Titrating in Propofol at the end of the case

[hununuh]

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I was in an ENT case today. It was one of those cases where it's very stimulating up until the end of the case, but there's pretty much 0 closure, so they go from high stimulation to no stimulation, and the case ends.

To facilitate emergence, rather than spending 10-15min at the end of the case, awaiting sevo to reach 0.2%, I got the patient breathing spontaneously, and started to wean down the gas early on. I supplemented with propofol bolus as MAC was down to 0.7, and further on. By the time they were almost finished, patient was on 0.4% sevo. I essentially transitioned from sevo to propofol anesthesia at this point.

Patient woke up 5-10 min after the procedure ended, but my attending wasn't too happy, saying that patient would've woken up faster with just sevo alone, and that having both gas and propofol deepens the patient much more, thereby delaying the emergence.

Do other people do this, or is my approach to faster emergence a non-sense approach? Also, how much propofol do you give at the end of the case if you do this? Thank you.

 

[deleted59964]

depends how much propofol you use, when, and when you turn the gas off. like much of our field, how you do it is more important than what you do.

realise though that gas washes out in an exponential manner, so getting half the gas off early doesn't achieve as much as you might think

 

[Consigliere]

Sounds pretty stupid to me. I'm at the point in my career that I care as much about fast wake-ups as I do about CRNAs calling themselves "nurse anesthesioligists." Just turn down the sevo, j.o. and keep the propofol in the Pyxis.

 

[nimbus]

Your attending is right.

 

[deleted875186]

Perhaps tell us how much prop you gave over what amount of time .... could be that you gave too much, 0.7 mac of gas is still pretty good dose.

Also, what type of ENT case, if it’s skmething like a FESS, perhaps not as stimulating as you think, I would be a bit more aggressive getting the gas off if your giving prop.

 

[WholeLottaGame7]

I was in an ENT case today. It was one of those cases where it's very stimulating up until the end of the case, but there's pretty much 0 closure, so they go from high stimulation to no stimulation, and the case ends.

To facilitate emergence, rather than spending 10-15min at the end of the case, awaiting sevo to reach 0.2%, I got the patient breathing spontaneously, and started to wean down the gas early on. I supplemented with propofol bolus as MAC was down to 0.7, and further on. By the time they were almost finished, patient was on 0.4% sevo. I essentially transitioned from sevo to propofol anesthesia at this point.

Patient woke up 5-10 min after the procedure ended, but my attending wasn't too happy, saying that patient would've woken up faster with just sevo alone, and that having both gas and propofol deepens the patient much more, thereby delaying the emergence.

Do other people do this, or is my approach to faster emergence a non-sense approach? Also, how much propofol do you give at the end of the case if you do this? Thank you.

I like the technique, but you did it wrong. The patient should be at 0.4% sevo or lower at that point with a standard wakeup. The point of titrating in propofol is to get the sevo to 0.0% by the time they're done.

When done right, I think the wake-up is smoother, anecdotally less emergence delirium, yadda yadda.

Don't sweat it, this is what residency is for.

 

[coffeebythelake]

Dont mind the technique, but as others have discussed not the easiest to implement. Sandwich technique may help reduce ponv, and pts do have a smoother emergence.

 

[Morzh]

Agree with wholelottagame. It's a nice strategy, but you have to employ it at the right time and in the right amount. It's somewhat of an "art of anesthesia" thing. However sometimes its just easier to just turn the gas off, and not be worrying about micro propofol boluses at the end of case. In the long run probably doesn't make much difference, so I see why some are ambivalent about it.

I've found myself doing it more and more over the past year, and agree that the wake ups are usually slick, patients wake up happy (propofol has a known "sense of well being" effect), and I like to think maybe less N/V although I don't know if there's data to support that in this specific scenario.

My general strategy: as they're closing get gas down and get them breathing spontaneously + reversal, turn gas totally off and watch the sevo run off. I'm not worried about MAC "being below 0.7" and awareness or any of that because they're reversed, and the surgery is over anyway. (They suture skin on awake patients all the time in the ED, you don't need GA for subcuticulars esp if local was injected). Once the end-tidal sevo is 0.3-0.4 I'll start giving ~10-30mg boluses q3-5 minutes (titrate to spontaneous RR and vitals). These small boluses at the end of a case are more potent than at the beginning, or in a MAC case, because of "neural inertia" voodoo and residual gas/narcotic. The goal is to get volatile to absolute 0 so you've basically transitioned to a TIVA albeit for only 10-20 minutes. And try to time when the closing is actually going to be done and don't give anything within 5 minutes of that, or else you may indeed have a 10 minute wake up and not impress your attending. It takes some practice but it's a thing of beauty to extubate a comfortable patient without any bucking right as the final dressing is going on.

 

[Allagash]

Almost always use it. Especially long cases to get the gas off. Use nitrous and propofol for the last 15 min. Usually 10 mg every 5 min. Never delays. Always smooth and quick emergence.

 

[deleted697535]

Why not use des and a bite block?
They loterally jump off the bed going from 0.7 des to 0.3 in 20 secs

 

[hununuh]

Thank you everyone for the response. They are very helpful, and now I know what I was doing wrong.

@Newtwo, I'd like to try Des, but don't think our residency program even has DES stocked anywhere. I think they got rid of all vaporizers for Des.

 

[deleted697535]

why? expense or saving the planet?

 

[hununuh]

$$, as always

 

[deleted162650]

Nitrous is your friend.

 

[deleted162650]

Sounds pretty stupid to me. I'm at the point in my career that I care as much about fast wake-ups as I do about CRNAs calling themselves "nurse anesthesioligists." Just turn down the sevo, j.o. and keep the propofol in the Pyxis.

Sounds like @Consigliere makes his own propofol at the end of the case.

 

[anbuitachi]

the concern with some people is that a lot of these ENT scope cases are being done close to the brain, and they literally go from lot of stimulation to none. there is a risk of moving and causing dmg due to the narrow spaces in the sinuses/proxmity to somewhat important structures. that's why we try to keep them DEEP in these cases, or paralyze. i would imagine the risk is the highest at the end if you are lightning them up. forget the scope, the ET tube alone can cause the patient to buck and move.
it's very difficult to immediately pull the tube right when they are done. though i mean waiting 5-10 minutes is not a big deal IMO unless we are talking about quick ENT cases like T&As or something. mainly referring to ENT cases with no closures

 

[nimbus]

Our ENTs inject a bunch of local with epi for hemostasis so there’s not much stimulation and we’ve gone mostly to LMAs for these.

 

[woopedazz]

If you're trying to convert to TIVA half-way through the case, why not just run TIVA throughout?

 

[deleted875186]

Our ENTs inject a bunch of local with epi for hemostasis so there’s not much stimulation and we’ve gone mostly to LMAs for these.

Precisely. They usually don’t need more than an ice pack on PACU as well.

 

[cchoukal]

I teach the residents that 1 mL/min is 100 mcg/kg/min in a 100 kg patient and they are often blown away by how high a dose is achieved with a modest hand-delivered amount of propofol at the end of cases (1 mL/min is basically GA on top of however much sevo you still have on board). Point is: it’s easy to over do it on the propofol during emergence and delay things.

 

[deleted171991]

why? expense or saving the planet?

The official reason is saving the planet. The real reason is $$$.

By the way, des is nitrous + sevo for lazy people.

 

[deleted697535]

I thought no one in north america used nitrous anymore?

 

[jope]

I've seen this technique as resident in pediatrics - where you give about 0.5-1 mg/kg at end of the case for a deep extubation to supposedly lower the chance of laryngospasm. I have not found it be that useful other the very rare deep extubations in healthy adults that I've done (ie. orbital floor # repair).

Even though I do care about the planet, I prefer a more predictive fast emergence so I will still use Des. With the new ET control machines, it's easy to go from the 1 MAC Des to N20/O2 70/30 and Des of 1-2% to as they start skin closure to speed up things a little bit. Once I confirm that they are breathing spontaneously at the end of the case by having a lower respiratory rate or putting the patient on pressure support, I will just borderline hyperventilate off the volatile as soon as final suture goes in.

Theoretically, I could be causing cerebral vasoconstriction and limiting my washout, but it doesn't present significantly from my experience. The limited period of mild hypoventilation waiting for them to establish sponteneous breathing gives me a CO2 buffer to hyperventilate.

 

[deleted162650]

I thought no one in north america used nitrous anymore?

From now on, whatever you think, just think the opposite.

 

[deleted697535]

Lol... I was gonna say something but i wont bite...
Saving the world throwing out des but keeping nitrous...

From now on, whatever you think, just think the opposite.

 

[anbuitachi]

Our ENTs inject a bunch of local with epi for hemostasis so there’s not much stimulation and we’ve gone mostly to LMAs for these.

For FESS? thats pretty crazy. they do inject epi, sometimes we do blocks too, but still they are shoving a giant scope up there, their injection is like you said mostly for hemostasis, not saying its an insane lot of stimulation but its not little either. And sometimes we have to suction them out pretty well , even the stomach occasionally, if its a complicated FESS and the blood loss is not insiginifcant. these patients are usually sitting head up a bit so the blood just goes down into the pharynx

Once one of attendings wanted to get the patient breathing during the case, the ENT surgeons heard it and asked if we could please not do that, because they did not want any risk of patient bucking/moving as they were working closing to the brain

Precisely. They usually don’t need more than an ice pack on PACU as well.

Postop pain isn't much.

 

[Noyac]

If you're trying to convert to TIVA half-way through the case, why not just run TIVA throughout?

Because for as long as anesthesiologists have been trying to time their wake-ups, they have been playing around with ways to do this. The sandwich technique has proven (even if it is anecdotal) to be an effective way to time the wake-up. For some reason! And I’m sure someone smarter than me will explain it here, it is easier to time things when you chance the maintenance agent at the end of the case. I assume it has to do with receptors and the amount of saturation.

To the OP, your technique is well accepted. Your timing will get better and better as you learn your surgeons and your pts. This is what residency is for. Personally, I shoot for removal of volatile agents 10 min from closure in the shorter 1-2 hr cases. For the longer cases I will shoot for 20min. If the case is stimulating as you describe I will probably start getting gas off at about 5-10min from the end of the case. A good bolus of lidocaine can help eep the pt still too, sometimes, maybe.

 

[Radar26]

Also watch out for the ENT service that tries to “help you out” by decompression the stomach with an OG tube before turning the patient over to you- that often is stimulating enough to ruin your smooth wake up as you are titrations your anesthetic off...

 

[Twiggidy]

For FESS? thats pretty crazy. they do inject epi, sometimes we do blocks too, but still they are shoving a giant scope up there, their injection is like you said mostly for hemostasis, not saying its an insane lot of stimulation but its not little either. And sometimes we have to suction them out pretty well , even the stomach occasionally, if its a complicated FESS and the blood loss is not insiginifcant. these patients are usually sitting head up a bit so the blood just goes down into the pharynx

Once one of attendings wanted to get the patient breathing during the case, the ENT surgeons heard it and asked if we could please not do that, because they did not want any risk of patient bucking/moving as they were working closing to the brain


Postop pain isn't much.

Are you saying it's insane to use an LMA? If that's the case then question your ENT. In residency we had an ENT who wanted nothing MORE than LMA's for his FESS cases.

That being said, if you're using an LMA just pull the thing deep and stick in an oral airway if needed

 

[anbuitachi]

Are you saying it's insane to use an LMA? If that's the case then question your ENT. In residency we had an ENT who wanted nothing MORE than LMA's for his FESS cases.

maybe insane is too strong of a word lol. but i just dont realy see the benefit of using an LMA for these cases and having them breathe on their own. yea sure you can do it, just like how can you use lma for anything, but i dont see the benefit. a lot of people do these cases head away, with the bleeding trickling down, with a LMA, you risk laryngospasm, etc.

 

[deleted162650]

Keep ‘em paralyzed. Get the gas off. So easy now with Sugg.

Also watch out for the ENT service that tries to “help you out” by decompression the stomach with an OG tube before turning the patient over to you- that often is stimulating enough to ruin your smooth wake up as you are titrations your anesthetic off...

Just head ‘em off at the pass by putting down the OG at the beginning.

 

[AdmiralChz]

I thought no one in north america used nitrous anymore?

Not only is it used very frequently, but if I had to guess its use is going up with nitrous being the hot "new" thing to offer at a "boutique" L&D for laboring mothers.

 

[anbuitachi]

Not only is it used very frequently, but if I had to guess its use is going up with nitrous being the hot "new" thing to offer at a "boutique" L&D for laboring mothers.

not sure who pushed for this crap.

 

[anbuitachi]

Also watch out for the ENT service that tries to “help you out” by decompression the stomach with an OG tube before turning the patient over to you- that often is stimulating enough to ruin your smooth wake up as you are titrations your anesthetic off...

definitely agree. once had a paralyzed 50yo patient on 1 mac of gas, normotensive. as soon as i inserted the OG, pressure went to 230, before the case even started. insane

 

[IMGASMD]

not sure who pushed for this crap.

People who think it will make a good sound bite and publicity. Obviously, not anyone who actually have to manage it....

 

[deleted697535]

Nitrous is a 'new' thing in L&d? You cant do a fess with an lma!?! What?? Where do you all get this from?

Many hospitals have literally 10 years of exprience doing fess with lma

 

[anbuitachi]

Nitrous is a 'new' thing in L&d? You cant do a fess with an lma!?! What?? Where do you all get this from?

Many hospitals have literally 10 years of exprience doing fess with lma

you can, but why would you? im not sure why people are so obssessed with LMAs. it has its uses.. but its not exactly amazing. like i know most people do shoulder replacements with LMAs.. but who came up with this stuff, one day they decided tubing is no good, lets do LMA? next thing you know people will be doing posterior spine fusions with LMA! how about craniectomies??

 

[nimbus]

you can, but why would you? im not sure why people are so obssessed with LMAs. it has its uses.. but its not exactly amazing. like i know most people do shoulder replacements with LMAs.. but who came up with this stuff, one day they decided tubing is no good, lets do LMA? next thing you know people will be doing posterior spine fusions with LMA! how about craniectomies??

In these cases, an LMA prevents blood from entering the laryngeal aperture extremely well, even better than an ETT. It also facilitates smooth and fast wakeups. That’s why many surgeons and anesthesiologists prefer it.

 

[anbuitachi]

In these cases, an LMA prevents blood from entering the laryngeal aperture extremely well, even better than an ETT. It also facilitates smooth and fast wakeups. That’s why many surgeons and anesthesiologists prefer it.

thats maybe if you guarantee a perfect seal, which a lot of times does not happen, cause you are shoving it blind instead of visualizing. isn't that why LMA is contraindicated in aspiration risks? it faciliates fast wakeups because you are giving less anesthesia, you aren't bombing them with 250mcg of fentanyl at a time, and facilitates smooth wakeup probably because many people pull LMAs deep before the patient is fully following commands. i find awake patients to tolerate LMA less well than ETT tubes prob because of the size. but yea i do think it has its uses, especially in quick cases that require general but you dont want to mask the patient, then put in an LMA will help you free up your hands and avoid paralytics. but i dont see much benefit in putting LMAs in procedures that last several hours

 

[2Fast2Des]

Only If I have left over propofol then I'll slowly titrate some in, might as well use it up instead of squirting it in the health dept certified containers.

In patient's I know may wake up buck wild I'll use the left over prop, but also 100mg lidocaine is a charm. Basically, get em spontaneous, gas down +\- nitrous, sugga in, propofol here and there, getting to last 5 minutes IV lidocaine, blow gas off to zero, tube out no bucking, pt sleepy and comfy. I usually use sub anesthetic ketamine up front and redosing as needed so they're usually pretty good in not needing any prop to emerge smoothly. For long cases I do my multimodal formula and they wake up without a peep without bolusing anything.

 

[deleted162650]

LTA’s are great for these cases as well. Helps them tolerate the tube while you lighten them up.

 

[anbuitachi]

Only If I have left over propofol then I'll slowly titrate some in, might as well use it up instead of squirting it in the health dept certified containers.

In patient's I know may wake up buck wild I'll use the left over prop, but also 100mg lidocaine is a charm. Basically, get em spontaneous, gas down +\- nitrous, sugga in, propofol here and there, getting to last 5 minutes IV lidocaine, blow gas off to zero, tube out no bucking, pt sleepy and comfy. I usually use sub anesthetic ketamine up front and redosing as needed so they're usually pretty good in not needing any prop to emerge smoothly. For long cases I do my multimodal formula and they wake up without a peep without bolusing anything.

ketamine is the best

 

[Twiggidy]

thats maybe if you guarantee a perfect seal, which a lot of times does not happen, cause you are shoving it blind instead of visualizing. isn't that why LMA is contraindicated in aspiration risks? it faciliates fast wakeups because you are giving less anesthesia, you aren't bombing them with 250mcg of fentanyl at a time, and facilitates smooth wakeup probably because many people pull LMAs deep before the patient is fully following commands. i find awake patients to tolerate LMA less well than ETT tubes prob because of the size. but yea i do think it has its uses, especially in quick cases that require general but you dont want to mask the patient, then put in an LMA will help you free up your hands and avoid paralytics. but i dont see much benefit in putting LMAs in procedures that last several hours

my day (and the surgeon's day) moves a lot faster if I can drop a LMA. theoretically, if the case doesn't require muscle relaxation you can use a LMA and let the patient breath and just titrate narcotic. I walked in on a partner once using a LMA for a fem-tib. A bit cavalier and I'd probably not do the same but "length of case" isn't a contraindication.....i also remember a big M/M fiasco during residency when one attending did an Hand Revascularization with an LMA. Nothing happened, it was mostly presented because it irritated the director.

 

[anbuitachi]

my day (and the surgeon's day) moves a lot faster if I can drop an LMA. theoretically, if the case doesn't require muscle relaxation you can use an LMA and let the patient breath and just titrate narcotic. I walked in on a partner once using an LMA for a fem-tib. A bit cavalier and I'd probably not do the same but "length of case" isn't a contraindication.....i also remember a big M/M fiasco during residency when one attending did an Hand Revascularization with an LMA. Nothing happened, it was mostly presented because it irritated the director.

yea thats why i said pretty much almost any case can technically get a LMA. its like in europe they use LMA with paralytics as well. at least for me, the main benefit of using LMA is to speed things up in short cases. I just dont think theres any benefit in using a LMA for a 10 hour case. Id rather use a LMA for a fem tib bypass than for a case where the head is away and theres blood going down near the airway. And thats a weird reason to present a case at a M&M...

 

[narcusprince]

Are you saying it's insane to use an LMA? If that's the case then question your ENT. In residency we had an ENT who wanted nothing MORE than LMA's for his FESS cases.

That being said, if you're using an LMA just pull the thing deep and stick in an oral airway if needed

All Fesses are not created equally. How many sinuses will they be entering, turbinates? Nasal restructuring? Dude we sound pretty weak.

 

[Twiggidy]

And thats a weird reason to present a case at a M&M...

Lots of weird things about that facility

 

[Noyac]

not sure who pushed for this crap.

Midwives. They want yet another reason not to involve the real medical professional. We have it at our facility I think. It is initiated by the OB service. But I’m not sure anyone has done it. Then again, I wouldn’t know.

 

[deleted171991]

maybe insane is too strong of a word lol. but i just dont realy see the benefit of using an LMA for these cases and having them breathe on their own. yea sure you can do it, just like how can you use lma for anything, but i dont see the benefit. a lot of people do these cases head away, with the bleeding trickling down, with a LMA, you risk laryngospasm, etc.

You equal LMAs with spontaneous ventilation. Big mistake. The best LMA anesthesia is done with controlled ventilation (faster asleep, faster awake). Learning how to properly use LMAs is a HUGE educational deficit that still exists in many residency programs. If one doesn't know how to fit LMAs well enough for controlled ventilation, how would one be able to use them during a can't ventilate can't intubate scenario?

By the way, in an ENT case, you can tape some soft suction tubing to the back of the LMA, and keep suctioning during the case. 😉

 

[anbuitachi]

You equal LMAs with spontaneous ventilation. Big mistake. The best LMA anesthesia is done with controlled ventilation (faster asleep, faster awake). Learning how to properly use LMAs is a HUGE educational deficit that still exists in many residency programs. If one doesn't know how to fit LMAs well enough for controlled ventilation, how would one be able to use them during a can't ventilate can't intubate scenario?

By the way, in an ENT case, you can tape some soft suction tubing to the back of the LMA, and keep suctioning during the case. 😉

the other problem with LMAs is there are like a ton of different ones. every institution uses something else. and for emergency airways, im using the LMA as a temporizing measure. i dont care much about stomach insufflation at that point. i dont really believe 100% of the air goes into the trachea with controlled ventilation with LMA 100% of the time.

 

[deleted162650]

You equal LMAs with spontaneous ventilation. Big mistake. The best LMA anesthesia is done with controlled ventilation (faster asleep, faster awake). Learning how to properly use LMAs is a HUGE educational deficit that still exists in many residency programs. If one doesn't know how to fit LMAs well enough for controlled ventilation, how would one be able to use them during a can't ventilate can't intubate scenario?

By the way, in an ENT case, you can tape some soft suction tubing to the back of the LMA, and keep suctioning during the case. 😉

Let me ask you this: if you’re plan is controlled ventilation w/ or w/o paralysis, what do you gain by using an LMA?

I’ll regularly put the pt on PCV at a low rate after induction and LMA placement if they’re apnic, but once they start breathing again I just let them.