Let’s now blame the Anesthesiologists for contributing to Climate change!

[epidural man]

We are arguing about the wrong thing.

Once again, JC and CMS should shoulder most of the blame.

We can’t use multi-dose vials. We have to use a new needle and new syringe (even with a redose of the same drug) each time. Our “fiber” optic scopes are single use. Our pulse ox, BP cuffs, laryngoscope blades (and other stuff I’m not thinking of) are single use. And why? Does a single use laryngoscope prevent a post op infection from a knee scope?

---

Members don't see this ad.

 

[CoolDoc1729]

“Emissions of anesthetic gases in the United States alone are estimated to equal the annual emissions of one coal-fired plant, or nearly 1 million automobiles per year”.
Really compelling medical indication to convert General Anesthesia-> Regional Anesthesia!

Anesthesiologists Tackle Climate Change in the OR

Anesthesia gases are a critical tool in health care, but they also play a significant role in making the global health care industry the world’s fifth largest emitter of greenhouse gases.

www.cuimc.columbia.edu

How about getting all the nurses not to remote start their Yukons half an hour before their shift ends ? At least the anesthetic gases have a purpose

 

[nimbus]

I still think you need to get good

And you get good with sevo wakeups when you stop using des.

 

[jwk]

They do. So do 1970s cars. Just lacking significant safety features.

And no pulse ox, end tidal CO2, agent monitors, etc. Just an EKG, a BP cuff, and a precordial stethoscope well into the 80's.

 

[periopdoc]

It's not THAT hard to get a good sevo wake up even in the morbidly obese. Residents and CRNAs included. If we're just going to assume docs and providers are going to not face the incentive to "get good" with sevo to be equivalent to des... I would say that's a broader systems issue that doesn't necessarily require re-adopting des to fix.

You've changed your claim from des reducing OR time/PACU discharge time to des improving PACU safety and reducing PACU workload in super morbidly obese patients.

That's fine, I just don't think there is strong evidence for this either. I think there's some reduction in post op complications w/OLV cases associated with des if I remember right? If you've seen or done some research on des being demonstrably better that would be interesting to see.

Marginally quicker to follow commands does not mean improved PACU safety to the tune of $500k+environmental concerns, but maybe you're aware of research I'm not. -shrug-

Ah, the Lake Wobegon of SDN where the anesthesiologists are strong, the anesthesia assistants are good looking, and all the CRNAs are above average. Sure wish I could work there. Unfortunately, I work in the real world, where the bell shaped curve is wider than your average circulator's hips, personal motivations do not always align with our efficiency goals, surgeons randomly decide when to close long cases, and patients don't behave predictably.

My argument remains, simply, that the claimed $500,000 system savings is dubious at best, though they may have saved $500,000 on anesthesia gasses. Who crows about saving $500k over 8 institutions anyway?

I should have been more clear, about the target for my supporting arguments, but figured people here were smart enough that I didn't need to spell it out.

At the system level, DES reduces OR time, and time to patients being ready for PACU discharge. (Whether the latter reduces the actual time to discharge is dependent on other things in the system, but patients being ready for discharge reduces work load either way). Both come with significant costs savings to the institution.

I added an additional argument, for the "just get Good" crowd. Even at the individual, "Good anesthesiologist," level, Des has benefits in the obese population that are simply not attainable with Sevo, and obesity rates are skyrocketing. Having my super morbidly obese, FRC of a squirrel, patient be alert and talking as we roll into PACU allows me to move on to the next patient faster. Can we get that with Sevo? Not reliably. I love walking through PACU, past my "Des is for weaklings" colleagues who are holding airways open, while I'm just chatting away with my wide awake, morbidly obese patient.

 

[periopdoc]

And yes, I use a lot of Sevo. Some locums places, it's the only option, and it doesn't make sense to use Des in cases under 2 hours, except in the morbidly obese where the benefits probably kick in at 1 to 1.5 hours.

 

[rowsdower88]

"Des is for weaklings" colleagues who are holding airways open

These guys need to get good.

I understand your position. I still disagree with it. Des ain't magic sauce IMHO.

Edit: I'm at a tertiary center in WI where there's more cheese than blood circulating. Got rid of des two years ago for context. Maybe I should change my phrasing from "get good" to "get competent", because management of sevo wake ups should be a necessity for an anesthesiologist regardless of body habitus.

 

[Arch Guillotti]

past my "Des is for weaklings" colleagues who are holding airways open

They don't sound very skilled

 

[Southpaw]

If you can wake someone up comfortably on one gas you should be able to do it on another. I’m not really a systems guy so I don’t care what other people do or whether or not they’re good. I can’t control others. Just don’t take my sugammadex.

 

[periopdoc]

If you can wake someone up comfortably on one gas you should be able to do it on another. I’m not really a systems guy so I don’t care what other people do or whether or not they’re good. I can’t control others. Just don’t take my sugammadex.

I may not care as deeply about my partner's patients as I do my own, but I do care, and it is my job to care. Besides, the original point, that I was arguing against, was a systems point.

When I was a youngster, I used to think that SDN was full of the real hot-shot docs. Now that I'm a literal grey hair, I realize that it's a lot more like Fresh and Fit. "Just be more alpha bro."

Full of perfect anesthesiologists who have never had a complication in their life. Never once have misjudged and gotten a little heavy handed with the opiates, or the paralytics, and subsequently had to hold an airway open in PACU for a few minutes, or maybe assist with breathing.

I get it. I used to be there. Not so much now. This career has a way of humbling you over the years, and I don't need to sooth any insecurities by pretending to be perfect anymore.

It's funny you bring up sugammadex. It's a perfect metaphor. If you are "good" with managing your NMBs, you don't need it, and it's expensive. Here in the real world, where physiology is individual, and surgeons are unpredictable, sometimes sugammadex is a real life saver.

 

[rowsdower88]

I may not care as deeply about my partner's patients as I do my own, but I do care, and it is my job to care. Besides, the original point, that I was arguing against, was a systems point.

When I was a youngster, I used to think that SDN was full of the real hot-shot docs. Now that I'm a literal grey hair, I realize that it's a lot more like Fresh and Fit. "Just be more alpha bro."

Full of perfect anesthesiologists who have never had a complication in their life. Never once have misjudged and gotten a little heavy handed with the opiates, or the paralytics, and subsequently had to hold an airway open in PACU for a few minutes, or maybe assist with breathing.

I get it. I used to be there. Not so much now. This career has a way of humbling you over the years, and I don't need to sooth any insecurities by pretending to be perfect anymore.

It's funny you bring up sugammadex. It's a perfect metaphor. If you are "good" with managing your NMBs, you don't need it, and it's expensive. Here in the real world, where physiology is individual, and surgeons are unpredictable, sometimes sugammadex is a real life saver.

If this is Fresh and Fit, I need you to red pill me on desflurane.

Your claim as I understand it is something like: desflurane availability and judicious use at large centers results in cost-savings in excess of $500k.

So many things in medicine and anesthesia are vibes based. I think your whole argument for des cost-benefit is vibes-based and my vibes on des are different from your vibes. I don't think desflurane availability results in significant cost savings, that's my vibe.

Your sugammadex analogy is flawed. I can point to budgetary studies that show cost savings when sugammadex is used over neo/glyco based on predicted reductions in complications. As far as I know, you can't do the same with des. That's the difference between the sugammadex and des analogies - we leave the realm of vibes when we can discuss the numbers.

If we can't argue on the numbers, we shouldn't be making claims like $500k in cost savings because we don't REALLY know. I can't prove your vibes are wrong on des, but unless you can back up your vibes with numbers you can't prove mine are either. In that case, I have no reason to be opposed to allowing the penny pinchers to take away your des.

Edit: I'll even grant that your vibes are on average better than my vibes because you've been doing this longer, the problem is I still weigh $500k+environmental damage > vibes.

A Clinical and Budgetary Impact Analysis of Introducing Sugammadex for Routine Reversal of Neuromuscular Blockade in a Hypothetical Cohort in the US

Sugammadex rapidly reverses the effects of rocuronium- and vecuronium-induced neuromuscular blockade (NMB), offering a more complete and predictable NMB recovery than cholinesterase inhibitors. Despite clinical benefits, cost pressures on hospital budgets ...

www.ncbi.nlm.nih.gov

 

[deleted875186]

I may not care as deeply about my partner's patients as I do my own, but I do care, and it is my job to care. Besides, the original point, that I was arguing against, was a systems point.

When I was a youngster, I used to think that SDN was full of the real hot-shot docs. Now that I'm a literal grey hair, I realize that it's a lot more like Fresh and Fit. "Just be more alpha bro."

Full of perfect anesthesiologists who have never had a complication in their life. Never once have misjudged and gotten a little heavy handed with the opiates, or the paralytics, and subsequently had to hold an airway open in PACU for a few minutes, or maybe assist with breathing.

I get it. I used to be there. Not so much now. This career has a way of humbling you over the years, and I don't need to sooth any insecurities by pretending to be perfect anymore.

It's funny you bring up sugammadex. It's a perfect metaphor. If you are "good" with managing your NMBs, you don't need it, and it's expensive. Here in the real world, where physiology is individual, and surgeons are unpredictable, sometimes sugammadex is a real life saver.

It’s completely different from suggamadex.

 

[Southpaw]

I may not care as deeply about my partner's patients as I do my own, but I do care, and it is my job to care. Besides, the original point, that I was arguing against, was a systems point.

When I was a youngster, I used to think that SDN was full of the real hot-shot docs. Now that I'm a literal grey hair, I realize that it's a lot more like Fresh and Fit. "Just be more alpha bro."

Full of perfect anesthesiologists who have never had a complication in their life. Never once have misjudged and gotten a little heavy handed with the opiates, or the paralytics, and subsequently had to hold an airway open in PACU for a few minutes, or maybe assist with breathing.

I get it. I used to be there. Not so much now. This career has a way of humbling you over the years, and I don't need to sooth any insecurities by pretending to be perfect anymore.

It's funny you bring up sugammadex. It's a perfect metaphor. If you are "good" with managing your NMBs, you don't need it, and it's expensive. Here in the real world, where physiology is individual, and surgeons are unpredictable, sometimes sugammadex is a real life saver.

I do appreciate you caring. You’re probably president of your group and invested in everyone’s success. I truly find that admirable. But that’s not me. This is my 10th year out of residency. If you think des makes that big of a difference, I believe you. I’ve personally only used sevo since finishing residency but I respect my partners who use des no less. I simply don’t think that there’s a massive difference. I do sincerely believe that there are deeper issues at hand beyond sevo or des if any anesthesiologist routinely finds themself in pacu managing an airway. I’m not saying I’m the super duper best anesthesiologist out there as I make plenty of mistakes, but I am saying that after residency and a few years of practice things get pretty routine.

I’ve only seen two real serious game changers in my practice since finishing residency that I can think of off hand. One is sugammadex. It’s a literal game changer for NMB reversal. It’s backed by good evidence including ASA practice guidelines this year. The other is additives to my regional block meds to get my blocks to > 24 hrs.

 

[pgg]

past my "Des is for weaklings" colleagues who are holding airways open

They don't sound very skilled

My favorites are the ones who take every single patient to the PACU with an oral airway, totally obtunded, because they think deep extubations are slick and efficient. Doesn't matter what gas they use or when they turn it off, always out of the OR a minute after the drapes come down. (Or they would be, if the circulating nurse was ready to help move the patient off the table.)

After an efficient turnover in PACU, they're on their way again to go efficiently start another case, content in their little tunnel, oblivious to the overall impact of their decisions.


I'm not saying that desflurane is magic, but in the overall continuum of wakefulness at 5 minutes post PACU arrival you've got

good <-----> bad
skilled desflurane wakeup ...... skilled sevoflurane wakeup ..... skilled isoflurane wakeup ............................................................... why bother waking them up just deep extubate 'em and go +/- a jaw thrust

It's just surprising that people are actually arguing that there aren't concrete advantages to using des, or that prompt crisp wakefulness in PACU is somehow irrelevant. The blood:gas and blood:fat partition coefficients aren't made-up numbers, they're in every textbook. PACU throughput doesn't matter everywhere, but it matters some places. It's an odd source of pride to love sevo so much that one is unable to admit des has advantages, and to throw out "get good" advice.

Whatever - not really a hill to die on. When we lost desflurane I was annoyed, but I still managed to get out of bed the next morning.

 

[pgg]

Gotta love slick, hyperefficient, ultra deep, super opioid heavy, oral+nasal airway, partially neuromuscular blocked (wouldn’t want them coughing and thrashing!) wake ups.

It’s so common in practices I’ve worked in that I sometimes wonder if I missed the part of training where giving PACU a barely alive patient was considered super awesome.

Signature move #2 is Precedex for everyone

Induction
Tube
Sevo to 3%
Nice big slug o' Precedex
4 mg of Zofran (whether the case is expected to be 25 minutes or 5 1/2 hours)
BP of 75/40 while the circ preps
BP of 68/37 while the prep dries
BP of 66/31 while draping
25 mg of ephedrine immediately followed by incision
BP 176/104
etc

 

[rowsdower88]

It's just surprising that people are actually arguing that there aren't concrete advantages to using des, or that prompt crisp wakefulness in PACU is somehow irrelevant. The blood:gas and blood:fat partition coefficients aren't made-up numbers, they're in every textbook. PACU throughput doesn't matter everywhere, but it matters some places. It's an odd source of pride to love sevo so much that one is unable to admit des has advantages, and to throw out "get good" advice.

No one denies the physics, that's a strawman.

The argument is whether or not having des available (to the tune of $500k per earlier source) is worth the benefits.

“Get good?” For the vast majority of people I see it’s more like “get below average” because the wakeups I described above are most of what I see.

Desflurane on the other hand is *almost idiot proof for wake-up speed

If the problem is that the anesthesiologists you guys are working with are so incompetent that smooth sevo/iso/tiva wake ups are not routinely achieved, maybe des does become a viable cost saving option.

I'm starting to get persuaded. I just don't want to practice wherever you guys are practicing.

 

[Southpaw]

Some of the problems you guys are discussing are both bothersome and won’t be solved with des. They will be solved however with competency. Des can’t help overdosing precedex and/or narcotics. Nor can it help bringing partially paralyzed patients to the pacu.

 

[ProwlerturnGas]

The smugness and pomposity are particularly strong in this thread, even for SDN

 

[rowsdower88]

Signature move #2 is Precedex for everyone

Induction
Tube
Sevo to 3%
Nice big slug o' Precedex
4 mg of Zofran (whether the case is expected to be 25 minutes or 5 1/2 hours)
BP of 75/40 while the circ preps
BP of 68/37 while the prep dries
BP of 66/31 while draping
25 mg of ephedrine immediately followed by incision
BP 176/104
etc

I should do more chart stalking. Maybe my colleagues are doing this and I've just been blissfully unaware.

I can't remember the last time we've had an emergency in the PACU though. Maybe everyone is sending their questionable extubations to the unit automatically.

 

[nimbus]

If folks are having a lot of problems in PACU, it’s not a sevo vs des issue.

 

[deleted1156722]

I think it’s a crna thing, as they never have time in training to hone skills in anything really, it’s too much to expect them to be anything beyond wildly average imo. Also laziness and lack of knowledge in docs sitting cases.

Competence is a really rare thing in this world. Whether it’s medicine or street sweeping or office work, the competent people always survive layoffs or land new jobs easily when they do move on or get axed. It’s the hottest commodity of all time

No worries as CRNAs are also “greening anesthesia” and becoming global stewards!

New Guidance on Greening Anesthesia

A new guidance document provides actionable steps to mitigate greenhouse gas emissions from inhaled anesthetics.

nurseanesthesiology.aana.com

 

[GassYous]

Signature move #2 is Precedex for everyone

Induction
Tube
Sevo to 3%
Nice big slug o' Precedex
4 mg of Zofran (whether the case is expected to be 25 minutes or 5 1/2 hours)
BP of 75/40 while the circ preps
BP of 68/37 while the prep dries
BP of 66/31 while draping
25 mg of ephedrine immediately followed by incision
BP 176/104
etc

It's like you have a camera in my room

 

[rowsdower88]

The smugness and pomposity are particularly strong in this thread, even for SDN

 

[vector2]

Interesting podcast relevant to the topic

Is emergence from sevoflurane substantially faster than from isoflurane? – Depth of Anesthesia

depthofanesthesia.com

I forget the source but one of the papers they cite had a study where they randomized people to iso vs sevo. In an over 2h case they left the patients on 1 mac of gas until literally the final bandage was on and only then they turned off the vaporizers. The iso pts took ~10 minutes longer to follow commands.

 

[deleted1156722]

Interesting podcast relevant to the topic

Is emergence from sevoflurane substantially faster than from isoflurane? – Depth of Anesthesia

depthofanesthesia.com

I forget the source but one of the papers they cite had a study where they randomized people to iso vs sevo. In an over 2h case they left the patients on 1 mac of gas until literally the final bandage was on and only then they turned off the vaporizers. The iso pts took ~10 minutes longer to follow commands.

Interesting podcast.
Here is another one- the RISCCS trial (Randomized Isoflurane and Sevoflurane Comparison in Cardiac Surgery) -sev is not superior to iso in ICU LOS.

Comparison of isoflurane and sevoflurane in cardiac surgery: a randomized non-inferiority comparative effectiveness trial

Volatile anesthetics possess cardioprotective properties, but it is unknown if the cardioprotective effects extend equally to all members of the class. Although sevoflurane is a relatively newer anesthetic than isoflurane, its introduction into practice ...

www.ncbi.nlm.nih.gov

 

[Drwine]

These last couple of posts completely miss why isoflurane vaporizors belong in the dust bin in developed countries. With sevoflurane the concentration can be rapidly adjusted to anticipate increased levels of stimuli. There are only a handful of times in a cardiac case where the stimulation is high and with our current practice of low dose narcotic to facilitate early extubation being able to turn up and the sevo creates more stability. I tell fellows and residents that isoflurane is the anesthetic equivalent of the compact fluorescent light bulb in the era of LED lights.

 

[epidural man]

I just love desflurane.

I wish we still had it. What a great drug - and who doesn’t love low flow anesthesia.

 

[GassYous]

These last couple of posts completely miss why isoflurane vaporizors belong in the dust bin in developed countries. With sevoflurane the concentration can be rapidly adjusted to anticipate increased levels of stimuli. There are only a handful of times in a cardiac case where the stimulation is high and with our current practice of low dose narcotic to facilitate early extubation being able to turn up and the sevo creates more stability. I tell fellows and residents that isoflurane is the anesthetic equivalent of the compact fluorescent light bulb in the era of LED lights.

I use iso all the time...

 

[Dr. Rude]

These last couple of posts completely miss why isoflurane vaporizors belong in the dust bin in developed countries. With sevoflurane the concentration can be rapidly adjusted to anticipate increased levels of stimuli. There are only a handful of times in a cardiac case where the stimulation is high and with our current practice of low dose narcotic to facilitate early extubation being able to turn up and the sevo creates more stability. I tell fellows and residents that isoflurane is the anesthetic equivalent of the compact fluorescent light bulb in the era of LED lights.

There are a great many places in the world that would be deliriously happy to have fluorescent lights.

 

[pgg]

I just love desflurane.

I wish we still had it. What a great drug - and who doesn’t love low flow anesthesia.

Yeah. Elegant. Tube in, flow to 0.4 lpm, never need to touch it. Can't really do that with sevo - it's just too soluble and you can't get enough molecules into the patient at that flow rate and still achieve an acceptable end tidal concentration.

Oh well. Life goes on.

 

[coffeebythelake]

Yeah. Elegant. Tube in, flow to 0.4 lpm, never need to touch it. Can't really do that with sevo - it's just too soluble and you can't get enough molecules into the patient at that flow rate and still achieve an acceptable end tidal concentration.

Oh well. Life goes on.

low flow is fine but you need to overpressurize the system with sevo.
you can't "set it and forget it" with sevo like you can with des.

 

[pgg]

low flow is fine but you need to overpressurize the system with sevo.
you can't "set it and forget it" with sevo like you can with des.

Splitting hairs here but I've found that even topping out at 8% on the sevo dial isn't enough, unless you have flows over 1 lpm, at least initially when uptake is very high. Or a long lead time until incision when plodding along at 1/4 or 1/2 MAC for a while doesn't matter. I have seen sevo vaporizers that go to 12 (or 14? don't remember) but not lately and I'm not sure if it was even in the US.

I'll concede that it doesn't really matter in the grand scheme of things if the first few minutes of a low-flow anesthetic isn't really low flow.

 

[coffeebythelake]

Splitting hairs here but I've found that even topping out at 8% on the sevo dial isn't enough, unless you have flows over 1 lpm, at least initially when uptake is very high. Or a long lead time until incision when plodding along at 1/4 or 1/2 MAC for a while doesn't matter. I have seen sevo vaporizers that go to 12 (or 14? don't remember) but not lately and I'm not sure if it was even in the US.

I'll concede that it doesn't really matter in the grand scheme of things if the first few minutes of a low-flow anesthetic isn't really low flow.

10 LPM with induction and intubation, after confirmation of capnography, quickly crank up sevo to 6-8% and drop flows to < 0.5-1 LPM. Perhaps a few seconds of high flow with the sevo on but not more than that. Never had an issue with insufficient FI Sevo% or more importantly the ET Sevo%. Even with the bigger patients. I actually start to come back on the sevo dial after a few minutes.

 

[coffeebythelake]

Major medical group wipes study advocating doctors give less anesthesia to reduce carbon footprint

A top medical group deleted mention of research suggesting that reducing anesthetic gas in surgery could be an effective tool to combat climate change.

www.foxnews.com

FOX News enters the discussion, and unsurprisingly the racist vitriol and stupidity of their commentors are in full display

 

[coffeebythelake]

Interesting podcast relevant to the topic

Is emergence from sevoflurane substantially faster than from isoflurane? – Depth of Anesthesia

depthofanesthesia.com

I forget the source but one of the papers they cite had a study where they randomized people to iso vs sevo. In an over 2h case they left the patients on 1 mac of gas until literally the final bandage was on and only then they turned off the vaporizers. The iso pts took ~10 minutes longer to follow commands.

How you use sevo matters. Goal is 0.7 MAC and no more. Don't let the patient accumulate sevo that it ends up in the fat soluble compartment which hangs out and keeps redistributing back to the brain. Low flow. Let EtCO2 creep up, give reversal, get them breathing spontaneously or pressure support when closing, turn off sevo early and turn up flows while flushing out circle system, don't touch or stimulate the patient, supplement with small hits of propofol or IV lidocaine at signs of wiggling. Get some nice wake-ups that don't hang out forever in PACU. I shake my head at the residents, CRNAs, and *gasps* other attendings that run their patients at 1.0+ MAC of gas for no reason.

 

[coffeebythelake]

I use iso all the time...

For reasonably short cases it is quite easy to time the wakeup.
For the longer cases I use it if patient is planned to go to ICU intubated..

 

[deleted875186]

How you use sevo matters. Goal is 0.7 MAC and no more. Don't let the patient accumulate sevo that it ends up in the fat soluble compartment which hangs out and keeps redistributing back to the brain. Low flow. Let EtCO2 creep up, give reversal, get them breathing spontaneously or pressure support when closing, turn off sevo early and turn up flows while flushing out circle system, don't touch or stimulate the patient, supplement with small hits of propofol or IV lidocaine at signs of wiggling. Get some nice wake-ups that don't hang out forever in PACU. I shake my head at the residents, CRNAs, and *gasps* other attendings that run their patients at 1.0+ MAC of gas for no reason.

I do exactly the same. Tube in, down to 2 liter flow at 2-3% dialed in while taping tube and things, then immediately down to 0.5 liters and vaporizer dialed up to 6% or so for the next 10 mins until incision.

 

[T-burglar]

Lol you nerds

 

[nimbus]

Nice series for the nerds by the OG. Chapter 5 most relevant to this thread.