Emergence

[IkeBoy18]

As a new CA-1, one of the gray areas is emergence. Ive been with several different attendings with different philosophies, which is great for the big picture, but makes it harder for me to nail down the concept. One attending wanted me to work in 1g of dilaudid through the case, 40yo male, lap chole, no PMH, procedure took 1.5 hrs, patient had pintpoint pupils and wasnt breathing on his own and needed narcan. The next patient rec'd 0.5 of dilaudid on emergence and was extubated just fine. Another pt had respirations of 23 while blowing off the gas at the end of a case and the attending gave a total of 1g of dilaudid and 100 of fent, she said she likes to wake up with a RR of 8, and the patient woke up just fine.

I guess I would like some more guidance on this nuance of working narcotics in through the case and waking up with narcotics without overdoing it. Thanks for any responses.

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[jwk]

1 mg of Dilaudid on a healthy 40y/o male isn't really excessive unless you gave the bulk of it late in the case. What was their EtCO2? With narcs on board, they may not start breathing until it's in the 50-55 range. Using narcan should be a rarity. It causes more problems than it solves.

Did you give multiple narcotics on this case as well? If so, what and how much? I'm getting away from using multiple narcotics. If I want Dilaudid anyway, I just give Dilaudid. They don't need Dilaudid and fentanyl.

 

[rakotomazoto]

Every patient's emergence can be a little different, you will see some people wake up sweating, yelling, swearing, pulling out the ETT. Others will calmly open their eyes and open their mouth as instructed while you take out the tube. Different attendings have their preferences and patients will react differently to the same techniques. That's the art, figuring out which tricks to employ with which patients. You will eventually develop your own set of habits or preferences, based on your experiences. Just wait until you run into an attending who practices opioid-free anesthesia. Good luck with that! Personally, I plan my narcotic dosing based on the case, the patient, the comorbidities, medication history, the surgeon, etc. It shouldn't be a cookie cutter one size fits all approach, that's what separates a physician from a nurse.

 

[NICMAN]

You could do multimodal therapy and skip the narcotics altogether as long as there are no contraindications. Ask the surgeon for local port-site infiltration, oral celebrex/tylenol/lyrica 30 min before placement of OG tube, IV ketamine (5mcg/kg/min), lidocaine infusion (1-2 mg/kg/hour), and Dexamethasone (10 mg IV). Also consider magnesium. Run the ketamine and lidocaine into the PACU with no respiratory depression. They will be very comfortable and their opioids will be more efficacious when they actually have pain (i.e., when they are awake). Some residents look at me bug-eyed when I do this but some advanced institutions like UT Southwestern, Vanderbilt, Duke and others do this (including my own institution).

Also, plenty of places do zero opioid bowel surgery bundles--and patients actually do much better.

 

[vector2]

For the time being you need to do whatever your attending says, but your post essentially answered your own question. The first patient got a fair amount of dilaudid throughout the entire case which made you end up flying blind regarding the respiratory status- the last two got dilaudid only after they were breathing...see the trend? Personally, I'm not a big fan of working in dilaudid as soon as a case gets going, especially for something as short as a lap chole in a patient who presumably doesn't take anything for pain chronically. I typically give 50-100mcg fentanyl on induction based on their size, another 50-100 fentanyl around incision and insufflation, and then I don't give any more narcotics until they're breathing or unless they become intensely stimulated in the middle of the procedure (and even in this situation, I'm more likely to give a slug of propofol and temporarily overpressurize the volatile rather than slam in more fentanyl). Additionally, I give IV tylenol, toradol, decadron, and a whiff of ketamine early in every lap chole unless there's a contraindication. Lap choles if done multimodally rarely need more than fentanyl 150-200mcg in the beginning and dilaudid 0.4-0.6mg near the end.

 

[Mman]

emergence is an art, not a science, and there are lots of different ways to paint it. Try them out and see which you like better than others but be comfortable with any way. In the end, you'll be able to do it all.

 

[criticalelement]

As a new CA-1, one of the gray areas is emergence. Ive been with several different attendings with different philosophies, which is great for the big picture, but makes it harder for me to nail down the concept. One attending wanted me to work in 1g of dilaudid through the case, 40yo male, lap chole, no PMH, procedure took 1.5 hrs, patient had pintpoint pupils and wasnt breathing on his own and needed narcan. The next patient rec'd 0.5 of dilaudid on emergence and was extubated just fine. Another pt had respirations of 23 while blowing off the gas at the end of a case and the attending gave a total of 1g of dilaudid and 100 of fent, she said she likes to wake up with a RR of 8, and the patient woke up just fine.

I guess I would like some more guidance on this nuance of working narcotics in through the case and waking up with narcotics without overdoing it. Thanks for any responses.

If you gave one mg of dilaudid to a healthy 40 yo male you sure as ***t are going to have trouble waking him up.. ONLY FENTANYL for cases.... The other drugs are too long acting. Let the Pacu do that... This guy should have received 100mcg of fentanyl maybe 150.. then wake him up.. give him more if he needs it.. Your job is to wake the patient up complication free,, doesnt matter what it looks like.. as long as it is safe...

If you working with me I would be giving you noogies giving so much narcotic

 

[Robotic Wis-Hipple]

1g (gram) of dilaudid will do that to you.......

Opioid dosing to me has more nuance than it appears you're taking into account. With that said, I don't subscribe to the "this is a 4mcg/kg (fentanyl) case" practice style. I like to titrate based on clinical signs, with the exception of up front dosing which I like to do. Giving 0.5mg of dilaudid at the end of the case at once is going to delay extubation on a significant percentage of patients. For short cases I tend to only use fentanyl with adjuncts, but occassionally ill use dilaudid as well. But type of case, hx of patient, especially in regards to presence or absence of expected opioid tolerance, etc all plays a role.

Now, as a CA-1 you certainly have to follow your attendings desires, but I'd also say having a goal of RR of 8 may be a little low. If you narcotize to RR of 8 for emergence while still on gas (smaller TVs but increased rate) and then remove that gas and the ETT stimulating their trachea, I'll wager you may have a significant number of overly sedated, poorly ventilating patients in the PACU.

 

[deepstate2016]

If you gave one mg of dilaudid to a healthy 40 yo male you sure as ***t are going to have trouble waking him up.. ONLY FENTANYL for cases.... The other drugs are too long acting. Let the Pacu do that... This guy should have received 100mcg of fentanyl maybe 150.. then wake him up.. give him more if he needs it.. Your job is to wake the patient up complication free,, doesnt matter what it looks like.. as long as it is safe...

If you working with me I would be giving you noogies giving so much narcotic

Much of an ideologue? Some take more some take less. To blanket every case with that statement t is Jennie to say the least. Try again cadet.

 

[Planktonmd]

You could do multimodal therapy and skip the narcotics altogether as long as there are no contraindications. Ask the surgeon for local port-site infiltration, oral celebrex/tylenol/lyrica 30 min before placement of OG tube, IV ketamine (5mcg/kg/min), lidocaine infusion (1-2 mg/kg/hour), and Dexamethasone (10 mg IV). Also consider magnesium. Run the ketamine and lidocaine into the PACU with no respiratory depression. They will be very comfortable and their opioids will be more efficacious when they actually have pain (i.e., when they are awake). Some residents look at me bug-eyed when I do this but some advanced institutions like UT Southwestern, Vanderbilt, Duke and others do this (including my own institution).

Also, plenty of places do zero opioid bowel surgery bundles--and patients actually do much better.

Oh man.... This is beyond multimodal... this is polypharmacy and honestly crazy!
Celebrex+ Acetaminophen + Lyrica + Ketamine + Lidocaine + Magnesium + Dexamethasone + GA intra-op followed by Ketamine and lidocaine infusions in PACU... for a cholecystectomy?

 

[btbam]

You could do multimodal therapy and skip the narcotics altogether as long as there are no contraindications. Ask the surgeon for local port-site infiltration, oral celebrex/tylenol/lyrica 30 min before placement of OG tube, IV ketamine (5mcg/kg/min), lidocaine infusion (1-2 mg/kg/hour), and Dexamethasone (10 mg IV). Also consider magnesium. Run the ketamine and lidocaine into the PACU with no respiratory depression. They will be very comfortable and their opioids will be more efficacious when they actually have pain (i.e., when they are awake). Some residents look at me bug-eyed when I do this but some advanced institutions like UT Southwestern, Vanderbilt, Duke and others do this (including my own institution).

Also, plenty of places do zero opioid bowel surgery bundles--and patients actually do much better.

Way to confuse the CA-1 even more.

 

[deleted171991]

This is a brand new CA-1. Of course he makes mistakes, and that's great, because that's how he'll learn. There is more than one way to skin a cat. In residency, I was trained with the dilaudid preload method, especially for longer cases, where opiates can give tram-track stability. And I mastered that. Then, as an attending, I worked more with outpatients, so I got used to giving only and just enough fentanyl, without provoking nausea, and I got good at that. And so on. There are many options for pain control. There is no best; the best is the one that serves my purposes for that specific case. OP should learn as many as he can from his attendings.

The key with most of them is titration. You can always give more, you can seldom take back (narcan will wear off in the PACU, potentially creating an emergency). So I titrate everything patiently, based on years of experience, like a good cook adding condiments to the soup. Titrate to what? To vital signs. It's not rocket science, despite the fact that some people make it complicated, but it is somewhat of an art. That's why good anesthesiologists can do it with fentanyl and/or with dilaudid and/or with ketamine and/or whatever is available, and use each of them for its benefits while minimizing the side effects (by limiting the dose and combining drugs).

There should be almost no dogma, like "fentanyl is good, dilaudid is bad". The more ways one knows how to do something, the more patients can be safely and successfully taken care of. How do I choose? Based on what's available and what has worked well in the past with the same surgeon and procedure. In anesthesia, as in many other fields, experience beats knowledge. If it works, don't fix it, just don't let it become a dogma.

 

[deleted162650]

^^

 

[Ronin786]

Lots of good advice in the above posts.

Most important thing I would say is to become comfortable with a lot of different narcotics. Spend a week using only fentanyl, maybe another with hydromorphone. Try some spine cases with sufentanil or remifentanil (and then realize how terrible remi can actually be in some cases).

Other things I've noticed regarding opioids:

1) People shy away from hydromorphone a lot because of it's potency, so much so that they end up underdosing compared to what they would have given with fentanyl.

2) I haven't found any data to back this up in a brief search, but I believe that low vs high amounts of opioids don't have a significant impact on PONV. I.e. if you're going to get PONV from opioids then you might as well use a good enough dose where they don't wake up throwing up AND feeling like a truck hit them.

I'm sure you'll find your own way of doing things, but keep an open mind and try a lot of different techniques.

 

[deleted171991]

I haven't found any data to back this up in a brief search, but I believe that low vs high amounts of opioids don't have a significant impact on PONV. I.e. if you're going to get PONV from opioids then you might as well use a good enough dose where they don't wake up throwing up AND feeling like a truck hit them.

I respectfully disagree. Opiates (and especially fentanyl overdose) are one of the main reasons of PONV, especially in outpatient cases. And PONV is one of the main things that can make a patient really unhappy; if asked, most of them will choose pain over nausea.

There are certain doses where almost nobody gets nauseous, and certain ones where a lot of patients do. For example, I tend to shy away from giving more than 2-3 mcg/kg/h of surgery, and 5-7 mcg/kg in total, of Fentanyl. If I approach that level, I look for some other drug/option. And I am a big fan of opiates (I just try to use them judiciously).

 

[Ronin786]

I respectfully disagree. Opiates (and especially fentanyl overdose) are one of the main reasons of PONV, especially in outpatient cases. And PONV is one of the main things that can make a patient really unhappy; if asked, most of them will choose pain over nausea.

There are certain doses where almost nobody gets nauseous, and certain ones where a lot of patients do. For example, I tend to shy away from giving more than 2-3 mcg/kg/h of surgery, and 5-7 mcg/kg in total, of Fentanyl. If I approach that level, I look for some other drug/option. And I am a big fan of opiates (I just try to use them judiciously).

I won't argue at all that opioids are a main cause of PONV. I don't know of it being a dose-dependent relationship though.

Those are interesting numbers you use, but is that your average outpatient procedure or would you do the same for a major belly or orthopedic procedure?

 

[fakin' the funk]

If you gave one mg of dilaudid to a healthy 40 yo male you sure as ***t are going to have trouble waking him up.. ONLY FENTANYL for cases.... The other drugs are too long acting. Let the Pacu do that... This guy should have received 100mcg of fentanyl maybe 150.. then wake him up.. give him more if he needs it.. Your job is to wake the patient up complication free,, doesnt matter what it looks like.. as long as it is safe...

- every patient has a different dose-response for benzos, hypnotics, opioids, etc.
- having a VERY comfortable patient will indeed slow/delay emergence (assuming you're extubating awake)
- having a reasonably comfortable patient at emergence is usually a good thing
- having some endpoint that you're titrating to/against is a good thing
- it's OK to give long-acting opioids in the OR, the "that's PACU's job" attitude is super narrow minded and weak

 

[deleted171991]

I won't argue at all that opioids are a main cause of PONV. I don't know of it being a dose-dependent relationship though.

Those are interesting numbers you use, but is that your average outpatient procedure or would you do the same for a major belly or orthopedic procedure?

For major procedures where I need serious postop pain control, I would go to dilaudid early, so I would still try not go over those fentanyl doses, for outpatient. Those numbers are just estimates, by the way; my pain control is an art, not a protocol, so I don't have exact numbers.

 

[criticalelement]

Just remember.... you know all those news stories about kids dying after surgery and stuff.. tonsillectomy.. brain death.. airway obstruction ... 12 years old... so on and so forth... ? I bet you they were breathing 8 times per minute or less and not 21 times per minute. and had a pain score of negative 5 on extubation.


Take it easy with the narcotics..

I dont mind if i ask a patient if he/she is in pain... pauses for like 5 seconds to think about it.... and replies yes I am....

 

[NICMAN]

Oh man.... This is beyond multimodal... this is polypharmacy and honestly crazy!
Celebrex+ Acetaminophen + Lyrica + Ketamine + Lidocaine + Magnesium + Dexamethasone + GA intra-op followed by Ketamine and lidocaine infusions in PACU... for a cholecystectomy?

My point is that there are a lot of different ways to accomplish the same goal. All medications have advantages and drawbacks. The practice of anesthesia in Ghana (if you ever do mission work) with only a mapleson D, an O2 tank and ketamine will require different plan than the high-turnover outpatient clinic. Drug shortages happen too. There will come a day when propofol or sux, or dilaudid/fentanil will be unavailable. I typically keep it simple with healthy lap choles, but what about the severe OSA morbidly obese chronic pain patient with liver failure? I leave cookbook anesthesia to the nurses. They are good at protocols. Physicians should be good at applying evidence-based medicine to the pathophysiology of each particular patient.

 

[criticalelement]

. Physicians should be good at applying evidence-based medicine to the pathophysiology of each particular patient.

In other words keep the dilaudid in the pixis unless you have a 20 hour spine and you can work it in hours before wake up.

 

[criticalelement]

...

 

[Ezekiel2517]

As a new CA-1, one of the gray areas is emergence. Ive been with several different attendings with different philosophies, which is great for the big picture, but makes it harder for me to nail down the concept. One attending wanted me to work in 1g of dilaudid through the case, 40yo male, lap chole, no PMH, procedure took 1.5 hrs, patient had pintpoint pupils and wasnt breathing on his own and needed narcan. The next patient rec'd 0.5 of dilaudid on emergence and was extubated just fine. Another pt had respirations of 23 while blowing off the gas at the end of a case and the attending gave a total of 1g of dilaudid and 100 of fent, she said she likes to wake up with a RR of 8, and the patient woke up just fine.

I guess I would like some more guidance on this nuance of working narcotics in through the case and waking up with narcotics without overdoing it. Thanks for any responses.

As a CA-1, you can gain some guidance by reading a book like Jaffe, which will give you a general idea of the pain associated with a particular procedure. Other factors you need to consider are age, chronic opioid use or tolerance, comorbidities such as morbid obesity, use of non-opioid pain meds, and use of nerve blocks or local infiltration by surgeon. Also, you should consider that for a procedure that is done or can be done in a surgicenter setting where the patient is going home the same day, it's uncommon to give any opioid other than fentanyl. There are some surgicenters I go to where I am given the narcs to use for the day by the RN and I'm only given fentanyl. I honestly don't even know if other choices are available lol. If it's a long case and the patient is relatively healthy, I'll sometimes give 2 of dilaudid up front way before incision. Gives you a little preemptive analgesia and a nice stable case. Point is there are a lot of ways to do this and you'll figure out what's best for you.

 

[Ignatius J]

Just remember.... you know all those news stories about kids dying after surgery and stuff.. tonsillectomy.. brain death.. airway obstruction ... 12 years old... so on and so forth... ? I bet you they were breathing 8 times per minute or less and not 21 times per minute. and had a pain score of negative 5 on extubation.


Take it easy with the narcotics..

I dont mind if i ask a patient if he/she is in pain... pauses for like 5 seconds to think about it.... and replies yes I am....

I see what you are saying but I highly doubt it was narcotics that killed those kids.

 

[Random Anesthesiologist]

Try toradol next time.

 

[2Fast2Des]

You could do multimodal therapy and skip the narcotics altogether as long as there are no contraindications. Ask the surgeon for local port-site infiltration, oral celebrex/tylenol/lyrica 30 min before placement of OG tube, IV ketamine (5mcg/kg/min), lidocaine infusion (1-2 mg/kg/hour), and Dexamethasone (10 mg IV). Also consider magnesium. Run the ketamine and lidocaine into the PACU with no respiratory depression. They will be very comfortable and their opioids will be more efficacious when they actually have pain (i.e., when they are awake). Some residents look at me bug-eyed when I do this but some advanced institutions like UT Southwestern, Vanderbilt, Duke and others do this (including my own institution).

Also, plenty of places do zero opioid bowel surgery bundles--and patients actually do much better.

I've been doing this as a resident following the Vanderbilt protocols at my residency when I can, minus asking the surgeons for infiltration (how dare anesthesia tell them anything). Some of my attendings think the lidocaine will shut the heart down or is plain vodoo, some think the ketamine will give make them go bonkers for the rest of their lives and others are totally on board. Magnesium I'd love to run but have been told that pts will never wake up or will be so weak due to the sedative/nmb prolonging effect. I thought that to be strange since preggo women get it all the time and I don't think I've seen them dying in droves.. I've gone through cases where I have given minimal narcs (100mcg for induction) throughout the case and pt wakes up smooth as hell and utilize narcs prn in the pacu. Only problem is CRNA comes gives me break/lunch draws up more fentanyl/dilaudid, come back and see the EMR filled with numerous boluses and/or hypotensiveness thats being hastily attempted at being corrected when things were so much smoother when I left.

One of my attendings have told me that that gabapentin preop isn't a good idea because of some reports of post op resp dysfunction and complications? anyone have thoughts on it?

 

[Mman]

I've been doing this as a resident following the Vanderbilt protocols at my residency when I can, minus asking the surgeons for infiltration (how dare anesthesia tell them anything). Some of my attendings think the lidocaine will shut the heart down or is plain vodoo, some think the ketamine will give make them go bonkers for the rest of their lives and others are totally on board. Magnesium I'd love to run but have been told that pts will never wake up or will be so weak due to the sedative/nmb prolonging effect. I thought that to be strange since preggo women get it all the time and I don't think I've seen them dying in droves.. I've gone through cases where I have given minimal narcs (100mcg for induction) throughout the case and pt wakes up smooth as hell and utilize narcs prn in the pacu. Only problem is CRNA comes gives me break/lunch draws up more fentanyl/dilaudid, come back and see the EMR filled with numerous boluses and/or hypotensiveness thats being hastily attempted at being corrected when things were so much smoother when I left.

One of my attendings have told me that that gabapentin preop isn't a good idea because of some reports of post op resp dysfunction and complications? anyone have thoughts on it?

My thought is perhaps some of your attendings are a bit crazy.

 

[2Fast2Des]

My thought is perhaps some of your attendings are a bit crazy.

Do you think this multimodal cocktail should be for all surgical patients? I want to figure out whether this is something that should be applied to all pts or is it only a certain class that should get. Like low risk lap chole or EUA to the big ex-lap/spine case? I also want to be able to give some methadone as well, saw a paper of it used in I believe cardiac surgery and worked well for pain control.

 

[deleted171991]

My thought is perhaps some of your attendings are a bit crazy.

Or they are old enough to have seen lidocaine toxicity (e.g in Bier blocks).

 

[deleted171991]

Do you think this multimodal cocktail should be for all surgical patients? I want to figure out whether this is something that should be applied to all pts or is it only a certain class that should get. Like low risk lap chole or EUA to the big ex-lap/spine case? I also want to be able to give some methadone as well, saw a paper of it used in I believe cardiac surgery and worked well for pain control.

KISS.

 

[Mman]

Or they are old enough to have seen lidocaine toxicity (e.g in Bier blocks).

I'm not sure what an IV lidocaine infusion of something on the order of 1-2 mg/kg/hr has to do with a Bier block where you give 50 ml of 0.5% lidocaine as a bolus if the tourniquet malfunctions. Same drug...sure. Dose drastically different. I've done plenty of Bier blocks and fortunately never had a problem yet.

 

[deleted171991]

I'm not sure what an IV lidocaine infusion of something on the order of 1-2 mg/kg/hr has to do with a Bier block where you give 50 ml of 0.5% lidocaine as a bolus if the tourniquet malfunctions. Same drug...sure. Dose drastically different. I've done plenty of Bier blocks and fortunately never had a problem yet.

I agree. I was just explaining the train of thought, or more like the lack of it.

My previous group had one case of toxicity with Bier blocks a few years ago. One of the cuffs was leaking, and the patient seized. It ended well, but it was ugly enough to convince a number of people to avoid them in the future.

 

[NICMAN]

Do you think this multimodal cocktail should be for all surgical patients? I want to figure out whether this is something that should be applied to all pts or is it only a certain class that should get. Like low risk lap chole or EUA to the big ex-lap/spine case? I also want to be able to give some methadone as well, saw a paper of it used in I believe cardiac surgery and worked well for pain control.

Methadone can work well, but I don't like giving drugs that last dramatically longer than the time I will be managing the patient (e.g., >6 hours) unless it is decadron.

 

[Velefunt]

Oh man.... This is beyond multimodal... this is polypharmacy and honestly crazy!
Celebrex+ Acetaminophen + Lyrica + Ketamine + Lidocaine + Magnesium + Dexamethasone + GA intra-op followed by Ketamine and lidocaine infusions in PACU... for a cholecystectomy?

Forgot the bilateral TAP blocks...

 

[2Fast2Des]

UPMC apparently does ERAS, and apparently pts do pretty well with that polypharmacy cocktail

 

[NavyFlightDoc]

I'm not rigid about this, but I do ask my residents routinely why they are so eager to " work in some hydromorphone" during the case. In the case of my confused CA-1's, I know that it is because some of our colleagues (both residents and attendings) have told them they should do so. However, with experience comes wisdom, and it's easier to gather prospective knowledge of your patient's narcotic to pain ratio in patients who breathe when you're done keeping them from doing so. As you gain experience, you get better at anticipating the ratio correctly. Until then, I find it much easier for residents to do this when they've given fentanyl only, as the bulk of the respiratory depression (and pain relief) wears off quickly. Mostly, that's okay. Laryngoscopy and incision are more generally more painful than skin closure and waking up. If you end up with rapid shallow breathing when you're trying to wake up, give a little fentanyl, maybe a PACU sized dose of hydromorphone. But don't "work in" 2 mg of hydromorphone just because it's a long case.

Full disclosure: I want them to have better, faster wake-ups selfishly, as well as altruistically. It's nice not to stand there staring at each other while delaying my other room, or while worrying about the CA-1 in the other room doing something I didn't even know I should be concerned about. On the other hand, I get a chance to give my canned lecture on approaching intraop narcotic use rationally.

 

[Scotty_G]

Ike remember this and keep tract as you go through residency. Look at your patients in pacu who get tons of opiods intrap vs your patients who get smaller amounts. Who requires more pain-medicine postop in PACU? It is usually the ones who have gotten tons intraoperatively.

 

[MaximusD]

If you gave one mg of dilaudid to a healthy 40 yo male you sure as ***t are going to have trouble waking him up.. ONLY FENTANYL for cases.... The other drugs are too long acting. Let the Pacu do that... This guy should have received 100mcg of fentanyl maybe 150.. then wake him up.. give him more if he needs it.. Your job is to wake the patient up complication free,, doesnt matter what it looks like.. as long as it is safe...

If you working with me I would be giving you noogies giving so much narcotic

No.

 

[nimbus]

Larry Saidman's words to me when I gave 100mcg fentanyl to a sinus surgery patient as a CA-1, "you've ruined a perfectly good anesthetic."