Bucking on extubation-is it that bad?

[leaverus]

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What about bucking and inner-ear surgery? Has anyone ever heard of or read a case report where bucking damaged a fresh repair?

no, but what use is evidence against a pissedoff surgeon who'll believe whatever he wants and blame you anyway? just extubate deep unless airway/aspiration is a concern

 

[pgg]

What about bucking and inner-ear surgery? Has anyone ever heard of or read a case report where bucking damaged a fresh repair?

Miller and many other sources cite ossiculoplasty and other middle ear surgeries as an indication for a super-smooth emergence. Smells very dogma-ish to me. I struggle to imagine a plausible mechanism by which coughing through a patent endotracheal tube, or higher intra-abdominal pressures would be problematic. I guess I could see an increased risk of bleeding or hematoma formation if the patient gets hypertensive at emergence, or if the cough/buck/valsalva raises venous pressures. I would assume all patients have nonfunctional eustachian tubes postoperatively.

ENTs seem to have universal concern for middle ear volume and pressure changes. I'm skeptical that it really matters, but I like smooth wakeups better than rough ones regardless.

 

[Pooh & Annie]

I've not cared about what they'd rather see a long, long time ago.

I believe you. You seem pretty miserable and your posts are usually scathing. That's probably reflected at work too, which unfortunately probably results in unhappy co-workers and a continuous downward spiral.

 

[Consigliere]

I believe you. You seem pretty miserable and your posts are usually scathing. That's probably reflected at work too, which unfortunately probably results in unhappy co-workers and a continuous downward spiral.

LOL! Stick to the provision of anesthesia there, Dr. Phil.

 

[propadope]

Maybe if you tear the cuff on a tooth on the way in ... 🙂

I don't know. Maybe. But it's plastic. We fill them with saline for air transport and they don't leak. I wouldn't expect lidocaine to leak when saline doesn't, but maybe some drug does get across.

When we had tetracaine crystals available (residency), I would sometimes add them to a lidocaine LTA and spray the cords and trachea prior to intubation. Good for a little longer.

How does nitrous diffuse into the cuff over time and cause increase in cuff volume/pressure? Lidocaine in the cuff needs a lot of time to work. But it is supposed to work. It has been shown to be more effective than saline

 

[criticalelement]

i dont even turn the ventilator off. I turn the gas off and leave the ventilator on.. I only turn the ventilator off when the patient is following commands.... How is that for bucking?

 

[chfo]

i dont even turn the ventilator off. I turn the gas off and leave the ventilator on.. I only turn the ventilator off when the patient is following commands.... How is that for bucking?

Same thing for me. With appropriate amount of narcotic titrated to EtCO2, patients wake up comfortably. Rarely bucking.

 

[Carbocation1]

I believe you. You seem pretty miserable and your posts are usually scathing. That's probably reflected at work too, which unfortunately probably results in unhappy co-workers and a continuous downward spiral.

@Consigliere has stated in the past that he is very happy in real life and comes here to SDN primarily to vent. He is a stud anesthesiologist who makes bank as a partner, and has a sweet life with a wife and kids.

 

[Consigliere]

@Consigliere has stated in the past that he is very happy in real life and comes here to SDN primarily to vent. He is a stud anesthesiologist who makes bank as a partner, and has a sweet life with a wife and kids.

This guy knows the deal! The only dark patch in my life at this time is the miserable performance of the g-damn Philadelphia Eagles.

 

[propadope]

How does nitrous diffuse into the cuff over time and cause increase in cuff volume/pressure? Lidocaine in the cuff needs a lot of time to work. But it is supposed to work. It has been shown to be more effective than saline

I believe lidocaine in the cuff is most effective when it is preceded by topicalization w/ LTA

 

[drmwvr]

Same thing for me. With appropriate amount of narcotic titrated to EtCO2, patients wake up comfortably. Rarely bucking.

How do you "titrate" narcotic to ETCO2 during mechanical ventilation?

 

[Pooh & Annie]

@Consigliere has stated in the past that he is very happy in real life and comes here to SDN primarily to vent. He is a stud anesthesiologist who makes bank as a partner, and has a sweet life with a wife and kids.

Happy, well-adjusted folks don't typically hate on others too much. It also surprises me that a very happy person would need to vent so much. Everyone's different though. If that's what he stated I'm sure he's delightful.

 

[deleted162650]

How do you "titrate" narcotic to ETCO2 during mechanical ventilation?

Let's say the pt is on the vent and you're holding him at an ETCO2 of 40. You notice the pt starts trying to over breathe the vent. Start sprinkling in narcs until he stops trying to over breathe at an ETCO2 of 40. You've now titrated narcotic to ETCO2 on a mechanically ventilated pt.

 

[chfo]

How do you "titrate" narcotic to ETCO2 during mechanical ventilation?

Pressure-support or just manual-spontaneous.

 

[deleted162650]

Miller and many other sources cite ossiculoplasty and other middle ear surgeries as an indication for a super-smooth emergence. Smells very dogma-ish to me. I struggle to imagine a plausible mechanism by which coughing through a patent endotracheal tube, or higher intra-abdominal pressures would be problematic. I guess I could see an increased risk of bleeding or hematoma formation if the patient gets hypertensive at emergence, or if the cough/buck/valsalva raises venous pressures. I would assume all patients have nonfunctional eustachian tubes postoperatively.

ENTs seem to have universal concern for middle ear volume and pressure changes. I'm skeptical that it really matters, but I like smooth wakeups better than rough ones regardless.

So presumably the ENTards are worried about coughing/bucking causing elevated middle ear pressure disrupting their repair. As you alluded to, I would argue that this is anatomically/physiologically impossible in a pt who is intubated (even if they have wide open Eustachian tubes).

If you think about a diver equalizing his ears on a dive, it requires a forced exhalation against a closed mouth and pinched shut nose, but also an open epiglottis so the increased intra-thoracic pressure can be transmitted to the pharynx (nasopharynx specifically) where the E-tubes terminate. A true valsalva with a closed glottis will not equalize your ears no matter how hard you try.

Now with an intubated pt, any intra-thoracic pressure is totally isolated from the pharynx by the ETT and its cuff. Any pressure that is generated will just go out through the circuit. Additionally, with an open mouth and nose, the pharynx pressure (and therefore middle ear pressure) will never rise above the ambient atmospheric pressure regardless of how vigorous the coughing and bucking is.

So as long as your pt doesn't do a Frenzel maneuver on emergence that ossiculoplasty should be fine.

 

[criticalelement]

So presumably the ENTards are worried about coughing/bucking causing elevated inner ear pressure disrupting their repair. As you alluded to, I would argue that this is anatomically/physiologically impossible in a pt who is intubated (even if they have wide open Eustachian tubes).

If you think about a diver equalizing his inner ear on a dive, it requires a forced exhalation against a closed mouth and pinched shut nose, but also an open epiglottis so the increased intra-thoracic pressure can be transmitted to the pharynx (nasopharynx specifically) where the E-tubes terminate. A true valsalva with a closed glottis will not equalize your ears no matter how hard you try.

Now with an intubated pt, any intra-thoracic pressure is totally isolated from the pharynx by the ETT and its cuff. Any pressure that is generated will just go out through the circuit. Additionally, with an open mouth and nose, the pharynx pressure (and therefore inner ear pressure) will never rise above the ambient atmospheric pressure regardless of how vigorous the coughing and bucking is.

So as long as your pt doesn't do a Frenzel maneuver on emergence that ossiculoplasty should be fine.

try telling that to a private practice surgeon who operates on 20 people per week at y our facility.. You will be on the un employment line .. just like many 'ologists.

 

[deleted162650]

.

 

[Ignatius J]

try telling that to a private practice surgeon who operates on 20 people per week at y our facility.. You will be on the un employment line .. just like many 'ologists.

You don't say it to them. You keep it to yourself, accommodate when you can, resist the urge to get in a pissing contest, and do whatever you think is best, explaining your actions if necessary. "The plan was for a smooth extubation. He coughed a little, whereas I tried to titrate in more sedative in hopes of extubating smoothly."

Never had any issues this way.

 

[epidural man]

Someone head over to the ENT area and ask this question. Have them explain the mechanism of increased pressure.

Also ask them why they would rather have the patient blow the sutures in the car ride home when they increase pressure 10x more than in the operating room when they cough and yak, and why they wouldn't want to see if their suture line holds in the operating room where they could fix it?

It seems to me - every surgeon should BEG us to make the patients cough and buck.

We actually do it on purpose after tonsils to test the tonsil beds. It has prevented some re-bleeds in the PACU I am sure of it. They cough, we suck - if it is dry, we proceed with extubation. If it is a little red and juicy - turn the bed back - more zapping - then cough and test - then extubate.

I cannot even comprehend - wrap my little brain around this issue - why a surgeon thinks a smooth extubation is in any way in the patient's (and their) best interest.

I don't have non-coughing wake ups. I gave up trying a long time ago. I guess maybe people talk about me (according to some people on here) - eh...whatever.

I'll tell you what seems to impress though - since I use hardly any opioids, and I use des - I get the patient to move himself over to the bed most of the time. The room team loves that. My guess is they forget about the coughing. Or if they aren't going to move themselves (I learned this at an OB hospital as a resident), instead of rolling the patient the usual way, I place the roller under them, then tilt the OR bed towards the hospital bed (that is situated lower) and the patient naturally rolls down hill right on top of their hospital bed - with no effort. This also seems to get some oohs and ahhs every time - which is very strange because we should all be doing that anyway.

 

[RxBoy]

Has anyone ever seen stitches come undone when pt bucks on extubation? I never have, although I guess it COULD happen.

Similarly, I sometimes work with an inner ear surgeon who goes nuts with any bucking, but I've never heard of or read any case reports that document any damage to any inner ear repair from bucking. Is he just being a douche?

Learn propofol sandwich and respect the tube.

Start a propofol gtt last 10-30 min before extubation depending on length of case. Shut off gas. Then shut off prop 3-5 min before extubation. They wake up wide awake, little to no bucking.

Here is a key thing I did not know as a junior resident... People buck cause the tube irritated their trachea. 99% of the time this happens because the tube moved in the trachea, even millimeters. This can happen when hitting the tube when you suction, shaking them to wake up, adjusting the circuit, scrub tech hitting the circuit with their elbow, changing bed positions, ect.

If you want limited to no bucking, propofol at the end and let sleeping dog lie. Dont touch the tube, dont irritate the patient. Let them wake up by themselves. Say their name, eyes will open and you pull tube. With experience, you can time this perfectly.

 

[criticalelement]

Learn propofol sandwich and respect the tube.

Start a propofol gtt last 10-30 min before extubation depending on length of case. Shut off gas. Then shut off prop 3-5 min before extubation. They wake up wide awake, little to no bucking.

Here is a key thing I did not know as a junior resident... People buck cause the tube irritated their trachea. 99% of the time this happens because the tube moved in the trachea, even millimeters. This can happen when hitting the tube when you suction, shaking them to wake up, adjusting the circuit, scrub tech hitting the circuit with their elbow, changing bed positions, ect.

If you want limited to no bucking, propofol at the end and let sleeping dog lie. Dont touch the tube, dont irritate the patient. Let them wake up by themselves. Say their name, eyes will open and you pull tube. With experience, you can time this perfectly.

ive heard this ... pushing propofol at end of case business a few times in the past year or so..... I don't do that since I want to wake the patient up... not put him back to sleep and propofol
puts patient to sleep............

I usually yell at the top of my lungs to the patient, "Say my name Mother****er" Say what again.. I dare ya, I double dare ya:

 

[Impromptu]

Learn propofol sandwich and respect the tube.

Start a propofol gtt last 10-30 min before extubation depending on length of case. Shut off gas. Then shut off prop 3-5 min before extubation. They wake up wide awake, little to no bucking.

Here is a key thing I did not know as a junior resident... People buck cause the tube irritated their trachea. 99% of the time this happens because the tube moved in the trachea, even millimeters. This can happen when hitting the tube when you suction, shaking them to wake up, adjusting the circuit, scrub tech hitting the circuit with their elbow, changing bed positions, ect.

If you want limited to no bucking, propofol at the end and let sleeping dog lie. Dont touch the tube, dont irritate the patient. Let them wake up by themselves. Say their name, eyes will open and you pull tube. With experience, you can time this perfectly.

For a strange reason the "No Touch" technique is a tough one to learn. We want to appear to be doing something.

 

[chfo]

For a strange reason the "No Touch" technique is a tough one to learn. We want to appear to be doing something.

Exactly, people stimulate the patient in stage 3, which gets them in stage 2, which gets them coughing, and bucking, and causing more movement of the endotracheal tube, causing more coughing and bucking, for the next 3 minutes.

Let a sleeping dog lie.

 

[agammaglobulin]

I'm only a resident but thought I'd offer my 2 cents. Strategies that have worked for me are: (1) Not touching/bothering/moving the patient until they're awake (2) switch to Propofol at end of case vs gas (3) Intracuff lido (long cases) or LTA (short cases) (4) Pressure Control > Volume control (5) IV Lido 1-1.5mg/kg at end of case (takes them longer to wake up though)

 

[WholeLottaGame7]

Someone head over to the ENT area and ask this question. Have them explain the mechanism of increased pressure.

Also ask them why they would rather have the patient blow the sutures in the car ride home when they increase pressure 10x more than in the operating room when they cough and yak, and why they wouldn't want to see if their suture line holds in the operating room where they could fix it?

It seems to me - every surgeon should BEG us to make the patients cough and buck.

We actually do it on purpose after tonsils to test the tonsil beds. It has prevented some re-bleeds in the PACU I am sure of it. They cough, we suck - if it is dry, we proceed with extubation. If it is a little red and juicy - turn the bed back - more zapping - then cough and test - then extubate.

I cannot even comprehend - wrap my little brain around this issue - why a surgeon thinks a smooth extubation is in any way in the patient's (and their) best interest.

I don't have non-coughing wake ups. I gave up trying a long time ago. I guess maybe people talk about me (according to some people on here) - eh...whatever.

100% agree

 

[IceMD]

Lidocaine in the cuff has several small studies in support of it. The idea is some diffuses out over time, the amount of which is increased if the lidocaine is alkalinized to allow more non-charged drug to cross the plastic. It seems to work more often than not when I do it, but it's certainly not 100%. There does always seem to be significantly less fluid in the cuff at the completion of a long case then what I put in initially. Two downsides are that removing the fluid takes significantly longer than removing air if you want to pull the tube fast for any reason, and the cuff occasionally needs to be topped-off as fluid diffuses out over long cases and a leak develops.

http://www.ncbi.nlm.nih.gov/pubmed/9816717

 

[deansrv72]

It is "******ed" if you don't, after giving the ET lido, drop the cuff, give a large breath with the bag, and reinflate the cuff. The medicine percolates up and thru the cords.

Works quite well, actually.

I'm just curious, and maybe you can explain the physics to me, but.. If you give lido via ET, doesn't that volume of lido just get displaced along the bronchi? Where does this percolating volume come from? Suspended at the end of the ET? Even if one was super super fast, and injected the lido down the tube, had a PPV at the ready, deflated the cuff, then squeezed the lido back up, I still don't see your rationale/procedure occurring. Maybe I'm wrong.

 

[drmwvr]

I'm just curious, and maybe you can explain the physics to me, but.. If you give lido via ET, doesn't that volume of lido just get displaced along the bronchi? Where does this percolating volume come from? Suspended at the end of the ET? Even if one was super super fast, and injected the lido down the tube, had a PPV at the ready, deflated the cuff, then squeezed the lido back up, I still don't see your rationale/procedure occurring. Maybe I'm wrong.

You are wrong. Try it. Or don't.

 

[deansrv72]

Thanks for the thoughtful response which doesn't answer the question. And not that it matters to you, nor anyone, but even my colleagues (yes, physicians/anesthesiologists) all concur that your scenario is laughable, at best.