I am relatively new to the specialty (pre-exams so critiques welcome) but think about this kind of thing loads, currently my practice has been to use ketamine for paradoxical emergence around the time you would probably be starting the des. Then switch off the sevo and start nitrous at low flows so that they equilibrate around 0.6MAC. cruise the end of the procedure post stimulating parts on nitrous low flows with whatever opiates and ket I've got on board.
I've never done it that way but that does sound neat. I hadn't heard of paradoxical emergence before - thanks! When I use nitrous, I tend to start it from the beginning to reduce sevoflurane requirement and hence uptake (in for a penny, in for a pound). In practice I find switching from sevo to propofol produces the best wake up (fairly rapid, much nausea, less fogginess). However, this is more error-prone so the conditions have to be right (visible and reliable IV access, known height and weight for TCI use, processed EEG probe applied, preferably not paralysed). I'm hoping to make a video on this at some point. (N.B. I cannot make any recommendations over RU-vid - above is academic conversation only)
