i have been working on smoother wakeups. the technique i have been employing is using either morphine or fentanyl and titrating in 2mg per cc of mso4 or 10 mcg of fent to keep respirations about 12- 18 per minute. (obviously in patients that are spont vent.) while doing this i cut back on the gas in increments. when it comes time to extubate they usually will open their eyes to command, wont buck as much and seem more comfortable. i try this in patients that i am not worried about resp depress and airway issues. adn the morphine keeps em more comfortable into postop for obvious reasons.
the question is, do many of you do this? i have worked with some ppl that almost refuse to use narcs near the end of the case on anyone. i dont know if they have been burned in the past or what. this also is adults, not peds where i currently am.
gasspassah - lost to a great candidate - so not too upset about it...sure takes alot of work off my back and met great people in the process....thanks for asking
athomas--I was pulling for you in Seattle. It's a hard race when you're running against someone whose entire program went to seattle and all showed up at the breakfast to vote. How did everyone enjoy the conference? I had a blast, and it really made me proud to see just how big and supportive our organization was. Hope everyone can make it to DC next year!
i likewise had a great time - i didn't know but apparently the U of Pitt has had a number of students in this position - strong showing - but good for them and her!! she will do great.
OK I am new here, but a CRNA for 10 years...I use induction doses of fentanyl 10-15 ug/kg, 50 of propofol, (NO VERSED!!-which WILL hose your wakeup) muscle relaxant of choice usuallly Mivacrap and whiffs of desflurane-even for 30 minute cases. I have never had a problem with bucking or pain on extubation. I always give decadron 8mg and Zofran 4mg to prevent any nausea...Give it a try
OK I am new here, but a CRNA for 10 years...I use induction doses of fentanyl 10-15 ug/kg, 50 of propofol, (NO VERSED!!-which WILL hose your wakeup) muscle relaxant of choice usuallly Mivacrap and whiffs of desflurane-even for 30 minute cases. I have never had a problem with bucking or pain on extubation. I always give decadron 8mg and Zofran 4mg to prevent any nausea...Give it a try
Decadron for nausea seems to be the "in" thing right now, but keep in mind there is a low but potentially huge future problem with AVN.
Read your literature on context sensitive half-life of Fentanyl. When you bolus Fentanyl, you get a smooth rise, plateau and decrease in levels of narcotic. I resist the urge to use POISON ( Vapors) in high doses. I use just enough to keep the BIS/Array at amnestic levels. You would be suprised at how little gas/nitrous you need for amnestic levels. Narcotics are easy on the Hemodynamics. You have to give large doses up front "preemptively" to blunt the laryngoscopy and the cold steel. When you start giving 100 ugs here and 150 there you really do not know where your blood levels are..With the large doses you can predictably emerge a pt within 30minutes. Remember Fentanyl is alot more forgiving than Sufenta on respiratory drive. Give it a try....
10 to 15 ug/kg??? isn't that a bit high? unless the case is going to last 4 hours or more...
Read your literature on context sensitive half-life of Fentanyl. When you bolus Fentanyl, you get a smooth rise, plateau and decrease in levels of narcotic. I resist the urge to use POISON ( Vapors) in high doses. I use just enough to keep the BIS/Array at amnestic levels. You would be suprised at how little gas/nitrous you need for amnestic levels. Narcotics are easy on the Hemodynamics. You have to give large doses up front "preemptively" to blunt the laryngoscopy and the cold steel. When you start giving 100 ugs here and 150 there you really do not know where your blood levels are..With the large doses you can predictably emerge a pt within 30minutes. Remember Fentanyl is alot more forgiving than Sufenta on respiratory drive. Give it a try....
I agree with gotosleepy - 10-15mcg/kg is too much for a lot of cases. 20cc of fentanyl up front on a 1hr TAH = Narcan at the end. I'm curious what kind of PACU discharge times you have with this much narcotic.
And keep depending on that BIS monitor - you'll get burned someday. It's that "...You would be suprised at how little gas/nitrous you need for amnestic levels..." that can get you in big trouble. The idea is NOT to see how little agent you can get by with. It's to make SURE your patient is asleep, which of course the BIS does not do. Any monitor that will show a bowl of Jello is asleep is not one I want to use. And I wasn't aware the BIS was an amnesia monitor as well as an awareness monitor.
I will use 10 mcg/kg on a 20 minute tonsillectomy without problems (Without Narcan). Occasionally the patients will have nausea (last PI study was 3%). Our PACU times have DECREASED since our team has decreased the inhaled agents. I haven't cracked a Narcan vial in 5 years. And about depending on the BIS monitor..We just started using it 3 months ago and do NOT intend on buying one. It just confirmed what we were practicing. I personally do not like the monitors. Just because the reading is 50 does not mean you have Analgesia on board. I have had them jump with "general Anesthetic numbers" By the way the makers of the PSARRAY 4000 and the BIS monitor sell their equipment with the idea of how much agent you do NOT need. They will not stand by their numbers "making SURE your patient is asleep". I believe in the older studies that 1/4 MAC of vapors with nitrous is amnestic. The least amount of vapor the better. Sufenta on the other hand is different...The case has to be at least an hour long for a Sufenta bolus...Even then you will have a comfortable, responsive patient who will not be breathing. Enough said for now ..gotta start another case
I agree with gotosleepy - 10-15mcg/kg is too much for a lot of cases. 20cc of fentanyl up front on a 1hr TAH = Narcan at the end. I'm curious what kind of PACU discharge times you have with this much narcotic.
And keep depending on that BIS monitor - you'll get burned someday. It's that "...You would be suprised at how little gas/nitrous you need for amnestic levels..." that can get you in big trouble. The idea is NOT to see how little agent you can get by with. It's to make SURE your patient is asleep, which of course the BIS does not do. Any monitor that will show a bowl of Jello is asleep is not one I want to use. And I wasn't aware the BIS was an amnesia monitor as well as an awareness monitor.
OK I am new here, but a CRNA for 10 years...I use induction doses of fentanyl 10-15 ug/kg, 50 of propofol, (NO VERSED!!-which WILL hose your wakeup) muscle relaxant of choice usuallly Mivacrap and whiffs of desflurane-even for 30 minute cases. I have never had a problem with bucking or pain on extubation. I always give decadron 8mg and Zofran 4mg to prevent any nausea...Give it a try
snake i was wondering if you have even experienced the "rigid chest" syndrome from pushing that much fent. not that i dont like the idea of alot of narcs. however is this rigid chest thing a concern when you use that much fent. or is it more based on the speed at which you push it?
I always thought the 'Rigid Chest' was from rapid Fentanyl bolus, not necessarily the amount. That said, in almost 10 years of critical care, I don't think I have ever seen the rigid chest phenomena from Fentanyl....I have only read about it. I also hope I do not see it any time soon! :)
athomas91
1,093 Posts
gasspassah - lost to a great candidate - so not too upset about it...sure takes alot of work off my back and met great people in the process....thanks for asking