Titrating in Propofol at the end of the case

[thinkorswim]

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?

I wouldn't say learning how to use or properly place an LMA is a significant educational deficit -- one of the first things you do after placing an LMA is to give a few breaths to test the seal then troubleshoot if needed. You just need to put in the reps.

I think the true handicap in training is testing the limits of LMAs. All the academic dogma that is preached (no paralytic with an LMA, never use one in prone position, avoid them in obese patients, etc.) really limits how comfortable some people are with them.

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[anbuitachi]

I wouldn't say learning how to use or properly place an LMA is a significant educational deficit -- one of the first things you do after placing an LMA is to give a few breaths to test the seal then troubleshoot if needed. You just need to put in the reps.

I think the true handicap in training is testing the limits of LMAs. All the academic dogma that is preached (no paralytic with an LMA, never use one in prone position, avoid them in obese patients, etc.) really limits how comfortable some people are with them.

i think its because there hasn't been a need to. like i can do a fem tib bypass by putting in an oral airway, straps, slap the mask on the patient, and turn on the vent. but why bother. just slap in a tube, takes a minute. similarly can also do a fem tib bypass with 1 24g IV. but why test those limits?

 

[deleted171991]

I wouldn't say learning how to use or properly place an LMA is a significant educational deficit -- one of the first things you do after placing an LMA is to give a few breaths to test the seal then troubleshoot if needed.

Except that some people are quite happy with LMAs that leak at 10-15 cmH2O, because they rely on the patient breathing spontaneously. Which is not OK. With few exceptions, one shouldn't do a case with an LMA if one is not prepared to paralyze the patient.

 

[deleted171991]

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.

I gain speed and convenience, both at induction and emergence. An LMA is much less stimulating than an ETT, so I can keep the patient lighter (if not using a muscle relaxant). Plus I can avoid a difficult intubation. There has been at least one big debate thread about this, so I won't go into details.

I also tend to let the patients breathe (on PSV) most of the time, as long as I can deliver the same MV as with PCV; I just don't plan my anesthetic around it, like the CRNAs, and then struggle to deepen the anesthesia when the patient is still too light by the time of incision (especially with a fast surgeon). I also don't hunt for SV, especially not at the price of an EtCO2 > 50-55 (again unlike the CRNAs).

 

[Twiggidy]

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.

Exactly. I thought the main point of an LMA is (some) airway protection and the allow the patient to breath. I understand FFP's response that LMA education is a bit suboptimal in residency but I think it has more to do with using the incorrect size. Also, yes, there is some variation in the different LMAs.....i prefer the Unique.

 

[Noyac]

Except that some people are quite happy with LMAs that leak at 10-15 cmH2O, because they rely on the patient breathing spontaneously. Which is not OK. With few exceptions, one shouldn't do a case with an LMA if one is not prepared to paralyze the patient.

That’s a strong statement. And not necessarily how I see things.

 

[Noyac]

I gain speed and convenience, both at induction and emergence. An LMA is much less stimulating than an ETT, so I can keep the patient lighter (if not using a muscle relaxant). Plus I can avoid a difficult intubation. There has been at least one big debate thread about this, so I won't go into details.

Yet another statement that I don’t entirely agree with.

 

[deleted162650]

one shouldn't do a case with an LMA if one is not prepared to paralyze the patient.

Talk about dogma

 

[deleted171991]

Talk about dogma

No. The dogma is LMA = SV.

 

[Ezekiel2517]

The worst attendings in residency are the ones who micromanage, especially little crap like this. Quite a bit of anesthesia is an art and it takes time to perfect techniques. Just like this experience was a learning point for you that will allow you to improve your technique

 

[Hork Bajir]

To the OP: I'm actually a huge fan of waking people up on propofol. You'll hear people tell you all sorts of bogus reasons why you shouldn't do it, but the way I see it is this:

- Let's say you have iso/sevo on for a few hours, and then you turn it off...
- Volatile will go from 1 MAC to 0.3 MAC in a matter of minutes
- Volatile will take FOREVER (sometimes >1hr, depending on how long it's been on) to go from 0.3 MAC to 0% end tidal, which is what you want for a crisp wakeup
- So you turn off the volatile ~45 minutes before the case ends, but for that last stretch where the patient is still being stimulated and you don't want them to move (or have awareness/recall while paralyzed), but the gas is only at 0.2 MAC, you need to do SOMETHING to bridge the gap
- It doesn't take much propofol to guarantee amnesia/hypnosis when you consider the synergy that you get with the last little bit of remaining volatile
- If you run a propofol infusion at LOW doses for <45 minutes or so, in my experience, people will wake up VERY quickly when you shut it off

Next time you have a multi-hour case, I suggest you try this strategy:
- Run gas for the first X hours
- Turn the gas off completely about 45 min-1hr before planned wakeup
- Bolus 10-20mg propofol to get a serum level, and start propofol infusion at 80 mcg/kg/min (this is my magic lucky number). After 15 minutes, cut it to 65. 15 minutes later, cut it to 50. As you get closer to wakeup, continue to back off on the prop infusion, as low as 25-30 depending on whether/how much end-tidal volatile is still sticking around
- If at all possible, get the patient breathing spontaneously on CPAP or on pressure support- titrate additional narcotics to respiratory rate PRN
- If the volatile is gone/almost gone and you're worried about the patient getting too light, add 50% nitrous
- If the patient moves (or you think they're about to move), it's ok to bolus a little prop... but LESS IS MORE. If the patient coughs and you give 40 or 50mg of prop, you've f@#%^d the whole thing up. 10-20mg boluses max- the key is to be mindful of how much total propofol you've given, and not let that amount exceed some budget that you set for yourself
- If you've done things right, when the last stitch or staple is going in, the end-tidal concentration of volatile is ZERO, and you've got the patient on a LOW-dose propofol infusion (maybe down to 45 or so) +/- nitrous. Turn both of them off, and oftentimes you can extubate before the drapes come down

After years of experimenting, this has become my go-to technique for waking ppl up after a long case. The beauty of anesthesia is that there are a million ways to skin a cat, and no doubt you will find something that works for you. The benefit (and PAIN) of residency is that you see tons of ways to do things, and you will have attendings tell you that something like this is stupid for XYZ reasons. Ask questions, decide if the answers you are being given make sense, and decide whether what you're being told is something that you want to incorporate into your own practice or not. Then smile and move on. At the end of the day, you are going to need to know more than one way to do things, so this one can be another arrow in your quiver.

I can tell you without a doubt, though, that it is 100% possible to wake people up on a dime by switching to prop at the end of the case... But like anything else, it takes practice to learn the technique.

 

[pgg]

I also tend to let the patients breathe (on PSV) most of the time, as long as I can deliver the same MV as with PCV; I just don't plan my anesthetic around it, like the CRNAs, and then struggle to deepen the anesthesia when the patient is still too light by the time of incision (especially with a fast surgeon). I also don't hunt for SV, especially not at the price of an EtCO2 > 50-55 (again unlike the CRNAs).

Interested in your opinion on PSV with LMAs, if you don't mind dancing on the head of a pin for a moment. I see a lot of people use PSV with LMAs and I don't really get why. Not wrong, just maybe unnecessary?

I rarely use pressure support with LMAs because it doesn't seem to offer any benefit over some CPAP.

With ETTs and spontaneously breathing patients, there is significant resistance to flow due to the narrow lumen of the tube. I think PSV is useful in reducing work of breathing and atelectasis from the extra NIF required to breathe through a straw. PSV has clear advantages here.

But LMAs add essentially zero resistance. An anesthetized spontaneously breathing patient will settle on a MV that puts their PaCO2 at whatever their brain's current "set point" is (influenced by lots of factors). With an LMA and 5 of CPAP they'll make respiratory effort to achieve a MV of X and an ETCO2 of Y. Add some PS and they'll settle into a MV of X and an ETCO2 of Y.

In other words, I've never been convinced that PSV actually increases MV over what you'd get with SV in a patient with an LMA. I'm not suggesting it's wrong or harmful, just maybe useless?

 

[deleted162650]

With ETTs and spontaneously breathing patients, there is significant resistance to flow due to the narrow lumen of the tube.

Actually not really unless you’ve got something smaller than a 6 in there. Try it sometime.

Benumof’s book has a nice table of flow rates for various size ETTs.

 

[sevoflurane]

I like PSV with LMAs in certain scenarios. Anterior hips for example where the surgeon might want some paralysis during certain parts of the procedure.
Say maybe 30 mg of roc. I then can lower my trigger to say 2 or 3 L/M and avoid larger doses of paralysis while still maintaining TV/MV with the addition of PSV. Could definitely use an ETT. But I typically don't for ant. hips of triple arthrodesis in the lateral position.

RR, TV and MV are affected by lots of things we do to an anesthetized patient. Including drugs, inhaled agents and tourniquets.

 

[sevoflurane]

I haven't read the entire thread so I am not sure I am being repetitive with the above statement.

FWIW, I also like a propofol bolus at the end of the case. ETT or LMA.
I tend to have the patient extubated or LMA removed and a mask/NC on the patient as they are closing.
By the time the drapes come down. The patient is immediately ready to be moved to the pacu bed/gurney.

 

[sevoflurane]

RR, TV and MV are affected by lots of things we do to an anesthetized patient. Including drugs, inhaled agents and tourniquets.

I guess what I am trying too say here is that the anesthetized "brain set point" can be different than the "pacu brain set point"... especially if you have long tourniquet times. So I don't really chase that high MV in that scenario as RR and MV will settle after the washout.

 

[sevoflurane]

To the OP: I'm actually a huge fan of waking people up on propofol. You'll hear people tell you all sorts of bogus reasons why you shouldn't do it, but the way I see it is this:

- Let's say you have iso/sevo on for a few hours, and then you turn it off...
- Volatile will go from 1 MAC to 0.3 MAC in a matter of minutes
- Volatile will take FOREVER (sometimes >1hr, depending on how long it's been on) to go from 0.3 MAC to 0% end tidal, which is what you want for a crisp wakeup
- So you turn off the volatile ~45 minutes before the case ends, but for that last stretch where the patient is still being stimulated and you don't want them to move (or have awareness/recall while paralyzed), but the gas is only at 0.2 MAC, you need to do SOMETHING to bridge the gap
- It doesn't take much propofol to guarantee amnesia/hypnosis when you consider the synergy that you get with the last little bit of remaining volatile
- If you run a propofol infusion at LOW doses for <45 minutes or so, in my experience, people will wake up VERY quickly when you shut it off

Next time you have a multi-hour case, I suggest you try this strategy:
- Run gas for the first X hours
- Turn the gas off completely about 45 min-1hr before planned wakeup
- Bolus 10-20mg propofol to get a serum level, and start propofol infusion at 80 mcg/kg/min (this is my magic lucky number). After 15 minutes, cut it to 65. 15 minutes later, cut it to 50. As you get closer to wakeup, continue to back off on the prop infusion, as low as 25-30 depending on whether/how much end-tidal volatile is still sticking around
- If at all possible, get the patient breathing spontaneously on CPAP or on pressure support- titrate additional narcotics to respiratory rate PRN
- If the volatile is gone/almost gone and you're worried about the patient getting too light, add 50% nitrous
- If the patient moves (or you think they're about to move), it's ok to bolus a little prop... but LESS IS MORE. If the patient coughs and you give 40 or 50mg of prop, you've f@#%^d the whole thing up. 10-20mg boluses max- the key is to be mindful of how much total propofol you've given, and not let that amount exceed some budget that you set for yourself
- If you've done things right, when the last stitch or staple is going in, the end-tidal concentration of volatile is ZERO, and you've got the patient on a LOW-dose propofol infusion (maybe down to 45 or so) +/- nitrous. Turn both of them off, and oftentimes you can extubate before the drapes come down

After years of experimenting, this has become my go-to technique for waking ppl up after a long case. The beauty of anesthesia is that there are a million ways to skin a cat, and no doubt you will find something that works for you. The benefit (and PAIN) of residency is that you see tons of ways to do things, and you will have attendings tell you that something like this is stupid for XYZ reasons. Ask questions, decide if the answers you are being given make sense, and decide whether what you're being told is something that you want to incorporate into your own practice or not. Then smile and move on. At the end of the day, you are going to need to know more than one way to do things, so this one can be another arrow in your quiver.

I can tell you without a doubt, though, that it is 100% possible to wake people up on a dime by switching to prop at the end of the case... But like anything else, it takes practice to learn the technique.

I like your post but that recipe would not have worked for me at all yesterday.

8 ORIFs and 8 blocks all by 3 pm (one hour cases). Definitely different ways of skinning a cat as you say.
With regional on board... I run .5 MAC at low flows on nearly all of my patients. Pull the LMA/Tube early with a few propofol boluses. (definitely more than 1-2 ccs at a time). Monitor RR/TV add a little more or a little less as necessary. Usually hypnotic doses as regional is carrying me through most of the case. This basically turns into an endo case with the goal being an alert patient in pacu shortly after arrival.

 

[anbuitachi]

To the OP: I'm actually a huge fan of waking people up on propofol. You'll hear people tell you all sorts of bogus reasons why you shouldn't do it, but the way I see it is this:

- Let's say you have iso/sevo on for a few hours, and then you turn it off...
- Volatile will go from 1 MAC to 0.3 MAC in a matter of minutes
- Volatile will take FOREVER (sometimes >1hr, depending on how long it's been on) to go from 0.3 MAC to 0% end tidal, which is what you want for a crisp wakeup
- So you turn off the volatile ~45 minutes before the case ends, but for that last stretch where the patient is still being stimulated and you don't want them to move (or have awareness/recall while paralyzed), but the gas is only at 0.2 MAC, you need to do SOMETHING to bridge the gap
- It doesn't take much propofol to guarantee amnesia/hypnosis when you consider the synergy that you get with the last little bit of remaining volatile
- If you run a propofol infusion at LOW doses for <45 minutes or so, in my experience, people will wake up VERY quickly when you shut it off

Next time you have a multi-hour case, I suggest you try this strategy:
- Run gas for the first X hours
- Turn the gas off completely about 45 min-1hr before planned wakeup
- Bolus 10-20mg propofol to get a serum level, and start propofol infusion at 80 mcg/kg/min (this is my magic lucky number). After 15 minutes, cut it to 65. 15 minutes later, cut it to 50. As you get closer to wakeup, continue to back off on the prop infusion, as low as 25-30 depending on whether/how much end-tidal volatile is still sticking around
- If at all possible, get the patient breathing spontaneously on CPAP or on pressure support- titrate additional narcotics to respiratory rate PRN
- If the volatile is gone/almost gone and you're worried about the patient getting too light, add 50% nitrous
- If the patient moves (or you think they're about to move), it's ok to bolus a little prop... but LESS IS MORE. If the patient coughs and you give 40 or 50mg of prop, you've f@#%^d the whole thing up. 10-20mg boluses max- the key is to be mindful of how much total propofol you've given, and not let that amount exceed some budget that you set for yourself
- If you've done things right, when the last stitch or staple is going in, the end-tidal concentration of volatile is ZERO, and you've got the patient on a LOW-dose propofol infusion (maybe down to 45 or so) +/- nitrous. Turn both of them off, and oftentimes you can extubate before the drapes come down

After years of experimenting, this has become my go-to technique for waking ppl up after a long case. The beauty of anesthesia is that there are a million ways to skin a cat, and no doubt you will find something that works for you. The benefit (and PAIN) of residency is that you see tons of ways to do things, and you will have attendings tell you that something like this is stupid for XYZ reasons. Ask questions, decide if the answers you are being given make sense, and decide whether what you're being told is something that you want to incorporate into your own practice or not. Then smile and move on. At the end of the day, you are going to need to know more than one way to do things, so this one can be another arrow in your quiver.

I can tell you without a doubt, though, that it is 100% possible to wake people up on a dime by switching to prop at the end of the case... But like anything else, it takes practice to learn the technique.

other than cost, why not just run them on prop for the case then? i sometimes do entire cases with 80mcg/kg/min of prop and a fent infusion. titrate down prop/fent near the end, get them breathing, and extubate. let them wake up in the PACU nice and calm

 

[dhb]

I like your post but that recipe would not have worked for me at all yesterday.

8 ORIFs and 8 blocks all by 3 pm (one hour cases). Definitely different ways of skinning a cat as you say.
With regional on board... I run .5 MAC at low flows on nearly all of my patients. Pull the LMA/Tube early with a few propofol boluses. (definitely more than 1-2 ccs at a time). Monitor RR/TV add a little more or a little less as necessary. Usually hypnotic doses as regional is carrying me through most of the case. This basically turns into an endo case with the goal being an alert patient in pacu shortly after arrival.

If you are running 0.5 mac of gas why do you bother with the propofol? The patient will be wide awake 5min after you stop the sevo.

 

[sevoflurane]

If you are running 0.5 mac of gas why do you bother with the propofol? The patient will be wide awake 5min after you stop the sevo.

The above statement is not necessarily true.

I like time to washout any remaining inhaled agent.

I prefer a propofol wakeup to a volatile wakeup (haha pun intended).

Propofol wakups are just smooth and offer short term pleasant sedation with some added benefits like PONV prevention.

Truth is Volatile agents are dirty. But a necessary evil for most of our anesthetics.

 

[deleted162650]

Prop’s not really necessary to smooth out an LMA wake up. Helps with an ETT though. And don’t forget nitrous. It’s a great tool for wake ups to washout the volatile and get this - it’s right there on the machine!!

 

[anbuitachi]

If you are running 0.5 mac of gas why do you bother with the propofol? The patient will be wide awake 5min after you stop the sevo.

definitely not true. the sevo lingers forever.

 

[anbuitachi]

Prop’s not really necessary to smooth out an LMA wake up. Helps with an ETT though. And don’t forget nitrous. It’s a great tool for wake ups to washout the volatile and get this - it’s right there on the machine!!

i like propofol cause i get them breathing and just pull the tube. i use nitrous a lot too, but some minor issues i have w it is 1 it decreases reserve, so if something does happen, laryngospasm or patient just wakes up like crap, you have less time to work with. and two it takes a little bit longer to titrate to narcotic to resp rate if you do that, since you also have to breathe the nitrous off, which you dont have to do with propofol.

 

[deleted162650]

i like propofol cause i get them breathing and just pull the tube. i use nitrous a lot too, but some minor issues i have w it is 1 it decreases reserve, so if something does happen, laryngospasm or patient just wakes up like crap, you have less time to work with. and two it takes a little bit longer to titrate to narcotic to resp rate if you do that, since you also have to breathe the nitrous off, which you dont have to do with propofol.

You don’t extubate with the nitrous still on, you turn it off when you’re ready for them to wake up so the decreased reserve argument just doesn’t hold water. They’re still on 100% O2 if they spasm, etc.

 

[anbuitachi]

You don’t extubate with the nitrous still on, you turn it off when you’re ready for them to wake up so the decreased reserve argument just doesn’t hold water. They’re still on 100% O2 if they spasm, etc.

nitrous isn't still on but theres often left over nitrous. most people wake up/start moving way before end tidal nitrous goes to zero. theres also rapid diffusion as well. but like i said its only a minor issue.

 

[dhb]

definitely not true. the sevo lingers forever.

It's not the same coming down from 0.5 mac than 1.2

 

[anbuitachi]

It's not the same coming down from 0.5 mac than 1.2

yea its faster

 

[hununuh]

Thank you everyone for the wonderful discussion. I find these very helpful. I have a follow up question though.

Is there any literature that support the transition from sevo to propofol to reduce the emergence time or make the emergence more smooth? I found an article for peds, but couldn't find anything for adult population. Thank you again!

 

[VisionaryTics]

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

I'm an ENT resident, and was always taught to suction the stomach out after FESS/septoplasty/etc. And many, many times, I've tried to get the tube down and the patient starts bucking and coughing and pouring blood out of the nose all over my nice dressing.

Just the other day, I went to suction the stomach, and the anesthesiologist had left an OG in at the start of the case. I just pulled it out. I was like, "this is so easy. Why haven't we always being doing this?"

Added this to my bag of tricks for my practice.

 

[deleted171991]

Interested in your opinion on PSV with LMAs, if you don't mind dancing on the head of a pin for a moment. I see a lot of people use PSV with LMAs and I don't really get why. Not wrong, just maybe unnecessary?

I rarely use pressure support with LMAs because it doesn't seem to offer any benefit over some CPAP.

With ETTs and spontaneously breathing patients, there is significant resistance to flow due to the narrow lumen of the tube. I think PSV is useful in reducing work of breathing and atelectasis from the extra NIF required to breathe through a straw. PSV has clear advantages here.

But LMAs add essentially zero resistance. An anesthetized spontaneously breathing patient will settle on a MV that puts their PaCO2 at whatever their brain's current "set point" is (influenced by lots of factors). With an LMA and 5 of CPAP they'll make respiratory effort to achieve a MV of X and an ETCO2 of Y. Add some PS and they'll settle into a MV of X and an ETCO2 of Y.

In other words, I've never been convinced that PSV actually increases MV over what you'd get with SV in a patient with an LMA. I'm not suggesting it's wrong or harmful, just maybe useless?

I can't contradict you.

With a well-fitting LMA, I may use a small amount of PSV, to maintain the tidal volume at controlled-ventilation levels (i.e. about 6 ml/kg). Why? So I ventilate less dead space (don't get me started how many CRNAs are surprised when their patients get light on Vt of 230). It gives me the resemblance of PCV that I like. Otherwise, even for a few hour-case, one could argue that the patient should not tire out even on SV.

Plus what sevo said above.

It's really about skinning the cat. One could argue that your method is safer, since it doesn't risk insufflating the stomach.

 

[deleted171991]

definitely not true. the sevo lingers forever.

@dhb pointed it out correctly: when you did the case on less than 1% of sevo, it's a completely different wakeup than coming from 2%. I actually tend to wash out nitrous and wake up the patients on sevo and 100% O2 (and trust me, they are actually more clear-minded than the other way round, plus no diffusion hypoxia during transport or in the PACU).

 

[Hork Bajir]

I actually think that whether you go from sevo to prop, prop to iso, nitrous to des etc doesn’t really matter as long as you are switching to something different toward the end of the case. My logic is that you are starting a new context sensitive half time when you start a new drug- and as I mentioned in my earlier post, because you get some syngergy from the lingering tail of the volatile (or whatever you were on for the start of the case), you can get away with using relatively lower doses of whatever second agent you switch to.

To address some of the points people have raised above:
- Because I run the prop for a relatively short period of time and at lowish doses, it goes away FAST when I shut it off; this is not true if you run a TIVA as your primary anesthetic for the whole case
- Agree that this technique isn’t worth the trouble for short cases. Best used for cases that are a few hours long
- Another advantage of prop for wake up is that you are uncoupling your ventilation from your metabolism/elimination of hypnotic agent. If they hypoventilate a bit on the way to PACU, the liver will continue chewing up any remaining propofol at the same rate
- I am not aware of any literature supporting any of this. Entirely anecdotal and experiential, although there is some logic behind it in terms of the pharmacology

 

[Hork Bajir]

I haven't read the entire thread so I am not sure I am being repetitive with the above statement.

FWIW, I also like a propofol bolus at the end of the case. ETT or LMA.
I tend to have the patient extubated or LMA removed and a mask/NC on the patient as they are closing.
By the time the drapes come down. The patient is immediately ready to be moved to the pacu bed/gurney.

When the drapes come down and the patient is extubated and calmly looking around, the look on the surgeon’s face (if they’re not expecting this) is priceless. Forget Ninja status... A stealthy deep extubation under the drapes is a straight Jedi move.

However, I have timed this move incorrectly before, ie pulling the tube too soon or in the wrong patient, and then had to struggle with bag masking under the drapes, desaturation, blah blah... Which makes you look like a pretty big dummy. Great when it works, not so slick when it doesn’t

 

[nimbus]

Anyone else notice skinny middle aged smokers wake up wicked fast, clear-headed and without nausea? Had a guy today for laparoscopic inguinal hernia repair. Gave my basic generic fentanyl/sevo/roc anesthetic. Extubated before drapes came down and fully conversant before leaving the OR.

 

[vector2]

Anyone else notice skinny middle aged smokers wake up wicked fast, clear-headed and without nausea? Had a guy today for laparoscopic inguinal hernia repair. Gave my basic generic fentanyl/sevo/roc anesthetic. Extubated before drapes came down and fully conversant before leaving the OR.

See it all the time. Nicotine induces CYPs and it’s also protective for PONV

 

[pgg]

Someone should do a study using nicotine patches in nonsmokers as PONV prophylaxis.

 

[deleted162650]

Someone should do a study using nicotine patches in nonsmokers as PONV prophylaxis.

I’m just gonna tell people to start smoking 2 weeks prior to their procedure.

 

[anbuitachi]

When the drapes come down and the patient is extubated and calmly looking around, the look on the surgeon’s face (if they’re not expecting this) is priceless. Forget Ninja status... A stealthy deep extubation under the drapes is a straight Jedi move.

However, I have timed this move incorrectly before, ie pulling the tube too soon or in the wrong patient, and then had to struggle with bag masking under the drapes, desaturation, blah blah... Which makes you look like a pretty big dummy. Great when it works, not so slick when it doesn’t

The wrong patient..? Did you sneak in someone else's room and pull the tube

 

[anbuitachi]

I actually think that whether you go from sevo to prop, prop to iso, nitrous to des etc doesn’t really matter as long as you are switching to something different toward the end of the case. My logic is that you are starting a new context sensitive half time when you start a new drug- and as I mentioned in my earlier post, because you get some syngergy from the lingering tail of the volatile (or whatever you were on for the start of the case), you can get away with using relatively lower doses of whatever second agent you switch to.

To address some of the points people have raised above:
- Because I run the prop for a relatively short period of time and at lowish doses, it goes away FAST when I shut it off; this is not true if you run a TIVA as your primary anesthetic for the whole case
- Agree that this technique isn’t worth the trouble for short cases. Best used for cases that are a few hours long
- Another advantage of prop for wake up is that you are uncoupling your ventilation from your metabolism/elimination of hypnotic agent. If they hypoventilate a bit on the way to PACU, the liver will continue chewing up any remaining propofol at the same rate
- I am not aware of any literature supporting any of this. Entirely anecdotal and experiential, although there is some logic behind it in terms of the pharmacology

I see some people switch from iso to des and I don't really think this makes the wakeup faster

 

[deleted162650]

I see some people switch from iso to des and I don't really think this makes the wakeup faster

It’s better to just run des at low flows the whole case. With the flow rates you need to run to washout the first agent, it’s not any cheaper to switch at the end. This has been specifically studied.

 

[Hork Bajir]

The wrong patient..? Did you sneak in someone else's room and pull the tube

The wrong patient for this move would be the dude/dudette with lots of juicy secretions, significant OSA, a bushy beard/thick neck/difficult to mask, suboptimal pulmonary reserve, risk factors for laryngospasm, etc

 

[deleted162650]

The wrong patient for this move would be the dude/dudette with lots of juicy secretions, significant OSA, a bushy beard/thick neck/difficult to mask, suboptimal pulmonary reserve, risk factors for laryngospasm, etc

Amateur

 

[anbuitachi]

It’s better to just run des at low flows the whole case. With the flow rates you need to run to washout the first agent, it’s not any cheaper to switch at the end. This has been specifically studied.

Yea that's why I just stick to my iso.

 

[Noyac]

I haven't read the entire thread so I am not sure I am being repetitive with the above statement.

FWIW, I also like a propofol bolus at the end of the case. ETT or LMA.
I tend to have the patient extubated or LMA removed and a mask/NC on the patient as they are closing.
By the time the drapes come down. The patient is immediately ready to be moved to the pacu bed/gurney.

Your pts have to be moved to the gurney? Still room for improvement.

 

[Noyac]

I like your post but that recipe would not have worked for me at all yesterday.

8 ORIFs and 8 blocks all by 3 pm (one hour cases). Definitely different ways of skinning a cat as you say.
With regional on board... I run .5 MAC at low flows on nearly all of my patients. Pull the LMA/Tube early with a few propofol boluses. (definitely more than 1-2 ccs at a time). Monitor RR/TV add a little more or a little less as necessary. Usually hypnotic doses as regional is carrying me through most of the case. This basically turns into an endo case with the goal being an alert patient in pacu shortly after arrival.

Thats ninja style there!

 

[Noyac]

If you are running 0.5 mac of gas why do you bother with the propofol? The patient will be wide awake 5min after you stop the sevo.

Because the propofol wake up is better. Pts love the propofol.

 

[sevoflurane]

Your pts have to be moved to the gurney? Still room for improvement.

Haha... yeah. Nurses love that shait.

 

[deleted162650]

Your pts have to be moved to the gurney? Still room for improvement.

Gurney??? Ppffft. If your patients aren’t walking to PACU, you’re doing something wrong.

 

[vector2]

Gurney??? Ppffft. If your patients aren’t walking to PACU, you’re doing something wrong.

PACU?? pfffftttt, my pts walk straight to the uber that they requested while the intern was still closing their skin

 

[Noyac]

Gurney??? Ppffft. If your patients aren’t walking to PACU, you’re doing something wrong.

Well obviously I too have room for improvement.