Lap Chole and Narcotics

snakebitten · Jan 16, 2006

Here is my recipe for lap choles. By the way, I work on an Indian reservation where we do 20 per week.

1. 750 mics of Fentanyl all up front

2. 100 mg propofol

3. Vec. 5 mg

4. Des/Nitrous

5. Toradol 60 IM

6. Decadron 10 mg for antiemetic

Surgeons take anywhere from 30-40 minutes

7. Neostigmine/Robinol

Eyes open, suction no bucking extubate...

Of course, there are deviations on the narcotic requirements for the elderly, very young (yes we 10-12 year old choles) and more for the drunks.

Nitecap · Jan 16, 2006

Seems like alot of decadron for antiemetic effects, thought 4mg would be good.

jwk · Jan 16, 2006

15cc of Fentanyl and 5 of vec for a 40 minute case??? I guess my question would be why so much?

snakebitten · Jan 16, 2006

Yes, I know alot of you think that 15cc of Fentanyl is excessive. It has worked for me for 10 years here. I run very little gas 2-3% Desflurane with Nitrous. Gas (and Narcan by the way) are intruments of the devil. High narcotics dosages as you all know have many beneficial attributes. For those of you who are worried about recall...I used the BIS monitor for a couple of years and the numbers were in the 20's with the low inhalational agents. I stopped using the BIS for many reasons--no problems.

I do not think that the Decadron is an excessive dose when used alone. I agree that 4mg would suffice if you are using Zofran or droperidol with it. Just my preference. The last time I had some hurl in the PACU was 5 years ago when I used Morphine.

I have a couple of colleagues who were trained by Dr. Stanley? He was some dude in the south who despises gas opting for narcotics. Anyways, they use 100mics of Sufenta on induction all up front and rarely have a problem with emergence. Now they do hurl more frequently but you get the point.

Later

Mike

SedareDolorem · Jan 16, 2006

Yes, I know alot of you think that 15cc of Fentanyl is excessive. It has worked for me for 10 years here. I run very little gas 2-3% Desflurane with Nitrous. Gas (and Narcan by the way) are intruments of the devil. High narcotics dosages as you all know have many beneficial attributes.

High dosage of opiates have its benefits as well as its drawbacks. With a PACU filled with well trained nurses capable of quickly discover and treat resp insuff - good. Especially if going home the same day isnt an option for the patient.

I have also used fentanyl in doses of 15-20 ml/operation (I assume we talk about the same strength - 0.05 mg/ml), but that was cardiac surgery with the patient extubated a couple of hours later at the thorax ICU.

But if it works for you (with more or less naloxone, it seems), thats fine.

Desflurane is like breathing barbed wire in gaseous form, I guess that you could reduce narcotics if you for example used sevoflurane instead. Honestly, I would rather use isoflurane instead of Des. But thats just my personal feeling - Des is propably as good as anything for those used to it.

If you still want to keep those high narc dosages, what about alfentanil or even remifentanil?

snakebitten · Jan 17, 2006

I agree, Desflurane or as our my other colleagues call it "Deathflurane" is like inhaled barbed wire IF you use insufficient narcotics. It works like a charm with higher doses of narcotics. I might try switching over to Sevo now that they lost their patent and its cost per bottle will plummet. I can't wait to talk to the Desflurane rep who has been badmouthing Sevo (cost, potential low flow Comp A etc...) now that Baxter (the same company who peddles Des) now will be selling Sevo. Man, she is going to owe us some serious food bribes :chuckle . As for remifentanil and alfenta--It is not cost effective. Compare Fentanyl (dirt cheap) to the others. I don't like the idea of giving these rapidly metabilized/distributed drugs and then only having to rescue them soon on emergence. Again, just my preference. What ever works for you-more power to you.

Mike CRNA

SedareDolorem · Jan 17, 2006

I agree, Desflurane or as our my other colleagues call it "Deathflurane" is like inhaled barbed wire IF you use insufficient narcotics. It works like a charm with higher doses of narcotics.

When I did neuroanesthesia about eight years ago, we did acousticus neurinomas. Loong operations that sometimes took a whole day. The neurosurgeons wanted the patients awake and communicable immediately after surgery to be able to assess them. Back then we used enflurane or isoflurane (iso for prolonged operations).

When the operation was soon finished, we took away the gas and switched to propofol infusion instead, to have the patient as awake and alert as possible after extubation. It worked just fine.

I might try switching over to Sevo now that they lost their patent and its cost per bottle will plummet. I can't wait to talk to the Desflurane rep who has been badmouthing Sevo (cost, potential low flow Comp A etc...) now that Baxter (the same company who peddles Des) now will be selling Sevo. Man, she is going to owe us some serious food bribes :chuckle .

Heh heh.. Good idea! Maybe you can talk her into sponsoring your next staff party? :beercuphe

I can see your problem. In Sweden we have tax financed health care, and even the poorest bum get full medical service. Cost is not an issue in the same way as it is over there.

In your place, I would try to use isoflurane instead - its propably a lot cheaper than "dieselflurane" anyway.. And its not longer necessary to give the patient as much fentanyl to get them to tolerate not only the surgeon, but the agent as well..

If fast awakening is important, I would switch to propofol infusion during the last fifteen minutes or so - or maybe use it for the whole operation.

As for remifentanil and alfenta--It is not cost effective. Compare Fentanyl (dirt cheap) to the others. I don't like the idea of giving these rapidly metabilized/distributed drugs and then only having to rescue them soon on emergence. Again, just my preference. What ever works for you-more power to you.

Long recovery times in the PACU costs money too, I guess. Fentanyl is good, but if you insist on those high dosages, it seems like shorter acting stuff combined with a final iv shot of for example ketobemidone before extubation would be an alternative?

Hmm.. I hope you bear with me, I realize I have given you advice that you really didnt ask for. As always - if its not broken, its seldom any need to fix it. But Im just discussing, hope you dont mind!

/Anders, Nurse Anesthesist, Sweden

SedareDolorem · Jan 17, 2006

Hmm.. I accidentally double posted what I wrote above, and couldnt find a delete button to remove the doubled message completely.

So I edited it instead, and try to use this mess for something fun instead..

Do you folks know what its called when two ortopedic surgeons is studying a 12 lead ECG?

Answer : A double blind study.

/Anders, Nurse Anesthesist, Sweden

rn29306 · Jan 18, 2006

Do you folks know what its called when two ortopedic surgeons is studying a 12 lead ECG?
Answer : A double blind study.

Interactions between anesthesia providers, patients, and surgeons:

The half-asleep monitoring the half-awake being operated on by the half-witted.

XIGRIS · Jan 19, 2006

Here is my recipe for lap choles. By the way, I work on an Indian reservation where we do 20 per week.
1. 750 mics of Fentanyl all up front
2. 100 mg propofol
3. Vec. 5 mg
4. Des/Nitrous
5. Toradol 60 IM
6. Decadron 10 mg for antiemetic
Surgeons take anywhere from 30-40 minutes
7. Neostigmine/Robinol
Eyes open, suction no bucking extubate...
Of course, there are deviations on the narcotic requirements for the elderly, very young (yes we 10-12 year old choles) and more for the drunks.

I'm going to try this. 750mcgm of Fentanyl..... Thanks Mike

SedareDolorem · Jan 20, 2006

I'm going to try this. 750mcgm of Fentanyl..... Thanks Mike

Keep your naloxone handy! :)

/Anders, Nurse Anesthesist, Sweden

deepz · Jan 21, 2006

Keep your naloxone handy! :)
/Anders, Nurse Anesthesist, Sweden

And your ephedrine/neo/vasopressor of choice

!