra early for it to be effective.
🙄
are you a nurse? ( sorry, couldn't resist )))))
learn your ventilator and what can you do with it. You are Anesthesiologist, aren't you?
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Thanks for the insight! I had no idea AC (with underlying VC) is the same as SIMV (with underlying VC)!!! I need to stop reading from nursing books.
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Lets see, as far as modes on our Datex Ohmeda AS/3 machine... We have VC, PC, and SIMV. Tried the konami code on startup once but couldn't unlock SIMV/PS or PC/VG modes. 🙁
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Up, up, down, down, left, right, left, right, B, A, start?
Pretty sure that unlocks SIMV/PC and APRV in the draegers... Too bad you don't have any of those...
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😱
wow. do you know WHY are they locked? How are you supposed to learn all the modes if they lock them?
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Probably has to do with the $$$$$$$
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People that didn't grow up with Nintendo ITT.
I would have tried 007 373 5963 myself.
I would have tried 007 373 5963 myself.
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867 5309?
(sorry, I know it's a big change of subject, just the first thing to pop into my head)
(sorry, I know it's a big change of subject, just the first thing to pop into my head)
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I bring the injection port to hold in my mask hand then push drug with the other
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Please, explain, how LOCKING the already existing modes of the machine is going to save the $$$$$?
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Sorry, I wasn't clear. What I meant was that wherever that person is training might not have paid to "unlock" those modes. A lot of vents, and I'm assuming anesthesia machines, have all the modes available in the software... the sales guy/whoever just has to unlock them after the hospital/etc has paid for them. It doesn't SAVE money, per se... it just forces people to PAY the money.
Another possibility is that the machines he uses are ancient and don't have those modes and he was joking about "unlocking" them with the Konami code (it's a Nintendo thing)...
Thanks. Yeah, I didn't understand that konami code reference and was too lazy to google it )))
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Dude you should check out a ventilator chapter in an ICU book if your understanding of vent modes is this jacked up and machine-specific...
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ICU vents and anesthesia vents are 2 totally different beasts.
But you obviously don't understand the difference if you think reading about ICU vents will be the cure. You have no grasp of the engineering differences between the 2 if you think they are simply the same. Yes they both ventilate, yes they both have similar "vent modes", but they are engineered by a completely different design. I'll give you that a piston driven anesthesia vent is a cousin to the modern ICU vent, but when you consider the intrinsic waste scavenging and circle re-breathing its obvious that its a distant cousin at best.
If you are being condescending and implying that I don't even know the basic difference between VC/PC/SIMV and simple options like I:E ratios/peep/inspiratory pause/PS/ect. then you are simply being arrogant.
Either way I know how to manage both and understand the difference.
I think you need to brush up on your ANESTHESIA vent, you can start by reading the vent chapter in:
dorsch dorsch "understanding anesthesia equipment" and compare that to your favorite ICU book.
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You sir, know nothing about my knowledge base.
I, however, read your rambling posts, as well as misinterpreted some apparent sarcasm, and made a suggestion.
So cool the f*ck out.
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out of curiosity, what year in training are you now?
i have a feeling as you do more cases you'll find that early spontaneous breathing is a great way for a smooth quick wakeup.
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CA2 with nothing but general and specialty anesthesia months behind me (no pain/peds/neuro/SICU yet). No where near the experience as an attending but a good chunk of general cases under my belt.
My question to you.... Standard CA1 case: 250 pounder for robotic hys BSO 3 hour in with iso at mac 1.0 in steep trendelenberg... estimated 30 minutes to go but who knows, maybe they'll have to do a cysto. You know out of steep trendelenberg to closure of lap sites takes them 10 minutes. What would be your strategy for a fast wake up?
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