TIVA without Propofol

[monchi]

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There's a propofol "shortage" at my hospital, which has led to some interesting uses of other induction and non-induction agents.
Overall, not a bad experience. I've learned a hell of a lot about different ways to induce people, and really appreciate just how awesome propofol is.

But, I have yet to do a TIVA without it. We're reserving propofol for endoscopies and MRI (thank God!!) but I'm thinking of neuromonitoring cases, or someone with MH.

I have a few ideas, but wanted to throw it out there.
What do you have experience with?

 

[Pilot Doc]

But, I have yet to do a TIVA without it. We're reserving propofol for endoscopies and MRI (thank God!!) but I'm thinking of neuromonitoring cases, or someone with MH.

I have a few ideas, but wanted to throw it out there.
What do you have experience with?

I asked one of the greybeards at my program about that. Ketamine ... really high dose ketamine.

 

[Shadowfax8]

I love to use Precedex for TIVA cases in concert with Remifentanil. While there has not been documented concern of recall with Precedex, it is still a relatively new drug and for added safety I utilized scopolamine as part of the induction for enhanced amnesia. The additional benefits of scopolamine's antiemetic and antisialogogue effects are nice too.

 

[monchi]

I love to use Precedex for TIVA cases in concert with Remifentanil. While there has not been documented concern of recall with Precedex, it is still a relatively new drug and for added safety I utilized scopolamine as part of the induction for enhanced amnesia. The additional benefits of scopolamine's antiemetic and antisialogogue effects are nice too.

The neuromonitoring techs were telling me that most people here are using Precedex, with 0.5 MAC of a gas. But pts aren't relaxed, so sometimes they're sitting up in the middle of the case. AND, my hospital is completely out of Remi. And thiopentol, to boot. Yeah, it's a hospital in the US. 🙄

I think people have been running Fentanyl infusions with the Precedex.
I need to look up what Scope does to the neuromonitoring. That sounds great for a non-neuromonitoring case though.

 

[Planktonmd]

How about good old inhaled agents with an infusion of the narcotic of your choice?
If you give enough Narcotics you can keep the Vapor at a low concentration.
You guys have Sevo don't you?

 

[Shadowfax8]

Well, the initial question that started this thread was with regards to TIVA. Thus inhalational agents are not an option. Now, in my practice I still tend to use inhalational agents during cases requiring SSEPs and/or MEPs. I make sure to start with short acting paralytics at first so as to not attenuate the MEPs and also communicate with the monitoring tech while they're acquiring their baseline SSEP's prior to incision. Once they have their baseline, if I need more anesthetic I simply utilize narcotics and not mess with the vaporizer so as not to obviate the SSEP's change from baseline. While the literature will tell you that volatiles and even N20 will attenuate amplitude and alter latency, if you can achieve adequate baseline prior to incision, then all they're assessing is change from baseline. The only time I every really do TIVA anymore is to keep my comfort level up with the technique if ever I should have no other options, such in 3rd world medicine during missionary trips when vaporizers won't necessarily be available.

 

[SleepIsGood]

as long as you have 0.7 MAC with an inhal agent, there's no problem with SSEPs/EMGs/MEPs. Some people say 0.5MAC. Just run some remifent and you should be good....Remi apparently decreases MAC by up to 50%

 

[Licoricestick]

OP also asked about TIVA in context of MH. For that I agree with Pilot - Ketamine. Just don't forget the Midaz and a little chat with the PACU nurses about finding a corner where you can turn the lights down a bit and let them sleep it off without shaking them every two seconds to ask what their pain score is.

I suppose you could try a thio infusion, but probably best only if you were planning on sending them to expensive care I+V anyway, an advantage would be you could use BIS.

 

[loveumms]

methohexital also works. I like to use that in conjunction with fentanyl and precedex.

Dont' worry our hospital has a shortage of propfol, remi, thiopental and vec. Good experience since we need to learn how to use everything 😉

 

[Impromptu]

BUMP

I just finished a neuroanesthesia month as a CA-1, was looking for a thread on TIVA, found this semi-recent one, and thought I'd throw in a few of the various TIVA mixes I was instructed to use when we had MEPs (we didn't use TIVA for SSEPs).

Once we were ready and switched from gas to TIVA our neuroanesthesia director and a few other attendings liked a combination of propofol, remifentanil (starting at 0.02 mcg/kg/min), and dexmedetomidine (starting at 0.5 mcg/kg/hr). Some did a basic propofol and remi mix, but another attending chooses sufentanil drips over of remifentanil.

Whichever mix we used, all the cases went really well. Combine that with my inexperience and I don't have much of an opinion on which is the best choice for TIVA. However, I am glad that the propofol shortage is much less severe, especially since that is what we are now using for burst suppression.

 

[sevoflurane]

There are a billion choices to choose from. Choose one that fits your duration and stimulation of your particular surgery. In residency, I would advise you to not use something you are familiar with.... For your own knowledge and the reason you post this thread try something else. There is no silver bullet.

I suggest something like thiopental (burst supression), ketamine (increase amplitude), mag (lots of good stuff), versed and sufentanyl. Maybe a sux drip if you are doing SSEP's. Throw in a Bis if you are worried.

It's not about "the" anesthetic agent... it's all about how you use it. IMO.

You can also add precedex.

To much to set up? Prolly... but you are in residency. This is your time. Learn these modalities. They work.

 

[pgg]

methohexital also works. I like to use that in conjunction with fentanyl and precedex.

I know you posted this 8 months ago ...

Do you have problems with patients moving during TIVAs that use methohexital? I've used a lot of it lately for inductions because of the propofol shortage, and I've found it to be a big pain unless I also use some muscle relaxant. Lots of myoclonic movements, hiccups.

 

[Code Brown]

Have used Ketamine infusion more and more recently.
Usually bolus with 100mg, then run at 0.5 to 1.5 mg/kg/hr.

Works well, once you've used it a few times and have a good judgement of when people are fully zonked vs still aware. I recommend having a propofol stick around as "backup".

People also have a decent wake up and stay pretty stable from a hemodynamic standpoint. Plus it's apparently cheap so admin won't flip. Also doesn't build up in the system when you're done.

Drawbacks:
1. Can be hard to ascertain if patients are zonked (sedation=dissociation here) vs aware. They prob won't remember a thing if not fully out, but they also don't need to be responsive when you'te sticking in an OG or temp probe. When you first start to use it, you tend to overdo it which means long time in the pacu. That said, extubating is usually pretty easy because they are pretty safe (read point 2 below).

2. Excessive secretions can turn you into Mr Suction every few minutes.

3. Tachycardia - just think PCP. Seriously, the last couple of times the HR went up by 20-30. This can be compounded with Glyco if you paralyze them.

4. Nursing are often not used to it so can be freaked out by ketamine patients. Just try dropping someone off in the ICU on a ketamine drip for sedation.

That said, hemodynamically it's a pretty cool drug to use.

 

[Idiopathic]

lidocaine at 2mg/minute as an adjunct is a very effective means of decreasing propofol administration, so you can conserve, at least. its not right for every patient, but works great for many

 

[mid|ine]

I always liked a combo of propofol, ketamine and remi. We didn't have dex available. I know you said propofol was in short supply can it can be left out or replaced with a barbituate or benzo.

 

[epidural man]

Ketamine .15 to .25 mg/kg/hr (after a intial 1mg/kg bolus) - i totally disagree with the higher doses mentioned above.

lidocaine gtts (several ways to dose - I use this a lot - don't forget the bolus initially)
1. 2mg/min (if less than 80kg) 3mg/min (if greater than 80kg)
or
2. .225xkg=ml/hr (for the 8mg/cc bag)

or
3. 30mcg/kg/min

or

4. 2mg/kg/hr. (Lots of the studies used 2mg/kg/hr or 1.5mg/kg/hr.)

Dexmetotomidine (infusion or intranasal) I rarely load this drug as recommended by the manufacturer. I love intranasal - give all 200mcg.

Magnesium infusion (if you don't believe me about the utility of magnesium in anesthesia - google scholar search on 'magnesium infusion anesthesia')

If you need opioid - sufenta gtts .3mcg/kg/hr

A wiff of vapor if you need to.

Keep the lidocaine running after extubation and if you can, during the pacu.

For a great affect, preop gabapentin (900 to 1200mg) and and 1000mg tylenol and 400mg celebrex and maybe preop valium 10mg. A guy at our place does the valium and he loves it. I have never tried it.

 

[wine thief]

we tried etomidate/remi infusions. we had long wakeups and vomiting in the pacu with this method. our sseps people don't "allow" volatile unless they're monitoring emg only. (why are they dictating our anesthetic? we have pretty weak leadership). we were able to get some propoven and have fairly severely restricted propofol use otherwise so we're back to prop/remi or sufenta.

 

[Idiopathic]

we tried etomidate/remi infusions. we had long wakeups and vomiting in the pacu with this method. our sseps people don't "allow" volatile unless they're monitoring emg only.

this sounds like the worst anesthetic ever and your somatosensory people are apparently both awful and ill-informed.

 

[pgg]

our sseps people don't "allow" volatile unless they're monitoring emg only. (why are they dictating our anesthetic? we have pretty weak leadership).

Leadership begins at home, educate them and administer the anesthetic you feel is best.

"The patient's asleep, any time you guys want to start the procedures is fine with me. Yes, the gas is on. It'll be OK."

What are they gonna do, reach over and twist the blue dial to the off position themselves?

 

[wine thief]

pgg/idiopathic, believe me, I hear you. we do a gazillion spines and the surgeons bring in millions for the hospital. the sseps people are very aggressive and tell the surgeons that neuromonitoring will be compromised if we use gas. the surgeons don't care as long as they can operate.

we're also in a very litigious area so people get touchy when you start talking about compromised neuromonitoring. we even use tiva for low lumbar cases, well below the cord. the propofol shortage forced our hand and we finally set up a meeting with anesthesia, surgery and the neurophysiologists. the surgeons never bothered showing up.

 

[Idiopathic]

pgg/idiopathic, believe me, I hear you. we do a gazillion spines and the surgeons bring in millions for the hospital. the sseps people are very aggressive and tell the surgeons that neuromonitoring will be compromised if we use gas. the surgeons don't care as long as they can operate.

we're also in a very litigious area so people get touchy when you start talking about compromised neuromonitoring. we even use tiva for low lumbar cases, well below the cord. the propofol shortage forced our hand and we finally set up a meeting with anesthesia, surgery and the neurophysiologists. the surgeons never bothered showing up.

just amazing - i understand that the surgeons/hospital owns the neuromonitoring group and stuff but they should at least understand what works and what doesnt

 

[mid|ine]

For a great affect, preop gabapentin (900 to 1200mg) and and 1000mg tylenol and 400mg celebrex

Totally agree with this, and its often over looked.