1. Vapor: If we can’t live with it, can we live without it? Reid Rubsamen, M.D. Staff Anesthesiologist OR Medical Director John Muir Medical Center Walnut Creek, California

2. Relevant Financial Relationships: None I will be speaking about drugs for the induction and maintenance of anesthesia and about intra-operative awareness monitoring. I paid my own way to this meeting and I am not a paid consultant to any relevant companies.

3. O CF 3 F F F F F O F Sevoflurane F F F Cl O F F Desflurane Isoflurane 3M Dry Cleaning Fluid O CF 3 F

4. Motivation Inhalational anesthetics are basically medical grade organic solvents. New technology makes it possible to reduce or eliminate vapor from anesthetic practice. I have conducted approximately 2000 anesthetics with total intravenous anesthesia (TIVA) without prophylactic use of anti-emetic drugs and without vapor or nitrous oxide. Patients wake up more smoothly compared with my own experience using vapor.

5. Dramatic Short Term Side Effect Reduction With TIVA Very dramatic reduction of post operative nausea/vomiting. Less dysphoria at wake-up. Essential elimination of laryngospasm on emergence.

6. TIVA Can Be Used Widely Oxygen/air/propofol/opiates +/- muscle relaxants. Spontaneous breathing with laryngeal mask airway is not a problem. Need propofol pump and level of consciousness monitoring. Sevoflurane is the preferred induction agent for small children without an IV.

7. Vapor is the Easy Chair Muscle relaxation included. Awareness not a problem. Hypertension “management.” End tidal gas analysis ensures robustness.

8. TIVA Workload is Higher for the Anesthesiologist Awareness risk requires monitoring. Higher doses of muscle relaxant required. Blood pressure management with TIVA is a-la-carte. Psychologically very difficult for anesthesiologists to use no vapor at all.

9. The Future? Short term benefits of eliminating vapor from anesthesia practice are compelling. TIVA can be widely used. Are there long term toxic effects of vapor and/or TIVA on children or adults? Need prospective, controlled TIVA versus vapor clinical trial. Need more technology to make TIVA easier to do.

10. Conclusions TIVA can essentially replace the use of vapor except for the important pediatric application of inhalation induction for which sevoflurane is the preferred drug. The favorable short term side effect profile of TIVA compels me to avoid the use of vapor in my practice where possible.