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Your problem sounds familiar :-) Ill begin with apologizing for my poor english :) Prepare for the intubation by elevating the op table until you get a comfortable working position. Preoxygenate thoroughly - that will help you work a little more calmly without hurry. Pile up the patiens pillow so it supports only the neck, letting the head of the patient tilt back slightly. And when you insert the laryngoscope blade into the mouth, do it from the right, letting the laryngoscope blade "scoop away" the patients tongue to the left. An usual beginners fault is to insert the laryngoscope blade in the midline, leaving the tongue under the blade. This will make it much more difficult to create sufficient space for inspection and maneuvering the endotracheal tube. So, be sure to get the tongue to the left (thats what the flange on the Macintosh blade is for) and Ill think you will do just fine. /Anders K, Nurse Anesthetist, Sweden

Well folks. If I start with a normovolemic patient, I´ll use colloid 1:1, and crystalloid 3:1. At least in theory. Because at the op floor, I´ll tend to go more after clinical signs. When my medulla oblongata tells me that the patient reacts like he/shes hypovolemic, I´ll act on that gut feeling. I dont use equations :chuckle Most patients get hypovolemic right from the start from regional blocks and the vasodilatation from anesthetics. Hypertonic patients have cronically constricted peripheral blood vessels, and compensates this with a relatively smaller blood volume. Add some anesthesia to that - and you get an even more pronounced hypovolemia. Maybe thats the cause of the 2:1 colloid volume replacement? The first litre of colloid is for preop hypovolemia, the other litre for intraop blood loss? I know my english sucks, but I hope you follow me? /Anders Kohkoinen, Nurse Anesthesist, Sweden

I don´t think that "lawyers opinion" is a valid medical parameter anywhere in the civilized world, Athomas :chuckle Patients are individuals, and so are anesthesia providers. Experienced anesthesia workers finds their own "style", based on knowledge about both different techniques, drugs, comorbidities and - themself. And thats not stranger than the fact that different painting artists develop their own style over time. So.. Be careful to wish for rigid "standards" - they may be easy to learn and adhere to for unexperienced beginners, but will severily hamper your own artistery of anesthesia later. /Anders Kohkoinen, Nurse Anesthesist, Sweden

When I awake my patients, I´ll go from full MAC to 0.5% rapidly. When the patient reach 0.5% sevo, they are still in full surgical anesthesia (small centered pupils etc). Extubating then is in my opinion pretty much the same (stimulationwise) as extubating at full MAC. Only difference is that I dont have to wait so long for the patient to open their eyes (and of course, I have to be gentle and not stimulate the patient into excitation). I use no Guedel or nasal airway after extubation unless really needed to - gentle chin lift is usually sufficient. Removing a laryngeal mask deeply (yeah, 0.5% sevo is still "deep" for me) makes good sense, because its a bit frustrating to have a patient biting down on the LM shutting off their own airway with their teeth.. Its also easier to clean up the pharynx without causing laryngospasm after removal of the LM if the patient is a little deeper. However - I routinely use glucopyrrulate (Robinul) 0.2 mg preinduction to minimize the need for suctioning. /Anders Kohkoinen, Nurse Anesthesist, Sweden

Over here, we usually call pre excitation extubation "deep", post excitation extubation "shallow" (or at least the swedish equivalent of that word). If "deep" means full MAC, then I never extubate deep. So you made a good point there. /Anders Kohkoinen, Nurse Anesthesist, Sweden

One of my nurse anesthesist colleagues doubles as a scrub nurse sometimes. Being an anesthesia competent scrub nurse has an interesting bonus - in that position she can observe the different ways we nurse anesthesists work and deal with the situations. Different ways to skin the same cat. Nurse anesthesists works mostly solo. Yes, we have scrub nurses, nurses aides and surgeons in the same OR, but seldom our own colleagues. So, I thought it would be nice to discuss a little about how we do our thing? And as always - there is very little rights and wrongs. I´ll go first. -------------------------------------------------------------------- *Anesthesia induction for small kids unable to cooperate usually goes smoothly when you do the "balloon play". I´ll prefill the circuit with 70/30 nitrous/oxygen and show the kid the "funny balloon". Takes a couple of breaths in the mask myself and show how the balloon moves. (Few tips: the balloon under the teddybear is fun too, or under a pillow ). And after that, of course - let the kid test the balloon play. After sedated, I turn on the Sevo vaporizer on max (8%) and they fall asleep with a giggle, without crying or coughing. * My way of terminating general anesthesia (intubated). As soon as there is no further need of relaxation, I reverse it away (0.5mg glycopyrrulate + 2,5mg neostigmine), usually when the surgeons put the final sutures in the fascia. At the same time I remove the nitrous, increase oxygen to 80% and increase fresh gas flow to reduce rebreathing. To compensate for the loss of nitrous, I increase sevoflurane slightly to remain at the same MAC level. When most of the nitrous is exhaled (according to gas analysis), I maintain the same tidal volume, but reduce frequence from perhaps 12 to 3-4 breaths/minute to accumulate carbon dioxide. The 80% oxygen usually keeps hypoxemia away. Final train-of-four checks to be sure that no remaining relaxation exists. When spontaneous breathing reoccurs, I switch off the ventilator. And then I just wait for the surgeon to finish. At the last skin sutures, I turn the agent off and put fresh gas flow on max (18 litres/minute with a Dräger Primus). Removal of NG-tube and suction of pharynx. I usually extubate deeply, before the patient reaches excitation - if no contraindication such as gastric reflux och a full stomach exists. When endtidal sevo is 0.5%, spontaneus ventilation of good quality and a endtidal carbon dioxide is acceptable - out goes the tube. Chin lift and perhaps a little supplemental oxygen. I keep the patients chin until lifted to the hospital bed. If they dont maintain a free airway, I turn them on their sides. And off to the PACU. /Anders Kohkoinen, Nurse Anesthesist, Sweden

hrrmmppff :imbar yeah, i can see the picture before me.. like a pan pizza, diameter about five meters across, clad in blue scrubs and a pair of black crocs peekin out from under the edge.. if you look closely at the center of that pizza, the two round objects there are not olives, but my eyes trying to stare reproachfully at you, folks! /anders, nurse anesthesist, sweden :lol_hitti

I had Birks before when I worked psychiatry. A lot of walking and some running too. Im heavy, so the corksoles started to crack around the edges, leaving a small trail of crumbles behind me wherever I went .. After wearing out (to disintegration) two pairs of Birks in two years, I switched to rubber soled Reebok sandals. I have worn that type of footwear ever since until I encountered my first pair of Crocs. Crocs provide much better suspension than anything else I have tried - so good that the beginning case of heelspur that I felt was developing, has gone into remission completely. /Anders, Nurse Anesthesist, Sweden

Hmm.. Damn.. Not very thrustworthy for a nurse to stumble on the units like that, is it? :chuckle I meant to write 1.97 meters. The same as 197 cm. Trust me, Im a nurse! *Smile* /Anders, Nurse Anesthesist, Sweden

Crocs are the shoes to wear! Im male, 1.97 cm tall and a weight of 135 kg (and Im an european too, and dont give a rats *** about your american units ) - and for those of you who dont care to convert that to feets, inches and lb´s, its sufficient to say that I´m big - quarterback big! Before, I usually wear thick, soft rubber soled sports sandals (Reebok, Merrell etc) but I have switched to Crocs. The most comfortable work shoe in the universe. They tend to be broad, and workmates to me with slender feets dont like them for that reason. They are soft and almost a little "squishy" - so I think that people with a need for a more stable shoe wouldnt like them either. But for me and my weight (shock absorbance is everything) they are absolutely unbeatable! /Anders, Nurse Anesthesist, Sweden

Well, not necessary! If you keep opiate levels low, you´ll use more gas to keep intraop stress levels down. If you in that situation give fentanyl you´ll surely have a blood pressure drop. But the drop in BT isnt a direct farmacological effect of fentanyl, its the fentanyl that removes the "pain" that kept the patients BT up earlier. If you start with a stiff dose (the dosages that Snakebite propose) with opiate at induction time, and afterwards just add gas - youll find yourself using much less agent. And you also get a very circulatory stable patient too. Circulary stable, but hard to get to breathe sufficiently afterwards in a reliable way. The first time I emtied a full 20 ml syringe of fentanyl into a patient, I admit it felt adventurous.. I was used to tosages of 5-10 ml per case. (0.05mg/ml) High dosages of opiates has distict advantages, especially with circulatory challenged patients. It has its distinct drawbacks too - respiratory depression. /Anders, Nurse Anesthesist, Sweden

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

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

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. 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. 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

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?