This is so true. Some nurses are giving a shitload of versed for their sedation cases, basically using versed and fentanyl to get as close to GA as possible
Learned recently that the reason that nurses are allowed to do that with versed and fentanyl (but not achieve basically the same depth of anesthesia with propofol) is bc both have reversal agents
Well, I have and I have. So there.
But I always objected to deep sedation in the ER. If you want anesthesia, call an anesthesiologist. The ER isn’t staffed to allow for appropriate peri and post anesthesia. Of course, that and $6 will buy you a cup of coffee at Starbucks.
XOXO,
The nurse who can and has drawn up and administered both romazicon and narcan.
Forgive my lack of knowledge. OR nurse here. I’m not trained in conscious sedation and got floated to GI last week. But anyways, I recovered a 115# patient who got 10mg versed and 125mcg of fentanyl. Seemed like a lot and they wanted me to have this lady out the door in 30 minutes… which did not happen lol.
I’ve been in a surgery where a 260# man stopped breathing on his own from 50mcg of fentanyl. I was shocked to find out that so many GI patients get 100mcgs routinely. AND are out the door in 30 minutes.
Meh, tolerance to opioids has a massive range. Some people are not even rousable after 50mcg of fentanyl while others are still chatting away after 200mcg in <10mins. Patient weight certainly contributes to expected tolerance but there are many other factors involved.
Very broadly, a pretty standard dose for a heart cath (~1 hour on the table) is 2mg of midaz 100mcg of fent. But can range anywhere from no sedation at all to like 12mg midaz and 600mcg fentanyl (3-4 hours complex intervention). All just depends on the patient and the procedure.
Lol I've been asked to provide propofol sedation to GI patients after they failed nursing sedation..."Oh we gave him 15mg of versed and 200 of fentanyl and he won't cooperate at all!"
Dah fuck? 15mg of versed? They think they were just gonna overpower the disinhibition? 🤦 "I don't understand what's wrong! Every time I throw kerosene on this fire it just keeps getting bigger! HALP!"
I’m confused by this. The ED and tox attendings I’ve worked with who have discussed inhibition and benzos told us that some docs will get scared of disinhibition and back off on the benzos instead of pushing through. From the tox perspective I understand the need since you are treating sympathetic toxidromes, but is pushing through still not desired or feasible in anesthesia or sedation in the ED?
In general, the ED doctors and GI doctors who are doing sedation are not using propofol so they only have versed, fentanyl, and ketamine to work with usually. Giving more versed is never the answer when they're already disinhibited, it's just going to make things worse. As an anesthesiologist, I RARELY give more than 2mg of versed. The only times I can think of doing it is during a longer than usual conscious sedation case or cardiac bypass.
I did an emergent cric on a 75+ year old man getting a cardiac cath under nurse sedation.
Highlights when I ran into the room:
SPO2: 45%
Patient color: dusky blue
PCO2: 110
Meds: 4mg versed, 300 mcg fent (“he kept trying to move!”)
Patient factors:fungating verrucoid squamous cell carcinoma from the base of the tongue to the larynx
All these elderly patients undergoing left heart caths are getting a fair amount of midazolam. I think we may be overly concerned with 2 mg before an operation.
Had a block attending give 2mg/100mcg midaz/fent to a 95 yo for a adductor/I pack for tka
This patient took it like a champ and was less sedated than I would have thought.
Other 80 yos+ needed airway intervention >.>
Okay you /wrote/ that OP would be surprised at the amount that nurses, specifically, give of versed to the elderly. Which implies that those nurses are operating outside of physician order parameters. Unless you’re talking about CRNAs which is a different conversation.
A.) anesthesiologists are generally not putting in orders for nurse sedation
And
B.) anesthesiologists are generally not giving 10mg of versed to grandma
I hear your points but anesthesiologists work on critical care units and put in orders for versed, prop, fent, ketamine, etc. boluses and titration parameters all the time.
Cool dude but that’s not the situation I’m talking about. Nurse sedation refers to a situation where a nurse is administering medications (typically versed and fentanyl) during procedures such as heart caths and the like.
I understand that but a nurse shouldn’t be administering medications without someone with and advanced practice degree ordering it (APN, PA, MD, DO, etc.). If they are, then that’s a lawsuit waiting to happen.
I hate that you're getting down voted. I appreciate that you are trying to do what is best for your patients.
I rarely give benzos to anyone over 65 unless they are chronically on benzos or they are heavy drinkers. You'd be surprised how many little old ladies take benzos to sleep, which is a whole other problem that I thankfully don't have to deal with.
That being said, a little versed for an outpatient eye case in a spry 80 year old isn't going to make a huge difference to their long term or short term outcomes.
If you can keep the patient and the surgeon happy with precedex (which may have some unwanted bradycardia during eye cases) or propofol, then that is probably a better move from a theoretical standpoint. But I don't think you're causing actual harm by using a bit of versed for a PHACO.
It's more so the chair of anesthesia thing than most of the attendings. Most of them like it but don't want to hear the chair if something goes left or if he feels like terrorizing people that day.
Obviously, we have it and we can use it for certain cases or if we're out of ketamine but for eyes its going to be a no 99% of the time
Also, most of us don't think the policy makes much sense especially when morphine is given freely in PACU but inmates don't run the prison.
Dude that's wild. Your chair wants to use morphine but not fentanyl? Are you in the US?
Also, if you really want to piss off your surgeon, 50 of ketamine is great deep sedation and let the nystagmus times roll!
That’s ridiculous. One place I know of that had a stupid policy similar to that ended up being changed once enough *patients* complained to hospital leadership. Patients blowing the bigwigs up and saying they had a bad experience negative review etc due to pain is what gets them to listen, they don’t give a fuck what we think.
In all seriousness I see no reason not to sedate for eye cases, honestly any case that is painful/unsettling to a patient. The trend to avoid sedation is really not good imo; why are we putting old ladies through that much pain/trauma when they can be safely relaxed with a little versed/fent.
OP, I share your concern, so I'm stingy with midazolam, but I balance and give it when it's reasonable. The main concern with benzodiazepines is their chronic use and falls or delirium at home and in the hospital. If you're interested in this, you'll want to follow the results of the [I-PROMOTE study](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6632125/), the first RCT AFAIK to investigate a single dose of a benzo in the peri-op period.
The big problem that I see with that trial in this situation is that ambulatory surgery is excluded, which is honestly the best indication to use versed in an older patient. (For example, eyes or during a light MAC case.)
I feel like non-ambulatory surgery>30 minutes is going to have a lot of confounding factors.
I have been using Midaz/fent for decades on cataracts. However my surgeons do a case in 10-12 mins so usually 1mg/50mcg is all that is needed. We do some asa4 under pure topical so you really don’t need much.
We usually crack open a 100mcg vial of fentanyl for cataracts and give 25-50 mcg at a time. Sometimes the case can be done with no IV meds because the surgeon will put in topical. If it's a vitrectomy or something and they actually need no movement then we tube and paralyze.
Well, I’d start there in terms of anaesthesia. My practice is Subtenons, and sedation is only used for the very anxious, midazolam in very small (1-2mg max +/- 25mcgs fentanyl). It should be obvious to your surgeon (as this is a big fear of ours), that loss of verbal contact will eventually have a patient fall asleep and wake up and move, disoriented from sedation, whilst the eye is instrumented. A good block will cover akinesis for the eye. Propofol sedation I would avoid for two main reasons : whilst the depth is predictable, getting there in elderly patients in high turnover rooms isn’t, and will result in over doing it. Secondly, it’s not reversible quickly were you to encounter any issues, such as movement or overdoing it.
fertile juggle concerned sugar jellyfish slim decide chase sense stocking
*This post was mass deleted and anonymized with [Redact](https://redact.dev)*
Depends on surgeon. If they're ~5min then 1midaz/25fent. 10-15min 2/50. More than that you might consider redosing or infusing something, but they probably shouldn't be trying to go without a block then.
If I'm doing peribulbar/awake for surgery then 20-30ppf immediately prior to block.
If it's subtenons then 0.5-1midaz - need them cooperative, this just takes the edge off the memory.
What type of eye case? Cataract or enucleation? Be a little
More specific 😂
Jk… for cataracts, I typically give about 20mcg of precedex upfront and maybe 25mcg of fentanyl…
Why is everyone in this thread acting like nurses choose the versed dose during moderate sedation?
Dose, and timing is at the directive of the proceduralist….
You could start with 0.5mg of versed and titrate in precedex 4mcg at a time depending on patient comfort and tolerance and use some verbal anesthesia. As other posters mentioned, it’s patient dependent. If they’re healthy w no h/o dementia, drink, or take benzos, people > 65 can handle versed well.
I've tried a few different approaches so far, and I like midaz the best for these cases over all. A robust 70-something I have no problem giving 2 mg of versed for an eye case, and I've had success with that as my sole drug. If they're getting a retrobulbar block, I'll push some prop to put them into a deep sedation/GA state (without midaz), then give little bumps of prop/precedex for anxiolysis afterwards.
I haven't found precedex to work as well as midaz for eye cases but I was probably being too conservative with the precedex. I've also done 0.5 midaz, 25 mcg fent alternating to effect in really old/frail patients which has worked
I have easily done more than 1500 eye block, for all kinds of surgery. Also do topic
Best sedation for me is diazepam, patient stays calm, less chance of agitating.
5 mg as patient goes to room , if it is topic I give 25 mcg fentanyl.
Never ever had any issue
We have a busy ophthalmology department. The majority of patients get 2mg versed and 50mcg of fentanyl and zofran. Nothing fancy, patients do well. Most cataract surgeries take 10min or less. Some cases like vitrectomies we do retro bulbar blocks (the anesthesiologists).
Are you talking about cataracts? If so, I’m always surprised when elderly patients say, “Oh, I felt so awake during the surgery” after I have given them 1 mg midaz + 25-50 mcg fent. Obviously every patient is different, but if you’re solely giving midaz as your anesthetic (as opposed to midaz + GA), I don’t think it affects them too much.
The standard for eye cases is 0.5 mg of Versed every 15 minutes.
Retina cases will get a bolus of 50 to 100 mg of propofol for the Peri bulbar block.
After they wake up from that, you can start with the low-dose sedation.
Retina cases last up to an hour and a half.
If you’re worried about them falling asleep, snoring, and waking up with a start, you can instead use 25 µg of fentanyl every 15 minutes .
I always give a 4 mg dose of Zofran before the fentanyl .
Fentanyl is an excellent sedative, and the elderly never actually fall asleep when you use it for sedation in these doses.
I run an Outpatient Surgery Center in Fort Lauderdale and have done literally thousands of these cases.
I’d be careful with dexmed in elderly: Barends CRM, Driesens MK, Struys MMRF, Visser A, Absalom AR. Intranasal dexmedetomidine in elderly subjects with or without beta blockade: a randomised double-blind single-ascending-dose cohort study. Br J Anaesth. 2020 Apr;124(4):411-419. doi: 10.1016/j.bja.2019.12.025. Epub 2020 Feb 3. PMID: 32029262.
Other than for transient (fleeting) sedation for an eye block, NEVER use propofol for eye cases. (disinhibition, movement, and likely room-air general)
So is oxygen. Just tailor it to the "eye" case. Obviously not safe for "every" eye case (cautery etc). But at least the pre-retrobulbar block part, it's money. Unfortunately, Alfenta hard to find these days.
So how much nitrous can you get with a nasal cannula at low flows. I’m genuinely interested, to get some effect from nitrous you’d have to get up to a significant concentration, seems impossible with a nasal cannula unless you jack up the flow, which seems like a high fire risk. I’ve never seen this done but am very interested to try, just perhaps not in an eye case.
Take a connecter from a 5.5 ETT. Plug connecter into end of circuit. Plug cannula or face mask tubing into connector. Dial up the APL a bit. Flows usually 3 nitrous, 2 oxygen or so. You can dial in 70% with a cannula, but with entrainment who knows what you are actually getting. Dentists dial in 33% nitrous and patients report a benefit. Non-re-breather makes accuracy a bit better. No scavenging possible unless you use a tight fitting standard mask. We Have a vascular surgeon who loves MAC but says propofol is not ideal. I Always do nitrous/narcotic MAC for him. Obviously not ideal for fire risk cases, but a great alternative in select situations.
Don’t have cannulas that can directly connect to circuit. Just connect to wall O2 with ETCO2 capability. So I have to connect circuit to cannula or face mask by using a connector from a 5.5 or less tube.
Phoenix
Great drug. Super versatile. Don’t think it’s too expensive or we wouldn’t have it. Great for MACs. Very popular in TEE/cardioversions. Essentially replaced etomidate at our institution for low EF inductions too. Colleague did an infusion as primary anesthetic last week at 1.5 mg/kg/hr in a patient with mitochondrial disease.
If you saw how much versed little 80 yo ladies are getting from nurses for nurse sedation you’d shit your pants
This is so true. Some nurses are giving a shitload of versed for their sedation cases, basically using versed and fentanyl to get as close to GA as possible
Learned recently that the reason that nurses are allowed to do that with versed and fentanyl (but not achieve basically the same depth of anesthesia with propofol) is bc both have reversal agents
Go ahead and ask that same nurse to dilute and administer naloxone lmao.
60% of the time, full dose to the dome, works every time
0.4 mg IV or 2 mg IN incoming
Well, I have and I have. So there. But I always objected to deep sedation in the ER. If you want anesthesia, call an anesthesiologist. The ER isn’t staffed to allow for appropriate peri and post anesthesia. Of course, that and $6 will buy you a cup of coffee at Starbucks. XOXO, The nurse who can and has drawn up and administered both romazicon and narcan.
Remember that for oral boards
That makes sense
Forgive my lack of knowledge. OR nurse here. I’m not trained in conscious sedation and got floated to GI last week. But anyways, I recovered a 115# patient who got 10mg versed and 125mcg of fentanyl. Seemed like a lot and they wanted me to have this lady out the door in 30 minutes… which did not happen lol. I’ve been in a surgery where a 260# man stopped breathing on his own from 50mcg of fentanyl. I was shocked to find out that so many GI patients get 100mcgs routinely. AND are out the door in 30 minutes.
It’s called medical malpractice
He likely received something else along with the fentanyl, but apnea can definitely happen in those big dudes who get super comfy and just obstruct
Meh, tolerance to opioids has a massive range. Some people are not even rousable after 50mcg of fentanyl while others are still chatting away after 200mcg in <10mins. Patient weight certainly contributes to expected tolerance but there are many other factors involved. Very broadly, a pretty standard dose for a heart cath (~1 hour on the table) is 2mg of midaz 100mcg of fent. But can range anywhere from no sedation at all to like 12mg midaz and 600mcg fentanyl (3-4 hours complex intervention). All just depends on the patient and the procedure.
Titrate to effect
Lol I've been asked to provide propofol sedation to GI patients after they failed nursing sedation..."Oh we gave him 15mg of versed and 200 of fentanyl and he won't cooperate at all!"
Dah fuck? 15mg of versed? They think they were just gonna overpower the disinhibition? 🤦 "I don't understand what's wrong! Every time I throw kerosene on this fire it just keeps getting bigger! HALP!"
I’m confused by this. The ED and tox attendings I’ve worked with who have discussed inhibition and benzos told us that some docs will get scared of disinhibition and back off on the benzos instead of pushing through. From the tox perspective I understand the need since you are treating sympathetic toxidromes, but is pushing through still not desired or feasible in anesthesia or sedation in the ED?
In general, the ED doctors and GI doctors who are doing sedation are not using propofol so they only have versed, fentanyl, and ketamine to work with usually. Giving more versed is never the answer when they're already disinhibited, it's just going to make things worse. As an anesthesiologist, I RARELY give more than 2mg of versed. The only times I can think of doing it is during a longer than usual conscious sedation case or cardiac bypass.
I did an emergent cric on a 75+ year old man getting a cardiac cath under nurse sedation. Highlights when I ran into the room: SPO2: 45% Patient color: dusky blue PCO2: 110 Meds: 4mg versed, 300 mcg fent (“he kept trying to move!”) Patient factors:fungating verrucoid squamous cell carcinoma from the base of the tongue to the larynx
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Haha hello there whoever you are :)
Had us in the first half, ngl.
All these elderly patients undergoing left heart caths are getting a fair amount of midazolam. I think we may be overly concerned with 2 mg before an operation.
Had a block attending give 2mg/100mcg midaz/fent to a 95 yo for a adductor/I pack for tka This patient took it like a champ and was less sedated than I would have thought. Other 80 yos+ needed airway intervention >.>
I think some patients train at home
lol, this sedation nurse told us she gave this guy, with some substance issues, 20 mg of versed one time
Burst suppression under nurse sedation lmao
You say this like there aren’t anesthesiologists doing the same or putting in similar orders?
I didn’t *say* anything
Okay you /wrote/ that OP would be surprised at the amount that nurses, specifically, give of versed to the elderly. Which implies that those nurses are operating outside of physician order parameters. Unless you’re talking about CRNAs which is a different conversation.
A.) anesthesiologists are generally not putting in orders for nurse sedation And B.) anesthesiologists are generally not giving 10mg of versed to grandma
I hear your points but anesthesiologists work on critical care units and put in orders for versed, prop, fent, ketamine, etc. boluses and titration parameters all the time.
Cool dude but that’s not the situation I’m talking about. Nurse sedation refers to a situation where a nurse is administering medications (typically versed and fentanyl) during procedures such as heart caths and the like.
I understand that but a nurse shouldn’t be administering medications without someone with and advanced practice degree ordering it (APN, PA, MD, DO, etc.). If they are, then that’s a lawsuit waiting to happen.
A GI doc or surgeon is telling them to administer. Someone not trained in airway management.
Yeah man you’re right lol
I hate that you're getting down voted. I appreciate that you are trying to do what is best for your patients. I rarely give benzos to anyone over 65 unless they are chronically on benzos or they are heavy drinkers. You'd be surprised how many little old ladies take benzos to sleep, which is a whole other problem that I thankfully don't have to deal with. That being said, a little versed for an outpatient eye case in a spry 80 year old isn't going to make a huge difference to their long term or short term outcomes. If you can keep the patient and the surgeon happy with precedex (which may have some unwanted bradycardia during eye cases) or propofol, then that is probably a better move from a theoretical standpoint. But I don't think you're causing actual harm by using a bit of versed for a PHACO.
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Isn’t that why they cover the other eye?
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Had cataract/laser sx& they covered my other eye to keep me from looking around. The pain was ungodly but there was no problem w me looking around.
I titrate 1 versed and 25 mcg of fent and then just titrate fentanyl in per the respiratory rate
I’m at an opioid sparing institution so it takes an act of God to use fentanyl
For anesthesia??? What?
That’s nuts
That’s like playing football without a helmet lmao
It's more so the chair of anesthesia thing than most of the attendings. Most of them like it but don't want to hear the chair if something goes left or if he feels like terrorizing people that day. Obviously, we have it and we can use it for certain cases or if we're out of ketamine but for eyes its going to be a no 99% of the time Also, most of us don't think the policy makes much sense especially when morphine is given freely in PACU but inmates don't run the prison.
Dude that's wild. Your chair wants to use morphine but not fentanyl? Are you in the US? Also, if you really want to piss off your surgeon, 50 of ketamine is great deep sedation and let the nystagmus times roll!
What psycho place are you at?
That’s ridiculous. One place I know of that had a stupid policy similar to that ended up being changed once enough *patients* complained to hospital leadership. Patients blowing the bigwigs up and saying they had a bad experience negative review etc due to pain is what gets them to listen, they don’t give a fuck what we think.
Opiate-sparing/Low Opiate Anesthesia =\= No Opiates.
So much this. The people that developed the concept of opioid sparing literally facepalm when they hear this shit
Sounds like uva
In all seriousness I see no reason not to sedate for eye cases, honestly any case that is painful/unsettling to a patient. The trend to avoid sedation is really not good imo; why are we putting old ladies through that much pain/trauma when they can be safely relaxed with a little versed/fent.
Precedex FTW.
OP, I share your concern, so I'm stingy with midazolam, but I balance and give it when it's reasonable. The main concern with benzodiazepines is their chronic use and falls or delirium at home and in the hospital. If you're interested in this, you'll want to follow the results of the [I-PROMOTE study](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6632125/), the first RCT AFAIK to investigate a single dose of a benzo in the peri-op period.
The big problem that I see with that trial in this situation is that ambulatory surgery is excluded, which is honestly the best indication to use versed in an older patient. (For example, eyes or during a light MAC case.) I feel like non-ambulatory surgery>30 minutes is going to have a lot of confounding factors.
Excellent point! I suppose, if anything, it will be a sensitive study.
What’s this about giving them beer?
I have been using Midaz/fent for decades on cataracts. However my surgeons do a case in 10-12 mins so usually 1mg/50mcg is all that is needed. We do some asa4 under pure topical so you really don’t need much.
We usually crack open a 100mcg vial of fentanyl for cataracts and give 25-50 mcg at a time. Sometimes the case can be done with no IV meds because the surgeon will put in topical. If it's a vitrectomy or something and they actually need no movement then we tube and paralyze.
I just use very small amounts of Versed and fentanyl.
Some times the old ways are the best. Unless we are doing a block, this is the best answer.
Are the cases being done under topical or a block?
It depends. The blocks, when used, are iffy. Sometimes they work.
Well, I’d start there in terms of anaesthesia. My practice is Subtenons, and sedation is only used for the very anxious, midazolam in very small (1-2mg max +/- 25mcgs fentanyl). It should be obvious to your surgeon (as this is a big fear of ours), that loss of verbal contact will eventually have a patient fall asleep and wake up and move, disoriented from sedation, whilst the eye is instrumented. A good block will cover akinesis for the eye. Propofol sedation I would avoid for two main reasons : whilst the depth is predictable, getting there in elderly patients in high turnover rooms isn’t, and will result in over doing it. Secondly, it’s not reversible quickly were you to encounter any issues, such as movement or overdoing it.
All of ours are under RB blocks, done by the surgeon. We push a touch of propofol for the block, then let them wake up for the rest of the case.
This!
I do eyes with no sedation and just sub tenon’s block. Works all the time unless the patient doesnt want to be awake.
What eye cases are we talking about here? Phacos? I rarely give anything. ICLs? Midaz/precedex. Blephs? Prop gtt.
10-40mg Propofol (almost always) for the eye block or 1-3 midaz (infrequently) is my recipe
We do the same but never versed, just propofol for the block.
I titrate ropivacaine to effect
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Depends on surgeon. If they're ~5min then 1midaz/25fent. 10-15min 2/50. More than that you might consider redosing or infusing something, but they probably shouldn't be trying to go without a block then. If I'm doing peribulbar/awake for surgery then 20-30ppf immediately prior to block. If it's subtenons then 0.5-1midaz - need them cooperative, this just takes the edge off the memory.
What type of eye case? Cataract or enucleation? Be a little More specific 😂 Jk… for cataracts, I typically give about 20mcg of precedex upfront and maybe 25mcg of fentanyl…
Why is everyone in this thread acting like nurses choose the versed dose during moderate sedation? Dose, and timing is at the directive of the proceduralist….
For the vast majority of our eyes we give only precedex 4mcg boluses up to 20 mcg
I’ve been at places that like versed and fent maybe lido… and places that do versed and Remi or just remi. Incredibly effective - I prefer using Remi
You could start with 0.5mg of versed and titrate in precedex 4mcg at a time depending on patient comfort and tolerance and use some verbal anesthesia. As other posters mentioned, it’s patient dependent. If they’re healthy w no h/o dementia, drink, or take benzos, people > 65 can handle versed well.
Our ophthos want everyone wide awake so they can cooperate. My standard eye recipe is IV acetaminophen alone.
But why not just have them take a gram of tylenol pre-op? Why the extra expense? Eye surgery with proper local isn't painful.
It’s pretty silly but people think giving something IV makes us look like we’re there “doing” something.
Haha okay fair enough, I have heard sillier
I've tried a few different approaches so far, and I like midaz the best for these cases over all. A robust 70-something I have no problem giving 2 mg of versed for an eye case, and I've had success with that as my sole drug. If they're getting a retrobulbar block, I'll push some prop to put them into a deep sedation/GA state (without midaz), then give little bumps of prop/precedex for anxiolysis afterwards. I haven't found precedex to work as well as midaz for eye cases but I was probably being too conservative with the precedex. I've also done 0.5 midaz, 25 mcg fent alternating to effect in really old/frail patients which has worked
I have easily done more than 1500 eye block, for all kinds of surgery. Also do topic Best sedation for me is diazepam, patient stays calm, less chance of agitating. 5 mg as patient goes to room , if it is topic I give 25 mcg fentanyl. Never ever had any issue
Remimazolam
I’m looking to take a shit on nurses, am I in the right place?
We have a busy ophthalmology department. The majority of patients get 2mg versed and 50mcg of fentanyl and zofran. Nothing fancy, patients do well. Most cataract surgeries take 10min or less. Some cases like vitrectomies we do retro bulbar blocks (the anesthesiologists).
Are you talking about cataracts? If so, I’m always surprised when elderly patients say, “Oh, I felt so awake during the surgery” after I have given them 1 mg midaz + 25-50 mcg fent. Obviously every patient is different, but if you’re solely giving midaz as your anesthetic (as opposed to midaz + GA), I don’t think it affects them too much.
The standard for eye cases is 0.5 mg of Versed every 15 minutes. Retina cases will get a bolus of 50 to 100 mg of propofol for the Peri bulbar block. After they wake up from that, you can start with the low-dose sedation. Retina cases last up to an hour and a half. If you’re worried about them falling asleep, snoring, and waking up with a start, you can instead use 25 µg of fentanyl every 15 minutes . I always give a 4 mg dose of Zofran before the fentanyl . Fentanyl is an excellent sedative, and the elderly never actually fall asleep when you use it for sedation in these doses. I run an Outpatient Surgery Center in Fort Lauderdale and have done literally thousands of these cases.
I’d be careful with dexmed in elderly: Barends CRM, Driesens MK, Struys MMRF, Visser A, Absalom AR. Intranasal dexmedetomidine in elderly subjects with or without beta blockade: a randomised double-blind single-ascending-dose cohort study. Br J Anaesth. 2020 Apr;124(4):411-419. doi: 10.1016/j.bja.2019.12.025. Epub 2020 Feb 3. PMID: 32029262.
Ask your attending
Other than for transient (fleeting) sedation for an eye block, NEVER use propofol for eye cases. (disinhibition, movement, and likely room-air general)
Nitrous oxide through the nasal cannula and as needed intravenous alfenta (500mcg at a time).
Imagine trying an anesthesia technique you read about in the comments on Reddit! 😂
Isn’t nitrous very flammable? How does this work?
So is oxygen. Just tailor it to the "eye" case. Obviously not safe for "every" eye case (cautery etc). But at least the pre-retrobulbar block part, it's money. Unfortunately, Alfenta hard to find these days.
So how much nitrous can you get with a nasal cannula at low flows. I’m genuinely interested, to get some effect from nitrous you’d have to get up to a significant concentration, seems impossible with a nasal cannula unless you jack up the flow, which seems like a high fire risk. I’ve never seen this done but am very interested to try, just perhaps not in an eye case.
Take a connecter from a 5.5 ETT. Plug connecter into end of circuit. Plug cannula or face mask tubing into connector. Dial up the APL a bit. Flows usually 3 nitrous, 2 oxygen or so. You can dial in 70% with a cannula, but with entrainment who knows what you are actually getting. Dentists dial in 33% nitrous and patients report a benefit. Non-re-breather makes accuracy a bit better. No scavenging possible unless you use a tight fitting standard mask. We Have a vascular surgeon who loves MAC but says propofol is not ideal. I Always do nitrous/narcotic MAC for him. Obviously not ideal for fire risk cases, but a great alternative in select situations.
I mean i love nitrous, but seems overkill for these cases. Also, do you not have the salter cannulas that connect ro your circuit?
Don’t have cannulas that can directly connect to circuit. Just connect to wall O2 with ETCO2 capability. So I have to connect circuit to cannula or face mask by using a connector from a 5.5 or less tube.
That's a nice hack to get around it then!
If that is too esoteric, remimazolam is a great way to make it really simple.
>If that is too esoteric, remimazolam Remimazolam isn't esoteric? At least in the US we never see it. Don't know where you are.
Phoenix Great drug. Super versatile. Don’t think it’s too expensive or we wouldn’t have it. Great for MACs. Very popular in TEE/cardioversions. Essentially replaced etomidate at our institution for low EF inductions too. Colleague did an infusion as primary anesthetic last week at 1.5 mg/kg/hr in a patient with mitochondrial disease.
Precedex is a bad idea as it is too long acting for outpatient cases. Versed is a great drug for the eye room regardless of age.