March FY23

[kristenhorsman]

I have chosen an article for March regarding the waste of propofol in the OR. Please reference the email for the article PDF.

Please answer the following two questions:

1. How often do you use propofol for maintenance in your general anesthetic- rarely, sometimes, often? Why?
2. What is your opinion of implementing a propofol preparation tool similar to the one that was utilized in the article?

[kty67]

Katya
1. I use propofol a lot. I like to use drip 50 mcg/kg/min in addition to 0.5 MAC inhalation agent for general anesthesia as well for MAC cases. Wake up with propofol is much nicer and patients are happier.
2. I usually try to guess how much I needed for cases. If patient is small size for colonoscopy or short procedure i use 30-50 ml. For longer procedures i can use bigger bottles. I don’t like to draw it for multiple patients and fill syringes as I needed. I try not to waist a lot.

[sjsimmons]

1. Where I trained as an SRNA, most providers performed their general anesthetic with either propofol or an inhalation agent, not both. At Johns Hopkins, it seems more common that providers will use both to maintain their anesthetic. Therefore, I tend to use propofol more frequently in my practice, even if only to provide half of the anesthetic, especially in the outpatient surgery center. I agree with the previous post that propofol seems to smooth emergence. I have also noticed that when using 50-75 mcg/kg/min of propofol + 0.5 MAC inhalation agent, patients tend to have a more predictable emergence (possibly because the patient is receiving less of each agent).

2. As a newer CRNA, I can relate to the issue of propofol waste in the OR. It is difficult to accurately estimate the amount of propofol needed for a case due to various factors (patient weight, duration of the procedure, vial sizes, tubing types). I believe that a propofol preparation tool would be beneficial in guiding for newer CRNAs and SRNAs with their selection of the number and size of propofol vials needed for anesthetic delivery. Although this study only found a yearly savings of about $400, it found a 60% reduction in propofol waste in surgery centers, which may be beneficial in helping prevent future drug shortages. I would be interested to see how the implementation of preparation tools for other commonly used drugs may affect drug waste and shortages.

[Anne McNulty CRNA]

(1) I use propofol for 90% of my cases. I do believe that propofol is a drug with excessive waste, If you don't have an additional syringe drawn up and ready, the attending thinks you are not prepared. At JHU , my most common cause of propofol waste is due to cases not being correctly posted. Most cases are over posted. At other hospitals that I have worked, Syringe pumps other than Alaris were available for use. There was much less propofol waste , as you could use 10cc. 20cc or 50 ccs syringes. (2) The propofol preparation tool that these authors devised is extreme micro-management. They must have the same surgeons and ASA 1 cases. I am a long provider . It is my observation that the does of propofol to render a patient unconscious and ready for intubation is much higher than it was 30 years ago. If you are doing a sedation case, the dose may be less if you are using Midazolam, Fentanyl, Precedex. I do not like attending micro-management for sedation cases, The customized tool that the authors used was not original. The sample size was very small. The median waste was 27 ml. Potential yearly saving of $15K. Who gets the savings? The ASA owning the surgi center? This article is an example of CRNA DNP's desperate to publish and a magazine desperate for publications. It is time for the development of a new agent for sedation case and induction of anesthesia for general cases.

[aileenm4]

1. I use Propofol as sole maintenance for my cases in specific cases like teen girls with bad PONV or children who have post op delirium, a good percentage of the time I use Propofol as a lower dose adjunct for certain cases.
@. I think the chart would be helpful to use as cases were similar in time and with surgeons who are timely in their posi=tings. Its interesting that all that was looked at was cost savings to the institution rather than the saving of the water system and landfills of disposal of the wasted drugs. It would have been nice to mention.

[kels]

I often use Propofol as my primary anesthetic on individuals who have a history of severe PONV . I sometimes use Propofol as my primary anesthetic on elderly individuals for who may have a history of dementia. In theory this tool could be helpful but I think I would be very challenging to implement at a facility with so many providers that provide anesthesia in so many different ways

[Wai-Ling Lo]

1. How often do you use propofol for maintenance in your general anesthetic- rarely, sometimes, often? Why?
I use TIVA/propofol for about 80% of my cases. I like pts waking up calm, well rested and not nauseous.

2. What is your opinion of implementing a propofol preparation tool similar to the one that was utilized in the article?
I agree with Anne and Kels that the tool may not be too helpful because of the wide range of patients (from ASA 1 to 4+++) coming for various different procedures makes the prediction of propofol use difficult. 

[Jennifer Hannon]

1. I use propofol a ton, almost every long anesthetic. I like to use drip 75 mcg/kg/min in addition to 0.3-0.4 MAC inhalation agent for general anesthesia as well for MAC cases. Get them back breathing at 50mcg/kg/min of propofol and turn your gas off with low flows and ride the wave down as they are closing. Makes for a smooth wakeup.
2. I think it may be beneficial in the beginning, but like everything in medicine, look at your patient first and individualized care. Another guideline may help intuition, but trust yourself and your artistry with propofol over some chart.

[Amy Swank]

I use Propofol usually as a significant component of my anesthetic plan. With the data that I've been reading about regaring Inhalational Agents and their long-term environmental impact, plus the quicker emergence with TIVA and Propofol, I prefer Propofol leaning plans of care versus IAs. It would be interesting to compare the money saved using TIVA versus Propofol waste. Less PONV, less time in PACU, happier patients, etc.

I agree that the tool is not one that I would encourage implementation of - micro-managing and not someting I would get behind. I try hard to minimize waste of Propofol.