Des

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Simba1711 said:
I don’t really see a significant difference in wake-up between des and sevo either. For me I can’t justify using it given the environmental and price concerns. It’s pretty disgusting how much waste we produce compared to other countries as well. Other countries reuse breathing circuits and don’t use disposable laryngoscopes.
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zizzer said:
Desflurane is a bit faster offset, but when you understand the pharmacokinetics of sevoflurane, which many don't, there is very little if any to gain in the speed of wakeup comparison. With essentially no benefits, the cost and climate impact are the reasons against it. It has nothing to do with us "flexing" on people, as you keep trying to make it out to be. I think you're the one not talking the time to understand the responses.

I'm not sure I'm against completely removing them, but it is a bit grating to see people using then routinely, often not on low flows, because they claim the wakeups are faster. I routinely see these people giving patients a full age-adjusted MAC of anesthesia or even more for their cases.
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The anti-desflurane argument is oddly emotional. Of all the waste and pollution and expense that saturates this business we're in, I've never seen as much pearl clutching as when it comes to desflurane. Remifentanil and dexmedetomidine and IV acetaminophen are other examples of drugs that are (or were) very expensive yet offered marginal or niche benefits. But no one really denies that they have attributes that are useful.

And it's strange that the most common criticism of desflurane is more a criticism of its users: some variation of a snide you-just-need-to-get-better-at-anesthesia comment has appeared repeatedly in this thread. It's an oddly perplexing choice to pivot to an insult.

Usually coupled with an explanation of how skilled people (not desflurane users) can overcome sevoflurane's objectively less desirable blood:gas solubility coefficient, while also claiming the difference doesn't exist or isn't relevant.

I'm using sevoflurane right now and it's just fine. The empty vaporizer slot next to it is just an eyerolling annoyance, that's all.

I'll let it go. If my point hasn't sunk in by now I guess it never will.
 
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kidthor said:
They do!? Do they clean them somehow?
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Nope, we just use a filter on the tube end. Not magic, but very safe. In Norway, the only things from our circle we toss after each anesthetic is the tube/lma, oropharyngeal airway (if used) and the filter.

As for Des, we still have cassettes, but as long as the patient's not extraordinarily fat, I'll rather do TIVA,sevo if the case calls for gas for whatever obscure reason. Most of my colleagues as well.
 
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pgg said:
The anti-desflurane argument is oddly emotional. Of all the waste and pollution and expense that saturates this business we're in, I've never seen as much pearl clutching as when it comes to desflurane. Remifentanil and dexmedetomidine and IV acetaminophen are other examples of drugs that are (or were) very expensive yet offered marginal or niche benefits. But no one really denies that they have attributes that are useful.

And it's strange that the most common criticism of desflurane is more a criticism of its users: some variation of a snide you-just-need-to-get-better-at-anesthesia comment has appeared repeatedly in this thread. It's an oddly perplexing choice to pivot to an insult.

Usually coupled with an explanation of how skilled people (not desflurane users) can overcome sevoflurane's objectively less desirable blood:gas solubility coefficient, while also claiming the difference doesn't exist or isn't relevant.

I'm using sevoflurane right now and it's just fine. The empty vaporizer slot next to it is just an eyerolling annoyance, that's all.

I'll let it go. If my point hasn't sunk in by now I guess it never will.
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I agree with you that Desflurane has its uses, and with all the environmental waste that goes on I’m unconvinced that we should fixate specifically on eliminating it. On balance I try to use it almost never and I try to go low flow on everything. It’s probably not a great thing for the environment if we can avoid it. But it’s not a hill to die on.

As a thought experiment I’m curious about the environmental impact of all the ortho reps flying around with nonsensical with trays of custom parts. Plus all that hair and teeth bleach and silicone.

Also what’s the environmental impact of all of the unnecessary surgeries we get roped into or all of the futile end of life ICU care?
 
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pgg said:
The anti-desflurane argument is oddly emotional. Of all the waste and pollution and expense that saturates this business we're in, I've never seen as much pearl clutching as when it comes to desflurane. Remifentanil and dexmedetomidine and IV acetaminophen are other examples of drugs that are (or were) very expensive yet offered marginal or niche benefits. But no one really denies that they have attributes that are useful.

And it's strange that the most common criticism of desflurane is more a criticism of its users: some variation of a snide you-just-need-to-get-better-at-anesthesia comment has appeared repeatedly in this thread. It's an oddly perplexing choice to pivot to an insult.

Usually coupled with an explanation of how skilled people (not desflurane users) can overcome sevoflurane's objectively less desirable blood:gas solubility coefficient, while also claiming the difference doesn't exist or isn't relevant.

I'm using sevoflurane right now and it's just fine. The empty vaporizer slot next to it is just an eyerolling annoyance, that's all.

I'll let it go. If my point hasn't sunk in by now I guess it never will.
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Pgg you ain't all that bad either. You have pretty good analysis I must say.
 
pgg said:
The anti-desflurane argument is oddly emotional. Of all the waste and pollution and expense that saturates this business we're in, I've never seen as much pearl clutching as when it comes to desflurane. Remifentanil and dexmedetomidine and IV acetaminophen are other examples of drugs that are (or were) very expensive yet offered marginal or niche benefits. But no one really denies that they have attributes that are useful.

And it's strange that the most common criticism of desflurane is more a criticism of its users: some variation of a snide you-just-need-to-get-better-at-anesthesia comment has appeared repeatedly in this thread. It's an oddly perplexing choice to pivot to an insult.

Usually coupled with an explanation of how skilled people (not desflurane users) can overcome sevoflurane's objectively less desirable blood:gas solubility coefficient, while also claiming the difference doesn't exist or isn't relevant.

I'm using sevoflurane right now and it's just fine. The empty vaporizer slot next to it is just an eyerolling annoyance, that's all.

I'll let it go. If my point hasn't sunk in by now I guess it never will.
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Fair enough. Desfluane does objectively wear off slightly faster. I haven't used it in years, but maybe I'll give it a try again on an obese patient to see if it's a little more useful than I'm giving it credit for.

That said, I'm not trying to be snide or to brag about being good at timing sevoflurane wakeups. I'm sure there are others who are better at it. It's just annoying seeing people use needlessly high volatile, not understanding the specifics of how it wears off, then claiming they need N2O or desflurane because sevoflurane isn't fast enough. Sure, desflurane has a niche benefit because it wears off a bit faster. Some people talk as if they can't do timely wakeups without it though. If people know how to appropriately clear sevoflurane in a time-efficient manner but still find desflurane even easier and prefer it, then my ranting isn't directed at them.
 
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I just had an anesthesia tech come up to me because despite her telling my colleague multiple times he leaves the room with the sevo vaporizer at 8 liters / min. What a waste and stupid way to pollute the environment.
 
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Simba1711 said:
I just had an anesthesia tech come up to me because despite her telling my colleague multiple times he leaves the room with the sevo vaporizer at 8 liters / min. What a waste and stupid way to pollute the environment.
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As in there’s sevo dumping into the room!?
 
Low flow is all well and good until a resident does Low flow from time 0 and you're addressing an awareness issue post op **** show
 
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zizzer said:
I don't follow how low fresh gas flow leads to awareness.
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I think there was a post earlier about possible awareness and the person in the or did low flow with sevo after securing the airway. If you don’t put the sevo concentration high when you do low flow the sevo concentration won’t be high enough to reduce awareness because it will take forever for the sevo concentration to rise. I usually have the flow around 2 liters a min and then decrease it to low flow after the procedure starts.
 
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Simba1711 said:
I don’t really see a significant difference in wake-up between des and sevo either. For me I can’t justify using it given the environmental and price concerns. It’s pretty disgusting how much waste we produce compared to other countries as well. Other countries reuse breathing circuits and don’t use disposable laryngoscopes.
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kidthor said:
They do!? Do they clean them somehow?
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We reuse breathing circuits too. We just change the mask and HME between cases unless the circuit is visibly soiled. At the end of the day, all the circuits get changed. We do it the Norwegian way in California.
 
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The whole fast wake up is pretty silly imo. They always blame us for the room being behind but they never blame the surgeon for showing up late or taking forever. God forbid we take a little bit longer to wake up patient for patient’s safety they blame us.
 
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zizzer said:
I don't follow how low fresh gas flow leads to awareness.
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It generally isn't possible to go straight to low flows (0.5 lpm or less) immediately after induction, when using soluble volatile anesthetics like sevo or iso, even with the vaporizer pegged at max. You need at least a few minutes of modestly higher flows (> 1 lpm) and adequate minute ventilation to physically get enough molecules of gas into the patient's brain. If you don't, the end tidal concentration won't be high enough to prevent awareness when the propofol wears off. You may get away with it with sevo at 8%. With iso, the knob doesn't go high enough and you can't start the case under 0.5 lpm. Desflurane is insoluble enough that the fresh gas flows can stay under 0.5 lpm from the start. You need to put the vaporizer at 12-16% initially but it works.

You'll see new residents and CRNAs muck this up with LMAs, when they turn the flows down too much after induction and three minutes later the patient is moving and spitting out the LMA. If they do it with tubes and NMBDs the result won't be movement but high risk for awareness and recall.
 
pgg said:
You'll see new residents and CRNAs muck this up with LMAs, when they turn the flows down too much after induction and three minutes later the patient is moving and spitting out the LMA.
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Or the flow is set to 10LPM with sevo set to 1.5% and they also won’t give opioids because opioids are now the devil.
 
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What's the deal with low flows and awareness? Don't you look at the gas analyzer to check end tidal sevo?
 
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coffeebythelake said:
Please explain. A resident not paying attention using low flows at a set rate is also not going to pay attention to overpressurizing the vaporizer and making fine adjustments to reach target et concentration?
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He's being snarky, you misspelled over-pressurize in the original post...internet doctors

PpfSuxTube said:
Low flow is all well and good until a resident does Low flow from time 0 and you're addressing an awareness issue post op **** show
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This is a problem with the attending, not the resident, maybe be there a bit after time 0 and provide education...just being snarky

The fallacy of relative privation (there's always something worse so this problem isn't valid!) is something that hopefully the intelligent people on this thread recognize. Yes Russia, cow poop, vacations, surgical waste, driving to get pizza contribute to greenhouse gases (for you @PpfSuxTube)..but that doesn't mean you can't contribute a low cost (switching to low-flow sevo) contribution to something that may be rewarding (less 100 degree months in Phoenix please!).

I don't fault anyone as long as they provide a safe anesthetic. I'm doing locums now in rural places, I've been with some real old timers (and machines, tapping to make the bobbins work!) who have enjoyed learning about low flow (flushing, looking at end tidal), a few have said they wished they knew about it. Be prescient, be self-aware, do good.

For academic attendings: teach this please, when I was at a PP gig I had a new hire from a real ivory tower come in and get freaked out sevo was set at 6...not encouraging
 
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Maverikk said:
The fallacy of relative privation (there's always something worse so this problem isn't valid!) is something that hopefully the intelligent people on this thread recognize. Yes Russia, cow poop, vacations, surgical waste, driving to get pizza contribute to greenhouse gases (for you @PpfSuxTube)..but that doesn't mean you can't contribute a low cost (switching to low-flow sevo) contribution to something that may be rewarding (less 100 degree months in Phoenix please!).

I don't fault anyone as long as they provide a safe anesthetic. I'm doing locums now in rural places, I've been with some real old timers (and machines, tapping to make the bobbins work!) who have enjoyed learning about low flow (flushing, looking at end tidal)
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Low flow with those old school machines that are even faulty. Sounds very safe... well done. What is end tidal?
 
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DocMcCoy said:
I mean if you consider how much is used worldwide ya it probably would have a meaningful impact. That being said I love my nitrous. Take the Des, never understood the appeal. I don’t think there is anything wrong with trying to reduce waste. But, it is laughable to focus on the gas without addressing the sickening amount of hospital waste we produce everyday.
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Yeah…coz it’s laughing gas.
 
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