Busy ENT Room

[Beeftenderloin]

New CA1 here. Doing a busy ENT room on Monday. 7-8 cases, mostly nasal airway reconstructions, tonsillectomies, etc. with a pair of private practice ENTs that really try to push the pace of the room. Any tips out there on reliably quick and/or smooth wake-ups in these cases?

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[Psai]

Turn off gas early and do prop bumps

Use nitrous or des

 

[Hoya11]

New CA1 here. Doing a busy ENT room on Monday. 7-8 cases, mostly nasal airway reconstructions, tonsillectomies, etc. with a pair of private practice ENTs that really try to push the pace of the room. Any tips out there on reliably quick and/or smooth wake-ups in these cases?

don't turn the vent on, intubated, bag, wait for them to come back.. get them breathing early that's the whole trick. I use sux

 

[Iso4ane]

And have you syringes prepped and ready to go a few cases ahead. If Jay Ko is not around you can draw up the meds too.

 

[Shimmy8]

Not that I disagree with above...but you’re a CA-1 and it’s August. My main piece of advice is focus on the patient and discuss/learn from your attending to formulate plans. Don’t get bogged down with details and forget the big picture.

The quick little tricks/tips will come with time.

 

[chocomorsel]

Not that I disagree with above...but you’re a CA-1 and it’s August. My main piece of advice is focus on the patient and discuss/learn from your attending to formulate plans. Don’t get bogged down with details and forget the big picture.

The quick little tricks/tips will come with time.

Absolutely agree. This doesn’t seem like an appropriate room for a CA1. This should be a CA3 room where it is all about efficiency. Too early for all this:

 

[dchz]

Not that I disagree with above...but you’re a CA-1 and it’s August. My main piece of advice is focus on the patient and discuss/learn from your attending to formulate plans. Don’t get bogged down with details and forget the big picture.

The quick little tricks/tips will come with time.

+1

you don't even know how to do all the tricks yet, but you're gonna go ahead and be fast at doing them?

 

[deleted875186]

Whike it’s satisfying to wake people up promptly and time things perfectly, you earn no extra points for doing so in residency. I would use it as a day to learn how to time short cases to wake up quickly off gas, or you could try some deep extibations if appropriate.

 

[ProtonPump]

Agree with everyone else, as a CA-1 work on being safe, speed comes with experience. Don't deep extubate the T&A's, it's not worth it. For the Senior residents looking to up the tempo, have your meds and fluids ready to go at the start of the day also for the cases where they ENT is going to spin 90º try just leaving the OR table that way all day (saves two spins per case).

 

[Beeftenderloin]

Not that I disagree with above...but you’re a CA-1 and it’s August. My main piece of advice is focus on the patient and discuss/learn from your attending to formulate plans. Don’t get bogged down with details and forget the big picture.

The quick little tricks/tips will come with time.

Of course taking care of the patient and thoroughly understanding the basics comes first. But if patient looks good, I get caught up on charting, and set up for next case, I’d just like some additional food for thought on how to make the day run more smoothly.

 

[shepardsun]

also for the cases where they ENT is going to spin 90º try just leaving the OR table that way all day (saves two spins per case).

Started doing this for all my 90 and 180 cases and it's changed my life. Attending is gonna be in the room for induction and emergence anyway, might as well make themselves useful and bag for you while you intubate/extubate at the head of the bed. Saves so much time.

 

[Beeftenderloin]

Absolutely agree. This doesn’t seem like an appropriate room for a CA1. This should be a CA3 room where it is all about efficiency. Too early for all this:

I’m at a small to medium size community program that’s also a level 1 trauma center, level 3 NICU and covers high risk OB. Seniors are typically doing the “bigger” cases so occasionally CA-1s get put in rooms a little above their pay grade.

 

[deleted162650]

CA-1s get put in rooms a little above their pay grade.

That’s good for you. At my program CA-1’s did everything including cardiac. You grow up quick. By the end of CA-1 year I felt comfortable in any main OR type case.

 

[IMGASMD]

You’re less than 50 days in. High turnover room like this, IMO, is inappropriate. Like other have said, you should focus on the mechanics of doing the case. I would actually take my time and not rushing anything. I would extubate everyone responsive, awake with an attending. The last thing you need as a ca1, who’s 50 days in, is extubate too early and having trouble with airway in an ENT case. Let the patient take their time to wake up.

 

[IMGASMD]

That’s good for you. At my program CA-1’s did everything including cardiac. You grow up quick. By the end of CA-1 year I felt comfortable in any main OR type case.

We do ob and cardiac first year too, but usually after December. We don’t baby our residents either; but 1/2 hr ENT rooms, before CA1 even get the charting done, ENT is already giving you the 5 min warning.

But we are also not a big program that actually let their pgy1 spent months doing anesthesia rotation. I’ve heard some bigger place will have pgy1 starting in January doing anesthesia relevant stuff.

 

[Psai]

Whike it’s satisfying to wake people up promptly and time things perfectly, you earn no extra points for doing so in residency. I would use it as a day to learn how to time short cases to wake up quickly off gas, or you could try some deep extibations if appropriate.

Actually in residency you get punished by getting some asa5 micu addon that goes until 10pm because slow surgeon

 

[shepardsun]

Actually in residency you get punished by getting some asa5 micu addon that goes until 10pm because slow surgeon

Truth. You get absolutely no personal benefit from efficiency and high turn over in residency. You just get more cases. As soon as I came to term with that, and that fact that you could never count on getting out at a certain time/relieved by the late list, I became a much happier person.

 

[anbuitachi]

is anyone concerned of fire risk when using nitrous for ENT cases like tonsils. the tonsils are pretty close to the tube. 70% nitrous is pretty concentrated.

for a lot of ENT cases i like a combination of nitrous with propofol, since nitrous comes off quickly and from my experience usually have less crazy wake up/stage 2 than desflurane.

deep extubation is a possibility but i dont like doing that for Tonsils if they aren't going to protect their airway well..
also our PACU nurses are not good with deep extubations or airway management


Also as a resident i dont care about how fast i am since the early i finish, the more cases they add to my room. the best time to finish is 4-5pm since that is usually the safe time here. finish before 4 and you risk getting a case added and you are then looking at a 7pm+ leave..

 

[facted]

Started doing this for all my 90 and 180 cases and it's changed my life. Attending is gonna be in the room for induction and emergence anyway, might as well make themselves useful and bag for you while you intubate/extubate at the head of the bed. Saves so much time.

Instead of this, organize your lines so that the spin doesn't take any time. One day you'll be on your own...

 

[Mman]

New CA1 here. Doing a busy ENT room on Monday. 7-8 cases, mostly nasal airway reconstructions, tonsillectomies, etc. with a pair of private practice ENTs that really try to push the pace of the room. Any tips out there on reliably quick and/or smooth wake-ups in these cases?

As others mentioned, just worry about the basics and it's your attendings job to help keep the day moving. But simply as an observation, note that a busy ENT day in the real world might have 20+ cases in the room and be done by 3, not 7 or 8 cases and then you will appreciate how fast you will eventually be able to do things.

 

[ProtonPump]

Instead of this, organize your lines so that the spin doesn't take any time. One day you'll be on your own...

If there is enough space in the OR, I find that the fixed 90º position of the bed and the anesthesia machine can be maintained in such a way that you can still bag and control everything from the head of the bed and still not have to spin.

 

[facted]

If there is enough space in the OR, I find that the fixed 90º position of the bed and the anesthesia machine can be maintained in such a way that you can still bag and control everything from the head of the bed and still not have to spin.

If you have the room and can configure as such, then great. But honestly, if you think about the direction of your lines and monitor cords, a 90 ( or even 180) spin shouldn't taken more than a few seconds.

 

[facted]

If you want to wake up patients on a dime, I suggest 70% nitrous, 30mcg/kg/min and titrate remi from .1 up to .3. turn down remi to .05 10 minutes out and don't turn off anything else off until head is to you and you're ready. Patient will wake up within a minute or two vast majority of the time. I personally leave the remi at .05 during wake up, but you can turn it off when you turn everything else off. These wakeups areincredibly smooth, no bucking.

That being said, obviously expensive with the remi. Also, titrate a small amount of fent through the case, none in the last 15 or 20 minutes. And dexamethasone and zofran for PONV prophylaxis. With this, patients do fantastic and surgeons will be very happy with you.

 

[anbuitachi]

If you want to wake up patients on a dime, I suggest 70% nitrous, 30mcg/kg/min and titrate remi from .1 up to .3. turn down remi to .05 10 minutes out and don't turn off anything else off until head is to you and you're ready. Patient will wake up within a minute or two vast majority of the time. I personally leave the remi at .05 during wake up, but you can turn it off when you turn everything else off. These wakeups areincredibly smooth, no bucking.

That being said, obviously expensive with the remi. Also, titrate a small amount of fent through the case, none in the last 15 or 20 minutes. And dexamethasone and zofran for PONV prophylaxis. With this, patients do fantastic and surgeons will be very happy with you.

do you do this in Private practice?

 

[abolt18]

We do ob and cardiac first year too, but usually after December. We don’t baby our residents either; but 1/2 hr ENT rooms, before CA1 even get the charting done, ENT is already giving you the 5 min warning.

But we are also not a big program that actually let their pgy1 spent months doing anesthesia rotation. I’ve heard some bigger place will have pgy1 starting in January doing anesthesia relevant stuff.

Ours is one program that does a lot of anesthesia and anesthesia related rotations our intern year (3 months OR anesthesia, 1 month acute pain, 1 month chronic pain, 1 month CTICU staffed entirely by anesthesia faculty).

But more in response to the original topic of this thread, I definitely know that I have a lot of inefficiencies and I work to improve those, but if a nurse says some crap like "anesthesia delay" when I'm turning over my room, I'm happy to tell them that I'm going to do it right or not do it at all and they can enjoy the few minutes of a break.

I also err on the side of a slower wakeup over having them coughing on the tube ready to take it out before my attending gets in the room. I don't mind that everyone is staring at me and the patient waiting for them to blow off that last bit of volatile. I had to stand there staring at the med student while he sutured. I know this will get better with time and experience.

 

[facted]

do you do this in Private practice?

Yes, I've used it from time to time. I don't work alone too often and I can't trust CRNAs to do it exactly right (turning down remi 15 minutes our is essential, for example).

 

[deleted162650]

If you want to wake up patients on a dime, I suggest 70% nitrous, 30mcg/kg/min and titrate remi from .1 up to .3. turn down remi to .05 10 minutes out and don't turn off anything else off until head is to you and you're ready. Patient will wake up within a minute or two vast majority of the time. I personally leave the remi at .05 during wake up, but you can turn it off when you turn everything else off. These wakeups areincredibly smooth, no bucking.

That being said, obviously expensive with the remi. Also, titrate a small amount of fent through the case, none in the last 15 or 20 minutes. And dexamethasone and zofran for PONV prophylaxis. With this, patients do fantastic and surgeons will be very happy with you.

That’s a lot of extra work especially in a busy ENT room. For every case you’re gonna reconstitute/dilute remi, set the pump, one more line to worry about? Everything you can do with remi, you can do with carefully titrated fentanyl.

 

[facted]

That’s a lot of extra work especially in a busy ENT room. For every case you’re gonna reconstitute/dilute remi, set the pump, one more line to worry about? Everything you can do with remi, you can do with carefully titrated fentanyl.

It's honestly not that much work, can easily set it up at the end of the previous case. But yes, it's one more thing.

You can do a lot with fent, but try the technique I mentioned above and then try to replicate it with Fent. The reliability and absolutely smooth wakeup that remi gives you, esp in airway cases is not easy to replicate with Fent, especially in short stimulating cases such as laryngoscopy and biopsy.

 

[Ezekiel2517]

These cases are not easy, quick, wake-ups, even for seasoned PP attendings. These patients all have bad OSA and other airway issues and there's blood in the airway. As a CA-1, your goal is not for efficiency with a room like this. Your goal is for a smooth day. No drama, such as a barely arouseable patient desatting in the pacu. I've seen it so many times when inexperienced people feel rushed. If you let people rush you, you will feel uncomfortable and won't think clearly and that's when mistakes happen. Don't allow them to rush you.

 

[Psai]

Ours is one program that does a lot of anesthesia and anesthesia related rotations our intern year (3 months OR anesthesia, 1 month acute pain, 1 month chronic pain, 1 month CTICU staffed entirely by anesthesia faculty).

But more in response to the original topic of this thread, I definitely know that I have a lot of inefficiencies and I work to improve those, but if a nurse says some crap like "anesthesia delay" when I'm turning over my room, I'm happy to tell them that I'm going to do it right or not do it at all and they can enjoy the few minutes of a break.

I also err on the side of a slower wakeup over having them coughing on the tube ready to take it out before my attending gets in the room. I don't mind that everyone is staring at me and the patient waiting for them to blow off that last bit of volatile. I had to stand there staring at the med student while he sutured. I know this will get better with time and experience.

I've never understood this. You have 3 years to do anesthesia. The whole point of intern year is to learn medicine.

 

[abolt18]

I've never understood this. You have 3 years to do anesthesia. The whole point of intern year is to learn medicine.

I can't say I know the reason, but I can say I really appreciated it as a resident having those intermittent months of reprieve from medicine/surgery rotations, as well as having friendly faces throughout the hospital that are "your people."

We do 3 total months of "intern" rotations during pgy 2-3 years including EM and cardiology. It works out just fine.

 

[anbuitachi]

That’s a lot of extra work especially in a busy ENT room. For every case you’re gonna reconstitute/dilute remi, set the pump, one more line to worry about? Everything you can do with remi, you can do with carefully titrated fentanyl.

Disagree with this one. Remi is quick on quick off. Fent is not. What are you titrating your fent to to make it so precise? Unless you are deep extubating at the end.

 

[deleted162650]

Disagree with this one. Remi is quick on quick off. Fent is not. What are you titrating your fent to to make it so precise? Unless you are deep extubating at the end.

You have much to learn young Padawan. And remi is not as fast off as advertised.

 

[Arch Guillotti]

You have much to learn young Padawan. And remi is not as fast off as advertised.

Remi is superior, just have to time it right.

 

[facted]

You have much to learn young Padawan. And remi is not as fast off as advertised.

Remi is off quickly, you just have to turn it down early enough. Think half lives.

 

[Mman]

Remi is off quickly, you just have to turn it down early enough. Think half lives.

if you are thinking half lives on a 15 minute case, you are thinking too hard. Remi has no place in a quick ENT room IMHO.

 

[anbuitachi]

if you are thinking half lives on a 15 minute case, you are thinking too hard. Remi has no place in a quick ENT room IMHO.

Depends on practice institution i'm guessing. we dont do deep extubations here cause our pacu nurse cant handle them. what are your techniques for quick ENT cases? these patients are often pretty sick, and ENT cases can be very stimulating with very short/no closure time and with little pain afterwards so we often dont even give any opioids other than remi. we sometimes use fentanyl but dont think it works as well as remi cause you need a lot of it to blunt bucking and with that much fentanyl just slows emergence.

 

[daneeka]

I'll add one to the mix: my favourite peds tonsils recipe

Setup:
Draw up several propofol syringes for the list (like for endoscopy)
Draw up 2mg remifentanil in 20mL
Squirt 1mL of the remi (100microg) into the propofol syringe to give 5microg/mL
If you're ampoule sharing you'll need a system to prevent cross contamination, otherwise it's a new remi ampoule for each case

Gas induction with N2O and sevo
IV
Lignocaine to cords
Intubate with oral RAE*

Connect to the pump:
Propofol 10mg/mL mixed with remifentanil 5microg/mL at 1.5mL/kg/hr (so remi ~1.3microg/kg/min)
Turn off the sevo and N2O

Then:
Fentanyl 1-2microg/kg
Dexamethasone 0.15mg/kg
Tramadol 2mg/kg
Parecoxib 1mg/kg

Titrate your TIVA; aim for spontaneous ventilation the whole time
Usually drop to 1.2mL/kg/hr of the remi/props mixture

Suction
Extubate deep left lateral
If misbehaving at induction, consider awake extubation

*Can use a flexi LMA instead if you/surgeon are comfortable

It sounds like a lot of work, but it isn't once you've got a system.
The wakeups are incredible. Opens eyes in PACU and asks for an icypole, then off to the ward.
Emergence delirium is still possible, but rare.

For kids >8 years, halve the remifentanil concentration otherwise they'll be apnoeic

 

[anbuitachi]

I'll add one to the mix: the ultimate peds tonsils recipe

Setup:
Draw up several propofol syringes for the list (like for endoscopy)
Draw up 2mg remifentanil in 20mL
Squirt 1mL of the remi (100microg) into the propofol syringe to give 5microg/mL
If you're ampoule sharing you'll need a system to prevent cross contamination, otherwise it's a new remi ampoule for each case

Gas induction with N2O and sevo
IV
Lignocaine to cords
Intubate with oral RAE*

Connect to the pump:
Propofol 10mg/mL mixed with remifentanil 5microg/mL at 1.5mL/kg/hr (so remi ~1.3microg/kg/min)
Turn off the sevo and N2O

Then:
Fentanyl 1-2microg/kg
Dexamethasone 0.15mg/kg
Tramadol 2mg/kg
Parecoxib 1mg/kg

Titrate your TIVA; aim for spontaneous ventilation the whole time
Usually drop to 1.2mL/kg/hr of the remi/props mixture

Suction
Extubate deep left lateral
If misbehaving at induction, consider awake extubation

*Can use a flexi LMA instead if you/surgeon are comfortable

It sounds like a lot of work, but it isn't once you've got a system.
The wakeups are incredible. Opens eyes in PACU and asks for an icypole, then off to the ward.
Emergence delirium is still possible, but rare.

For kids >8 years, halve the remifentanil concentration otherwise they'll be apnoeic

how do you get remi at 1.3 mcg/kg/min??
i'm sure it works for you since youve been doing it for a while but propofol and remifentanil mixtures separate when mixed

 

[daneeka]

how do you get remi at 1.3 mcg/kg/min??
i'm sure it works for you since youve been doing it for a while but propofol and remifentanil mixtures separate when mixed

Remifentanil 5microg/mL at 1.5mL/kg/hr = 7.5microg/kg/hr = 0.125 microg/kg/min

Just googled remi/props separating over time and you're right. The study I saw had the syringe in a vertical position whereas I use it in a horizontal position, so not sure if that makes a difference.

I also mix the remi/props immediately prior to using. Haven't noticed a problem tbh but I see where you're coming from.

 

[deleted162650]

Remi is superior, just have to time it right.

I might share that sentiment if was supervising nurses. I personally can do better with good ol’ fentanyl.

 

[deleted162650]

we sometimes use fentanyl but dont think it works as well as remi cause you need a lot of it to blunt bucking and with that much fentanyl just slows emergence.

Paralytic does a better job preventing bucking than any opioid.

Fentanyl doesn’t have to slow your emergence. It’s amazing how much fentanyl someone can take and still be awake. The key is getting rid of all the other crap on board. Skipping midaz goes a long way too.

 

[anbuitachi]

Paralytic does a better job preventing bucking than any opioid.

Fentanyl doesn’t have to slow your emergence. It’s amazing how much fentanyl someone can take and still be awake. The key is getting rid of all the other crap on board. Skipping midaz goes a long way too.

We dont paralyze in a lot of ENT cases. Some are too short and we dont have suggamedex readily available. All they got is the initial sux. And many other procedures involve nerve monitoring

 

[deleted162650]

We dont paralyze in a lot of ENT cases. Some are too short and we dont have suggamedex readily available. All they got is the initial sux. And many other procedures involve nerve monitoring

Don’t give sux. Low dose roc/vec. Titrate as necessary keeping them reversible but weak throughout the case. This will let you come way down on the amount of anesthesia/narcs you’re giving them. No sugg necessary. Obviously that won’t jive with neuromonitiring, but what cases are you monitoring aside from thyroids and parathyroids? Those cases have some closure time to work with anyways.

 

[Mman]

Depends on practice institution i'm guessing. we dont do deep extubations here cause our pacu nurse cant handle them. what are your techniques for quick ENT cases? these patients are often pretty sick, and ENT cases can be very stimulating with very short/no closure time and with little pain afterwards so we often dont even give any opioids other than remi. we sometimes use fentanyl but dont think it works as well as remi cause you need a lot of it to blunt bucking and with that much fentanyl just slows emergence.

Mask them down with nitrous and sevo, pop in an IV and put the tube in. ENT takes out tonsils, injects some local, and makes sure airway is dry. Get them on their side, take out tube, make sure still breathing well and take to PACU. Maybe a little precedex to smooth out the wake up.

 

[facted]

News flash: there's a ton of ways to safely do an anesthetic and look good doing it. Try a few methods and see what you like best for you.

 

[deleted162650]

News flash: there's a ton of ways to safely do an anesthetic and look good doing it. Try a few methods and see what you like best for you.

Ya but my way is the BEST!!

 

[anbuitachi]

Don’t give sux. Low dose roc/vec. Titrate as necessary keeping them reversible but weak throughout the case. This will let you come way down on the amount of anesthesia/narcs you’re giving them. No sugg necessary. Obviously that won’t jive with neuromonitiring, but what cases are you monitoring aside from thyroids and parathyroids? Those cases have some closure time to work with anyways.

what are you titrating to? twitches??

thyroids, parathyroids, parotids, some parts of neck dissections and free flaps,

 

[2Fast2Des]

But my attendings said their way is the only way, and any other way is wrong. Meaning how every other attending does their thing is wrong according to each other. How does that work?

 

[Beeftenderloin]

But my attendings said their way is the only way, and any other way is wrong. Meaning how every other attending does their thing is wrong according to each other. How does that work?

Fortunately I train at a place where most of the attendings are self aware enough to recognize everyone does things differently. But it still doesn’t stop them from demanding you do it their way when with them... and chewing you out when you don’t.