Whats the deal with crnas giving every drug in the pyxis??

[DrN2O]

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This months anesthesiology. More is better

Propofol: A Superior Strategy for PONV : Anesthesia & Analgesia

An abstract is unavailable.

journals.lww.com

I love graphs with axis that don't start at 0.

But why does everyone at my shop runs prop at 25? I get TIVA, but undiscriminately low dose prop reeks of cookbook.

Also, residents can't do TIVA without bis or sedline anymore. Is it too late to buy Masimo and Medtronics stocks?

 

[pgg]

I've never understood the idea of running low dose propofol with a volatile anesthetic. If you're that worried about PONV, just do a TIVA and skip the gas entirely.

 

[deleted1183938]

What about decadron? I give it to the vast majority of my patients.

That’s like standard of care though

 

[GassYous]

I've never understood the idea of running low dose propofol with a volatile anesthetic. If you're that worried about PONV, just do a TIVA and skip the gas entirely.

I like to run prop at 50-100 and half a mac of gas because there have been cases where the iv infiltrated or the bag runs out and patients have awareness.

I don't use the bis ever, it only really seems to alarm after the patient already moves so it's not really helpful imo.

 

[pgg]

I like to run prop at 50-100 and half a mac of gas because there have been cases where the iv infiltrated or the bag runs out and patients have awareness.

I don't use the bis ever, it only really seems to alarm after the patient already moves so it's not really helpful imo.

TIVA definitely requires a reliable IV. And vigilance ...

I did a case with a resident a few years back. Ran the antibiotics in through a secondary IV set that didn't have a check valve. IV had some resistance to it, so the propofol infusion went backwards and started filling the antibiotic bag. No alarm from the pump of course.

 

[Twiggidy]

I've never understood the idea of running low dose propofol with a volatile anesthetic. If you're that worried about PONV, just do a TIVA and skip the gas entirely.

Exactly this. Keep it simple

 

[NightyNight]

Not sure why this gives you a feeling of job security. I can assure you the bean counters (and the surgeons) neither know nor care about your anesthetic plan. So long as the patient wakes up alive and intact nobody cares…

Exactly. Quality is not the point. It’s just about how far you can go (cheaper labor) without a lawsuit (loss of revenue).

 

[Hoya11]

I've never understood the idea of running low dose propofol with a volatile anesthetic. If you're that worried about PONV, just do a TIVA and skip the gas entirely.

For longer cases, say between 1-3hrs, I routinely do 100 of prop drip and 1% ET Sevo for maintenance. Or some variation on that.

I do believe mixing in prop reduces nausea and emergence delirium

I never understood why you cant throw on 0.6% of sevo just to make sure no recall, add a little bronchodilation, muscle relaxation, and allows you to cut back on your prop drip. The 0.6 is not going to make you nauseas. Like why does it have to be PURE tiva. I see some CRNAs flushing out the machine with 10L/Min of oxygen after I turn on a little sevo because it interrupted their plan for pure TIVA.

Purely prop comes with more pacu delayed awakening, higher risk of airway obstruction in PACU, higher risk of hypotension, and less certainty of anesthetic depth at emergence/extubation.

I prefer a mix during maintenance and to wake up on gas. Propofol beneficial effects IMO are obvious.

 

[cytocide]

Magnesium and Bladder Discomfort after Transurethral Resection of Bladder Tumor: A Randomized, Double-blind, Placebo-controlled Study

In a randomized trial of 120 patients recovering from transurethral resection of bladder tumor, intravenous magnesium substantially reduced discomfort with a number needed to treat of only 2. Intravenous magnesium is a simple and inexpensive way to reduce bladder discomfort.

pubs.asahq.org

 

[Airway]

I love graphs with axis that don't start at 0.

But why does everyone at my shop runs prop at 25? I get TIVA, but undiscriminately low dose prop reeks of cookbook.

As I remember in the samba ponv guidelines there is a statement to low dose propofol preventing ponv and a reference to a paper with " appropriate cns" concentrations at 16 (?) mcg/kg/min. Was a bizarre paper

 

[jwk]

Magnesium?? Lidocaine?? Infusions?? Are you serious?? Never have I ever run a Lido infusion and only time I ever ran Mg was in the ICU for an asthmatic patient. And by running it I mean the nurse at bedside. What the hell is happening at your place???

Ah c'mon live a little.

 

[amyl]

I hate one anesthetic for all comers. Think gd it!
I think zofran and roc and sugamadex are the only thing I give almost every patient. Precedex, ketamine, tiva, Benadryl, emend, lido down the ett or lta, etc. all dependent on the patient.

 

[cytocide]

I hate one anesthetic for all comers. Think gd it!
I think zofran and roc and sugamadex are the only thing I give almost every patient. Precedex, ketamine, tiva, Benadryl, emend, lido down the ett or lta, etc. all dependent on the patient.

Think gd it=etomidate?

 

[Twiggidy]

I hate one anesthetic for all comers. Think gd it!
I think zofran and roc and sugamadex are the only thing I give almost every patient. Precedex, ketamine, tiva, Benadryl, emend, lido down the ett or lta, etc. all dependent on the patient.

I think there is a gray area between avoiding cook book anesthesia and keeping it simple.

 

[jwk]

I think there is a gray area between avoiding cook book anesthesia and keeping it simple.

All GA cases get lidocaine - I think it's a law or something. Everything else is debatable.

 

[UscGhost]

I've never understood the idea of running low dose propofol with a volatile anesthetic. If you're that worried about PONV, just do a TIVA and skip the gas entirely.

Reduce the risk of recall with a undetected IV disconnect, infiltration, etc. Also protects you in the event that the patient reports recall.

A solo TIVA also tends to have a longer wakeup.

So I don't generally do pure TIVA unless it's a short case

 

[Greenbayslacker]

Off topic but what is your protocol if a patient recalls 'remembering' the surgery? "I heard voices, I felt things," etc. Any follow-up questions to tease out what is reality versus not?

 

[DesiredMemberName?]

I've never understood the idea of running low dose propofol with a volatile anesthetic. If you're that worried about PONV, just do a TIVA and skip the gas entirely.

There is evidence that subhypnotic propofol infusion is as effective as other standard antiemetic options (e.g dexamethasone).

You yourself and others have acknowledged the potential headaches and pitfalls with a pure TIVA approach.

If you don’t want to run a TIVA why not at least capture some of the antiemetic benefit of a sub hypnotic propofol infusion?

 

[Drwine]

I know that we are getting into some thread drift but unfortunately target controlled TIVA has never taken hold in the US. The pharmacologic models have some limitations but I would suggest that it is useful to be aware and understand them. The FDA makes it very difficult for these devices to get approved in the US so we are 20 years behind Europe and Asia on TIVA. Unfortunately TIVA is like when I was a medical student many years ago inhalation anesthetics were delivered with copper kettles and vernitrols. 🙁

General purpose models for intravenous anesthetics, the... : Current Opinion in Anesthesiology

atient populations, which restricts applicability for the overall population, including (small) children, elderly, and obese patients. This forces clinicians to select specific models for specific populations. Recent findings Recently, general purpose models have been developed for propofol and...

journals.lww.com

An Overview of TCI and TIVA

An Overview of TCI and TIVA was written by two pioneers in the field of targeted drug delivery in anesthesia. Despite its small size, this book is a rich source of information on the structure, function, and clinical applications of target-controlled infusion (TCI) systems. [...] The text has...

books.google.com

 

[cchoukal]

Off topic but what is your protocol if a patient recalls 'remembering' the surgery? "I heard voices, I felt things," etc. Any follow-up questions to tease out what is reality versus not?

My first question is always: What surgery was it? 99.9% of the time it was a colonoscopy.

 

[nimbus]

My first question is always: What surgery was it? 99.9% of the time it was a colonoscopy.

Or a cataract.

 

[DrN2O]

Off topic but what is your protocol if a patient recalls 'remembering' the surgery? "I heard voices, I felt things," etc. Any follow-up questions to tease out what is reality versus not?

Look up Brice Questionaire. I use my own version, and has maybe got one "maybe" in 10 years. And since the "dream" was not traumatizing, meh 🤷

 

[DrN2O]

...so we are 20 years behind Europe and Asia on TIVA. Unfortunately TIVA is like when I was a medical student many years ago inhalation anesthetics were delivered with copper kettles and vernitrols. 🙁

Making someone new from Europe run a TIVA for spine without TCI reminds of myself seeing a copper kettle for the first time in Ecuador 15 years ago.

 

[coffeebythelake]

running low dose propofol infusions to "lower the dose of inhalational and reduce PONV" has become a thing recently. Not sure why. Anyone have any evidence for or against this practice? I honestly don't know.

Been a thing for a long time now