First I'll say I'm 7 weeks into clinicals, so I have a lot to learn...

Today I had a 20 yr pt for breast reduction, BMI 41 but otherwise "healthy", hx PONV, starting BP 120/81, HR 73. Intubated on sux, fent 150 mcg, prop 200 mg then started sevo. ET 2.7% on incision, no movement or incr in HR or BP. Decr ET to 2.5% d/t dec BP upper 80s. 15 min later surgeon says pt moving, HR incr 100, ET 2.5%, turned off vent, fent 50 mcg, bagged pt for several breaths (carefully so she didn't cough more) w/ incr flows at 6 L, ET now 2.9%. Of course, BP drops to 80 SBP, so I decr the gas to ET 2.7%, & fluids open, BP 90s, HR 60s. 30 min into case fent 50 mcg for HR 90s, BP 130s. 1 L LR in by now. 45 min into case BP 90s, HR 60s but surgeon says pt moving again, ET 2.7%. I feel like an idiot, but didn't see any signs that the pt was getting light. The surgeon wasn't making new incisions, still removing breast tissue/fat. Should I have had the pt deeper on sevo?(Let me add that the CRNA I was with kept leaving, and was gone at this point.) So I did the same as before--fent 50, sevo to 3%. Drop in BP, HR 50s, treated w/ ephedrine 10 mg rather than decreasing gas. Opened fluids, but pt has no foley so I don't want to give too much. Closely watching to make sure pt won't move again. 30 min later HR goes to 90s, BP 120s, fent 50. 10 min later BP 80s, more ephedrine. (and wondering if I should've given that fentanyl).10 min after that I turn to grab something & pt moved again, HR 100, ET 3%. Totally embarrassed at this point, still no CRNA in room, this time fent 100 mcg, sevo 3.2%. Rest of case goes ok, pt given ofirmev per surgeon & worked in some morphine when pt spont breathing at end of case. Pt extubated & to PACU w/out probs.

Case was 2.5 hrs & I ended up giving 2 L fluids by the end after chasing BP & giving meds, so she urinated on OR table, more embarrassment (how bad does it look when this happens?).

I didn't have a chance to talk to the CRNA about this after the case was over b/c it was my last of the day & he went to another case. I've only had one other pt move, during incision. Many of my cases have required MR (lap cases, robotics) so the pt can't move. I want to learn how to try & avoid this again. Usually I have my pts around 2-2.5% sevo, is this light? It seems like if I have more ET, they don't tolerate it. I don't mind using narcs or upping my ET, but when HR is 60s & BPs 80-90s, they seem like they are ok. I know each pt is different, but how do you know if they are getting light if vitals don't change & pt isn't trying to breathe spontaneously/you are overriding their drive? If HR goes from 60 to 70s but BP stays 90s, do you give fent or wait for more signs of needing it?

Was I wrong to give fent & incr sevo, which dropped pressure, rather than just do one or the other? Should I have gotten out more propofol to have ready after pt moved 1st time? I feel like an idiot & the surgeon probably thinks the same.

Thanks for any thoughts, advice.