How to have smooth wake-ups?

[kidthor]

Ah, I see where you are coming from. I was slightly exaggerating how long it felt like the cases were back then as well as the amount of attendings. Maybe I have PTSD from the surgical equivalent of watching paint dry. But I still would extubate. To be fair, I have always had a lower threshold for extubating after long cases or after hours cases. So even after 12 hours, I would still extubate barring huge amounts of PRBC's and fluid. 12 hours on a tube is still not as bad as 12 days in the ICU on a tube. And many of those get extubated without a tube exchanger in place. I usually reserve tube exchanger for difficult airways that I don't want to eat humble pie or where the patient has other reasons to be edematous.

The LMA trick was great when residents were closing and it could take 10 minutes or 90 minutes. Hard to time the extubation when there was so much variability between residents. Also, we would have hours of isoflurane buildup bc we were trying to save money. (nothing like saving $10 with iso then blowing it by throwing in an LMA!)

This all sounds like an overly complicated way to lose and airway eventually. It’s essentially indefensible with little upside.

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[Status Sciaticus]

how practical and safe is it to pull the tube and then reverse with sugammadex. or LMA exchange and then reverse?

 

[nimbus]

how practical and safe is it to pull the tube and then reverse with sugammadex. or LMA exchange and then reverse?

If the patient has a normal airway, it’s very safe. I would not do it with a difficult airway.

 

[BobLoblaw78]

This all sounds like an overly complicated way to lose and airway eventually. It’s essentially indefensible with little upside.

Disagree wholeheartedly. It is actually safer than any deep extubation. It is extubating deep to a SGA. To take it even further, if you extubated any airway and needed to reintubate but couldn’t, what would you do? SGA. I’m not advocating doing it for a full stomach or any case that LMA is inappropriate. Funny how it can be seen that differently

 

[Radetzky]

Reverse on removal of ports, before closing, lido spray in the trachea and on cords, PSV as soon as possible after reversal, then the tube comes out when the patient's ketamine induced grin appears. I do run TIVAs as often as possible, only run des when I'm lunch breaking a room, and only use sevo for spontaneous breathing LMA GAs or when I think a TIVA is not the right approach, mid case more often than not.

Nice dose of glyco for heavy smokers.

My TIVAs are propofol and remi/fent as maintenance, magnesium and ketamine for wakeups, sometimes lido.

How much ketamine and when?

 

[GassYous]

Why would you extubate and then put an lma? Or pull the tube then reverse? Sounds unnecessary. It really isn't that hard to extubate smoothly in most patients. And if they buck? Buck it.

 

[norski]

Are the majority of GAs TIVA where you work? Seems like TIVA is more common in Europe than it is in the USA.

Mixed bag. Some run gas for 90% of their cases, I'm at 20 gas/80 TIVA. Others 50/50, depending on the case.

I run prop+remi/fent/alfent without TCI protocols every once in a while, but I have to admit I wouldn't be super comfortable doing it without the knowledge/experience base granted me by running tons of TCIs.

 

[norski]

How much ketamine and when?

0.5mg/kg/hr the last hour.
Often augmented with magnesium, given no contraindications.

 

[norski]

How do you spray lidocaine on the vocal cords while they are still intubated?

With magic, of course.


Erm, I see that I should've put that first. Do you have lidocaine spray bottles with long, 25-30cm nozzles in the US? I use one of those, spray one puff with the nozzle 2cm from cords, then advance just inside the cords, one more puff,then the tube goes in,all in the same laryngoscopy. This for elective cases when I have five extra seconds for intubation.

 

[norski]

Lots of good suggestions here. There are many ways to accomplish a smooth wake-up but it’s a good idea to learn several as each technique has pros/cons.

One that hasn’t been mentioned yet is a remifentanil wake-up. Give a large dose of remi a few mins before you want to extubate, get all the other anesthetic off and leave the patient alone. They’ll usually open eyes spontaneously looking stunned. At this point you can switch vent off, ask for one spontaneous breath if you insist, or just extubate.

This is particularly nice for cases that you don’t want bucking and you don’t want to give lots of long acting opioids because you want a good neuro exam afterwards, like a crani or carotid.

I like the idea of remi bolus wakeups, but how much do you administer? For a remi(nmb free) intubation, I go between 3-4mcg/kg, give that 90 seconds, then tube, but other than letting the remi run (tci at 250-350 mcg/hr), never bolused it for extubation. Share, please!

 

[narcusprince]

Disagree wholeheartedly. It is actually safer than any deep extubation. It is extubating deep to a SGA. To take it even further, if you extubated any airway and needed to reintubate but couldn’t, what would you do? SGA. I’m not advocating doing it for a full stomach or any case that LMA is inappropriate. Funny how it can be seen that differently

Did you place your LMA over a tube? So you intubated with a 6.0 tube? All that plastic on plastic. Unnecessary and dangerous in this case. Would never do this on a 12 hour case. Indefensible….

 

[Arch Guillotti]

I like the idea of remi bolus wakeups, but how much do you administer? For a remi(nmb free) intubation, I go between 3-4mcg/kg, give that 90 seconds, then tube, but other than letting the remi run (tci at 250-350 mcg/hr), never bolused it for extubation. Share, please!

Why bolus it? Just as easy to wake them up on it without a bolus.

 

[DrAmir0078]

PGY4 here from Iraq...
My simple technique : -
1- Good analgesia perioperatively
2- Once skin sutured or 10 minutes at the end of the operation, off the Volatile - if Isoflurane you know when, if Desflurane you know when
3- Patient have spontaneous breathing, switch to SIMV - VC or PC or PSV; do you know how to play with it? Then switch to PSVpro and gently monitor your patient until 5/5 is achieved with good tidal volume. Talk to your patient, do NOT overstimulate, and never leave the patient without PSV, never let your patient breath spontaneously on manual (just when you check his reservoir bag) especially early during the end of the case, this will make the patient more tachypenic, exhausted; always on a mode of ventilation.
See your signs of recovery, especially opening the eye, can lift the head,,, etc means away from stage 2 laryngospasm
Then extubation with a jaw thurst and listen closely to the sound of air.... Here you go!
Excellent job!

 

[BobLoblaw78]

Did you place your LMA over a tube? So you intubated with a 6.0 tube? All that plastic on plastic. Unnecessary and dangerous in this case. Would never do this on a 12 hour case. Indefensible….

No. ETT doesn't go through the LMA. LMA is placed posterior to the ETT. It is Bailey maneuver as mentioned above and the image below. I haven't used this maneuver since being in PP and haven't used it for ages. But I still defend its use as it works great if needed.

 

[2Fast2Des]

PGY4 here from Iraq...
My simple technique : -
1- Good analgesia perioperatively
2- Once skin sutured or 10 minutes at the end of the operation, off the Volatile - if Isoflurane you know when, if Desflurane you know when
3- Patient have spontaneous breathing, switch to SIMV - VC or PC or PSV; do you know how to play with it? Then switch to PSVpro and gently monitor your patient until 5/5 is achieved with good tidal volume. Talk to your patient, do NOT overstimulate, and never leave the patient without PSV, never let your patient breath spontaneously on manual (just when you check his reservoir bag) especially early during the end of the case, this will make the patient more tachypenic, exhausted; always on a mode of ventilation.
See your signs of recovery, especially opening the eye, can lift the head,,, etc means away from stage 2 laryngospasm
Then extubation with a jaw thurst and listen closely to the sound of air.... Here you go!
Excellent job!

I don't see how a patient can get exhausted from breathing.... Every human breathes for the entirety of their existence.

 

[DrAmir0078]

I don't see how a patient can get exhausted from breathing.... Every human breathes for the entirety of their existence.

I have seen patient were put once they are getting spontaneous breathing on manual non mode ventilation and the tidal volume were like 10 to 25 ml and respiratory rate exceeding 40; probably we don't have TOF like you over there, and we just as said off volatiles and let him breath on his own. I have found those patients were having issues of anxiety, and tachypneic; unlike those who I woke them up with PSVpro slowly and as I said above; I remember I had three post cesarean section GA patients were put in the hallway waiting to go to the ward, and they were calm enough, unlike others and I got questioned from the OBs what did you give them? I said "nothing, just smooth recovery". I have said before "these my own opinion, and reflect my practice and how I learnt, and many wrong stuff I had learnt, I've could correct them here - so so many; but this technique of extubation, I have been practice them over almost two years now, and haven't seen any issue; It happens I used to switch to manual breath and telling the patient to breath more and with suction, , , etc, and one day an Attending at Baghdad Medical City shouted at me and said "what are you doing?"; I said "I am doing extubation", and he starts explaining the proper way of how to extubate the patient on a Mode of Ventilation even VC and not PSV or those weaning modes, and during the third year, I had that Attending who was very weird smart in his approach, and he shoveled up our thoughts and taught us the PSVpro. I can tell you a thing, even some cases - elective - we use PSVpro during induction on mask before intubation to synchronize with his hypopnea and always get supported breath (it is like delayed sequence induction). So, you have said it right "Every human breaths for the entirely of their existence".... we exchange thoughts !

 

[GassYous]

I don't see how a patient can get exhausted from breathing.... Every human breathes for the entirety of their existence.

Because when your breathing is obstructed, it increases the work of breathing
I mean isn't that obvious?

 

[Arch Guillotti]

I don't see how a patient can get exhausted from breathing.... Every human breathes for the entirety of their existence.

Through a straw?

 

[nimbus]

Even when I preoxygenate with a mask, many patients tell me it feels difficult to breathe through the breathing circuit.

 

[DrAmir0078]

Even when I preoxygenate with a mask, many patients tell me it feels difficult to breathe through the breathing circuit.

Yes, Dr. Nimbus,
I personally seen this, and found to switch to nasal cannula or face mask (non rebreather) is better during preoxygenation - same rules of DSI.
3 to 5 minutes of good tidal breathing is the standard I believe; away from 8 VC breathing.

 

[Twiggidy]

Why would you extubate and then put an lma? Or pull the tube then reverse? Sounds unnecessary. It really isn't that hard to extubate smoothly in most patients. And if they buck? Buck it.

This right here. Sounds like a lot of people are trying to re-invent the wheel.

 

[Twiggidy]

Even when I preoxygenate with a mask, many patients tell me it feels difficult to breathe through the breathing circuit.

Just basic Poiseuille's law. People sleeping through physics class again lol

 

[2Fast2Des]

Problem is that americans are a bunch of sissies and can't tolerate things that a child would tolerate anywhere else. Plenty of places do block only for surgeries but in America everyone says "I just want to be asleep, I don't want to know see or hear anything in the operating room". It is truly ridiculous. If you can't feel anything, what's the big deal? But psychological pathology is huge here. The number of people taking benzos or chronic opioids for nonindicated is completely unreasonable. When you don't have any real problems, I guess you have to make them up to feel better about yourself.

I have seen patient were put once they are getting spontaneous breathing on manual non mode ventilation and the tidal volume were like 10 to 25 ml and respiratory rate exceeding 40; probably we don't have TOF like you over there, and we just as said off volatiles and let him breath on his own. I have found those patients were having issues of anxiety, and tachypneic; unlike those who I woke them up with PSVpro slowly and as I said above; I remember I had three post cesarean section GA patients were put in the hallway waiting to go to the ward, and they were calm enough, unlike others and I got questioned from the OBs what did you give them? I said "nothing, just smooth recovery". I have said before "these my own opinion, and reflect my practice and how I learnt, and many wrong stuff I had learnt, I've could correct them here - so so many; but this technique of extubation, I have been practice them over almost two years now, and haven't seen any issue; It happens I used to switch to manual breath and telling the patient to breath more and with suction, , , etc, and one day an Attending at Baghdad Medical City shouted at me and said "what are you doing?"; I said "I am doing extubation", and he starts explaining the proper way of how to extubate the patient on a Mode of Ventilation even VC and not PSV or those weaning modes, and during the third year, I had that Attending who was very weird smart in his approach, and he shoveled up our thoughts and taught us the PSVpro. I can tell you a thing, even some cases - elective - we use PSVpro during induction on mask before intubation to synchronize with his hypopnea and always get supported breath (it is like delayed sequence induction). So, you have said it right "Every human breaths for the entirely of their existence".... we exchange thoughts !

Through a straw?

Just basic Poiseuille's law. People sleeping through physics class again lol

Not for the entirety of the case, I mean on emergence. I can't see someone being tired of coming off the vent for the brief period of emergence.. especially if psv is being utilized with appropriate support. What is the emergence time? 5 to 10 minutes? I don't use TOF anymore since sugammadex anyway

 

[LaryngoSpazz]

I like the idea of remi bolus wakeups, but how much do you administer? For a remi(nmb free) intubation, I go between 3-4mcg/kg, give that 90 seconds, then tube, but other than letting the remi run (tci at 250-350 mcg/hr), never bolused it for extubation. Share, please!

These days I primarily use remi as an infusion in certain cases. For wake-up I go up on infusion and turn everything else off 10-15 mins early. Then a couple minutes before I want to extubate I shut the remi off too. I rarely bolus anymore as my hospital only stocks it in 2mg vials. I used to have access to 100mcg syringes which for most patients was a good amount for a bolus during emergence. For someone with high opioid requirements that might not be enough and for a little old lady probably more than you need. The biggest problem with bolusing too much is that you’re likely to have bradycardia and hypotension.

 

[woopedazz]

I dose Remi bolus like fentanyl bolus (1:1). It's not at all accurate, but seems to work well.

 

[2Fast2Des]

Having to formulate\mix remi, bolus a tiny amount, and then waste the rest with the OR RN, doesn't seem too efficient, for a case that you haven't used remi on to begin with, and then do that for every case? I mean yes remi makes for great wakeup, and for select cases I can see it being worth the while, but not as a routine though

 

[epidural man]

"How to have smooth wake-ups?"

You can't (consistently). Just the way it crumbles....

Deep extubation works most times with a TIVA.

Sufenta infusion consistently works well.

Droperidol was an excellent "smooth awakening" agent. I haven't used it in many years.

 

[GASPER20]

I dose Remi bolus like fentanyl bolus (1:1). It's not at all accurate, but seems to work well.

I mainly use remifentanil as an infusion but would like to know how to bolus it for these situations. How much exactly are you giving and when? Is this after reversal and 50mcg at a time?

 

[OptionOffense]

The key is to have as little as your volatile agent off when they are emerging. You can do it slow or you can do it fast . If you do it slow your patient will be bucking and exhibiting crazy **** prior to extubation for a longer period of time. I do not titrate narcotics to RR. Have not since residency. I have learned thats a good way of overdosing patients with narcotics. GIve them what you think they need and thats it. Anesthetizing trachea is a good move with LTA, 5 percent lidocaine ointment is good. Precedex and Ketamine are the devil.

 

[surgndoc]

We’re giving droperidol to most patients now as an anti-emetic. As far as I know it’s mildly “sedating” but haven’t noticed a big change in wake ups.

My go to is ride the vent, nitrous+ narcotic, Wean the sevo over 10 mins during closure then once they react turn off the vent, see a few spontaneous breaths and extubate. Works well 95% of the time.

I see many residents only using PSV, and constantly lowering the support level for their wakeups. Seems to be a new trend. The wakeups consistently take forever in this fashion. Seems to be what’s taught nowadays.

 

[2Fast2Des]

We’re giving droperidol to most patients now as an anti-emetic. As far as I know it’s mildly “sedating” but haven’t noticed a big change in wake ups.

My go to is ride the vent, nitrous+ narcotic, Wean the sevo over 10 mins during closure then once they react turn off the vent, see a few spontaneous breaths and extubate. Works well 95% of the time.

I see many residents only using PSV, and constantly lowering the support level for their wakeups. Seems to be a new trend. The wakeups consistently take forever in this fashion. Seems to be what’s taught nowadays.

I use psv to emerge, no issues here. I pull the tube as the drapes go down or immediately after, no time for doing calculus or head lifts, pt either comes to as we roll out or in PACU

 

[Tramadeezy]

We’re giving droperidol to most patients now as an anti-emetic. As far as I know it’s mildly “sedating” but haven’t noticed a big change in wake ups.

My go to is ride the vent, nitrous+ narcotic, Wean the sevo over 10 mins during closure then once they react turn off the vent, see a few spontaneous breaths and extubate. Works well 95% of the time.

I see many residents only using PSV, and constantly lowering the support level for their wakeups. Seems to be a new trend. The wakeups consistently take forever in this fashion. Seems to be what’s taught nowadays.

My go to as well. 5 minutes or so left, high flows, sevo off nitrous on. Nitrous off 2 minutes before drapes down. Bridge with propofol 10-20mg as needed. Let the vent get all the volatile/nitrous off. Have to watch the patient closely. Always scenarios where I wouldnt do this but it works well for most cases. Watching patients breathe their way through stage 2 is painful and takes forever.

 

[woopedazz]

I mainly use remifentanil as an infusion but would like to know how to bolus it for these situations. How much exactly are you giving and when? Is this after reversal and 50mcg at a time?

It's potency is ~1:1 with fentanyl. So if you want to get an effect equal to "50mcg of fentanyl" you can give 50mcg of remi.

 

[deleted875186]

It's potency is ~1:1 with fentanyl. So if you want to get an effect equal to "50mcg of fentanyl" you can give 50mcg of remi.

Disagree, I beleive it’s almost 2:1 potency as fentanyl. It is hard to compare as the onset time is so much quicker for Remi.

 

[OptionOffense]

My go to as well. 5 minutes or so left, high flows, sevo off nitrous on. Nitrous off 2 minutes before drapes down. Bridge with propofol 10-20mg as needed. Let the vent get all the volatile/nitrous off. Have to watch the patient closely. Always scenarios where I wouldnt do this but it works well for most cases. Watching patients breathe their way through stage 2 is painful and takes forever.

They must think you're the bees knees

 

[FiO2@21]

Exceptionally smooth extubation overrated for most cases. Some exceptions: for hernias I do the typical private practice "pull tube when just before I see any signs of life" extubation with a goal of 10 RR using opioids. For breast/gynecomastia cases I pull it deep z(> 1.2 MAC), sit the pt up and jaw thrust as they're wrapping the pt up. For thyroids I stop the Remi after most of the gas is off and wait for their eyes to open. For carotids I start a precedex infusion after they unclamp.

For all the rest I might give ~0.25 precedex towards the end and wake them all the way up, replacing a bunch of the sevo with nitrous at the end. I honestly use a little less opioid than I used to. I target RR ~ 16 instead of 10.

They might cough, buck, or even sit up suddenly. But then they're awake and I can frequently chat with them and even have them move themselves to the other bed. Last week one of the circulating RNs saw that and said I could do her anesthesia anytime. A "cough less" extubation isn't the only way to look smooth.

 

[GassYous]

Exceptionally smooth extubation overrated for most cases. Some exceptions: for hernias I do the typical private practice "pull tube when just before I see any signs of life" extubation with a goal of 10 RR using opioids. For breast/gynecomastia cases I pull it deep z(> 1.2 MAC), sit the pt up and jaw thrust as they're wrapping the pt up. For thyroids I stop the Remi after most of the gas is off and wait for their eyes to open. For carotids I start a precedex infusion after they unclamp.

For all the rest I might give ~0.25 precedex towards the end and wake them all the way up, replacing a bunch of the sevo with nitrous at the end. I honestly use a little less opioid than I used to. I target RR ~ 16 instead of 10.

They might cough, buck, or even sit up suddenly. But then they're awake and I can frequently chat with them and even have them move themselves to the other bed. Last week one of the circulating RNs saw that and said I could do her anesthesia anytime. A "cough less" extubation isn't the only way to look smooth.

You can do all these cases with no coughing without deep extubation, remi, nitrous or precedex. It's just about timing. Get the gas off slowly and early.

 

[GuiltySpark]

Yeah I’ve nearly eliminated my use of nitrous and des due to environmental concerns. I used to use nitrous semi regularly too, but now almost never.

I still enjoy using Nitrous for wake-ups and I consider it an 'inhaled propofol'. I understand it's a potent Greenhouse Gas, however, why compromise my wake-ups when there are massive industries that are far worse emitters than the entirety of Anesthesiology? Is there good evidence to suggest that our small contribution will make giants leaps in reducing our footprint?

 

[GassYous]

I still enjoy using Nitrous for wake-ups and I consider it an 'inhaled propofol'. I understand it's a potent Greenhouse Gas, however, why compromise my wake-ups when there are massive industries that are far worse emitters than the entirety of Anesthesiology? Is there good evidence to suggest that our small contribution will make giants leaps in reducing our footprint?

you don't need it for good wake-ups

 

[OptionOffense]

Nitrous has gotten a bad rap but I still use it almost always. Why? It contributes significantly to mac.And thats what I want. I want an amnestic, asleep patient. I do not want to risk awareness. Risk of nausea? pfffft. Ill take that anyday over some patient telling me Im not nauseous but i remember the entire thing. PLus I think narcotic, ketamine, precedex all have a major hand in nausea even moreso than nitrous oxide.

 

[deleted875186]

Nitrous has gotten a bad rap but I still use it almost always. Why? It contributes significantly to mac.And thats what I want. I want an amnestic, asleep patient. I do not want to risk awareness. Risk of nausea? pfffft. Ill take that anyday over some patient telling me Im not nauseous but i remember the entire thing. PLus I think narcotic, ketamine, precedex all have a major hand in nausea even moreso than nitrous oxide.

Nitrous is well established as causing nausea. It’s a terrible greenhouse gas. It is convenient to use for wake ups, but that’s it, I would argue volatile plus or minus prop achieves as fast a wake up without downsides of nitrous.

Ketamine in large doses contributes to nausea, not small doses though. Precedex never causes nausea. Opioids cause nausea but at least they bring some analgesia, more than can be said for nitrous.

 

[OptionOffense]

I think it is a mistake to throw nitrous oxide by the wayside. Again, it contributes significantly to MAC, and the risk of nausea is there but not significantly higher than not using nitrous in the enigma2 trial. You wont make the newspapers because your patient has nausea but you will if she has awareness. Greenhouse mehh

 

[Dantrolene FC]

Nitrous is well established as causing nausea. It’s a terrible greenhouse gas. It is convenient to use for wake ups, but that’s it, I would argue volatile plus or minus prop achieves as fast a wake up without downsides of nitrous.

Ketamine in large doses contributes to nausea, not small doses though. Precedex never causes nausea. Opioids cause nausea but at least they bring some analgesia, more than can be said for nitrous.

PONV from nitrous is less than 1% if used for less than 1 hour.

 

[abolt18]

PONV from nitrous is less than 1% if used for less than 1 hour.

And what's the incidence of intraop awareness when running 0.7MAC of volatile or higher? Less than 0.01%? I am not opposed to the use of nitrous, especially at the end of a case. I just don't understand the reasoning for it from @OptionOffense . Awareness is SO low on my list of concerns.

 

[Arch Guillotti]

You wont make the newspapers because your patient has nausea but you will if she has awareness.

I don't get it.

 

[Dantrolene FC]

And what's the incidence of intraop awareness when running 0.7MAC of volatile or higher? Less than 0.01%? I am not opposed to the use of nitrous, especially at the end of a case. I just don't understand the reasoning for it from @OptionOffense . Awareness is SO low on my list of concerns.

When you’re in academics, nitrous at the end of a case makes it much easier to time a wake-up. Especially when you’re doing 3 hour EGDs under general with a 2 minute heads up of when they’ll be done.

 

[deleted875186]

When you’re in academics, nitrous at the end of a case makes it much easier to time a wake-up. Especially when you’re doing 3 hour EGDs under general with a 2 minute heads up of when they’ll be done.

As opposed to cranking flows and pushing some prop if they get a bit light???

 

[OptionOffense]

And what's the incidence of intraop awareness when running 0.7MAC of volatile or higher? Less than 0.01%? I am not opposed to the use of nitrous, especially at the end of a case. I just don't understand the reasoning for it from @OptionOffense . Awareness is SO low on my list of concerns.

Having a case of awareness is devastating to all those involved. I notice a trend that people(trainees and midlevels) forego gas (all gases) especially nitrous for TIVA protocols . I have also seen protocols that call for "no gases" in the name of ERAS. I have also witnessed us foregoing the use of gases to facilitate neuromonitoring. This is short-sighted especially how devastating a case of awareness is and how easy it is to prevent with a little bit of nitrous and or volatile agent . Part of me thinks there is a conspiracy by the precedex sales force to demonize nitrous and the volatile agents in favor of precedex infusions. Not to mention the climate freaks who say if I turn on a bit of desflurane I am the ****in' devil. Interesting times. It is only a matter of time where we see a well covered case of awareness under anesthesia amongst the many.

 

[OptionOffense]

And what's the incidence of intraop awareness when running 0.7MAC of volatile or higher? Less than 0.01%? I am not opposed to the use of nitrous, especially at the end of a case. I just don't understand the reasoning for it from @OptionOffense . Awareness is SO low on my list of concerns.

my only point was, why abandon the use of a fantastic agent because "it causes nausea" when the risk is higher but not 100 percent higher especially when the use of narcotics is still in full force use.

 

[Arch Guillotti]

Having a case of awareness is devastating to all those involved. I notice a trend that people(trainees and midlevels) forego gas (all gases) especially nitrous for TIVA protocols . I have also seen protocols that call for "no gases" in the name of ERAS. I have also witnessed us foregoing the use of gases to facilitate neuromonitoring. This is short-sighted especially how devastating a case of awareness is and how easy it is to prevent with a little bit of nitrous and or volatile agent . Part of me thinks there is a conspiracy by the precedex sales force to demonize nitrous and the volatile agents in favor of precedex infusions. Not to mention the climate freaks who say if I turn on a bit of desflurane I am the ****in' devil. Interesting times. It is only a matter of time where we see a well covered case of awareness under anesthesia amongst the many.

No gas, no awareness if you know what you are doing.