31 year old female, about 80 kg, 5'7", history of graves disease, presents for bilat. UL retraction repair. no allergies, no daily meds, no history of anesthetic issues. not on any daily meds. she is a physical status one, with no other medical history. the case is to be MAC.

we get in to the room, and surgeon says "she's gonna be tough. these cases are always tough for MAC." well, me being the MAC king, so i like to think, and i said "no problem, i'll get her right for ya!" put her down for the block (local skin, not retrobulbar or the like). case goes about an hour. she was wincing way more than should, even grunting at times.

attached is the anesthesia record to see my progression. throughout the case, there were periods of calm and sleep, but in the end, she was awake and chatting before we even rolled out of the OR.

any suggestions on how to handle these types of cases? what works on top of (or in lieu of) here? i have gotten some suggestions, but would like to hear from the group here.

drugs total for the case:
ketamine 50 mg
fentanyl 100 mcg
propofol 500 mg

local injection (by surgeon):
5 1/2 ml 2% lido with epi and bicarb --> he said it was 2-3 x's what he normally uses.