TIVA Where did i go wrong ?

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Mentalist

Mentalist

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A case of lap cholecystectomy. Patient On TIVA ( Propofol and Remifentanil infusion ) and cisatracurium muscle relaxant dose given at induction.

By the time surgeon started to suture the incisions, he complained on two occasions about the abdomen being tense .

Where did I go wrong ??

Im guessing that a pancuronium would be a better choice in this :idea:
 
Mentalist said:
A case of lap cholecystectomy. Patient On TIVA ( Propofol and Remifentanil infusion ) and cisatracurium muscle relaxant dose given at induction.

By the time surgeon started to suture the incisions, he complained on two occasions about the abdomen being tense .

Where did I go wrong ??

Im guessing that a pancuronium would be a better choice in this :idea:
Click to expand...

How long was the case?
 
Where you went wrong is when you made the decision to become an anesthesiologist.
 
Mentalist said:
A case of lap cholecystectomy. Patient On TIVA ( Propofol and Remifentanil infusion ) and cisatracurium muscle relaxant dose given at induction.

By the time surgeon started to suture the incisions, he complained on two occasions about the abdomen being tense .

Where did I go wrong ??

Im guessing that a pancuronium would be a better choice in this :idea:
Click to expand...

That's a really expensive anesthetic.

Pancuronium is rarely a good choice. It's easy to redose a shorter acting agent. Were you monitoring twitches? Had you redosed the cis? Given reversal yet? How light was the patient? Did you have enough narcotic on board? Lots of factors contribute to "tenseness" during closure, including and especially the extent of the surgeon's mental illness.
 
He can't close trocar holes without full muscle relaxant?
 
Per4mer8 said:
He can't close trocar holes without full muscle relaxant?
Click to expand...

This.

Give a little propofol bolus at the end if they start bucking. Bad surgeons always complain.

Am I the only one that thinks that a TIVA with cisatracurium and remi is a little much for a lap chole?

Pancuronium is not the relaxant of choice for a lap chole either. Why not just give an induction dose of Roc? Seems like you may have over complicated a basic anesthetic for a basic case.
 
sevoflurane said:
This.

Give a little propofol bolus at the end if they start bucking. Bad surgeons always complain.

Am I the only one that thinks that a TIVA with cisatracurium and remi is a little much for a lap chole?

Pancuronium is not the relaxant of choice for a lap chole either. Why not just give an induction dose of Roc? Seems like you may have over complicated a basic anesthetic for a basic case.
Click to expand...

Roc sucks I think....very unpredictable.

Remi?

I heard a great quote about remi one time...the physicain - when asked if he uses remi- said it was like standing up and paddling in a canoe ...sure one can do it, but why the hell would you?
 
epidural man said:
Roc sucks I think....very unpredictable.

Remi?

I heard a great quote about remi one time...the physicain - when asked if he uses remi- said it was like standing up and paddling in a canoe ...sure one can do it, but why the hell would you?
Click to expand...

I would choose Roc over Cis for a lap chole 100% of the time.

At .6mg/kg. Roc is very predictable IMO. Vec would be the only other relaxant I would use for a lap chole... but even then, with speedy surgeons, I still go with Roc. I use it on induction more than any other relaxant out there. For longer cases, I'll bring in vec after the tube is in.

Remi is a waste, provieds no post-operative analgesia, is associated with hyperalgesia and is expensive. I can do a way better job with Fentanyl/Dilaudid and ketafol.
 
As far as reversal at the end of the case, Vec is more predictable than Roc. If I'm redosing relaxant after induction, I redose with vec.
 
pgg said:
That's a really expensive anesthetic.

Pancuronium is rarely a good choice. It's easy to redose a shorter acting agent. Were you monitoring twitches? Had you redosed the cis? Given reversal yet? How light was the patient? Did you have enough narcotic on board? Lots of factors contribute to "tenseness" during closure, including and especially the extent of the surgeon's mental illness.
Click to expand...

No didn't monitor twitches.
did not.
Didn't apply BIS.

:laugh: Regarding surgeon mentality, true that one of the Anesthetist technician approached me saying whenever a surgeon tell you patient is tense flush some saline and tell him relaxant given
 
Mentalist said:
No didn't monitor twitches.
did not.
Didn't apply BIS.

:laugh: Regarding surgeon mentality, true that one of the Anesthetist technician approached me saying whenever a surgeon tell you patient is tense flush some saline and tell him relaxant given
Click to expand...

Not even that, if he's closing then the right answer to the complaint of tenseness is "oh good, I want him strong because he'll be awake in three minutes" ... and then hopefully he'll quit complaining and hurry up.


The bigger, and still unanswered 🙂 issue here is why on earth were you doing a lap chole with a cis/propofol/remi TIVA in the first place? If it was just for resident learning purposes then kudos, but that's a wacky recipe for an ordinary lap chole (for multiple reasons).
 
epidural man said:
Roc sucks I think....very unpredictable.

Remi?

I heard a great quote about remi one time...the physicain - when asked if he uses remi- said it was like standing up and paddling in a canoe ...sure one can do it, but why the hell would you?
Click to expand...

People stand up paddleboard for fun......same with remi
 
Mentalist said:
No didn't monitor twitches.
did not.
Didn't apply BIS.

:laugh: Regarding surgeon mentality, true that one of the Anesthetist technician approached me saying whenever a surgeon tell you patient is tense flush some saline and tell him relaxant given
Click to expand...

I think the BIS is overused, but for a TIVA with paralysis, I think I'd probably use one.
 
ive gotten to where i use remi for those cases where you arent going to paralyze that are fairly stimulating such as thyroids and some ENT procedures. it is a very expensive fast acting relaxant
 
sevoflurane said:
Remi is a waste,
Click to expand...
Not sure if that means something in addition to your opinions below

sevoflurane said:
provieds no post-operative analgesia,
Click to expand...
No kidding

sevoflurane said:
is associated with hyperalgesia
Click to expand...
Don't give it for so long or at so high a dose

sevoflurane said:
and is expensive.
Click to expand...
Not really anymore

sevoflurane said:
I can do a way better job with Fentanyl/Dilaudid and ketafol.
Click to expand...
Maybe so. Remi has strengths and weaknesses. I could see it being used for a chole esp if you're giving toradol at the end. Me personally, I probably wouldn't do it. But don't be such a hater.
 
fakin' the funk said:
Not sure if that means something in addition to your opinions below


No kidding


Don't give it for so long or at so high a dose


Not really anymore


Maybe so. Remi has strengths and weaknesses. I could see it being used for a chole esp if you're giving toradol at the end. Me personally, I probably wouldn't do it. But don't be such a hater.
Click to expand...

Not hating. However, I see no point in using it for a lap chole. It most certainly has a place, especially in the spine room... but for a chole? Puhhlease...Won't catch me using it that way. 😛
 
One thing that hasn't been mentioned: I don't know how many TIVA's you have under your belt, but it might very well be just as simple as there is a subtle but very appreciable synergism in volatile IA's and muscle relaxants and when you delete that small (but not insignificant) amount of extra muscle relaxation by performing a TIVA, this may likely explain the unexpectedly low level of muscle relaxation. That and as mentioned earlier, surgeons are whiny cry babies. (As we speak, my Ortho meathead keeps checking the blood pressure---a railroad of 103/63--to see where all the bleeding must be coming from). 😉
 
Roc and Sugammadex..you are already dropping the big bucks for an inpt case, so go all the way. Keep a little webcam output viewing the TOF of the pts perineal nerve and hookup the feed to a 70" plasma HD across from the surgeon.
 
fakin' the funk said:
We charge > $1000 for 1g IV acetaminophen.
Click to expand...

Remind me to never get anything done at your hospital. The cost of wholesale Ofirmev is $12. Multiply this times the usual 5-10x markup and you are around $100. Charging $1000 is ridiculous. :eyebrow:

http://lead.freemedprograms.com/buy-ULTIVA-online

Check out the link and tell me that ultiva isn't expensive... remember that the hospital will always mark up their wholesale cost by 5-10X. Marking it up by 100X is a bunch of BS.
 
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