• must see IVC when using TIVA
• if we lose BIS, then add on VA, or just use VA
• treat bradycardia
  • difficult to ⬆INO to maintain adequate CO
  • give glycopyrrolate 300 mcg
  • this also reduces oral secretions, ⬇need to suction at end of case
• emergence
  • adequate remi so that they are apnoeic, but obey commands (eg. to breathe)
    • this will mean they won't cough
• propofol alone
  • usually not enough for tube tolerance
• alfentanil
  • will usually support spontaneous ventilation
• remifentanil
  • will usually become apnoeic
  • not always needed (eg. in gynae, where propofol is adequate for PONV)
• caution titrating too low
  • patient may cough and aspirate
  • if near end of case, remove eye tapes, and be prepared to remove ETT/LMA quickly, instead of re-deepening
• use entropy
  • allows you to reduce dose, especially if there is burst suppression
• Start P-0.5 as patency check
• NMBA when change in Entropy
• Apnoeic point
  • Use voice only
  • Voice + shake = requires a deeper plane of anaesthesia
• No oxycodone before extubation for ENT
  • It clouds the picture
  • When patient is awake, there is still Remi on board, so minimal risk of hyperalgesia

• Chook's foot = 3 lines
  • Use one for propofol and Remi (3-way tap)
  • One for metaraminol = less dead space
  • One for IVF
• Can attach propofol to proximal port so can see propofol going into vein

• TIVA is a better anaesthetic
• VA when
  • poor IV access (eg. at induction)
  • brittle patient (severe VHD / ⬇EF) = slower induction desirable
  • sick patient / old NOF / trauma / after hours
    • can "set and forget" and focus on other tasks (instead of secure IVC, syringe, awareness)
• VA better at
  • blunting spinal reflexes (prevent patient from moving)
    • when using TIVA, need to use opioids / NMB / N2O to blunt spinal reflexes
    • VA tends to reach spinal cord faster - propofol is slower
    • especially when there is surgical stimulus that is early and painful, eg. burns, pilonidal sinus
    • deep on VA + N2O to prevent movement and LS
    • treat ⬇BP with vasopressor, instead of reducing VA in these cases
• VA more titrable / more control for DECREMENT
  • can wash VA out
  • but can only wait for propofol to redistribute = can lead to very slow wakeups
• TIVA
  • smoother wakeup
  • ⬇PONV
• TIVA + low-dose Sevo
  • backup / insurance (eg. if IVC fails)
  • ⬇movement
  • reduces amount of propofol required
  • MAC aware / amnesia 0.3
• Remi + VA
  • Very titratable

• Schnider
  • Ce (effect site concentration)
  • NB can also use Cp (plasma concentration)
  • Schnider = gives bigger bolus (but overall less)
• Marsh
  • Cp (plasma) only
  • generally a slower rise, so lower risk of apnoea
  • can also adjust slope
  • can have onset to eg. 180 secs for a more gradual effect, so we don't lose airway
  • ?? bigger bolus (despite targeting plasma) and less details to enter
• ok to use Schneider
  • main benefit of Marsh is slower onset

• Schneider model (Ce)

• 4 mcg/mL

• for gastroscopy / colonoscopy

  • Marsh Cpt 3 ug/mL

• Keep TTW (Time To Wake) < 10 mins

• propofol alone 3-6 ug/mL

• propofol + opioid 2.5-4 ug/mL

• EC50 for movement = 6.0 ug/mL

• Propofol + Remi
  • maintenance = 3.0
  • awake Ce 0.8 for R < 10
• less reliable for high BMI
  • can use mL/hr instead
  • or, use the maxiumum settings and titrate to clinical response

Propofol + Remi

• Start R4

• Add P2

• Increase at intubation to R6,P3

• Maintenance, decrease P to 2.2 (don't go below 2) for faster wakeup

  • Increase Remi as required (usually around 7-8)
  • Can add sevo at 0.5% to reduce dose of P+R

• can keep remi going until transfer on bed

• can give oxycodone when sutures being done

• Propofol alone (no fentanyl or midazolam)

  • less apnoea
  • need higher doses
  • maintenance = 4.0

• can also do

  • P 2.0 + Sevo 0.3 for faster wakeup
  • skin P 1.5, R 4.0

Propofol + Remi

• start with Remi
• increase gradually to get a sense of the awake Ce for patient
• low dose Remi will cause euphoria as well
• induction + intubation
  • P 5.0
  • R 5.0
• maintenance
  • P 2.5
  • R 4.0
  • try to reduce propofol to 2.1-2.2

Propofol + Remi

• start with Remi 0 - 2 - 4
• intubation
  • P 6.0
  • R 6.0
• maintenance
  • P 4.0, keep above 3.3
  • R 4-5
• wake up on R 2.0

Propofol + Remi

• anxiolysis / premed P 0.8
• induction P 6.0 + R 6.0
• maintenance P 3.0 + R 5.0
• stay on maintenance, and give vasopressor as required

Propofol + Remi

• induction
  • R 5.0
  • P 2.0
• increase remi to 9.0 for intranasal Ad injection + Q1 min BP

Propofol + Remi

• Give glycopyrrolate to all patients
  • unless existing tachycardia
  • prevents ⬇HR of remi and also ⬇secretions
• Induction
  • P 4.0
  • R 6.0-8.0
• Maintenance
  • P 2.8 (reduce to 2.2 when at skin)
  • R 7.0
• Emergence
  • P 1.0, then off
  • R 6.0
    • aim that they take breathe (only) to command (but NOT spontaneous = won't cough / buck)
    • can stick tongue out = can maintain airway

Propofol + Remi

• Keep propofol low for wake up
  • 2.0 < Ce < 3.0

Propofol + Remi

• R 4.0, P 0.5
• R 4.0, P 5.0 = intubation
• R 4.0, P 2.0 = maintenance
• R 6.0, P 1.5/1.4 = emergence, closing

Propofol + Remi

• R 3.0 P 6.0
• don't go below P 2.5

• kids = 1 mg/kg/hr
• adults = 0.67 mL/kg/hr
• elderly = 0.3-0.5 mL/kg/hr
• get into habit of noting the mL/hr on the TCI at steady state
• also run sevoflurane 0.3 MAC
  • in worse case scenario, patient will be amnesiac

• induction 8.0 (for LMA)
• maintenance 5.0
• patients will always breathe on oxycodone 3 mg

• Sevo off when suturing peritoneum
• Turn propofol off when deep sutures are done

• P-3.0, R-5.0
• P-2.5, R-3.0
• Intubation R-6.0
• Start R-1.0, P-0.1
• Then R-3.0
• If RSI, R-5.0, hand bolus propofol

• P-3.0, R-6.0
• After dural is closed, and NIM stopped, then start winding down
• When P-1.0, start Sevo at 0.5
• And R-3.0

• P-2.8, R-8.0
• Wean down to P-1.2, R-8.0
• Once pins out, turn off P
• Wake up on: P-0.8, R-4.0

• P-2.0 to 3.0
• If needing above 3.0, add another agent
• use low-dose VA = 0.2 MAC

• At end, P down, R up
• Then turn vent off, they will breathe on command, then extubate
• SGX at last moment

• P-4.0 R-4.0 to start
• After intubation, P-3.0 R-3.0

• P-1.0
• Remi to nystagmus
• P to tip over
• ⬆metaraminol for BP

• Hyoscine + Ketamine + Clonidine
• Start P-4.0, R-4.0
• Maintainance P-3.0, R-3.0

• P-3, R-4
• P-1.5, R-6 maintenance
• P-0, R-6 extubation = patient will obey commands

• Main anesthetic = Propofol + Fentanyl
• Remi is "icing on top" and BP control
• P-2.3
• D-0.2-0.3 mcg/kg/hr
• R-3.0-3.5
• F 5 mcg/kg at induction, then 1 mcg/kg/hr thereafter

• R-3.0 = anaesthesia
• R-6.0 = Normal surgical stimulus
• R-9.0 = Extreme stimulus, eg. laryngoscopy
• Start Remi at 2, then 4, then 6
• Test bolus metaraminol 0.3 mL to gauge effect, NB dead space is also 0.3 mL
• P-4.0 for induction
• Then before DL, R-9.0, P-6.0
• Then turn down, R-2.0, P-3.0

• Use remi as the anaesthetic to ge the propofol low
• P-2.5, R-6.0, metaraminol to enable the higher remi
• At end, R-8.0 and P-1.0-2.0
• Then SGX

• Aim for P-2.5
  • Can use Sevo achieve adequate depth if entropy indicates
  • Avoid higher levels for slow wake up
• R-6.0
  • Minimum
  • To assist immobility, especially if no NMBA used

• Start R-2.0

• Then Ps-1.0

• Increment both propofol and remi to find apnoea point (to simulate actual emergence where there is both propofol and remi)

• P-1.0, R-4.0

• P-1.3, R-5.0

• P-1.5, R-6.0

  • This is usually the apnoeic point
  • Check with eyes open to VOICE (not touch)
  • Eyes will have horizontal nystagmus

• Then P-4.5, then P-2.4

• And R-12 (which is double 6.0), then back to 9.0 (which is 50% less)

• Maintenance P-2.4, R-9.0

• Adjustments = P-0.1 down, R-0.5 up

• Rough ratio 1:4

• Wind Propofol down to 1.8 at end of case, and go up on Remi

• For NMBA-free intubation

  • Then P-12, Metaraminol 15
  • Wait for flow rate to be 0
  • Then back to P-6.0
  • Then R-20
  • Then back to maintenance

• add alfentanil to propofol syringe and run propofol TCI

• alfentanil 20 mcg/mL = 1 mg in 50 mL syringe

• Method

  • Good for D+C and minor procedures
  • P-6.0
  • A-60 ⮕ 40
  • will SV on alfentanil (unlike remi)

• Maitre model

  • Ce 60 for induction

• Scott model

  • requires higher levels, eg. 100

• Minto model (Ce)

• concentration

  • 2 mg in 50 mL NS = 40 mcg/mL

• ED95 = 2.5 ng/mL

• maintenance = 4 ng/mL

• if bradycardic and hypotensive

  • reduce dose of remi
  • give ephedrine (beware worsening bradyC with metaraminol)

• keep remi going at end of case

  • they don't need to be SV
  • just eyes open (ie. awake)
  • the remi will wear off very quickly

• keep rate < 0.2 mcg/kg/hr to avoid hyperalgesia

• Fentanyl equivalence ~ 50x

• R 10.0 = Fentanyl 500

• R 5 = Fentanyl 250

• R 2.0 = Fentanyl 100

• R 1.0 = Fentanyl 50

• PR5 = Remifentanil 5 mcg/mL
  • 20 mL syringe = 100 mcg Remi
  • better for SV
• PR10 = Remifentanil 10 mcg/mL
  • 20 mL syringe = 200 mcg Remi

• Eleveld 3.0, R-4.0
• Extubation P-2.0, R-6.0

• SBP 100 if medically stable

• not very stimulating
• LA infiltration by surgeons
• give 0.5 mg/kg fentanyl at end ~ 50 mcg

• start Remi at 4 ng/mL when patient gets in
• at induction, R 8 and Propofol 4
• waiting for surgery, R 6, P 3
• at simulating parts (eg. insertion of gag), increase Remi
• go higher on Remi for increased depth without prolonging wake up too much

ATOTW Tutorial 2016: https://www.wfsahq.org/components/com_virtual_library/media/e2236a3a7c77c47eb882f8342ab61bc2-342-Remifentanil-.pdf