Bucking on extubation-is it that bad?

[soorg]

Has anyone ever seen stitches come undone when pt bucks on extubation? I never have, although I guess it COULD happen.

Similarly, I sometimes work with an inner ear surgeon who goes nuts with any bucking, but I've never heard of or read any case reports that document any damage to any inner ear repair from bucking. Is he just being a douche?

---

Members don't see this ad.

 

[narcusprince]

Use Remi make it look slick everytime. Move along......

 

[soorg]

What dose?

 

[Urzuz]

Using remifentanil simply as a means to prevent bucking is unnecessary in my opinion. I occasionally use remifentanil for neurosurgical cases which is a unique population where bucking can oftentimes be dangerous, so it works out that I sometimes do use it to prevent bucking. But to use it solely to prevent bucking and nothing else seems like overkill to me.

If it is a situation in which bucking won't necessarily be detrimental to the surgery or the patient, but you would still like to avoid it, I would topicalize the cords with lidocaine (may not be useful for longer cases), give IV lidocaine as the gas is coming off (I usually use something like 50 mg), and make sure the patient's pain is well controlled with your opioid of choice.

If bucking means a ruined surgery or actually puts the patient in danger, and the patient is not a challenging airway, consider extubating the patient deep and staying with the patient in the room until they are safe for the recovery room.

 

[pgg]

I agree with Urzuz. If bucking matters, extubate deep.

An awake extubation doesn't have to be an eyes-open, responding patient. Some of the worst wakeups happen when people just wait 30 seconds or a minute longer than they have to before pulling the tube. Past stage 2, get the plastic out of the trachea.

Adequate analgesia, with whatever drug, is important. You can use remi, I guess. I don't think it matters which blue syringe gets used.

Also, be sure the endotracheal tube isn't too deep. If it's near or touching the carina, bucking will be an endless feedback loop of violent coughing. I think this, and waiting too long, are probably responsible for most really bad bucking.

 

[caligas]

the sooner you extubate the smoother you look, but the greater chance of airway problems. Everything is a balence of risks and goals.

 

[Ignatius J]

My response to requests for a non-coughing extubation is always "What are you going to do when the patient sneezes or coughs in PACU?"

Anyone who tells you they have 100% figured out how to extubate without bucking is lying through his teeth. I do my best, have gotten decent at it, but at the end of the day sometimes the patient coughs on the tube. It happens.

 

[pgg]

the sooner you extubate the smoother you look, but the greater chance of airway problems. Everything is a balence of risks and goals.

True, you just have to be vigilant and ready to handle problems.

I extubated a guy a little early a couple weeks ago, got a little breath holding and laryngospasm for my trouble, but 20 of succ and a couple minutes of mask ventilation fixed that. The larger tragedy was that I was resident-less for the day and had no one to blame for my clumsiness ...

 

[Crash cart]

If I have a case / surgeon that makes bucking a problem I will:

1) Extubate deep. In most cases, this is a safe practice -- it's really no riskier from an aspiration standpoint than sedating a patient with propofol for a TKA. Both patient's airway reflexes are suppressed. Obviously sometimes you can't. In that case...
2) I use 4% lido on the cords / trachea (but this really only helps if it's a short case). if it's a longer case I will...
3) Either bolus patient with 50 - 100 mg of 2% lidocaine as I'm diling back the vapor or just a run a lidocaine infusion throughout the case. In addition I will use N20 to wake up the patient at concentrations of > 50%. I turn it on as I turn off the vapor. So what if the sats temporarily dive into the 80s? Also, the risk of PONV from 10 minutes of N20 is negligible and nothing that 5 mg of phenergan can't handle.

These things only work if they've got enough narcs on board and the tube isn't on the carina.

That all being said, Ignatius's point is very true:

Anyone who tells you they have 100% figured out how to extubate without bucking is lying through his teeth. I do my best, have gotten decent at it, but at the end of the day sometimes the patient coughs on the tube. It happens.

After 10 years I am perpetually humbled by this job. Usually just when I think I have it all figured out.

 

[cchoukal]

I've wondered about the real physics of bucking, as well. It strikes me that it should be difficult for a patient to develop elevated intra-abdominal pressure (such that would burst stitches on a hernia, where this often comes up) with an endotracheal tube in place. Shouldn't it be necessary to have a closed glottis to develop such pressure? The same should theoretically be true for elevated ICP. And yet, the bucking patient often has really engorged EJs and can have a really tense abdomen, suggesting they really are generating pressures. I'm sure someone can educate me.

 

[Urzuz]

I've wondered about the real physics of bucking, as well. It strikes me that it should be difficult for a patient to develop elevated intra-abdominal pressure (such that would burst stitches on a hernia, where this often comes up) with an endotracheal tube in place. Shouldn't it be necessary to have a closed glottis to develop such pressure? The same should theoretically be true for elevated ICP. And yet, the bucking patient often has really engorged EJs and can have a really tense abdomen, suggesting they really are generating pressures. I'm sure someone can educate me.

I don't know if I have ever really thought hard about the pathophysiology of it, but my rudimentary, armchair, undergrad physics understanding is:

Tube irritates pharynx/larynx/trachea/carina -> cough reflex -> diaphragmatic and abdominal muscle contractions -> increased intrathoracic and intraabdominal pressures -> increased pressures get transmitted to head (ICP/eye/venous vasculature), abdomen (including all stitches, etc).

Normally when someone coughs, the force of muscle contraction changes into kinetic energy via air movement out of our mouths. Of course, some of this energy is also dissipated through all adjacent tissues. But, less energy gets dissipated into adjacent tissues when our glottis is open versus when it is closed. When the cuff is up on the endotracheal tube, it is effectively like having a "closed glottis" where air cannot escape from around the tube, leading to all the pressure generated by the musculature being transmitted to the adjacent tissues. Putting the cuff down on the tube may theoretically help a little, but still a significant amount of energy is being transmitted into adjacent tissues/vasculature.

Let me reiterate, I am not a physicist by any stretch of the imagination, but this is my best guess? I'm sure my explanation probably violated all three of Newton's laws somewhere along the way, haha...

 

[Random Anesthesiologist]

Nm

 

[narcusprince]

I use remi for bariatric surgery, some cranies, and many ent middle ear procedures. When I do use it I try to get as much gas off as possible then turn of the remi usually at 0.1 or 0.2. I like the wakeups. I used to extubate a lot of patients deep but also at my previous gig I recovered the patients. You can still extubate deep when the surgeons are closing port sites and placing dressings. I have yet to have a significant laryngospasm in the last 3 years requiring succinycholine use. Now almost exclusively extubate wide awake and rarely do they buck. Drop the pressure inthe cuff after suctioning while spontaneous breathing. Then once awake pull the tube.

 

[twoliter]

I don't know if I have ever really thought hard about the pathophysiology of it, but my rudimentary, armchair, undergrad physics understanding is:

Tube irritates pharynx/larynx/trachea/carina -> cough reflex -> diaphragmatic and abdominal muscle contractions -> increased intrathoracic and intraabdominal pressures -> increased pressures get transmitted to head (ICP/eye/venous vasculature), abdomen (including all stitches, etc).

Normally when someone coughs, the force of muscle contraction changes into kinetic energy via air movement out of our mouths. Of course, some of this energy is also dissipated through all adjacent tissues. But, less energy gets dissipated into adjacent tissues when our glottis is open versus when it is closed. When the cuff is up on the endotracheal tube, it is effectively like having a "closed glottis" where air cannot escape from around the tube, leading to all the pressure generated by the musculature being transmitted to the adjacent tissues. Putting the cuff down on the tube may theoretically help a little, but still a significant amount of energy is being transmitted into adjacent tissues/vasculature.

Let me reiterate, I am not a physicist by any stretch of the imagination, but this is my best guess? I'm sure my explanation probably violated all three of Newton's laws somewhere along the way, haha...

The cuff up on the ETT shouldn't act like a closed glottis (unless the patient is biting down on the tube, the APL valve is closed, tube kinked, etc.). Otherwise they exhale through the ETT as normal. Am I wrong?

 

[Pooh & Annie]

It is a lot of air at once trying to get through a pretty small cross-section over a decent distance

 

[deleted162650]

It is a lot of air at once trying to get through a pretty small cross-section over a decent distance

Put a 7 ETT in your mouth and blow. Not very restrictive at all. If for some reason you've got < a 6 in then maybe I'll buy that reasoning.

 

[narcusprince]

If a surgeon is worried about bursting stitches and blowing sutures I bet that second bowel movement at night sutures get popped. What about if a patient coughs or god forbid you have to put the patient on incentive spirormetry. Most of the coughing and bucking looks bad but its mostly theatrics. Pull the tube or dont snark your patients down with too much versed. In the real world of anesthesia make it look slick.

 

[criticalelement]

An awake extubation doesn't have to be an eyes-open, responding patient. Some of the worst wakeups happen when people just wait 30 seconds or a minute longer than they have to before pulling the tube. Past stage 2, get the plastic out of the trachea.
.

I don't agree with this. Awake extubation the patient must be awake. What does awake mean? ding ding ding.. eyes open. Moreover, i dont think there is such a thing as waiting too long to pull the tube..

 

[criticalelement]

Anyone who tells you they have 100% figured out how to extubate without bucking is lying through his teeth. I.

Wisdom.

 

[criticalelement]

the sooner you extubate the smoother you look, but the greater chance of airway problems. Everything is a balence of risks and goals.

The residents reading this should be the very least concerned with looking smooth and more concerned with SAFE. because believe me they will extubate someone too early and wish they had not. If you are not sure if patient is awake or not... wait a little longer... still not sure.. wait a little longer... pull it only when it looks so damn ridiculous with the bucking that the patient has to be awake... or when you are sure... Dont pull the tube when you are not sure. because if you arent sure, they aint awake.

 

[Urzuz]

The cuff up on the ETT shouldn't act like a closed glottis (unless the patient is biting down on the tube, the APL valve is closed, tube kinked, etc.). Otherwise they exhale through the ETT as normal. Am I wrong?

Two things:

1) If the patient is still being mechanically ventilated, then all bets are off. If they are coughing you don't know if it's against a closed valve or whatever. Most modern day ventilators are sophisticated enough to detect an "exhalation" as a patient is coughing, but dyssynchrony can still occur which can exacerbate this

2) Even if the patient is on the bag, or disconnect from the ventilator completely, coughing in general (ETT or no ETT) will lead to all the above that I wrote (increased intraabdominal/intrathoracic pressures being transmitted to adjacent tissues). The point I was trying to make is that a closed glottis and/or a closed system exacerbates this transmission of pressure, but having an open glottis doesn't prevent this. As a test, put your hand on your abdomen and give a light cough. You'll feel your abdominal muscles tense up. Now exacerbate that light cough x 100 when you have some foreign object riding in your larynx.

 

[ph8]

The residents reading this should be the very least concerned with looking smooth and more concerned with SAFE. because believe me they will extubate someone too early and wish they had not. If you are not sure if patient is awake or not... wait a little longer... still not sure.. wait a little longer... pull it only when it looks so damn ridiculous with the bucking that the patient has to be awake... or when you are sure... Dont pull the tube when you are not sure. because if you arent sure, they aint awake.

Things I have not regretted.......having an arterial line, wonderfully working 16g PIV's, and waiting an extra 10-30 seconds before extubation. Someone once told me "...when you think you're ready to extubate, wait 10 more seconds, and ask yourself the question again...."

 

[twoliter]

Two things:

1) If the patient is still being mechanically ventilated, then all bets are off. If they are coughing you don't know if it's against a closed valve or whatever. Most modern day ventilators are sophisticated enough to detect an "exhalation" as a patient is coughing, but dyssynchrony can still occur which can exacerbate this

2) Even if the patient is on the bag, or disconnect from the ventilator completely, coughing in general (ETT or no ETT) will lead to all the above that I wrote (increased intraabdominal/intrathoracic pressures being transmitted to adjacent tissues). The point I was trying to make is that a closed glottis and/or a closed system exacerbates this transmission of pressure, but having an open glottis doesn't prevent this. As a test, put your hand on your abdomen and give a light cough. You'll feel your abdominal muscles tense up. Now exacerbate that light cough x 100 when you have some foreign object riding in your larynx.

1) I'll give you that if they are still being mechanically ventilated, there could be dyssynchrony which would mimic (in regards to bucking) a closed epiglottis. I wasn't thinking about the patient still being on the ventilator, more along the lines of spontaneous ventilation (or at least an open APL in manual mode). 1 point Urzuz, 0.5 point me.

2) I agree that you can build up some intrabdominal pressure by contracting your abdominal muscles. But even with a light cough you are still starting that cough against a closed glottis. Try coughing without closing your glottis at all. You can't. Or at least I can't. You close the glottis to allow the pressure to build up to expel whatever is irritating your airway. Coughing without ever closing your glottis is called breathing.

 

[Monty Python]

Things I have not regretted......(snip) wonderfully working 16g PIV's, ...."

I learned to question the integrity/taping/functioning of any IV inherited from the ER, ICU, or ward before starting to transport to OR. Not infrequently an adult ER patient will have the ubiquitous 22g antecubital IV barely running, held in place with almost no tape.

 

[Urzuz]

2) I agree that you can build up some intrabdominal pressure by contracting your abdominal muscles. But even with a light cough you are still starting that cough against a closed glottis. Try coughing without closing your glottis at all. You can't. Or at least I can't. You close the glottis to allow the pressure to build up to expel whatever is irritating your airway. Coughing without ever closing your glottis is called breathing.

Now we are getting down to semantics . Though you can't cough technically with a closed glottis, coughing is a reflex that is hard wired into our bodies. The neurons that are sitting in the larynx/carina will still carry the signal to our CNS which will then relay the signal to the muscles involved in coughing (eg: diaphragm, abdominal muscles, etc), which will still contract in an effort to expel whatever foreign object is in the airway.

We have all seen it. Think about the last young healthy 20 year old man who you took care of that bucked. While the patient has an ETT in, though they aren't coughing and actually expelling the endotracheal tube from their airway, those muscles involved in the cough reflex are firing on all cylinders, so much so that sometimes they will physically fly off the table with the amount of force generated. That is the force that is being transmitted to adjacent tissues that is leading to increased intraabdominal pressure, increased ICP, increased venous engorgement, etc. Keep in mind, this is with the ETT still in. I guess if you're looking for a word for it, "retching" or "gagging" may be more appropriate than "coughing."

And to add to this, what is the first thing (usually) that a patient does who has been retching/gagging on the ETT, once they are freshly extubated? They let out a huge "real" cough! Same reflex is still going on, they are just now allowed to expel air and "cough" in the traditional sense.

 

[Impromptu]

No one has control to cause 100% smooth wake-ups. No one has the power to have 100% quick wake-ups. But you can make nearly 100% of them safe.

There are many ways to try and avoid bucking, and I would suggest learning many different techniques for all the situations you'll be in. I present the following as one way that has worked well for me (though I'll use different ways depending on the situation). After the initial dose of paralytic, I only give small re-doses to try and maintain between 1-3 twitches on TOF. When you think you are getting close to the end, but you still want to maintain some paralytic (more so than deepening the gas or giving propofol), try giving just 1-3 mg of rocuronium at a time. It won't last long. Start letting the CO2 build up by slowing the ventilator rate. Reverse as early as you can.

Turn the ventilatory rate down to 6. Turn the I:E ratio to 1:5.5. This allows the CO2 to build up and the long expiratory time allows them time to attempt a breath. Watch the capnogram closely. When you see that they attempt to take a breath, flip to manual. Those first breaths against the ventilator won't be bucking, because I may not have changed the volatile agent yet, or at least I've kept them at the same MAC with combinations of N2O, so they are still deep. Silence the alarms for a minute and give them 20-60 seconds to try and take breaths on their own. 100% O2 is safe for longer. You will often see them start to breathe small breaths that build up larger and larger. There are many options at this point. You can turn on the N2O, turn off the volatile agent, and titrate narcotic in based on their spontaneous ventilation and ETCO2. Or wake them deep. Or wake completely. This has given me some of the smoothest wake-ups. And allows me flexibility if the surgeon decided to let the medical students do all the suturing or if he does it all himself.

I went straight from volume control to spontaneous breathing and avoided SIMV and PS. But those are tools as well.

 

[criticalelement]

No one has control to cause 100% smooth wake-ups. No one has the power to have 100% quick wake-ups. But you can make nearly 100% of them safe.

There are many ways to try and avoid bucking, and I would suggest learning many different techniques for all the situations you'll be in. I present the following as one way that has worked well for me (though I'll use different ways depending on the situation). After the initial dose of paralytic, I only give small re-doses to try and maintain between 1-3 twitches on TOF. When you think you are getting close to the end, but you still want to maintain some paralytic (more so than deepening the gas or giving propofol), try giving just 1-3 mg of rocuronium at a time. It won't last long. Start letting the CO2 build up by slowing the ventilator rate. Reverse as early as you can.

Turn the ventilatory rate down to 6. Turn the I:E ratio to 1:5.5. This allows the CO2 to build up and the long expiratory time allows them time to attempt a breath. Watch the capnogram closely. When you see that they attempt to take a breath, flip to manual. Those first breaths against the ventilator won't be bucking, because I may not have changed the volatile agent yet, or at least I've kept them at the same MAC with combinations of N2O, so they are still deep. Silence the alarms for a minute and give them 20-60 seconds to try and take breaths on their own. 100% O2 is safe for longer. You will often see them start to breathe small breaths that build up larger and larger. There are many options at this point. You can turn on the N2O, turn off the volatile agent, and titrate narcotic in based on their spontaneous ventilation and ETCO2. Or wake them deep. Or wake completely. This has given me some of the smoothest wake-ups. And allows me flexibility if the surgeon decided to let the medical students do all the suturing or if he does it all himself.

I went straight from volume control to spontaneous breathing and avoided SIMV and PS. But those are tools as well.

The bold I disagree with. Reversal is the last thing I do. Probably when they take the drapes down is when i reverse.

The red above is weird to me..

 

[pgg]

I don't agree with this. Awake extubation the patient must be awake. What does awake mean? ding ding ding.. eyes open. Moreover, i dont think there is such a thing as waiting too long to pull the tube..

We can agree to disagree then.

I had a few attendings who believed as you do, that awake = wide awake, ready to do the NYT crossword puzzle. They required them to follow commands. "Can you give me a thumbs up?" Telling them to open their mouths so they can do another round of deep suction before extubation. I think that's rather unnecessary in 98% of cases.

Patients are often awake before their eyes are open. I mean, that's the normal way human beings wake up. When I woke up this morning, I was "awake" before I opened my eyes. Now, certainly, anesthesia with volatile agents is different, and it's not normal sleep. I didn't go through stage 2 before waking up this morning.

But usually there are clear, deliberate signs 15-30 seconds before they are "eyes wide open awake" and looking around the room, clearly wondering "why the hell is this tube in my mouth and who are all these people looking at me" and before the panic sets in. Some movements just don't come during or before they've passed through stage 2. Sometimes they're subtle. Facial expressions like grimacing, brow furrowing; head movement; some patterns of limb movement. The HR settling back down to 65 after a brief run to 95. A more regular and deep breathing pattern after a brief run of shallow tachypnea.

With practice and attention, you can pick up on the signs that a patient is "awake" and safe to extubate, before the eyes are open. If you do, you'll avoid a lot of the ugly coughing, head thrashing, clamping down on the bite block, etc.

If you don't want to do that, that's OK, there's nothing really wrong with waiting longer to pull the tube.


We're kind of digressing from the topic of this thread though, which is bucking on an endotracheal tube. That's a different issue, mostly unrelated to stage 2, emergence, and extubation criteria. Bucking is a bad balance between tracheal irritation and analgesics - not 100% avoidable, but there are definite uncontroversial mitigation strategies..

 

[DocFocker]

The bold I disagree with. Reversal is the last thing I do. Probably when they take the drapes down is when i reverse.

The red above is weird to me..

I love reversing early. It allows you to get them breathing on their own with the strength necessary for maintaining that post extubation. It allows you to assess their rate, TV, inspiratory effort, all basic criteria for extubation. It gives you a Gestalt for how well their pain is controlled etc. Why wait?

 

[amyl]

Tons of tricks. Lido down the tube (like kempen narcusprince) at the end, lta the cords up front if it's a short case, remi/nitrous, nitrous/propofol.... Basically get the gas off, extubate deep - if you are worried place an lma

 

[deleted162650]

Or wake them deep.

Now that's a trick!

 

[narcusprince]

Amyl I have done maybe 2 Kempen extubations simce residency one kid laryngospasmed on extubation. I have gotten away from the practice.

 

[deleted162650]

Is it just me or does lido down the tube seem ******ed?? It's doing nothing to anesthetize the cords and the area under the cuff which is where the vast majority of the contact/irritation is occurring.

 

[urge]

Amyl I have done maybe 2 Kempen extubations simce residency one kid laryngospasmed on extubation. I have gotten away from the practice.

What the heck is a Kempen extubation?

 

[Crash cart]

The residents reading this should be the very least concerned with looking smooth and more concerned with SAFE. because believe me they will extubate someone too early and wish they had not. If you are not sure if patient is awake or not... wait a little longer... still not sure.. wait a little longer... pull it only when it looks so damn ridiculous with the bucking that the patient has to be awake... or when you are sure... Dont pull the tube when you are not sure. because if you arent sure, they aint awake.

criticalelement has a very good point that it's always best to error on the side of safety, even if some pissy surgeon is making snarky comments from the computer (or the side of the OR table).

That being said, I wish I had taken more risks during residency. I wish I had pushed the envelope a little bit more. What better time to do this than while an ABA board certified attending is standing next to you? Be clear: I'm not advocating cowboy moves. I am saying that (especially CA-3 year) is a time to try out new techniques, explore a bit, push it. I maintain that given proper patient selection it's not "risky" practice to extubate deep, for example. You may have to push your attending a bit, but if you are thoughtful, respectful, and have a good reason for it ("Hey, next year I'm going to be on my own...you mind if we do this together to see how it goes?"). If no is the answer, then so be it. Try the following day. But IT'S BETTER TO EXPERIMENT WHEN THERE ARE FOUR HANDS AVAILABLE THAN TWO! Take it from me - I've been there! First year out when you're trying to prove yourself is not the best time to try something new...

I'd be curious to hear my academic colleagues' thoughts on this approach.

 

[pgg]

Is it just me or does lido down the tube seem ******ed?? It's doing nothing to anesthetize the cords and the area under the cuff which is where the vast majority of the contact/irritation is occurring.

It's not just you.

 

[bkell101]

Things I have not regretted.......having an arterial line, wonderfully working 16g PIV's, and waiting an extra 10-30 seconds before extubation. Someone once told me "...when you think you're ready to extubate, wait 10 more seconds, and ask yourself the question again...."

I swear u must be my attending....same exact thing I was told.

 

[drmwvr]

It's not just you.

It is "******ed" if you don't, after giving the ET lido, drop the cuff, give a large breath with the bag, and reinflate the cuff. The medicine percolates up and thru the cords.

Works quite well, actually.

 

[Consigliere]

I haven't cared about pt's bucking on the ETT since I finished residency.

 

[ZzzPlz]

As my former residency chair said, "never apologize when your patient is showing signs of life."

 

[deleted162650]

It is "******ed" if you don't, after giving the ET lido, drop the cuff, give a large breath with the bag, and reinflate the cuff. The medicine percolates up and thru the cords

Nope, still think it's ******ed. If I'm gonna go that route I'd rather just through a dab of lido ointment on the ETT.

I haven't cared about pt's bucking on the ETT since I finished residency.

I probably wouldn't care either if I was never actually in the room to watch the pts wake up

 

[Consigliere]

I probably wouldn't care either if I was never actually in the room to watch the pts wake up

I'm present for every extubation. Every one. Whether the pt. "bucks" on the ETT or not is as irrelevant as your attempted snarky post.

 

[Pooh & Annie]

I haven't cared about pt's bucking on the ETT since I finished residency.

Nothing wrong with that. But if it's routine I'm sure your partners who do care about bucking hear about how much "better" they are than you from the rest of the OR staff and surgeons (who don't understand, of course).

 

[Consigliere]

Nothing wrong with that. But if it's routine I'm sure your partners who do care about bucking hear about how much "better" they are than you from the rest of the OR staff and surgeons (who don't understand, of course).

They don't. Which is why they are my partners. We focus on the things that matter to surgeons: being fast, being funny, and always being there when they need us.

 

[leaverus]

you must not work with jerkoff plastic surgeons who DEMAND their patients not buck. And we all know that bucking and coughing on the tube is the only time after surgery that any sort of strain will be placed on those sutures.

 

[Pooh & Annie]

They don't. Which is why they are my partners. We focus on the things that matter to surgeons: being fast, being funny, and always being there when they need us.

Fair enough. Although I doubt you would know and they probably wouldn't say anything to you.
And reasonable surgeons understand that patients are gonna buck. But it's not usually hard to avoid and I guarantee they'd rather see that.

 

[Consigliere]

Fair enough. Although I doubt you would know and they probably wouldn't say anything to you.
And reasonable surgeons understand that patients are gonna buck. But it's not usually hard to avoid and I guarantee they'd rather see that.

I've not cared about what they'd rather see a long, long time ago.

 

[leaverus]

i've read lido IN the cuff might help but i've not tried it. anyone else?

 

[pgg]

i've read lido IN the cuff might help but i've not tried it. anyone else?

Maybe if you tear the cuff on a tooth on the way in ...

I don't know. Maybe. But it's plastic. We fill them with saline for air transport and they don't leak. I wouldn't expect lidocaine to leak when saline doesn't, but maybe some drug does get across.

When we had tetracaine crystals available (residency), I would sometimes add them to a lidocaine LTA and spray the cords and trachea prior to intubation. Good for a little longer.

 

[soorg]

What about bucking and inner-ear surgery? Has anyone ever heard of or read a case report where bucking damaged a fresh repair?