No more desflurane

[deleted875186]

Can you explain what is it with this nitrous morphine technique that made things so smooth?

I think iso and opioid achieves a very good wake up, just hard to time sometimes.

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[Aheadbyacentury]

Used it a bit in the children's hospital as a resident, it is less pungent than sevo so we start with nitrous in a scented mask then crank up the sevo after. For adults who are extreme needle phobic I've done mask inductions before but go straight to sevo.

I've never used nitrous as maintenance anesthetic and I've never used nitrous for speeding up emergence because sevo works just fine.

Maybe when they were using iso it made a difference?

50% nitrous contributes significantly to MAC. Nitrous is for people who like their patients asleep.

 

[coffeebythelake]

50% nitrous contributes significantly to MAC. Nitrous is for people who like their patients asleep.

bwahaha ok. plenty of other options out there.
of course it depends on your experience with the drug
if you've never emerged a patient without using nitrous, it might take you a long time to do so.

 

[deleted126335]

bwahaha ok. plenty of other options out there.
of course it depends on your experience with the drug
if you've never emerged a patient without using nitrous, it might take you a long time to do so.

Heavy nitrous narcotic anesthetics are more likely to have a very pretty emergence and make you look slick. They also cause lots of barfing, increased length of stays, maybe affect wound healing. Loved them for the first decade or so of my practice. Not so much now.

 

[Bryan O’Blivion]

I never understood why it’s still in the anesthesia machine. Maybe it used to be useful for wake ups or for mask inductions.

Nitrous blended with volatile during a cesarean under GA uterine bleeding is often less than with vapor alone, it seems. It works well for mask induction, at least for me. Often nice to keep someone asleep while a splint goes on, for instance. I don’t use desflurane much, but it seems like once in a while there’s a situation where it’s a good option. Also, I find the vaporizer nice to warm my hands on.

 

[coffeebythelake]

Also, I find the vaporizer nice to warm my hands on.

 

[epidural man]

I just got an email from one of the hospitals where I work stating that desflurane is being removed from the ORs in order to "avoid approximately 1,671 metric tons of CO2 from being released into the atmosphere."

Anyone else hearing this from your hospitals?

We got rid of it for cost savings only.

I never understood the minds of executives at medical companies. Desflurane has basically priced themselves out of the market. Had they been cheaper, lots would use it still.

 

[nimbus]

We got rid of it for cost savings only.

I never understood the minds of executives at medical companies. Desflurane has basically priced themselves out of the market. Had they been cheaper, lots would use it still.

Reminds me of when they jacked up the price of neostigmine after sugammadex was released.

 

[coffeebythelake]

Reminds me of when they jacked up the price of neostigmine after sugammadex was released.

Well this one is obvious. There were only 2 options. Low ball or hike the price. The first option probably not much money made with the usual slim generic margins. They know their product is way inferior to sugammadex, so thry want to get as much money out as possible before completely knocked out of the market

 

[cchoukal]

I used to warm my ekg stickers on the des vaporizer.

 

[<(^_^)>]

I never use Desflurane, but a single nuclear power plant reduces CO2 emissions by millions of metric tons every year. Had we increased our Nuclear Capacity going back to just 1995 we could have reduced CO2 emissions by hundreds of BILLIONS of metric tons.

Just saying. Eliminating Desflurane from ORs does as much to help reduce the adverse effects of climate change as switching brands of toilet paper has on the budget of a hospital.

But I can’t build a nuclear power plant back in 1995, while I can decide not use desflurane.

The “equivalent co2” is not the whole story, have to look at how long the gas stays before decomposing in the atmosphere, nitrous is a greenhouse gas that lasts a very long time, it should be eliminated from practice.

This is true, but it’s already reflected in the “global warming potential” values. GWP generally is over 100 year time frame, so it’s the amount of warming during that time frame. Nitrous lasts around 114 years per google and exerts weak warming throughout that time frame, while sevoflurane lasts 1 year (but exerts way more warming during that year period vs nitrous, but then 0 warming once it is degraded). In practice you’ll eventually reach a steady state where nitrous is contributing the expected X times worse than sevoflurane, but notably if a hot new volatile was invented and we switched from sevo to it, in 1 year the warming impact would be eliminated vs 114 years for nitrous.

Heavy nitrous narcotic anesthetics are more likely to have a very pretty emergence and make you look slick. They also cause lots of barfing, increased length of stays, maybe affect wound healing. Loved them for the first decade or so of my practice. Not so much now.

These effects appear to be dependent on duration of use. Nitrous Oxide–related Postoperative Nausea and Vomiting Depends on Duration of Exposure | Anesthesiology | American Society of Anesthesiologists effectively 0 difference if using it at the end of the case (but significant if used for 1, and certainly 2+ hours). I would be curious if you’ve seen any literature on short (<30 minutes of nitrous) impacting length of stays or wound healing.

 

[pgg]

Nitrous has its place. I rarely use it, except for

1) Peds mask inductions in older, cooperative kids. It's a kinder gentler induction if the kid voluntarily breathes some nitrous before turning on the sevo. And then the nitrous gets turned off. For little kids that have to be pinned down, I'd rather have the higher FiO2 with 8% sevo in oxygen. I'm not a believer that the 2nd gas effect or concentration effect are clinically relevant.

2) C-sections under general. Nitrous permits lower volatile concentrations, and you get less uterine atony.

 

[Drwine]

Nitrous has its place. I rarely use it, except for

1) Peds mask inductions in older, cooperative kids. It's a kinder gentler induction if the kid voluntarily breathes some nitrous before turning on the sevo. And then the nitrous gets turned off. For little kids that have to be pinned down, I'd rather have the higher FiO2 with 8% sevo in oxygen. I'm not a believer that the 2nd gas effect or concentration effect are clinically relevant.

2) C-sections under general. Nitrous permits lower volatile concentrations, and you get less uterine atony.

For older cooperative kids, I would rather "float like a butterfly and sting like a bee" with an IV and just inject some midazolam and/or some propofol so I can avoid polluting the OR with an inhalation induction. As far as c sections, fentanyl after delivery and a little propofol will let me run the same lower sevo concentration.

 

[woopedazz]

I just TIVA GA sections personally.

 

[Bryan O’Blivion]

I just TIVA GA sections personally.

Fine in theory, but becomes an issue of practicality, since most GA sections are the result of inadequate time for the placement of a successful neuraxial anesthetic. Usually there is one IV, and often multiple medications to administer. Utilizing the ETT to deliver an inhaled anesthetic agent can streamline workload considerably. Yes, there are ways around this such as drawing up the induction dose of propofol in a 60 cc syringe, using a push to go to sleep, and then slapping it on a syringe pump if available for maintenance. But, you know, the tube is already there.

 

[Aether2000]

Never use Des, never use nitrous. These gases are out of touch with the needs of the environment and out of step with the current (if not futile) push to preserve a world for the next few generations.

 

[woopedazz]

Fine in theory, but becomes an issue of practicality, since most GA sections are the result of inadequate time for the placement of a successful neuraxial anesthetic. Usually there is one IV, and often multiple medications to administer. Utilizing the ETT to deliver an inhaled anesthetic agent can streamline workload considerably. Yes, there are ways around this such as drawing up the induction dose of propofol in a 60 cc syringe, using a push to go to sleep, and then slapping it on a syringe pump if available for maintenance. But, you know, the tube is already there.

I hear the sentiment, but I disagree.

Usually there is one IV, and often multiple medications to administer.

Like every TIVA case. Except less medications peri-induction for these patients.

Using a push to go to sleep

Like most proper RSI induction cases.

and then slapping it on a syringe pump if available for maintenance

What hospital doesn't have a pump in the crash section room?


I run most of my cases on gas, but all my GA sections are TIVA. Lots of people don't think the drugs make a huge difference, and that's fair, but I'm not sold on the "it's too hard to put drugs into a syringe" argument.

 

[Drwine]

The biggest obstacle to TIVA in the US is after all of this time target control infusion pumps are still not approved. 😩😭
Modern TIVA in the US is equivalent to my days as a medical student on anesthesia rotation when we still had copper kettles and vernitrols to deliver halothane and we would need slide rules, thermometers and barometers to figure how much halothane we were delivering.

 

[Bryan O’Blivion]

I hear the sentiment, but I disagree.

Like every TIVA case. Except less medications peri-induction for these patients.

Every TIVA case? In some of mine I prefer two.

Like most proper RSI induction cases.

Few would disagree here.

What hospital doesn't have a pump in the crash section room?

Mine apparently. I have a couple of roller pumps, but no syringe pump.

I run most of my cases on gas, but all my GA sections are TIVA. Lots of people don't think the drugs make a huge difference, and that's fair, but I'm not sold on the "it's too hard to put drugs into a syringe" argument.

Well, to each their own. While occasionally I have a GA section where a patient has refused a spinal or something, the more common scenario is unfortunately an emergency, and I find the simplicity of vapor via ETT very helpful. Anecdotally, I have found that TIVA actually does seem to make a difference, and is better in terms of bleeding. In multiple uterotonics administered, still boggy kind of case, I’ll switch to TIVA, seems to help. Sometimes in patients with really poor oxygenation, there is no anesthetic benefit in what little N2O they will tolerate, and a propofol gtt is a great choice from the beginning. I just usually make my anesthetic plan the simplest one in an emergency, and if I don’t have a reason to change the plan, I don’t go looking for one.

 

[ProwlerturnGas]

The biggest obstacle to TIVA in the US is after all of this time target control infusion pumps are still not approved. 😩😭
Modern TIVA in the US is equivalent to my days as a medical student on anesthesia rotation when we still had copper kettles and vernitrols to deliver halothane and we would need slide rules, thermometers and barometers to figure how much halothane we were delivering.

WTF? Copper kettle and slide rules? Lol

 

[coffeebythelake]

The biggest obstacle to TIVA in the US is after all of this time target control infusion pumps are still not approved. 😩😭
Modern TIVA in the US is equivalent to my days as a medical student on anesthesia rotation when we still had copper kettles and vernitrols to deliver halothane and we would need slide rules, thermometers and barometers to figure how much halothane we were delivering.

Maybe before BIS or other brain wave monitors.

 

[Aheadbyacentury]

Tiva doesnt have a MAC

 

[D P356]

I only administer Nitrous during a section after baby is out and mother is losing it. I try to avoid the longer effects of ketamine, versed, fentanyl as compared to nitrous.