Combative wakeup strategies

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ethilo

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I'm curious what people's strategies are for waking a middle-age / adolescent male well-built patient who I can tell from early on in the case that the wakeup is going to be combative, aggressive, roller-coaster, potentially dangerous despite even if they were an ASA 1. Sometimes they bite down so hard the gauze roll bite block isn't even enough. Frequently I don't have 3 people around to hold them down if they go wild.

Not going to lie, I'm starting to dread these patients and am a little scared by them. I keep trying propofol boluses while off-gassing I've tried opioid heavy wakeups. I'd rather not lean on deep extubation if I don't have to. After I've encountered a few of these patients I definitely realize ASA1 does not necessarily mean "easy."

Thanks, constructive advice or personal pieces of wisdom are greatly appreciated.
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Two words: choke hold.
 
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Two words: one word: Precedex.

Or more narcotic.

Or deep extubation.

Or avoid midaz preop if it's a short case.

It'll get better. But every once in awhile someone will still surprise you.
 
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Pretty sure if everything else is good this is exactly when a deep extubation is great.

Or propofol. Beats a volatile emergence everytime.

I don't love precedex so I'll be the dissenting opinion there.
 
Psai said:
Why not a bump of sux
Click to expand...

Knuckle sandwich.

But yea, all good suggestions. Propofol is good. Nice slug of that, not weeny 10-20mg.

I think if it's good airway a deep extubation is a good choice. Sometimes these guys wake up crazy even after deep extubation but i find they are way worse with a hard piece of plastic in their trachea.
 
You tell a nurse to get on one side and an anesthesia tech to get on the other and not let him fall off. Narcotics and a propofol bonus help too.

One rule: I rarely fight anyone that is just a side sleeper. I've seen pacu nurses go WWE on patients that simply want to sleep on their side. Let 'em sleep on their side.
 
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Sevo during the case, nitrous last 15 mins. They wake up awake for the most part, very rarely have any issue.
 
Avoid midazolam. Make sure they go to sleep smooth. How they go to sleep is how they wake up.
 
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Physio Doc 2 Be said:
Right here. 10mcgs at a time until 0.5mcg/kg over the last 30ish minutes of the case. They wake up sleepin'.
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Outside of peds I don't think I've seen 0.5mcg/kg given ever. Maybe it's just my patient population in residency but no way attendings let us approach that. I really was never impressed with precedex in adults.

Maybe I'll play with it a bit more once out in practice on the bigger ones but in general I think either a deep extubation or the ol' propofol sandwhich work great.

I'm gonna play more with pgg's haldol he always advocates as well.
 
Robotic Wis-Hipple said:
Outside of peds I don't think I've seen 0.5mcg/kg given ever. Maybe it's just my patient population in residency but no way attendings let us approach that. I really was never impressed with precedex in adults.

Maybe I'll play with it a bit more once out in practice on the bigger ones but in general I think either a deep extubation or the ol' propofol sandwhich work great.

I'm gonna play more with pgg's haldol he always advocates as well.
Click to expand...

??? .5 is a normal dose. Precedex is amazing. Load them 1 mcg/kg and titrate

But yea I like propofol or precedex for smooth wakeup. Or remifentanil
 
Not a big fan of precedex for combative emergence....seems like dose is either too low and does nothing or too high and prolongs emergence. Would rather bolus prop 10mg at a time to effect. Even better for a young Asa 1 with easy airway is just pulling the tube deep.
 
I am neither anywhere close to adolescence but am not overweight- had my first surgery under GA last month- lap chole in a surgery center. According to the 6 recovery staff that tried to restrain me as I rotated over and over winding my monitoring wires and tubes and IV around me while mooning the staff. They used IV hydromorphine to put me down in doses causing hypoxia but then I awakened much more rationally. Of course I don't remember any of this. So in surgery centers where precedex is not available what is the drug of choice in the PACU for bad patients like me?
 
narcusprince said:
Avoid midazolam. Make sure they go to sleep smooth. How they go to sleep is how they wake up.
Click to expand...

What does it mean to "go to sleep smooth"? Verses going to sleep rough?

Also trainees dont become too dependent on precedex. Its still not widespread on community hospital formularies
 
Smooth induction, if their is any agitation before they go to sleep then likely they will wake up agitated. Caveat I have taken care of some very bad guys in my practice. Avoid ketamine.
 
If you try to restrain a patient while he's waking up you're in for a rough ride.
 
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I just have one of the female techs use their voice to wake them up. A gentle touch helps a lot too.
Works every time 30% of the time.

For the rest, I prefer a little propofol or narcotics.

Precedex works well too, but I have to plan in advance since that isnt in every room like the other things. Ill use it if there is a bigger history of PTSD or violent wakeups.


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Nitrous at end of case, prop, narcotics.

I swear its the volatile agent coming off quickly that causes some of the yournger pts to emerge like bats out of hell.
 
I have had multiple people tell me 'precedex doesn't work.' Usually I just take their patient that got 20mcgs or whatever, and turn that into 40, 80, 120....you get the idea. I've never had precedex 'not work.' Love precedex.
 
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Hamhock said:
I am not an anesthesiologist: would you or someone else please expand on this?

Thanks,
HH
Click to expand...

Delirium being exacerbated by impaired sensorium....meds that may linger at the end of a case can worsen post op delirium. Classic case would be something really short like ear tubes or tonsils that got PO midazolam that is absorbed slowly in the stomach--waking up kid will have lingering sedation making delirium worse.
 
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Hamhock said:
I am not an anesthesiologist: would you or someone else please expand on this?

Thanks,
HH
Click to expand...
Paradoxical dysinhibition - pts go nuts, become exited, agitated - basically secondary to inhibition of the restraining influences of the cortex and frontal lobe due to the GABA-mimetic action of benzodiazepines.
 
algosdoc said:
I am neither anywhere close to adolescence but am not overweight- had my first surgery under GA last month- lap chole in a surgery center. According to the 6 recovery staff that tried to restrain me as I rotated over and over winding my monitoring wires and tubes and IV around me while mooning the staff. They used IV hydromorphine to put me down in doses causing hypoxia but then I awakened much more rationally. Of course I don't remember any of this. So in surgery centers where precedex is not available what is the drug of choice in the PACU for bad patients like me?
Click to expand...

Get Precedex there.


--
Il Destriero
 
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The only thing I have to add to this is if you've given adequate narcs and then some. Try some metoprolol. Get the heart rate in the sixties. And most importantly, pull the tube deep. Or better yet use an LMA at every chance. I let them pull heir own LMA out if I don't pull it deep.
 
As you're emerging them just give a touch of ketamine (10-15mg). I've used it several times on bigger guys that I was afraid were going to hulk out and it worked like a charm.
 
IlDestriero said:
There's literature in peds that sevo increases emergence delirium.


--
Il Destriero
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I can't even think of the last ED case I had and I use sevo for the case and nitrous last 15 mins on just about everyone.

I will also add if you're really worried about the wakeup, there is nothing like remi. Precexex doesn't even come close.
 
Watch out for the allergy sign and propofol sign.

Allergy sign- multiple listed medications with non-specific "allergic" symptoms- i.e. "it upsets my stomach", "makes me dizzy", etc.

Propofol sign- Writhe in pain on propofol injection like they are being tortured.

If the patients have both of these signs, make sure you have written for narcotics in recovery and have a bit of propofol to bolus on emergence.
 
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My academic program leads hard on sevo, but i swear iso wake ups are the most smooth, specially for younger where you are afraid of delirium emergence.

Although, ive noticed for ortho cases if i can get them breathing spontaneous, without support, then wean gas to 2 SD of MAC when closing, i havent had any huge issues with delirium emergence. Sometimes you need to hit them with 20-30mg propofol, and that smoothes everything out.

We use precedex, but ive never seen an attending or anyone use it at the end sololy for preventing combative wake up.
 
Libertas said:
Delirium being exacerbated by impaired sensorium....meds that may linger at the end of a case can worsen post op delirium. Classic case would be something really short like ear tubes or tonsils that got PO midazolam that is absorbed slowly in the stomach--waking up kid will have lingering sedation making delirium worse.
Click to expand...

OTCAwesome said:
Paradoxical dysinhibition - pts go nuts, become exited, agitated - basically secondary to inhibition of the restraining influences of the cortex and frontal lobe due to the GABA-mimetic action of benzodiazepines.
Click to expand...

These are what I suspected were being referenced (well known), but I guess I was/am surprised that there is such a strong feeling about it...and that there is that much of an effect for anything but the shortest of cases (not including ORAL midaz).

Thanks, though. HH
 
OP, you're on the right track, you just have to dial in your execution a bit. You've already gotten good advice.

First, topicalize the trachea. LTA for shorter cases (<2 hrs) or lido paste on the ETT for longer cases. Nothing will make a 1/2 awake pt angrier than big plastic stick in their airway.

Next, get rid of the volatile - all of it. You want to be waking these guys up with 0.00% EtSevo. Bypass stage 2 with other drugs. People have mentioned prop which is good, but I like nitrous because it's right there on the machine and it goes away quick when I want it to. That brings me to #3:

Narcotics. People wake up happy when they're stoned. Any narc will work, but for some reason Dilaudid seems to make people the most puppy dog like. Titrate it in till they're breathing nice and slow - like RR of 6-8.

Also, plan out you're wake-ups and make it nice and slow and smooth. Going from a MAC of volatile to turning it off and cranking the flows up is a recipe for ugliness.

As far as choke holds go, it's amazing how much control you can have over someone with relatively little effort just by putting a hand on their forehead and keeping their head pressed against the table. If that doesn't work then maybe a whiff of sux - you know just enough to show 'em who's boss.

And Precedex, well I think it's a good sedative for people who really didn't need a sedative in the first place.
 
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SaltyDog said:
OP, you're on the right track, you just have to dial in your execution a bit. You've already gotten good advice.

First, topicalize the trachea. LTA for shorter cases (<2 hrs) or lido paste on the ETT for longer cases. Nothing will make a 1/2 awake pt angrier than big plastic stick in their airway.

Next, get rid of the volatile - all of it. You want to be waking these guys up with 0.00% EtSevo. Bypass stage 2 with other drugs. People have mentioned prop which is good, but I like nitrous because it's right there on the machine and it goes away quick when I want it to. That brings me to #3:

Narcotics. People wake up happy when they're stoned. Any narc will work, but for some reason Dilaudid seems to make people the most puppy dog like. Titrate it in till they're breathing nice and slow - like RR of 6-8.

Also, plan out you're wake-ups and make it nice and slow and smooth. Going from a MAC of volatile to turning it off and cranking the flows up is a recipe for ugliness.

As far as choke holds go, it's amazing how much control you can have over someone with relatively little effort just by putting a hand on their forehead and keeping their head pressed against the table. If that doesn't work then maybe a whiff of sux - you know just enough to show 'em who's boss.

And Precedex, well I think it's a good sedative for people who really didn't need a sedative in the first place.
Click to expand...

The hand against the fore hand is golden advice. My dad would do this to my brother and i when we were little, who then used this trick on our little cousins.

:)
 
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"Allergy sign- multiple listed medications with non-specific "allergic" symptoms- i.e. "it upsets my stomach", "makes me dizzy", etc."

To go along with this, any time the allergy list creeps above around 7, scan their problem list and there's probably a 90% chance fibromyalgia will be listed. The sensitivity encroaches on 95% if there are 2+ pain medicines on the list.

Probably 99% fibromyalgia if there are 7+ allergies, 2+ to pain and NONE of them are actually serious reactions. So you can toss all that stuff you learned in medical school about pressure points and all that jazz they say is needed to diagnose fibro...
 
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Not a lot to add because there's already a ton of good advice here.

One thing I can mention that I don't think I saw anywhere else on this thread:

PO Guanfacine, pre-op.


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sigrhoillusion said:
"Allergy sign- multiple listed medications with non-specific "allergic" symptoms- i.e. "it upsets my stomach", "makes me dizzy", etc."

To go along with this, any time the allergy list creeps above around 7, scan their problem list and there's probably a 90% chance fibromyalgia will be listed. The sensitivity encroaches on 95% if there are 2+ pain medicines on the list.

Probably 99% fibromyalgia if there are 7+ allergies, 2+ to pain and NONE of them are actually serious reactions. So you can toss all that stuff you learned in medical school about pressure points and all that jazz they say is needed to diagnose fibro...
Click to expand...

What if there are 60+ allergies listed?
 
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