Butorphanol 0.2 mg/kg IV
Cerenia 1 mg/kg IV (diluted 1:3 with 0.9% saline)
Please pre-oxygenate the patient for 5 minutes with a face mask and 100% O2 before intubation.
Propofol 4-6 mg/kg
Please draw up a total of 10 mg/kg propofol as intermittent injections of propofol at 0.5-1 mg/kg IV will be necessary to keep the patient asleep during the bronchoscopy. Ideally, no inhalant gas is used for anesthetic maintenance as this can be detrimental to the staff due to the improper scavenging of fumes. It is a delicate balance of providing enough propofol so the patient tolerates the procedure, but maintains the ability to breathe spontaneously and avoid hypoxemia.
Intubate the patient with a sterile endotracheal tube before performing the bronchoscopy. Provide intermittent positive pressure ventilation (give 6-8 breaths/min with the rebreathing bag) with 100% oxygen (flow rate 1L/min) for 2-3 minutes to adequately oxygenate the patient before the bronchoscopy/BAL. The reason for doing this is to ensure the patient's hemoglobin is adequately oxygenated (SpO2 >95%) and that the patient can tolerate the anesthesia before performing the procedure. If the patient desaturates below 95% and despite positive pressure breaths it continues to fall below 90% then I would consider canceling the procedure as the patient may not fair well during the bronchoscopy/BAL.
After providing intermittent breaths for 3-5 minutes on 100% oxygen, the patient can then be extubated for the bronchoscopy/BAL. Bentley will likely desaturate during the procedure so provide flow-by O2 and re-intubate if the SpO2 drops below 90% and provide intermittent breaths.
Monitoring recommended: SpO2, ECG, capnography, non-invasive blood pressure, temperature. Preferably, this equipment is placed during the preoperative period or after induction.
Fluid therapy: Balanced crystalloid at 3 mls/kg/hr
If Bentley becomes bradycardia from excessive vagal tone from laryngeal stimulation, give atropine 0.01-0.02 mg/kg IV.
Please re-intubate Bentley once the procedure is complete to ensure that he has a secured airway for recovery. 100% O2 and intermittent breaths should be given (as necessary) until he is extubated.
I would keep a pulse oximeter placed on Bentley post-procedure, and provide supplemental oxygen via an oxygen cage at 40% or via face mask at 100%.
No other medications are necessary for recovery.