Waking Up

[MAC10]

Anyone have good tips for a smooth and quick wake up?

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[UTSouthwestern]

Anyone have good tips for a smooth and quick wake up?

Don't use drugs. They're bad.




Failing that, the two things you want to consider are do I want to get the patient breathing first or do I want to dispel the evil vapors first (which controlled ventilation does rather quickly for you).

For most of my bread and butter cases, I have done the latter over the former if only because I have found that the patients wake up less dysphoric and combative. You have to time it right but I usually turn the gas down 20 minutes before the last stitch is thrown to usually 0.5 MAC with 50% nitrous. I throw in very small boluses of propofol (2-3 cc's) based on my feel of the patient's vitals. Give reversal as they are starting or finishing the next to last level to be sutured (depending on the size of the incision). Gas off 5-10 minutes before anticipated completion. Rate at usually 8 with good size tidal volumes. Nitrous still on. 50-100 mg of lidocaine IV then nitrous off as 2 minutes before the last stitch is to be done. Again, 2-3 cc dinks of propofol if I feel the patient is starting to emerge. Case done, site cleaned, dressing placed = 5-10 minutes. By that time, end tidal volatile = 0. I have usually by then turned the rate down to 4 or shut off the vent and am just giving intermittent hand bagging.

Patients wake up very rapidly and without any bucking or coughing, especially if you have used Sevo. Most of my patients just open their eyes and I tell them, "Good morning! Your surgery is all done. Do you want that tube out of your mouth?" To which they usually just nod their heads.

All of that depends on your being able to accurately judge if the patient has has been given adequate analgesia. Ketorolac if usable, makes that a moot point.

Just one way that I do my wake ups. Timing is critical and you have to develop a feel for making the changes, but remember that by the end of the case, the majority of the major stimulation has been completed.

Alternatively, you can get the patient breathing spontaneously, titrate in narcotics to control for pain, which you can judge by the vitals and the respiratory rate (pain = RR > 20 usually). In this case, you have to be able to judge when to turn off the gas to time the wake up perfectly. I would still use the lidocaine trick. Small dinks of propofol can really help you bridge the gap and I will sometimes give a few cc's as I make downward gas adjustments even if the patient still appears completely anesthetized as I know it will redistribute quickly and its effects will be terminated.

 

[VentdependenT]

Don't use drugs. They're bad.




Failing that, the two things you want to consider are do I want to get the patient breathing first or do I want to dispel the evil vapors first (which controlled ventilation does rather quickly for you).

For most of my bread and butter cases, I have done the latter over the former if only because I have found that the patients wake up less dysphoric and combative. You have to time it right but I usually turn the gas down 20 minutes before the last stitch is thrown to usually 0.5 MAC with 50% nitrous. I throw in very small boluses of propofol (2-3 cc's) based on my feel of the patient's vitals. Give reversal as they are starting or finishing the next to last level to be sutured (depending on the size of the incision). Gas off 5-10 minutes before anticipated completion. Rate at usually 8 with good size tidal volumes. Nitrous still on. 50-100 mg of lidocaine IV then nitrous off as 2 minutes before the last stitch is to be done. Again, 2-3 cc dinks of propofol if I feel the patient is starting to emerge. Case done, site cleaned, dressing placed = 5-10 minutes. By that time, end tidal volatile = 0. I have usually by then turned the rate down to 4 or shut off the vent and am just giving intermittent hand bagging.

Patients wake up very rapidly and without any bucking or coughing, especially if you have used Sevo. Most of my patients just open their eyes and I tell them, "Good morning! Your surgery is all done. Do you want that tube out of your mouth?" To which they usually just nod their heads.

All of that depends on your being able to accurately judge if the patient has has been given adequate analgesia. Ketorolac if usable, makes that a moot point.

Just one way that I do my wake ups. Timing is critical and you have to develop a feel for making the changes, but remember that by the end of the case, the majority of the major stimulation has been completed.

Alternatively, you can get the patient breathing spontaneously, titrate in narcotics to control for pain, which you can judge by the vitals and the respiratory rate (pain = RR > 20 usually). In this case, you have to be able to judge when to turn off the gas to time the wake up perfectly. I would still use the lidocaine trick. Small dinks of propofol can really help you bridge the gap and I will sometimes give a few cc's as I make downward gas adjustments even if the patient still appears completely anesthetized as I know it will redistribute quickly and its effects will be terminated.

UT, the lido is for decreasing airway response to ETT right? How much do you use?

 

[jetproppilot]

Anyone have good tips for a smooth and quick wake up?

Your goal is to be holding the mask on the patient's face with them breathing when they're ready to take the drapes down. This is one of the "art" areas of anesthesia, and probably the biggest issue with new clinicians is they start to wake the patient up when the drapes come down, not before.

In order to accomplish this, you have to plan ahead. The first step is to pick an anesthetic plan that has an intrinsically easy wake-up period when possible, i.e. an LMA. I use one whenever I can...knee scopes, ACLs combined with a fem/sci block, breast biopsies, hysteroscopies, etc etc etc.
Alot of people wont use one if the pt has GERD, which alot of people do. But if they have no symptoms on their medicine, they have no postural GERD component, are not a diabetic or a renal pt, I'll use one.
Put in the LMA, get 'em breathing, and at the end you can pull it even if they're still a little sleepy. Put an oral/nasal airway in prn. Remember, your goal is to get them to the pacu with a patent airway; if they're still sleepy, go ahead and pull it anyway as long as you are satisfied with their tidal volume. If you minimize opiods and use des or sevo they're gonna wake up quick.

For ETT cases your planning to extubate should begin 20-30 minutes or so before the case is over in a long case, like an ELAP for example. Once the fascia is closed, give your reversal and work on getting them breathing again. You've still got 15-20 minutes to accomplish this so it can be achieved. Takes practice, though, to lighten your volatile anesthetic enough but to keep enough gas on to keep the patient still. I usually give the reversal, turn off the vent, turn the des from 5 to 2.5, turn the flows up to 10 liters, 3 O2 and 7 N2O if you can, and since I'll have been sure to limit opiods in the last hour, usually you just hold your hand on the bag, holding justa little positive pressure (10mmHg or so) and after a minute or 2 you'll feel the bag start to move. Let the CO2 creep up...sometimes it'll go into the fifties in order for them to breathe, but thats ok.

You can use a variation of this for virtually any ETT case, even prone back cases. The key is to say to yourself "I'm gonna be pulling the tube when the last stitch is going in" (obviously in a prone case you'd say "I'm gonna pull the tube as soon as we flip"). Work backward in your head to plan for that and make it happen!

SO, the key is to get them breathing before the end.

 

[militarymd]

On shorter back cases where I'm not worried about airway swell, I pull it with them prone....

Anyways, I think one of the keys to a smooth and more importantly SAFE, wakeup, is to get most if not all of the volatile agent off prior to the end of the case.

Bad airway reflexes seems to me to be very related to light volatile anesthesia (so called stage II).

Use propofol to keep patients still while you work to get rid of the gas. Once the gas is gone, the tube or LMA can come out safely even if the patient is not awake....deep extubation or TIVA extubation

 

[UTSouthwestern]

On shorter back cases where I'm not worried about airway swell, I pull it with them prone....

Anyways, I think one of the keys to a smooth and more importantly SAFE, wakeup, is to get most if not all of the volatile agent off prior to the end of the case.

Bad airway reflexes seems to me to be very related to light volatile anesthesia (so called stage II).

Use propofol to keep patients still while you work to get rid of the gas. Once the gas is gone, the tube or LMA can come out safely even if the patient is not awake....deep extubation or TIVA extubation

Well said Military.

Vent, I usually use 1-1.5 mg/kg lido to a max of 100 mg (no particular reason for the max other than that is usually all I have in the box and taking into account any local that may have been used by my surgeons).

 

[Justin4563]

On shorter back cases where I'm not worried about airway swell, I pull it with them prone....

Anyways, I think one of the keys to a smooth and more importantly SAFE, wakeup, is to get most if not all of the volatile agent off prior to the end of the case.

Bad airway reflexes seems to me to be very related to light volatile anesthesia (so called stage II).

Use propofol to keep patients still while you work to get rid of the gas. Once the gas is gone, the tube or LMA can come out safely even if the patient is not awake....deep extubation or TIVA extubation

hey why would you pull out an endotracheal tube prone... hey it makes you look cool and slick but not the safest thing in the world... How do you know if the airway is still patent after you extubate... laryngospasm is a real real possibility everytime you extubate.. what if you have to re intubate...

the patient does not have to be grabbing the OR lights for extubation to occur.. Furthemore, he or she does not have to perform calculus to be extubated.. you can just tell when a patient meets extubation criteria and i suppose this is the art..

always.. always check to see if you have a patent airway. as jet pointed out.. the operative word is patent... even in mac sedation cases .. if you dont see ent tidal co2 you DO NOT have a patent airway and badness will shortly ensue..... after you pull the LMA out deep (always for me).. put an airway in and make sure you have a patent airway before going to recovery room.. you can bring the patient to recovery still sleeping but just mnake sure that airway is patent.. after you transfer to stretcher.. in the hallway... in the pacu... I dont care if you use supplemental o2 for the transfer. but just make sure the airway is patent......... everything else pales in comparison..

 

[coccygodynia]

UT - have you noticed any increase in postop sedation with the lido (esp neuro cases)? Are you using it at the beginning before the propofol induction as well?

All - Do you aim for a certain MAC level that correlates to a quicker wake-up (i.e., waiting until it reads 0.2 instead of 0.4)? I have been doing almost the same with my cases as UT (with the exception of the lido) ... my main reason for giving the bump of propofol at the end is for PONV.

 

[UTSouthwestern]

UT - have you noticed any increase in postop sedation with the lido (esp neuro cases)? Are you using it at the beginning before the propofol induction as well?

All - Do you aim for a certain MAC level that correlates to a quicker wake-up (i.e., waiting until it reads 0.2 instead of 0.4)? I have been doing almost the same with my cases as UT (with the exception of the lido) ... my main reason for giving the bump of propofol at the end is for PONV.

I have not noticed any significant post op sedation, even with my 88 year old patient with severe hydrocephalus for VPS. Timing is key. Giving it while the last few stitches are being thrown gives you a couple of minutes plus 5-10 for the dressing and move to the gurney. Still have the airway reactivity suppression, but most of the sedation, if any, will have worn off or begun to wear off.

I aim to get as much of the gas off as possible. Zero is fine as by that time, the last stitch is in or going in and again, the small dinks of propofol can buy you a couple of minutes of time.

 

[Tenesma]

I love extubating them while the drapes are still up ... when the drapes are down, the surgeon's eyes always bug out when they see the patient looking around w/ Nasal Cannula (i use that for effect if i can get away with it)... it is all about making a good show.... perception is reality...

 

[jetproppilot]

On shorter back cases where I'm not worried about airway swell, I pull it with them prone....

Anyways, I think one of the keys to a smooth and more importantly SAFE, wakeup, is to get most if not all of the volatile agent off prior to the end of the case.

Bad airway reflexes seems to me to be very related to light volatile anesthesia (so called stage II).

Use propofol to keep patients still while you work to get rid of the gas. Once the gas is gone, the tube or LMA can come out safely even if the patient is not awake....deep extubation or TIVA extubation

Geez, anesthesia stud, thats too much work! You really can get by without worrying about committing one hand to a propofol syringe and wasting money on more drugs.

Prior to reversal I'll suck out the oro-pharynx 'til its dry as a cow paddy so I won't have to do it later when the patient is light. Give the reversal, cut the gas in half, turn the flows up to 10 liters total to expedite volatile agent exit, get 'em breathing, and PRESTO! Your work is pretty much done. As long as the oropharynx is dry so as to minimize the "spit-on-the-vocal-chord-induced-laryngospasm, you can pull the tube at any point now. The key is IMMEDIATELY after extubation, take the mask, put it on the pts face, thumbs on top, index fingers below mandibular ridges, and pull up hard. Combine the resultant positive pressure with the -bilateral-pull-up-on-the-mandible-hard trick, and incidence of laryngospasm is very very low, even with end-tidal volatile anesthetic still present.

I don't give lidocaine at the end, and I dont bump with propofol. Pt breathing, oropharynx dry, pull the tube, do the positive pressure/mandible trick. No problems. Think you guys are adding steps that can be eliminated.

Goes to show you how varied the practice of anesthesia is.

 

[jetproppilot]

Geez, anesthesia stud, thats too much work! You really can get by without worrying about committing one hand to a propofol syringe and wasting money on more drugs.

Prior to reversal I'll suck out the oro-pharynx 'til its dry as a cow paddy so I won't have to do it later when the patient is light. Give the reversal, cut the gas in half, turn the flows up to 10 liters total to expedite volatile agent exit, get 'em breathing, and PRESTO! Your work is pretty much done. As long as the oropharynx is dry so as to minimize the "spit-on-the-vocal-chord-induced-laryngospasm, you can pull the tube at any point now. The key is IMMEDIATELY after extubation, take the mask, put it on the pts face, thumbs on top, index fingers below mandibular ridges, and pull up hard. Combine the resultant positive pressure with the -bilateral-pull-up-on-the-mandible-hard trick, and incidence of laryngospasm is very very low, even with end-tidal volatile anesthetic still present.

I don't give lidocaine at the end, and I dont bump with propofol. Pt breathing, oropharynx dry, pull the tube, do the positive pressure/mandible trick. No problems. Think you guys are adding steps that can be eliminated.

Goes to show you how varied the practice of anesthesia is.

Speaking of keeping things simple, reminds me of my times working with one of the best laparoscopic surgeons I've ever worked with, Dr. Phil Lindsey. Texan dude, fast, thorough, but kept things simple. We were doing a lap-chole one late night and he looked up suddenly from the monitor.

"Geez, I mighta hit the bowel."

He pulled out the scope like you were pulling out a sword, ran the tip by his nose, took a big sniff, and said:

"Nah. We're alright."

 

[rugirlie]

Speaking of keeping things simple, reminds me of my times working with one of the best laparoscopic surgeons I've ever worked with, Dr. Phil Lindsey. Texan dude, fast, thorough, but kept things simple. We were doing a lap-chole one late night and he looked up suddenly from the monitor.

"Geez, I mighta hit the bowel."

He pulled out the scope like you were pulling out a sword, ran the tip by his nose, took a big sniff, and said:

"Nah. We're alright."

Wow, this thread sounds very informative.. of course none of it means anything to me right now, but I hope its around in 4-5 years...

 

[Justin4563]

Geez, anesthesia stud, thats too much work! You really can get by without worrying about committing one hand to a propofol syringe and wasting money on more drugs.

Prior to reversal I'll suck out the oro-pharynx 'til its dry as a cow paddy so I won't have to do it later when the patient is light. Give the reversal, cut the gas in half, turn the flows up to 10 liters total to expedite volatile agent exit, get 'em breathing, and PRESTO! Your work is pretty much done. As long as the oropharynx is dry so as to minimize the "spit-on-the-vocal-chord-induced-laryngospasm, you can pull the tube at any point now. The key is IMMEDIATELY after extubation, take the mask, put it on the pts face, thumbs on top, index fingers below mandibular ridges, and pull up hard. Combine the resultant positive pressure with the -bilateral-pull-up-on-the-mandible-hard trick, and incidence of laryngospasm is very very low, even with end-tidal volatile anesthetic still present.

I don't give lidocaine at the end, and I dont bump with propofol. Pt breathing, oropharynx dry, pull the tube, do the positive pressure/mandible trick. No problems. Think you guys are adding steps that can be eliminated.

Goes to show you how varied the practice of anesthesia is.

so you extubate with the patients still deep...?


IM a big fan of a little positive pressure after extubation and the jaw thrust.. but i do it with one hand... two hands is over kill.. then you look like an amateur...

 

[Justin4563]

On shorter back cases where I'm not worried about airway swell, I pull it with them prone....

Anyways, I think one of the keys to a smooth and more importantly SAFE, wakeup, is to get most if not all of the volatile agent off prior to the end of the case.

Bad airway reflexes seems to me to be very related to light volatile anesthesia (so called stage II).

Use propofol to keep patients still while you work to get rid of the gas. Once the gas is gone, the tube or LMA can come out safely even if the patient is not awake....deep extubation or TIVA extubation

using propofol at the end of the case kinda defeats the purpose of waking the patient up.. if you wanna keep em asleep use the gas... I never use propofol ever again after the induction..

 

[rugirlie]

Here is a question.... where does all the variation result from? Do you all owe your own methods to your attendings during residency?

 

[jetproppilot]

so you extubate with the patients still deep...?


IM a big fan of a little positive pressure after extubation and the jaw thrust.. but i do it with one hand... two hands is over kill.. then you look like an amateur...

I'll give you that one, dude. Pinky finger under the left mandibular ridge, index finger and thumb on the top, right hand on the bag with a little positive pressure....

 

[Justin4563]

just practice and seeing many patients wake up over and over will tend to sway you to one practice over another... all of my attendings wanted patients awake and performing calculus etc.. not necessary..

 

[rugirlie]

just practice and seeing many patients wake up over and over will tend to sway you to one practice over another... all of my attendings wanted patients awake and performing calculus etc.. not necessary..

Oh I see you're in Jersey.. what hospital are you at?

 

[jetproppilot]

so you extubate with the patients still deep...?


QUOTE]

If they're breathing ok and they're not awake when its time to go, absolutely.

 

[VentdependenT]

I'll give you that one, dude. Pinky finger under the left mandibular ridge, index finger and thumb on the top, right hand on the bag with a little positive pressure....

So the goal is to squeeze the bag just enough to augment their breaths to provide a PEEP of 10 or so? Or do y'all have APL closed a lil bit more so you have a sort of BIPAP effect.

By the way this thread friggen rocks.

 

[jetproppilot]

So the goal is to squeeze the bag just enough to augment their breaths to provide a PEEP of 10 or so? Or do y'all have APL closed a lil bit more so you have a sort of BIPAP effect.

By the way this thread friggen rocks.

not so much to augment their breaths, but close the apl justa little so when you put your hand on the bag itll hold about 10 of peep..you'll hafta play with it for a few seconds to ensure the pressure doesnt go up too much...- this way you can feel them starting to "bite", i.e. start to take small-at-first tidal volumes..makes it easier to feel the "bites"...if you've timed it right they'll start to breathe...at that point i'll open the apl agin because its too much trouble to try and keep adjusting it...feel the bag and glance at the etco2 tracing and you'll start to see little blips which will get bigger as tidal volumes increase

 

[Justin4563]

I'll give you that one, dude. Pinky finger under the left mandibular ridge, index finger and thumb on the top, right hand on the bag with a little positive pressure....

Pinky finger under the left mandibular ridge.. oh yeah way to go... little positive pressure then you feel that bag collapse and thast a good thing

 

[Justin4563]

Oh I see you're in Jersey.. what hospital are you at?

Im up in north jersey near the sitay..... where are yoou?

 

[rugirlie]

Im up in north jersey near the sitay..... where are yoou?

I'm in central jersey but only until Aug 1st.. then I'm off to philly...

 

[jetproppilot]

Im up in north jersey near the sitay..... where are yoou?

HA!! Justin's goin for a HOOKUP on ol SDN!!!!!


again, just kiddin dudeski...

 

[rugirlie]

HA!! Justin's goin for a HOOKUP on ol SDN!!!!!


again, just kiddin dudeski...

Rightt... more like a shadowing opportunity.. hes probably oldd hehehe...

 

[rugirlie]

Im up in north jersey near the sitay..... where are yoou?

So you really hate medicine that much? What do you plan on doing when you leave the field?

 

[Justin4563]

open up a strip club..

 

[VentdependenT]

Propofol dinks are the bomb.

Jetprop, you arent in a big phat flubbery university teaching hospital anymore right? I've found that the little dinkers help when fresh blood is allowed to close and you still want the gas to come off.

 

[Disse]

Propofol dinks are the bomb.

Jetprop, you arent in a big phat flubbery university teaching hospital anymore right? I've found that the little dinkers help when fresh blood is allowed to close and you still want the gas to come off.

I'm in a big phat flubbery university teaching hospital with closures that last... oh.. longer than the actual case sometimes ( ) but I rare/never use propofol dinks and do what Jet does with the case. Works very well for me.

What works best for folks I guess.

 

[jetproppilot]

Propofol dinks are the bomb.

Jetprop, you arent in a big phat flubbery university teaching hospital anymore right? I've found that the little dinkers help when fresh blood is allowed to close and you still want the gas to come off.

I'm in disagreement with Military and UT in that I dont think you need all the gas off prior to extubation. If they're breathing smoothly at the end and youve got good tidal volumes, end tidal des is still at 2%, no big deal. Pull the tube, a little positive pressure with mandibular lift, and youre golden. No propofol needed.
I didnt use propofol dinks when I was a resident with fresh blood allowed to close.

 

[jetproppilot]

I'm in disagreement with Military and UT in that I dont think you need all the gas off prior to extubation. If they're breathing smoothly at the end and youve got good tidal volumes, end tidal des is still at 2%, no big deal. Pull the tube, a little positive pressure with mandibular lift, and youre golden. No propofol needed.
I didnt use propofol dinks when I was a resident with fresh blood allowed to close.

Geez, that was too harsh. Makes me sound like some rigid academic dude with his bow tie and all. Ya'll keep using your propofol dinks. Come to think of it, I'll use the 50mg inevitably left after induction sometimes. But Jet aint poppin' no new propofol vial for no propofol dinks!
My apologies. Rigid/bow tie academic dude statement retracted.

 

[militarymd]

different strokes...I say...

 

[MAC10]

Does anyone use Lidocane jelly on either the ETT, Eso temp, or NGT to help prevent bucking and coughing up the ETT at then end of the case? Does it help?

Also has anyone found that giving little fentanyl at the end of the case helps people wake up less agitated? Whats a good way to deal with the fighters?

 

[UTSouthwestern]

It does help. The only reason I don't do it routinely is that sometimes the patients complain of numbness in their posterior pharynx with difficulty swallowing.

 

[jetproppilot]

Does anyone use Lidocane jelly on either the ETT, Eso temp, or NGT to help prevent bucking and coughing up the ETT at then end of the case? Does it help?

Also has anyone found that giving little fentanyl at the end of the case helps people wake up less agitated? Whats a good way to deal with the fighters?

Theres this cool contraption called a Laryngo-Jet (no relation to me)...its a lidocaine 100mg plastic syringe with a long, thin (16" or so), say about eight inch tip on it with tiny holes running up and down the wand.
Expose the cords, stick the wand through the cords til the syringe is almost in the mouth, squirt the lidocaine, pull it out. Pretty cool contraption. Lasts about an hour I guess.
I wouldnt give fentanyl at the end unless you have a tachypneic pattern with great tidal volumes. May delay your extubation.

 

[beezar]

I'm a fentanyl user... (not personally... the pt... duh!) Like to give fentanyl at the end of a case for wakeup. But I never get them breathing on their own and try to titrate in narcotic... doesn't work well for me.

When I'm ready to turn off the volatile, give a bolus of 50-100mcg of fentanyl (depending on when the last dose of fentanyl is) then shut off the volatile, leaving only N2O/O2 (turn the flows really high). Give tiny boluses of fentanyl if the HR/BP shoots up during closure. The key is to get the volatile off, otherwise they won't breathe with the combo of fentanyl/gas. With the last stitch, turn off the nitrous, wait 30 seconds, tap their head and say their name, they open their eyes and follow commands and rarely ever buck, shut off the vent, tell them to take a deep breaths. Extubate, to the PACU where they usually sleep during their entire PACU stay and the nurses love you for it.

Of course, this takes a bit of practice, and i've been burned when I first started doing this, but works great now.

I think the key with any of these techniques is that you should only use mainly one anesthetic (whether it be volatile, propofol, or fentanyl) to smoothe the wake-up... once you have combos on board, you're screwed.

 

[jetproppilot]

Anyone have good tips for a smooth and quick wake up?

nice thread.