Hi guys,

One of my main sites has started doing a good number of lap gastric bypasses and sleeves. And, I'm going to be doing a lot of them (probably once a week). At the places where I have trained and done a good number of these cases I had either 1.) desflurane or 2.) precedex. My current site has neither drug (although we do have remi).

So, far I have done 4 or 5 of these cases as a CRNA and the results are "ok" but I'm looking to improve.

Here's a quick summary of the last case I did - lap GBP:

Pt: 40yo 375lbs, not sure what the BMI was, she was pretty short, but not too bad. HTN, DM, but overall pretty healthy. OSA - non-compliant with CPAP

LOS: 4.5hr - these are are all going to be done by new surgeons so this may be a typical surgical time

Anesthestic: (average during maintenance) ET% 1 sevo with a 100mcg/kg/min prop, 10mg of morphine as soon as the patient went to sleep, 200mcg of fent, none in the last 2hrs. Total prop dose was around 2grams.

I woke her up on high flow N20. Pt awake as the drapes comes down, breathing well, tube out. The patient opens her eyes to command but is drowsy. Sat in the PACU is 89%, I place a trumpet, sat up to 94%. Pt remains drowsy, but opens her eyes to command. Breathing 8/min, basically she's fine when she is awake, but when she nods off she obstructs ,and her sat drops.

The PACU nurses are horrified when I suggest she might need CPAP until she wakes up a little more.

So, here's my question, (given that pretty much all of these patients are going to desat if they are sleepy) should I

1.) always place a nasal trumpet postop and plan on cpap

2.) Or is there a way that I can improve my anesthetic to have the patient basically wide awake at the end of these cases? Maybe I should do straight TIVA (prop/remi) but it's going to take a lot of prop.... Maybe I should skip the morphine, although I feel like most of the post-op drowsiness is from residual sevo?

I almost always use N20, but for these cases I've been hesitant away (until the end) anyone using N20 the whole case?