Bucking before Extubation

[Psai]

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Had a middle aged patient with abdominal for a few days found to have an umbilical hernia. Previous bariatric surgery about a year ago but bmi still in the 30s, otherwise healthy with no diabetes or gerd. No significant po for about 24 hours but they put a NG in the patient in the ED with about 300-400 of bilious output and it's been on suction since. When we put the tube on suction in the OR, nothing came out.

At the end they closed skin with staples, I was prepared for skin sutures so my emergence was a bit quicker than normal and the patient was bucking when the gas was low. Gave him a little prop while the gas was coming off because the surgical attending asked me to keep him from bucking and the resident was holding the belly to protect the suture line.

Would you RSI? Can you extubate deep to prevent bucking? Does bucking even matter?

 

[deleted171991]

You put in a tube, not an LMA, right? There's your answer. 😉

Whenever in doubt about an RSI (and the airway/hemodynamics permit), just RSI. Especially if there was concern for bowel obstruction (hence the NGT).

Bucking doesn't matter, especially after a small surgery. If a suture can't hold with the surgeon supporting it, what will happen if the patient coughs later?

Never apologize for doing the right thing for the patient. In case of aspiration, everybody will point their fingers at you, the surgeon first.

P.S. With a NG tube, absence of evidence is not evidence of absence. I would argue that any patient with a NGT deserves RSI (among others, because the LES is kept open).

 

[anbuitachi]

i would definitely put RSI. anyone with NGT already in place gets RSI from me.
Just do a slower wakeup.

 

[deleted162650]

Quick wake ups are easy. Smooth wake ups are easy. Quick and smooth wake ups take practice:

Doesn’t really matter though. 100% chance the patient will cough before they leave PACU and strain to take a dump on POD#1. If the suture line is gonna blow, better to know about it now.

 

[DM27]

To echo the prior sentiments, they should be blessed if you did them the great honor of exposing their ****ty suturing now by having it bust from an intubated patient bucking rather than in the PACU when they're extubated and sneeze and then have to bring them back to the OR.

Smooth wakeups in many scenarios are done purely for the benefit of ego, and they are oh so satisfying to do. An LTA before intubating for a case 90 min or less can do wonders as can some IV lidocaine.

Also, smooth wakeups are way easier if you either transition to propofol or run propofol the entire case with no volatile, you just often need to deal with a slower return of mental status than you would with a volatile.

I would 100% RSI.