better wakeups for obese copd?

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I require my patients to be wide awake with tears rolling down their cheeks. The nurse and scrub tech are typically restraining their arms while I confirm oriented x4.

Given this criteria, any tips for how I can smooth my wakeups a bit? More precedex?

 

[Beeftenderloin]

Ultimately, obese lungs are still overall normally compliant and the obstructive/restrictive component of their obesity is only limited to a certain portion of the lung (mainly the base and posterior portions when supine). Similarly with aggressive insufflation. It takes an immense amount of PEEP to actually inflate these collapsed alveoli and so the PEEP you add with the vent ultimately only gets reflected on the non-affected, normal compliance alveoli that are already carrying the bulk of the oxygenation.

High PEEP in obese patients = alveoli collapsed by weight that remain collapsed and normal alveoli that are now overdistended = pulse ox go boop.

I've seen patients die due to this misunderstanding. It's also the ultimate boss move to find the BMI 55 patient on 100% FiO2 and high PEEP (sometimes as "low" as ~14) and fix their hypoxia by dropping the PEEP down to more normal ranges. Also head up helps.

This is exactly why, if you’re not mindlessly setting the PEEP to 5 like I do for the vast majority of patients, we should be titrating PEEP to driving pressure. It’s such an elegant way, IMO, to know that the PEEP you’ve added has actually recruited alveoli and isn’t just over-distending the ones that were already open, as you say.

 

[pgg]

I require my patients to be wide awake with tears rolling down their cheeks. The nurse and scrub tech are typically restraining their arms while I confirm oriented x4.

Given this criteria, any tips for how I can smooth my wakeups a bit? More precedex?

Ask them to give you a thumbs up!

 

[PpfSuxTube]

This is exactly why, if you’re not mindlessly setting the PEEP to 5 like I do for the vast majority of patients, we should be titrating PEEP to driving pressure. It’s such an elegant way, IMO, to know that the PEEP you’ve added has actually recruited alveoli and isn’t just over-distending the ones that were already open, as you say.

Thats all fine for long term tubed patients but for a lap chole or something other minor procedure under 2 hour procedure what difference could it possibly make... I have colleagues that don't even know how to change peep on the machine and the default is 0 peep at our place... there's no difference.

Once you get into day long cases, olv, cardiac ok then let's talk

 

[abolt18]

Thats all fine for long term tubed patients but for a lap chole or something other minor procedure under 2 hour procedure what difference could it possibly make... I have colleagues that don't even know how to change peep on the machine and the default is 0 peep at our place... there's no difference.

Once you get into day long cases, olv, cardiac ok then let's talk

I feel the same way about "hyperoxia"

 

[Beeftenderloin]

Thats all fine for long term tubed patients but for a lap chole or something other minor procedure under 2 hour procedure what difference could it possibly make... I have colleagues that don't even know how to change peep on the machine and the default is 0 peep at our place... there's no difference.

Once you get into day long cases, olv, cardiac ok then let's talk

I do plenty of day long cases, OLV, and cardiac. Although I can’t remember the last time I titrated PEEP to driving pressure in a cardiac case. It’s the bigger surg-onc/gyne-onc robots that I find I’m most often doing it “for real” in.

I still do it for morbidly obese gallbladders and the like, but I just do so recognizing that the degree of atelecto-trauma I’m preventing has no clinical significance over that time course.

 

[Burned_Out]

I like to perform pure TIVA, no gas that causes airway inflammation. Peripheral nerve block whenever possible to create a narcotic free experience. And no sedation upfront with versed, ketamine or precedex. If there is no reason to give it, don’t!

 

[anesthesiadoc]

Precedex + occasional nasal trumpet. If they need an oral airway, I don’t feel comfortable leaving the OR and bringing them to Pacu.

 

[UscGhost]

I like to perform pure TIVA, no gas that causes airway inflammation. Peripheral nerve block whenever possible to create a narcotic free experience. And no sedation upfront with versed, ketamine or precedex. If there is no reason to give it, don’t!

Versed reduces nausea.

Tiva has increased awareness risk.

Potential risks

 

[pgg]

I like to perform pure TIVA, no gas that causes airway inflammation. Peripheral nerve block whenever possible to create a narcotic free experience. And no sedation upfront with versed, ketamine or precedex. If there is no reason to give it, don’t!

Gas causes airway inflammation?

 

[nimbus]

I like to perform pure TIVA, no gas that causes airway inflammation. Peripheral nerve block whenever possible to create a narcotic free experience. And no sedation upfront with versed, ketamine or precedex. If there is no reason to give it, don’t!

Just prop/remi then?

 

[GassYous]

Nah, I agree. Though I have found bolus doses are good for guys who wake up swinging and girls who wake up over emotional. Does a good job of sedating them with causing respiratory issues.

It annoys be to no end to see people giving it for “multi-modality”. Seems like some people just want to give every med possible without thinking for an actual reason.

We used to do propofol, fentanyl, ketamine, precedex drips for spines. Now I just run propofol/gas and give ketamine/dilaudid up front.

 

[PpfSuxTube]

I like to perform pure TIVA, no gas that causes airway inflammation. Peripheral nerve block whenever possible to create a narcotic free experience. And no sedation upfront with versed, ketamine or precedex. If there is no reason to give it, don’t!

Whatever you're doing has very little evidence, possibly absolutely none.


And why do you call opioids narcotics? Isn't that the term for illegal opioids?

 

[Blackmateria]

Oral airway in when deep, suction thoroughly when deep. Turn sevo to 1 when they're nearing the end, and resp rate to like 4 breaths per minute. Once they start breathing, do two things. Give narcs to lower their rate to like mid teens and shut the gas off and turn flows to total of 1L. If they start moving while they are closing blast the sevo to 8 and crank the flows back up for a few breaths, a few seconds of 8 percent sevo will put them back down while still keeping them spontaneous. The whole key is keeping them slow and spontaneous. Once they are putting dressing on, shut the gas completely off and turn flows up. Gas will come off much faster since you've had it turned off for so long. In my experience its better to let the narcs make them comfy than let the gas or prop keep them asleep. This approach has served me well when alone in a surgery center at 6AM 😬

 

[cchoukal]

Gas causes airway inflammation?

I read a study once comparing BAL IL-2 levels in OLV between des and prop, and the prop group was worse.

 

[UscGhost]

Whatever you're doing has very little evidence, possibly absolutely none.


And why do you call opioids narcotics? Isn't that the term for illegal opioids?

I dont believe much regarding the opiod free anesthetics.

They usually just end up screaming in pacu, or the pacu nurses load them up anyways.

But maybe we are doing it wrong

 

[PpfSuxTube]

I dont believe much regarding the opiod free anesthetics.

They usually just end up screaming in pacu, or the pacu nurses load them up anyways.

But maybe we are doing it wrong

Its also a bit of a stretch to say that someone who get 200 fent for whatever day procedure is going to become a zombie junkie... I mean is there any evidence for that? Absolute hyperbole nonsense ..

 

[pgg]

This thread just proves there are many many ways to do things.

Giving opioids at the end of a case is something I almost never do, because I want fast wakeups. I give the opioid I think they'll need early. Titrating to respiratory rate makes no sense to me in a patient whose rate and minute volume is affected by volatile anesthetic. Late opioids peaking when I want them to wake up is not helpful.

I leave people densely paralyzed during closure, get the gas down to 1/2 MAC or less, then crank the fresh gas flows and give sugammadex as they're finishing. People breath when they're awake and they wake up when the gas is gone ... if they're not overnarcotized. Getting people breathing at the end of a case just reduces MV and slows gas removal.

I'm a fan of giving opioids for painful procedures and not giving them at all for non-painful procedures. I see people give 50 or 100 mcg of fentanyl for intubation in cath lab cases for example, and I don't understand why. I think esmolol is a better choice in most patients.

I think Precedex sucks and that CRNAs shouldn't be allowed or use it, and I think midazolam is the most overused drug in the anesthesia world.

Others disagree and they aren't killing people 🙂 so rock on with whatever works!

 

[cytocide]

This thread just proves there are many many ways to do things.

It also has a few embarrassing moments.

 

[Burned_Out]

Whatever you're doing has very little evidence, possibly absolutely none.


And why do you call opioids narcotics? Isn't that the term for illegal opioids?

I should do a study proving this works. And contrary to your opinion, inhalational agents do affect respiratory mechanics. At the very least, a COPD patient is going to take longer to expel inhalational gas than they would metabolize propofol. Narcotics, opioids, etc. Etc. The grammar police are out in force today.

 

[pgg]

And why do you call opioids narcotics? Isn't that the term for illegal opioids?

?

Narco is a medical prefix. We talk about narcolepsy and CO2 narcosis and narcotized patients who are sleepy.

 

[PpfSuxTube]

The grammar police are out in force today.

No, there's definite connotations btwn the word narcotic and what you're trying to insinuate.
Ive never heard anyone say the phrase narcotic free anesthesia. Opioid free anesthesia ofa is very well described and discussed in the literature.

You were trying to make yourself sound better than us and the rest of us peddlers of street drugs. So go **** off with your holier than thou nonsense that has absolutely no evidence behind it.

You don't know better than the rest of us, you're nothing special. Theres idiots like you in every department. Let's see you run your trial

 

[abolt18]

No, there's definite connotations btwn the word narcotic and what you're trying to insinuate.
Ive never heard anyone say the phrase narcotic free anesthesia. Opioid free anesthesia ofa is very well described and discussed in the literature.

You were trying to make yourself sound better than us and the rest of us peddlers of street drugs. So go **** off with your holier than thou nonsense that has absolutely no evidence behind it.

You don't know better than the rest of us, you're nothing special. Theres idiots like you in every department. Let's see you run your trial

Where I trained, people always used narcotic and opioid interchangeably. No negative connotation with either one. If anything they probably said narcotic more often than opioid.

 

[Burned_Out]

No, there's definite connotations btwn the word narcotic and what you're trying to insinuate.
Ive never heard anyone say the phrase narcotic free anesthesia. Opioid free anesthesia ofa is very well described and discussed in the literature.

You were trying to make yourself sound better than us and the rest of us peddlers of street drugs. So go **** off with your holier than thou nonsense that has absolutely no evidence behind it.

You don't know better than the rest of us, you're nothing special. Theres idiots like you in every department. Let's see you run your trial

You sure sound holier than thou in this thread. The ones who nitpick others in every department I've worked at usually start with belittling others use of terms abhorrent to them. They also critique everything someone else does because that's not what they do. It's usually these snotty new attendings who are so sure of themselves. They follow dogma because that was what they were taught in residency. Anything that deviates from that dogma is considered heretical. You know what....my first year in private practice I had to unlearn everything I learned in residency and fellowship. Because dog**** (I mean dogma) does not always apply in the community.

Oh, if you haven't been following... Fentanyl, oxycodone are commonly diverted for illicit use. So called "narcotics" as you so disdain.

 

[cytocide]

This forum used to be a good resource. It’s **** now.

 

[pgg]

This forum used to be a good resource. It’s **** now.

Then you should contribute something useful, or leave.

 

[Hoya11]

Oral airway in when deep, suction thoroughly when deep. Turn sevo to 1 when they're nearing the end, and resp rate to like 4 breaths per minute. Once they start breathing, do two things. Give narcs to lower their rate to like mid teens and shut the gas off and turn flows to total of 1L. If they start moving while they are closing blast the sevo to 8 and crank the flows back up for a few breaths, a few seconds of 8 percent sevo will put them back down while still keeping them spontaneous. The whole key is keeping them slow and spontaneous. Once they are putting dressing on, shut the gas completely off and turn flows up. Gas will come off much faster since you've had it turned off for so long. In my experience its better to let the narcs make them comfy than let the gas or prop keep them asleep. This approach has served me well when alone in a surgery center at 6AM 😬

i do the same, getting them spontaneous, off PS as early as possible i have found to be the smoothest. i cringe when i see the propofol bolus at emergence to "smooth it out" . once you have SV just titrate gas and flows up and down keeping SV until pulling at 0.2-0.4% et sevo, facemask to pacu

personally i have been burned by the idea that they will breath when they wake up, and now i make them prove adequate SV on the vent before airway removal.

 

[zero2460]

i do the same, getting them spontaneous, off PS as early as possible i have found to be the smoothest. i cringe when i see the propofol bolus at emergence to "smooth it out" . once you have SV just titrate gas and flows up and down keeping SV until pulling at 0.2-0.4% et sevo, facemask to pacu

personally i have been burned by the idea that they will breath when they wake up, and now i make them prove adequate SV on the vent before airway removal.

Propofol is actually less likely to have airway irritation and laryngospasm on emergence than sevo. Most of the literature has been done in peds, but the same holds true for adults - when's the last time you saw someone spasm on emergence from endo? Giving a bolus will blunt airway reflexes and respiration, but titrating in a small amout as you go from 0.5 to 0.2 MAC decreases airway reactivity nicely. I found that 20-30% of induction dose usually does the trick, and if you seen a decrease in respiration, you've given too much.

Propofol also has a lower incidence of emergence delerium than sevo. The EEG on wakeup mimics that of emergence from natural sleep, whereas sevo has a much different pattern. If you need someone following commands quickly, I favor prop over sevo. It's just harder to titrate given you don't have a real-time measure of the concentration in the pt.

Agree with spontaneous ventilation prior to pulling the tube. If you've hyperventillated someone with a baseline Co2 of 55 down to 32, they take a long time to breathe, even wide awake. Definitely long enough to drop their sat if they have a ****ty reserve.

I get my narcotics in well ahead of emergence so I'm not messing with ventilatory drive too close to emergence. Don't pay attention to respiratory rate nearly as much as ETCo2. Body habitus, position, insuflation, ETT size, and amount of vent support will all change respiratory rate and tidal volume in a spontaneously ventillated (or PS) patient, but ETCo2 will be significantly less affected. All other things equal, a pt with an ETCo2 of 47 and RR of 20 is more narcotized than one with ETco2 of 32 but RR of 8.

Generally, make sure pt is adequately reversed, showing good effort to breathe (Spon or PS with vent trigger set at 2.5-3.5), adequately pain controlled, and wakeup on a small amount of propofol. Works reliably for me.

 

[Hoya11]

Propofol is actually less likely to have airway irritation and laryngospasm on emergence than sevo. Most of the literature has been done in peds, but the same holds true for adults - when's the last time you saw someone spasm on emergence from endo? Giving a bolus will blunt airway reflexes and respiration, but titrating in a small amout as you go from 0.5 to 0.2 MAC decreases airway reactivity nicely. I found that 20-30% of induction dose usually does the trick, and if you seen a decrease in respiration, you've given too much.

Propofol also has a lower incidence of emergence delerium than sevo. The EEG on wakeup mimics that of emergence from natural sleep, whereas sevo has a much different pattern. If you need someone following commands quickly, I favor prop over sevo. It's just harder to titrate given you don't have a real-time measure of the concentration in the pt.

Agree with spontaneous ventilation prior to pulling the tube. If you've hyperventillated someone with a baseline Co2 of 55 down to 32, they take a long time to breathe, even wide awake. Definitely long enough to drop their sat if they have a ****ty reserve.

I get my narcotics in well ahead of emergence so I'm not messing with ventilatory drive too close to emergence. Don't pay attention to respiratory rate nearly as much as ETCo2. Body habitus, position, insuflation, ETT size, and amount of vent support will all change respiratory rate and tidal volume in a spontaneously ventillated (or PS) patient, but ETCo2 will be significantly less affected. All other things equal, a pt with an ETCo2 of 47 and RR of 20 is more narcotized than one with ETco2 of 32 but RR of 8.

Generally, make sure pt is adequately reversed, showing good effort to breathe (Spon or PS with vent trigger set at 2.5-3.5), adequately pain controlled, and wakeup on a small amount of propofol. Works reliably for me.

yeah it just seems to me like you are trading one hypnotic for another.. i find i dont need to do that, i dont really have any adverse events emerging on sevo

and most of the time i have a run propofol drip for the case so you can get advantages of a propofol anesthetic without waking up on propofol bolus

 

[zero2460]

yeah it just seems to me like you are trading one hypnotic for another.. i find i dont need to do that, i dont really have any adverse events emerging on sevo

and most of the time i have a run propofol drip for the case so you can get advantages of a propofol anesthetic without waking up on propofol bolus

Oh yeah if you're running a propofol gtt then you should get the same benefits. I typically don't run one but you're right, you're probably getting the same effect with that as titrating in some at the end.