Anesthesia emergence questions

[Mike1228]

Struggling with a few thing when it comes to emergence:

1.) Waking up after a GA case with the HOB toward you. I'm told not to slip in the oral airway & suction until the surgeon is completely done since the act of suctioning could cause bucking/coughing. Thing is, i would prefer to slip it in and suction while the patient is deep right before turning down the gas once the surgeon starts suturing the skin. Instead, im often told to start turning down the gas with skin suturing (which i understand) and then suction and oral airway/bite block after the surgeon is finished, but I dont like the idea of suctioning the patient while they are light on 0.5 MAC or less gas. When do you guys place oral airway/bite block AND suction during emergence? Do you do it deeper or when the patient is lighter and after surgeon has finished suturing?

2.) Emergence when HOB is turned away. Do you reverse and turn down gas before turning patient back OR do you just turn down gas as surgeon is finishing and then reverse once is HOB toward you?

3) MEP & SSEP monitoring!! I was under the impression that volatile gases will interrupt MEP monitoring since volatile definitely provides muscle relaxation. Then I was told gas is only contraindicated for SSEP monitoring, not MEP monitoring. This also is the reason why we used gas during thyroidectomies with neuro monitoring, which was confusing because I thought gas would interrupt recurrent laryngeal nerve monitoring.

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[GassYous]

Residency is about trying a bunch of different things while you're still working under someone else's license and tutelage. It is normal to struggle until you find your groove.

1) I almost never place a bite block. Only for the young strong healthy men. I only place oral airways if I have a fat patient that is hypoventilating after extubation or someone with no teeth that is not ventilating properly. I run low flows whole case (0.5-1 L/min) with iso/prop. Prop off when it seems like they are finishing up. Volatile off around same time. and turn on some nitrous I like to give it at least 15 minutes if possible but you can turn it down gradually. I suction when they finish with skin and reverse when dressings are going on. This is possible with sugammadex cause it's basically instantaneous but neo/glyco can take around 10 minutes to kick in depending on when you last paralyzed.

2) If the patient is relatively healthy and not super fat I just reverse and extubate hob away from me. If I have any question I turn them towards me and reverse right before the turn.

3) Gas is not contraindicated for either. It can decrease signal amplitude and increase latency but I just keep it below 0.6 mac and avoid nitrous until the end. Also, I run prop/ketamine and bolus fent. Ketamine helps with the neuromonitoring signal. I used to run prop/remi for thyroids but now I just use prop as an adjunct and use fentanyl. I rarely need more than 100 but the cases are usually under 2 hours. No need for remi just keep em deep.

 

[Katheudontas parateroumen]

Hey great questions and practical ones I’m still trying to find the best was as well. Definitely everyone has their own style.

1. 0.5 Mac alone on gas is probably too light for suctioning. However, with opioid on board, you’re probably good to do some suctioning. So I usually turn the gas down between 0.7-0.5 Mac and get the patient spontaneously breathing on pressure support and titrations opioid. Depending on how fast your surgeons are of course. So usually I’d give them what I think they need in terms of dilaudid/morphine about 15-45 min before case end. That’ll give enough time to know if what you gave is adequate. Another option is just suctioning deeper and give 1-1.5mcg/kg of fentanyl 15min before wake up and just let them ride the vent to blow all the gas off. Either way, I think suctioning deep and once awake is best. Suctioning light only leads to problems I think.
2. Kinda same approach here. I personally always try to get patient spontaneously breathing as soon as possible. Titrations opioid. Yeah I reverse as soon they are close to closing fascia.
3. I may have to check the books again but I’m pretty sure MEPs are much more sensitive to volatile than SSEP. MEP above Mac 0.5 gets greatly affected where as SSEP is a little more forgiving up to <1Mac.

 

[ethilo]

Private practice here
1) I echo what was said. Also residency is the time to cement how to do things in the safest manner possible, to learn what "textbook" is. It's once you get out into practice that you figure out how you will need to do it based on your comfort and the needs of the practice you are in. I had a partner recently say he couldn't remember the last time he DIDN'T deep extubate! Others are much more conservative 😁. My usual wake up is to preO2 to 100% suction oropharynx, cut gas off while closing fascia/skin, bolus the remaining propofol from my 20mL syringe I made for induction, extubate apneic, OPA in and O2 mask on, patient usually breathing again by the time the drapes are down. That's just my way, not necessarily the best but it seems like it is fast, safe, and not interrupting anyone else's work.

2) same strategy when they are spun away from me, I just will keep them down with more propofol.

3) VEP = Very sensitive. SSEP = Sorta sensitive , MEP = Moderately sensitive

 

[Arch Guillotti]

I had a partner recently say he couldn't remember the last time he DIDN'T deep extubate!

There is zero chance that would ever be said where I work.

 

[ethilo]

There is zero chance that would ever be said where I work.

Exactly! I got another guy who essentially never uses muscle relaxant for intubation. Different strokes for different folks. As long as you're being safe and have reasons for why you do what you do.

 

[vector2]

Struggling with a few thing when it comes to emergence:

1.) Waking up after a GA case with the HOB toward you. I'm told not to slip in the oral airway & suction until the surgeon is completely done since the act of suctioning could cause bucking/coughing. Thing is, i would prefer to slip it in and suction while the patient is deep right before turning down the gas once the surgeon starts suturing the skin. Instead, im often told to start turning down the gas with skin suturing (which i understand) and then suction and oral airway/bite block after the surgeon is finished, but I dont like the idea of suctioning the patient while they are light on 0.5 MAC or less gas. When do you guys place oral airway/bite block AND suction during emergence? Do you do it deeper or when the patient is lighter and after surgeon has finished suturing?

2.) Emergence when HOB is turned away. Do you reverse and turn down gas before turning patient back OR do you just turn down gas as surgeon is finishing and then reverse once is HOB toward you?

3) MEP & SSEP monitoring!! I was under the impression that volatile gases will interrupt MEP monitoring since volatile definitely provides muscle relaxation. Then I was told gas is only contraindicated for SSEP monitoring, not MEP monitoring. This also is the reason why we used gas during thyroidectomies with neuro monitoring, which was confusing because I thought gas would interrupt recurrent laryngeal nerve monitoring.

Insert OPA deep and suction deep and then suction again right before extubation if need be. Forcing those things when the pt is at half a MAC is not sound.

 

[epidural man]

I have yet to have a neuromonitor physiologist tell me that the signals are too poor from my 1 MAC.

I usually boost signals with ketamine though.

I'll suction with whatever MAC. That doesn't matter. I'm not sure the concern. You suction when it needs to be suctioned. That could be right before you pull the tube with 0.0 MAC. In my mind, it is much better to suction AFTER passing through stage two, or while in stage 3. I hate it when they bite the Yankeur. Ideally, if you have the perfect amount of opioid on board, you tap them on the forehead - and say "Hey, you are just waking up. You still have the tube in your mouth. You want the tube out?" And they gently nod their head - Then you say "open your mouth" and they comply - you suck them out real quick, and pull the tube.

Timing things take lots of practice, and it is tough in an academic setting since closure timing is so varied.

 

[GassYous]

Hey great questions and practical ones I’m still trying to find the best was as well. Definitely everyone has their own style.

1. 0.5 Mac alone on gas is probably too light for suctioning. However, with opioid on board, you’re probably good to do some suctioning. So I usually turn the gas down between 0.7-0.5 Mac and get the patient spontaneously breathing on pressure support and titrations opioid. Depending on how fast your surgeons are of course. So usually I’d give them what I think they need in terms of dilaudid/morphine about 15-45 min before case end. That’ll give enough time to know if what you gave is adequate. Another option is just suctioning deeper and give 1-1.5mcg/kg of fentanyl 15min before wake up and just let them ride the vent to blow all the gas off. Either way, I think suctioning deep and once awake is best. Suctioning light only leads to problems I think.
2. Kinda same approach here. I personally always try to get patient spontaneously breathing as soon as possible. Titrations opioid. Yeah I reverse as soon they are close to closing fascia.
3. I may have to check the books again but I’m pretty sure MEPs are much more sensitive to volatile than SSEP. MEP above Mac 0.5 gets greatly affected where as SSEP is a little more forgiving up to <1Mac.

If you blow off all the gas, you don't need to get them breathing spontaneously early. I just reverse when gas is low then I turn off the vent. As long as you didn't go too crazy on the opioids they will start breathing. If you did go crazy on the opioids it'll take them time to get to the paco2 that they ned to spontaneously breathe but it will happen eventually. Once their tidal volumes are okay I pull the tube. If you time it right you pull the tube before they start stage 2ing and bucking all over the place.

 

[epidural man]

Regarding reversal and turning the bed, etc -

I like them reversed long before emergence. I want them spontaneously breathing. I feel that feedback helps me.

 

[Reveler]

If you blow off all the gas, you don't need to get them breathing spontaneously early. I just reverse when gas is low then I turn off the vent. As long as you didn't go too crazy on the opioids they will start breathing. If you did go crazy on the opioids it'll take them time to get to the paco2 that they ned to spontaneously breathe but it will happen eventually. Once their tidal volumes are okay I pull the tube. If you time it right you pull the tube before they start stage 2ing and bucking all over the place.

Resident here. This was my preferred method when I was getting the hang of things in early CA1. I didn't like relying on the patient to achieve an adequate minute ventilation and they always blew off the gas slower than if they were completely controlled. Occasionally I'd have someone with no EtSevo that would just refuse to breath bc I hyperventilated the s*** out of them. I'd just have to remind them to breath as we rolled to PACU. Now I almost always get them spontaneous at the end if the procedure allows bc I think it provides useful information. If they're strong and pulling adequate TVs on the bag, then I prefer to extubate them deep unless there's a good reason to have them wide awake. This last point is definitely something that's been tough to get totally comfortable with as a resident imagining life outside the academic nursery.

 

[Reveler]

3) MEP & SSEP monitoring!! I was under the impression that volatile gases will interrupt MEP monitoring since volatile definitely provides muscle relaxation. Then I was told gas is only contraindicated for SSEP monitoring, not MEP monitoring. This also is the reason why we used gas during thyroidectomies with neuro monitoring, which was confusing because I thought gas would interrupt recurrent laryngeal nerve monitoring.

Small tangent: if doing MEPs and a patient is edentulous, do they need the tampons in their mouth?

 

[DrOwnage]

My usual wake up is to preO2 to 100% suction oropharynx, cut gas off while closing fascia/skin, bolus the remaining propofol from my 20mL syringe I made for induction, extubate apneic, OPA in and O2 mask on, patient usually breathing again by the time the drapes are down.

Yeah... Don't do this.

 

[Katheudontas parateroumen]

If you blow off all the gas, you don't need to get them breathing spontaneously early. I just reverse when gas is low then I turn off the vent. As long as you didn't go too crazy on the opioids they will start breathing. If you did go crazy on the opioids it'll take them time to get to the paco2 that they ned to spontaneously breathe but it will happen eventually. Once their tidal volumes are okay I pull the tube. If you time it right you pull the tube before they start stage 2ing and bucking all over the place.

Thanks for the feedback. What do you think are the best signs before they are in stage 2? I have started seeing patients start breathing more from the chest while on spontaneously to be something I’ve looked for. No evidence based. Swallowing? Irregular breathing? Eye brow furrowing? HR changes? All that is already too late in the game. Suction there and they start to buck. But yeah I can see that if they are breathing well enough it’s safe to pull the tube.

 

[woopedazz]

Yeah... Don't do this.

I do it all the time with alf/remi. If you can bag them peri-induction and the airway likely hasn't changed, and you know the opioid you used is wearing off in 10-30 seconds... Why not?

 

[Katheudontas parateroumen]

Yeah... Don't do this.

What about this don’t you like? If you think they are ok for deep extubation, then it seems to be an ok idea to bolus propofol to apnea to give yourself another margin of safety. Propofol should wear off pretty quick if it’s just 1mg/kg or something.

along the same lines of deep extubation... how safe do you guys think it is for the patient to be waking up or possibly stage 2 in the pacu? Worse is stage 2 while transporting? I feel like as long as I can see that the patient is not obstructing in the OR it seems safe to transport. But sometimes I’m still doing some chin lift or something, I just end up waiting for the patient to wake up on their own while I’m holding the mask.

 

[woopedazz]

HOB = Head of Bed?

1.) Waking up after a GA case with the HOB toward you. I'm told not to slip in the oral airway & suction until the surgeon is completely done since the act of suctioning could cause bucking/coughing. Thing is, i would prefer to slip it in and suction while the patient is deep right before turning down the gas once the surgeon starts suturing the skin. Instead, im often told to start turning down the gas with skin suturing (which i understand) and then suction and oral airway/bite block after the surgeon is finished,

Fair points. You can always suction early and get it relatively dry while their deep if you want... but it will reaccumulate if you sit there forever... Which you're going to because the gas is still on AND you haven't reversed them. So you will probably need to suction them again 5 minutes later after waiting for all that... so why traumatise the airway twice?

but I dont like the idea of suctioning the patient while they are light on 0.5 MAC or less gas.

Why? Does it really matter a patient bucks a bit if the surgical field is clear and the airway is secured? For what it's worth I rarely see a patient buck and I'm relatively aggressive with emergence/reversal so I can tube-out as the drapes come down.

Normally I reverse and blow gas off to get them to ~0.3-0.5 and then set low-flows so exhaled gas steadies between 0.3-0.4 during suturing (2-5mins) and suction right at the end; no bite block unless young and strong. They rarely buck if you're gentle and aren't clobbering their pharynx with the sucker. Worst case scenario = you can squirt in a top-up of propofol if the intern is taking >5mins to suture. They shouldn't be paralysed so you won't be giving them awareness, etc.

When do you guys place oral airway/bite block AND suction during emergence? Do you do it deeper or when the patient is lighter and after surgeon has finished suturing?

I do it properly deep if the case requires it. +/- a gentle suction at the end. If they move, you're clearly flying too close to the sun/being too rough with the suction.

2.) Emergence when HOB is turned away. Do you reverse and turn down gas before turning patient back OR do you just turn down gas as surgeon is finishing and then reverse once is HOB toward you?

Depends on case-by-case needs and what I'm running. If I'm running gas I'm pretty hesitant to have the patient anywhere near awake if they're away from my control point. Same with running straight TIVA with fentanyl/intermediate opioid bolus regimes.
If I'm running Remi --> I'm more reassured they won't do anything stupid while we wait for the bed to be turned --> I'll reverse and get them ready early with the head away from the machine.

3) MEP & SSEP monitoring!! I was under the impression that volatile gases will interrupt MEP monitoring since volatile definitely provides muscle relaxation. Then I was told gas is only contraindicated for SSEP monitoring, not MEP monitoring. This also is the reason why we used gas during thyroidectomies with neuro monitoring, which was confusing because I thought gas would interrupt recurrent laryngeal nerve monitoring.

They'll attenuate the response, but the attenuation should be pretty consistent for the duration of the case; unless you like to keep MAC oscillating between 0.5 and 1.5... So it depends on what you're using it for if it really is contraindicated or not. "The evoked potentials are exactly what they've been for the entire case."

 

[deleted875186]

Suction whenever. After doing enough cases you get a feel for when patient will buck with suctioning, putting in a bit block, or futzing around with stuff.

I will either ride the vent or PSV, depending on what I think will be fastest. I bolus prop at the end for younger patients for a more pleasant looking wakeup. Usually pull the tube awake because I think it’s safer, but I have no issue pulling it deep if head us towards me, easy airway, able to bag. Usually I’ll pull deep if I think it’s going to take a while to wake up.

I always wake up with a gauze bite block, personal preference, and I always place it while patients deep or even right after I induce.

 

[vector2]

So you will probably need to suction them again 5 minutes later after waiting for all that... so why traumatise the airway twice?

Important point here. One can do some damage with a yankauer, and while it may seem nitpicky I ask the residents to try and hold it like a pencil rather than with a knife grip. Death grips with 5 fingers and a lot of force are rarely the correct way to do things in anesthesia, regardless of whether we're talking about laryngoscopy, suctioning, OG placement, dropping a TEE probe, or ultrasound lines and blocks.

 

[DrOwnage]

I do it all the time with alf/remi. If you can bag them peri-induction and the airway likely hasn't changed, and you know the opioid you used is wearing off in 10-30 seconds... Why not?

I’m just saying there is no reason to deep extubate someone apneic. We do everything in anesthesia with a margin of safety. We put in central lines with ultrasound, we preoxygenate the patient before we intubate. I do a lot of deep extubations and it’s very easy to get someone to breathe, even if it means decreasing the gas down to 0.5 MAC to get them breathing and then increasing it again. Not every patient is the same and proof of breathing is a good thing, especially since this thread is influencing a trainee.

My steps:
Make sure that muscle relaxation is completely reversed and anti-emetic medication has been given. It is most easily done with inhalation anesthesia and minimal narcotic use. Make sure that tidal volume is adequate, and that the respiratory rate is less than 25. If the patient is breathing rapidly, titrate small amounts of a long-acting IV opioid (hydromorphone, morphine) until the respiratory rate settles down.
Insert an appropriately sized oral airway, and use a suction catheter to suction down the center of the airway and beside it on each side. Secretions are the enemy.

If the patient reacts at all to suctioning, he or she is not deeply enough asleep. Titrate small amounts of IV opioid or propofol, and/or give 1 mg/kg IV lidocaine. Suction again; confirm that the level of anesthesia is deep and that the patient does not react but is still breathing well. Deflate the cuff and remove the tube.

 

[deleted697535]

Intubation is a skill, extubation is an art
Its hard enough to translate it in text form.

one thing is for sure - ppl that say x,y,z can only be done a certain way are usually ones to avoid....

If you miss your window, you missed it... If you've already screwed it up 2 hours earlier it can be hard to claw it back
Loads of ways to do it both right, and wrong

I worked with one guy who couldnt not have laryngospasm on extubation! one week he was 8 from 8 kiddo's lol
He always chose the wrong time to do things. It was like dancing, and he just couldnt tap a beat

 

[DocVapor]

I mask ventilate everyone all the time. That way I don't have to worry about when to extubate.

Plus, my left forearm is JACKED.

 

[deleted162650]

Plus, my left forearm is JACKED.

Ya, I’m sure that’s from all the “mask ventilation”.

 

[Volatile]

Struggling with a few thing when it comes to emergence:

1.) Waking up after a GA case with the HOB toward you. I'm told not to slip in the oral airway & suction until the surgeon is completely done since the act of suctioning could cause bucking/coughing. Thing is, i would prefer to slip it in and suction while the patient is deep right before turning down the gas once the surgeon starts suturing the skin. Instead, im often told to start turning down the gas with skin suturing (which i understand) and then suction and oral airway/bite block after the surgeon is finished, but I dont like the idea of suctioning the patient while they are light on 0.5 MAC or less gas. When do you guys place oral airway/bite block AND suction during emergence? Do you do it deeper or when the patient is lighter and after surgeon has finished suturing?

2.) Emergence when HOB is turned away. Do you reverse and turn down gas before turning patient back OR do you just turn down gas as surgeon is finishing and then reverse once is HOB toward you?

3) MEP & SSEP monitoring!! I was under the impression that volatile gases will interrupt MEP monitoring since volatile definitely provides muscle relaxation. Then I was told gas is only contraindicated for SSEP monitoring, not MEP monitoring. This also is the reason why we used gas during thyroidectomies with neuro monitoring, which was confusing because I thought gas would interrupt recurrent laryngeal nerve monitoring.

1. I pretty much get everyone on PS at the end of the case. All of my patients have a gauze bite block after intubation. Always gauze after hearing about a risk management case for someone chipping their tooth on an OPA. My goal is PS when they are done closing fascia, I am down to .6-.7 Mac at that point. Usually reversal in after fascia closed but most of my patients are at 3-4 twitches during fascia anyway. Then can off during skin closure with low flows. Turn up flows when last couple stitches are going in. Most of the time I’m pulling the tube right after last stitch or when dressings are going on. I could give a **** if the patient happens to cough during dressings, I’ve never had a surgeon complain. I usually suction a second before I pull the ETT, they can’t bite it because of my lovely soft bite block. I can’t remember the last time I extubated someone deep.
2. Pretty much the same as above. If they were an easy airway I’ll usually extubate without turning the bed but our circulator nurses are actually helpful and know how to use the apl/bag if I need positive pressure. If they were a challenging airway I slow down a little and turn bed back.
3. I use volatile all the time at close to 1 Mac for both ssep and mep monitoring and have never had an issue. I actually used to use a nitrous/volatile combo when we only had iso and still never had a problem. Most of the concerns regarding this are academic horse manure. I cover at a hospital where we give roc during MEP monitoring and it’s fine, we just keep them at 3-4 twitches, granted that’s the only Neuro group I’ve seen not care. just my 2 cents

 

[DocVapor]

Ya, I’m sure that’s from all the “mask ventilation”.

No, you're thinking of why my RIGHT forearm is jacked.

I had to find some way to keep things symmetric.

 

[deleted162650]

No, you're thinking of why my RIGHT forearm is jacked.

I figured you clicked with the right.

 

[deleted697127]

Never extubating deep is soft.

 

[ethilo]

I do it all the time with alf/remi. If you can bag them peri-induction and the airway likely hasn't changed, and you know the opioid you used is wearing off in 10-30 seconds... Why not?

Exactly, I also pre-oxygenate before extubation to FiO2 100%. Most of my patients get an LTA sprayed on their cords at intubation so extubation essentially causes no stimulation. So I bolus ~0.5-1 mg/kg propofol at 0.3-5 mac, extubate while apneic. Most come back online within a few seconds. Rarely it's a couple minutes of apnea but that's generally not a big deal since I preoxygenated. They all start breathing with a OPA and facemask at 10 LPM when they do start breathing.

I've had 1 laryngospasm doing this strategy on a kid this last year. It was very easy to manage since I had preO2'd before extubation which gave me all the time in the world to manage it. All it took was another small propofol bolus, jaw thrust, and having him wear his original ambu mask from induction for a few minutes. Then lateral decubitus, face mask, OPA, and all was well again.

Obviously I wouldn't do it exactly like this if they were a BMI 50, septic with COPD and bed 180 degrees. That's again why you learn how to do it the cleanest safest way in residency for those moments.

 

[norski]

Never extubating deep is soft.

Yup, but also sound.

Extubating awake without cough is better. Courtesy of lido and/or remi.

 

[appcan]

I didn't see anyone mention this, but your anesthetic regimen (assuming no paralytics) doesn't really affect recurrent laryngeal nerve monitoring - probably because SSEPs and MEPs are going through 1st and 2nd order neurons, whereas the recurrent laryngeal nerve is going straight to the intrinsic laryngeal muscles.

Edit: http://www.medicalpro.com.br/wp-content/uploads/2013/04/Randoph-IONM_International-standards.pdf
Guidelines published in Laryngoscope state the following, "It is of note that nitrous oxide, other gas IH, and intravenous narcotics do not affect EMG readings. The depth of anesthesia from these agents must be sufficient to avoid any spontaneous activity of the vocal cords. This level of anesthesia may be deeper than usually employed when neuromuscular blockage is used."

Edit 2: Even a MAC around 0.5 might be pushing it for some patients when they're closing. I've had a young patient around 0.5-0.6 MAC with relatively low expected post-operative pain (i.e. I didn't need to give them much intra-op opioid, so reflexes not as inhibited as they could be) start reacting to the tube. I had a patient who smoked marijuana for 4 decades, and they got light (per vitals) just on a small incision at 0.9 MAC with residual fentanyl/propofol from induction. IMO, pt's history and how much medication they have on board are a big consideration on how low of a MAC you should tread during closure.

 

[Arch Guillotti]

I had a partner recently say he couldn't remember the last time he DIDN'T deep extubate!

He must do cupcake cases only!

 

[ethilo]

He must do cupcake cases only!

No doubt, or a lot of dental claims :-D

 

[deleted697127]

No doubt, or a lot of dental claims :-D

?