how do you wake a patient up with minimal bucking on an ET tube?

[dhb]

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[Dawkter]

Have been having some rough emergences recently after beach chair position. Tried lidocaine LTA (shoulder surgery ~90 mins) and that didn't seem to do much and neither did IV lidocaine prior to extubation. Narcotic use is minimal during these cases as the patient has typically had an IS block. Any additional tips to prevent coughing/bucking that I may have missed or is an extremely slow wakeup the best way to go?

 

[Random Anesthesiologist]

repair of a transsphenoidal CSF leak today, not a great case but it got me thinking about this thread.
90% of the time I've tried to prevent bucking by giving propofol-narcotic-lidocaine. I was turned off of deep extubations by the 20 minute wake-ups of an attending who thought deep extubations needed like ~ 2.5 MAC.
Anyway, today I went with the extubate 'deep' at 0.4 MAC, or just enough that I was confident that I was not in stage 2. It worked out perfectly, she woke up like she'd been napping on the couch not having metal shoved up her nose, and it was pretty much as fast as my typical wake up.
Not the most interesting story I know, but I thought I'd share and maybe change my vote from IV meds to extubate deep.

This is generally how I do it too. When they have twitches + reversal, and fascia is closed or closing skin elsewhere, gas goes off. I keep them triggering on volume assist to get gas off quickly (we only have des vs sevo in general rooms) and bolus prop as needed. I get em sucked out and put a bite block in with about 0.5 Mac. Once they breathe on their own with appropriate Vt and no pressure support needed, not in stage 2, tube comes out. Sometimes this means they're still sewing up belly or placing drains. After that Propofol/fent or morphine is your friend to keep their RR and movement controlled. Most of the time we are ready to move over before the drapes are pulled or bed in the room. I'm working on timing it to where drapes are pulled. Head or prone cases are different, I have to wait until drapes are down and bed turned back but still only takes a few minutes.

The worst is when I am having a pt breathe off the gas, but they need a set rate because they're not breathing on their own yet, and an attending comes in and turns the vent to pressure support with a rate of 3-6, with no triggering breaths yet. And then it takes 20-30 minutes to extubate. Kills me.

 

[Noyac]

Have been having some rough emergences recently after beach chair position. Tried lidocaine LTA (shoulder surgery ~90 mins) and that didn't seem to do much and neither did IV lidocaine prior to extubation. Narcotic use is minimal during these cases as the patient has typically had an IS block. Any additional tips to prevent coughing/bucking that I may have missed or is an extremely slow wakeup the best way to go?

A couple thoughts I have to address this are:
1) use an LMA. I havent put a tube in one of these pts in years.
2) if you must tube them then remember, your ISB is not going to cover the discomfort of the tube. Give some more opiods.