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

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mzxz34

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I want to get a nice wakeup with an ETT without all the ugly bucking. Some say to use a "high dose of narcotic." But I have no idea what that means. Which narcotic/ How much? when? I've blindly tried it with fentanyl but all that happens is that they just wake up later, not better or it does not work at all. I've tired to get them to breath on their own before wakeup and titrate narrcotic to respirstory rate but some patients move despite this and then buck. Any one have a specific plan that works each time or at least most times. Tell me in detail so I can reproduce it. Thanks.
 
Never intubate smokers.

Seriously, though, I've encountered much less bucking by using a smoother, more gradual emergence. That means not waiting until the last suture is in to turn the gas from 1 MAC to zero, then bumping the flows to like 12.

I usually turn the iso down to 0.5 or so once the most stimulating part of the surgery is done. Keep flows <1, they'll retain that volatile for quite some time. Once I sense bandages are going on in 10 or so min., turn the iso off, maintain flows <1. Their ET should be around 0.6 or so at that point. Start easing the flows up to 2-3 lpm. Once I'm ready to extubate, the flows head up a little higher, maybe 6-7. This is often before the final bandages are on. By now the ET should be 0.3 or less. The patient should be swallowing, too.

If I'm really good that day, I'll lean over, give a gentle glabellar tap, ask for eye opening, then pul the tube shortly after the drapes are down.

In short, I find that a slower course of emergence leads to less bucking. For me, that includes usually not cranking the flows to like 11 until it's time to pull. I have no evidence for this, and I could be entirely wrong, but something tells me that a flow of 12+ lpm into your trachea is probably a bit stimulating.

And seriously, if they're a smoker I'm resigned to coughing throughout the entire process.

Edit- I also use a small-side-of-normal ETT. Typically 7.0 for the ladies, 7.5 for the guys. I don't go looking to insert the largest possible tube. That's pointless.
 
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mzxz34 said:
I want to get a nice wakeup with an ETT without all the ugly bucking. Some say to use a "high dose of narcotic." But I have no idea what that means. Which narcotic/ How much? when? I've blindly tried it with fentanyl but all that happens is that they just wake up later, not better or it does not work at all. I've tired to get them to breath on their own before wakeup and titrate narrcotic to respirstory rate but some patients move despite this and then buck. Any one have a specific plan that works each time or at least most times. Tell me in detail so I can reproduce it. Thanks.
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Extubate from zero twitches.

Tiva is the gold standard.

For routine lap belly case or small lami, let's say I would give either ten of morphine or one of dilaudid once I have the pulse Ox on. Attach other monitors. Assess response. If they aren't apneic repeat the dose. Dont redose narcs unless case longer than a few hours or you find yourself needing more than .6-.7 mac (1.2ish for sevo and 4ish for des). Reverse once fascia closed, etc. and start breathing spontaneously. Titrate 1-2mv morphine or .2 dilaudid to rr 9-10 AND etco2 > 40. most pts will wake up like a dream. Obviously use fentAnyl for daysurg pts. Watch carefully after extubation for obstruction and be liberal with a jaw thrust prn. Worst case scenario: nalocibe. It's not the end of the world.
 
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Lidocaine ~0.5-1mg/kg about 5 minutes before moving the head or extubating works.
Fentanyl 50mcg (or equivalent) about 6-10 minutes before extubating works.
Sufentanil infusion is also very smooth.
I like to extubate off of nitrous with a fentanyl bolus at the end after blowing off all detectable volatile anesthetic. I've found a lot of the bucking comes from confusion with the residual VA (low enough to be awake but enough to confuse them). I try to avoid deep suctioning during emergence. I also try to avoid what one attending referred to as titrated opioid to a toxic dose (bradypnea and hypercarbia). They don't need to be breathing 10 at a EtCO2 of 50 to be comfortable. Some people will just fight.
 
proman said:
Lidocaine ~0.5-1mg/kg about 5 minutes before moving the head or extubating works.
Fentanyl 50mcg (or equivalent) about 6-10 minutes before extubating works.
Sufentanil infusion is also very smooth.
I like to extubate off of nitrous with a fentanyl bolus at the end after blowing off all detectable volatile anesthetic. I've found a lot of the bucking comes from confusion with the residual VA (low enough to be awake but enough to confuse them). I try to avoid deep suctioning during emergence. I also try to avoid what one attending referred to as titrated opioid to a toxic dose (bradypnea and hypercarbia). They don't need to be breathing 10 at a EtCO2 of 50 to be comfortable. Some people will just fight.
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I agree about the in-between level of volatile. I sometimes get through it by giving a small bolus of propofol to keep a deep anesthetic while the volatile gets below the mac awake, skipping the in-between time during emergency where you probably shouldn't pull the tube but when you are also more likely to get some bucking.
 
Question is when do you guys suction the oropharynx?
 
Dont think there is a way to reliably prevent it. In genreal more opoids seems to decrease it, lidocaine certainly as well. Maybe letting people blow off the gas slower (low flows). But like plank said, only way to be reliable is deep extubation.
 
lidocaine down the ET tube... or IV like everyone said above.
in my short experience, down the tube works better but they are groggy sometimes.

also, in select pt populations... drop the cuff early.
suction oropharynx while still very deep.
 
Nacrotics or deep extubation. Of course, you have to know when NOT to use them. All other techniques can fail when there is some type of stimulation at the end (Ortho putting cast, nurses yanking out foley, surgeon injecting local, You suctioning oropharynx etc etc).
 
As bert indicated, using low flows and titrating down the volatile agent towards the end of the case can aid in a fast, smooth emergence. Also, as others have said, lidocaine (either IV or via ETT) ~5-10 min prior to extubation can also aid in a smooth emergence (when I do this, I prefer to administer via ETT and inflating/deflating the cuff a few times; of course, this can prolong emergence). Additionally, towards the end of the case try to transition to spontaneous ventilation via SIMV or pressure support versus simply allowing the ETCO2 to rise and then turning the vent off). As with anything else, nothing is perfect and sometimes its unavoidable (other than deep extubations, the most reliably smooth extubations I've seen are in patients on precedex drips, but its not reasonable to do this for every GETA case).
 
SleepIsGood said:
Question is when do you guys suction the oropharynx?
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Before I do anything (decrease gas, decrease RR to get them breathing, reverse, etc), I do all stuff that might stimulate them, ie suction, NG/OG, bite block. And then I might suction again seconds before pulling tube if I think they are still juicy.

I want them to sleep through stage 2. Leave them alone. Everybody wants to shake them and shout "YOUR SURGERY IS OVER!!!! WAKE UP!!!!" as the patient now fights you incoherently. Best chance of a smooth wakeup is to not stimulate them during this time.

As mentioned by others, narcotics works well (and deep extubation, of course), and a hit of propofol will settle them down if they are beginning to fight and will wear off fast but keep them down during that critical point of the gas getting light.
 
Narcotized said:
I want them to sleep through stage 2. Leave them alone. Everybody wants to shake them and shout "YOUR SURGERY IS OVER!!!! WAKE UP!!!!" as the patient now fights you incoherently. Best chance of a smooth wakeup is to not stimulate them during this time.
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Exactly. Nothing makes me angrier than when I've done my job, prepared for a smooth wakeup, then at the final minute, the circ grabs a cold, wet towel and vigorously rubs all the prep off the belly. :slap:

And I didn't really address spont breathing in my original post, but I agree with those who have said get them breathing spontaneously as early as the surgeon/surgery will allow. Basically, a longer emergence is typically a smoother one. You're better off getting them to resume their breathing duties while still riding the iso than when you've turned it off and cranked the flows.

Think of this tomorrow morning when you wake up. Would you rather be shaken out of REM with an alarm clock, or be allowed to slowly emerge from your slumber as the sun rises?
 
amyl said:
lidocaine down the ET tube... or IV like everyone said above.
in my short experience, down the tube works better but they are groggy sometimes.

also, in select pt populations... drop the cuff early.
suction oropharynx while still very deep.
Click to expand...

The pimpin Kempen technique lidocaine down ET tube. I was going to comment on that one myself!!
 
the way to ENSURE a smooth, compliant (follows commands), controlled wakeup - nearly 100% of the time is with remi (other opioids are ok, but take more skill to titrate to appropriate depth).

i literally have case after case - open their eyes on command with the tube, take a couple of deep breaths, tube out, no bucking, chilling on way to pacu, fully awake in 5 min.

when you MUST guarantee a smooth emergence (ENT), remi/nitrous/prop is the way to go, for me. i also do head/neck blocks, so postop pain is not as much of an issue.

other pointers:
1. get them breathing spontaneously.
2. pull that tube while they are breathing spont., but still stage 3.
3. get enough opioid on-board
4. lidocaine 1-1.5mg kg within 5 min of pulling tube
5. suctioning and poking around should be done during complete GA, not during emergence. also, giving 0.2 of glyco up front will take care of most secretions.
 
Maybe it's the difference between PP and academics - some of this makes no sense to me.

The gradual emergence technique seems counterintuitive - unless they have a lot of narc on board, it seems like they would cough more. And although I'm all for a relatively quiet wakeup, in a busy OR, turnover time rules in most cases. I don't lighten up early, because often it's only five minutes or less to close an abdominal case in PP-land, and if you lighten up early, then extubating deep becomes far more risky. Leave the agent on, extubate, crank up the flows, depart.

Extubating deep is a HUGE plus if you're willing. If you have a good mask A/W going to sleep, more than likely you won't have a problem waking up. Patients can be extubated before reversal if needed. Even for ENT patients, if your surgeons have them reasonably dry, tonsils, sinuses, etc., can easily be extubated deep.

LTA's work well, especially on cases that are shorter. I don't think it helps on a four hour spine, but on a lap chole, sinuses, etc., they're very helpful.

Unless you're in an OP place, fentanyl early, MS or dilaudid late. We don't have remi on formulary, but when we did, we rarely used it. It's just not that useful a drug in our practice.
 
I agree that a deep extubation is the way to go if you want to ensure no bucking- so long as laryngoscopy was easy.

My adjuvants:
LTA
Lidocaine about 2 minutes before extubation
SV with with RR around 8-10 and etCO2 of >40<50
Suction 5 minutes before extubation. If needed later try to avoid deep suctioning.
I've been bolusing Precedex as of lately on routine cases and have really come around to using it outside of the back rooms. 20mcgs about 45 minutes before extubation. They wake up comfy and it cuts down on narcotics.
If they look like they are going to obstruct in any way... I prophylactically place an oral airway right after the ETT is removed.
Look at chest/TV/ good fog in the mask = heading out of the room.
 
Consigliere said:
I just let 'em buck......buck it.😎
Click to expand...

me too.. that kind of stuff is not important to me anymore. i want my patients pain free at the end but not too sleepy. so I let leave the ventilator on turn the gas off and when they buck.. and buck and buck.. they are ready to be extubated.. there you go..........
 
Narcotized said:
As you say, this is how private practice works, and there is huge resistance to anything suggested differently from a new guy. I don't particularly care for a lot of private practice.
Click to expand...

So, are you in private practice or academia?
If you are in PP and you are saying that you don't like it so early in the game, maybe you should go back to the university hospital where real anesthesia is done by real anesthesiologists?
Deep extubation does not necessarily mean taking the patient to PACU while still deeply anesthetized, you can take the tube out deep and then let them wake up with mask which will eliminate the bucking issue.
You could take them deep to PACU if you have really good PACU nurses but that is obviously rare.
 
I don't see any reason to bust this guys balls like you are doing.

He is simply relaying how his practice works and how he is dealing with it.

Deep extubations are not as simple as some try to make them sound. When done properly, they are great. When done improperly, they can be a mess. Deep extubations were not something that was really taught during my residency, I had to pick it up on my own afterwards. I have found that I am frequently met with blank stares when I try to explain to the nurses how I want the emergence to turn out. This occurs even with "experienced" CRNA's. Since I am not always present for emergence it is just easier to let the nurses wake the pt. up in a manner that they are accustomed to.


Planktonmd said:
So, are you in private practice or academia?
If you are in PP and you are saying that you don't like it so early in the game, maybe you should go back to the university hospital where real anesthesia is done by real anesthesiologists?
Deep extubation does not necessarily mean taking the patient to PACU while still deeply anesthetized, you can take the tube out deep and then let them wake up with mask which will eliminate the bucking issue.
You could take them deep to PACU if you have really good PACU nurses but that is obviously rare.
Click to expand...
 
I am not "busting anyone's balls" Arch!
He said that he does not like many things in private practice and I pointed out that if he thinks so bad of private practice maybe he should not be in private practice!
I hope I did not break any new SDN rules!
If something is not taught in residency this does not make it wrong, actually many things taught during residency are horrible and you spend years of your career working on unlearning them.



Arch Guillotti said:
I don't see any reason to bust this guys balls like you are doing.

He is simply relaying how his practice works and how he is dealing with it.

Deep extubations are not as simple as some try to make them sound. When done properly, they are great. When done improperly, they can be a mess. Deep extubations were not something that was really taught during my residency, I had to pick it up on my own afterwards. I have found that I am frequently met with blank stares when I try to explain to the nurses how I want the emergence to turn out. This occurs even with "experienced" CRNA's. Since I am not always present for emergence it is just easier to let the nurses wake the pt. up in a manner that they are accustomed to.
Click to expand...
 
Planktonmd said:
If you are in PP and you are saying that you don't like it so early in the game, maybe you should go back to the university hospital where real anesthesia is done by real anesthesiologists?
Click to expand...

I consider this busting his balls.

Planktonmd said:
I hope I did not break any new SDN rules!
Click to expand...

Don't worry, you would be banned if that were the case:meanie:.

🙂


Planktonmd said:
I am not "busting anyone's balls" Arch!
He said that he does not like many things in private practice and I pointed out that if he thinks so bad of private practice maybe he should not be in private practice!
I hope I did not break any new SDN rules!
If something is not taught in residency this does not make it wrong, actually many things taught during residency are horrible and you spend years of your career working on unlearning them.
Click to expand...
 
maceo said:
me too.. that kind of stuff is not important to me anymore. i want my patients pain free at the end but not too sleepy. so I let leave the ventilator on turn the gas off and when they buck.. and buck and buck.. they are ready to be extubated.. there you go..........
Click to expand...

😉 You must not do a whole lot of ENT. You avoid a lot of that red stuff when they don't buck on the tube after a tonsil or sinus case. Also nice for the carotids, craniotomies, etc.
 
jwk said:
😉 You must not do a whole lot of ENT. You avoid a lot of that red stuff when they don't buck on the tube after a tonsil or sinus case. Also nice for the carotids, craniotomies, etc.
Click to expand...

I would never extubate a crani without having first done a neuro exam. 50mcg of fentanyl 10 minutes before the head wrapping is all that's needed. As for carotids, some insist on an exam, some don't. I choose the prudent and get the exam prior to extubation. I really doubt that a bit of bucking on a carotid would be the cause of a hematoma. If a hematoma happens, it's from inadequate surgical hemostasis.
 
proman said:
I would never extubate a crani without having first done a neuro exam.
Click to expand...

Hmm.

What exactly does your neuro exam entail?

Following commands? Wiggling feet? How exactly does this change your management?

I understand where you are coming from but I think that stating you would "never" extubate a crani without a neuro exam is a little too much for me.
 
We want to see motor activity in all extremities (doesn't necessarily have to completely follow commands or perform calculus). Otherwise we go to CT intubated. It's our standard.
 
proman said:
We want to see motor activity in all extremities (doesn't necessarily have to completely follow commands or perform calculus). Otherwise we go to CT intubated. It's our standard.
Click to expand...

I can understand that.

I don't think I have ever been to the scanner after a planned case but I have been a couple of times after emergent crani's etc.

I guess that I find that our neuro exam is so rudimentary that I am not sure if it is a predictor of much.
 
DreamMachine said:
The other thing you can do is extubate deep and stick in an LMA. You call roll to CT with an LMA, if need be. Just a thought, if you want to avoid bucking.
Click to expand...

I don't see bucking from a crani being a big deal. If the concern is ICP, there's a chunk of brain missing that gives room to expand into. Switching to LMA sounds overly complex to me. Most of our cranis are kept fairly light at the end and extubated very quickly (we use nitrous routinely which helps speed wakeups).
 
Arch Guillotti said:
I can understand that.

I don't think I have ever been to the scanner after a planned case but I have been a couple of times after emergent crani's etc.

I guess that I find that our neuro exam is so rudimentary that I am not sure if it is a predictor of much.
Click to expand...

I don't know what the evidence is on this. There have been a couple that I know of, but then we do about 1000 cranis a year. The grid placements for seizure seem to be the most common to need a scan.
 
proman said:
I don't see bucking from a crani being a big deal. If the concern is ICP, there's a chunk of brain missing that gives room to expand into. Switching to LMA sounds overly complex to me. Most of our cranis are kept fairly light at the end and extubated very quickly (we use nitrous routinely which helps speed wakeups).
Click to expand...

Bucking on a crani not a big deal? It is at my place. And it's not just ICP. As in most cases, bucking=bleeding. Not a big deal on a total hip. BFD on carotids and cranis. As usual, real-world private practice vs academics. 😉
 
Narcotized said:
One of the places I work is a fairly busy outpatient center all about turnover and maximizing anesthesia dollars. MD's aren't present for extubations; just too many occurring too fast with inductions and preops also going on. Patients are brought to PACU in stage 3 and I've happened to appear during 3 laryngospasms in PACU with PACU nurses vigorously jaw thrusting to open the airway.

Who knows how long it would take to get Sux and Intubation stuff ready if needed. I think it's asking for a really disastrous outcome eventually if all ENT patients are going through stage 2 in PACU. As you say, this is how private practice works, and there is huge resistance to anything suggested differently from a new guy. I don't particularly care for a lot of private practice.
Click to expand...
all they will need is one hypoxic brain injury in a child under the age of 12 and a nurses note saying anesthesiologist was not there for emergence for a career to basically end.

DONT DEEP EXTUBATE ENT PATIENTS and if you must.... do it in the room and the patient does not leave the room until eyes are OPEN.. Those are my rules.
 
jwk said:
😉 You must not do a whole lot of ENT. You avoid a lot of that red stuff when they don't buck on the tube after a tonsil or sinus case. Also nice for the carotids, craniotomies, etc.
Click to expand...
I do all the above all day long... every day. I dont deep extubate cranis and certainly not carotids.. the only time i deep extubate is when i remove my lmas.. I take them out deep.. and the occasional thyroid when a surgeon insists. I usually say .. I dont think so.

Its just more risk.. safer extubating awake. Im at a point where i can make an awake extubation look like a deep extubation if im motivated enough.
 
jwk said:
Bucking on a crani not a big deal? It is at my place. And it's not just ICP. As in most cases, bucking=bleeding. Not a big deal on a total hip. BFD on carotids and cranis. As usual, real-world private practice vs academics. 😉
Click to expand...

Hmm, so you're saying that my academic neurosurgeons are better at hemostasis than your private ones? Okay! :laugh:

Seriously though, I'd consider avoiding bucking more critical to carotids than cranis. But I don't want either to buck, and tailor my anesthetic to avoid it.
 
DreamMachine said:
Overly complex to pull an ETT out and place an LMA?

There is edema and bleeding. Hypertension worsens bleeding. Bucking worsens ICP. It's usually not a big deal, but it's still best to avoid bucking with cranis on extubation.
Click to expand...

Agree totally with this point. You don't need to extubate deep to accomplish this. But I don't consider extubating deep to be worth the cost (ie no neuro exam in the OR). Certainly you accept that there are some cranis that should never be extubated deep (like brainstem or posterior fossa surgery), right? The very real risk of abolishing cranial nerve function far outweights the benefit.

Now to switch to an LMA would require altering the way I emerge. We usually shut off the volatile anesthetic when the dura is closed, and increase the nitrous to 70%. We treat hypertension with labetalol or esmolol. I give a dose of fentanyl around this time and muscle relaxation is reversed when the pins are out and the patient is spontaneously breathing (the VA is gone at this point) while the dressing is applied. Nitrous off, 2 minutes later they are moving their arms and legs and get extubated. We're in the ICU <15 minutes from end of surgery. Changing this to a deep extubation with swapping out to an LMA would not make an OR neuro exam possible and delay emergence. I don't see this as a viable option to avoid bucking (particularly when opioid or lidocaine at the end works so well).
 
maceo said:
Im at a point where i can make an awake extubation look like a deep extubation if im motivated enough.
Click to expand...

This is my goal for just about every case I do. I have removed bucking from my practice. I don't like it. I tolerate it only when doing T&A's on the kiddos- mainly because I'm the only anesthesiologist at the ENT center where I do them. Consequently, I like the little ones with 100% of their AW reflexes by the time I leave the pacu and proceed with the following case. If I knew there was a floater, I would avoid bucking.
 
It is obvious that many people are confusing deep extubation with leaving the OR while the patient is still deeply anesthetized!
These are 2 separate things and if you extubate deep you don't have to leave immediatly! You finish the case with mask and reach whatever level of consciousness you like then you leave.
I sometimes extubate while the surgeon is still closing and just finsh the case with mask and an oral airway.
For craniotomies, I am not sure why you need to have an ETT in the patient to perform a neuro exam?
If the neuro exam is abnormal and they need to reopen or they need to do a CT scan you can re intubate the patient can't you?
Why is it better to wake up a patient who just had a craniotomy with a foreign body in their trachea???
Deep extubation is simply converting a GA case from ETT to mask so the patient does not reach light levels of anesthetsia with a foreign body in the airway.
 
so how you guys perform a deep extubation? where I'm training, i have learned to leave the gas on about 1.0 MAC while having them sv with appropriate titration of narcs to RR --> drop the cuff and see if they buck or continue to breathe around the tube without bucking...if the latter, put in a nasal airway and pull the tube...

has worked fairly well for me until they buck when u drop the cuff...do u deepen them and try again or wait until they wake up? dont know the answer to that...
 
You can pull the tube anytime you want provided the patient is not in stage 2. On average i pull it at 0.3mac with rr between 8 and 12
 
Evidence for what?

I commend everyone for going for the smoothest wakeup possible, especially ENT cases, cranis, carotids, etc. Anybody can wake someone up by shutting off the gas and cranking up the flows but getting a good wakeup really is an art. If someone is gagging and bucking and coughing (which sometimes seems to be unavoidable despite all the tricks everyone does) I almost always just go ahead and pull the tube (as long as everything else looks good). Have not had to reintubate anyone yet (knock on wood).

proman said:
I don't know what the evidence is on this. There have been a couple that I know of, but then we do about 1000 cranis a year. The grid placements for seizure seem to be the most common to need a scan.
Click to expand...
 
DreamMachine said:
The other thing you can do is extubate deep and stick in an LMA. You call roll to CT with an LMA, if need be. Just a thought, if you want to avoid bucking.
Click to expand...

Very smooth Dream. I like that.
 
Narcotized said:
I don't feel safe working there, regardless of the ******* irrelevant comments made by somebody else (this board is nothing more than a chilling out diversion for me, so I won't be engaging in one of those pointless 100 post back and forths).
Click to expand...
If you come here after being out of residency for a couple of weeks and criticize private practice, then telling you that you should not do private practice is not irrelevant.
Your remark was insulting and completely out of context (notice that I did not use any childish or inappropriate language to describe you or your naive statements).
I am not sure how you concluded that because you are working with some sub-par people then all private practice must be not good enough for you!
 
dhb said:
You can pull the tube anytime you want provided the patient is not in stage 2. On average i pull it at 0.3mac with rr between 8 and 12
Click to expand...

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.
 
Congratulations!
You have seen the light 👍

GypsySongman said:
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.
Click to expand...
 
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