Combative wakeup strategies

[Psai]

---

Members don't see this ad.

What if there are 60+ allergies listed?

Better have your lawyer with you when you go see the patient

 

[AKMD_1984]

most practical and cost effective is titrating propofol IMO, keeping them spontaneous and taking the tube out, esp. if it was a reassuring airway to begin with given ASA - 1...and supporting if necessary with ventilation...biggest source of agitation is the tube at the time of extubation.
Second is pain, but usually, thats easier to treat and pick up just prior to extubation.

post op, it depends after assessing the patient...the usual culprits are hypoxia, inadequte ventilation, too much IV fluids causing CHF/pulm. edema like picture and causing dyspnea, pain etc need to be ruled before treatment.
I had a patient yesterday who I was called to see in PACU (i did not do the case) was on oxycontin 60 TID and percocet 10-325 q4hours and held his AM doses for inguinal hernia repair...he was agitated because of pain...so it really depends...hard part is figuring out what the cause is vs. blindly giving certain meds. Ofcourse some times you cant tell and treat anyway.

sure precedex will work, but its not available everywhere and its $$$.

High dose narcotic therapy and deep extubation places the patient at risk for hypoventilation and over sedation...also if a lot of these patients are ASA - 1 as you say, they may be opioid and benzo naive...

 

[Lurch]

I think there was 1 mention of clonidine. It's a gem and much cheaper than precedex. Titrate at 3-4mcg/kg in divided doses during case for patients in which emergence delirium is expected. Patient can get mildly hypotensive and sometimes bradycardic if you push too fast. Works well in peds and gyn especially. Also works as rescue drug in PACU.

Fair Warning: you will get offers of marriage from PACU RNs which depending on your nurses and stage in life might be a good thing (but probably not).

 

[shift_roro]

I used to anesthetize PTSD Marines all the time. Generous morphine, Iso, deep extubation. 1mcg/kg Precedex over 10 min at the end of the case is a game changer.

FTFY

 

[fakin' the funk]

Agree with others: precedex 0.5 mcg/kg is the best strategy. If they wake up crazy, keep giving 0.25-0.5mg/kg propofol to "reset."

Haldol or droperidol is fine if you can get 'em.

Ketamine 10-20mg is also excellent. Ketamine has a bad rep for bad wakeups, but in my experience, it's because the patients who were always gonna have bad/crazy/screaming/painful wakeups are the ones getting ketamine. Watch a youtube video of someone getting ketamine -- do they look combative? They're stoned af.

My extremely anecdotal opinion is that sevo gives rougher, more combative wakeups than des. Iso is even better/slower/smoother, but who the hell has the time?

Pure propofol wakeups tend to be happier, but still can be very very disinhibited and noncooperative.

 

[facted]

In my opinion, Remifentanil is far better than precedex. They don't care about the tube at all, it doesn't last forever, it's readily reversible if you have any issue, and I can time a remi wakeup far better than a precedex one.

 

[ethilo]

Thanks for all the advice, everyone. I've been really focusing on it this last week and analyzing how to get smooth wakeups. My main hope was to get something that was easily accessible and convenient while giving smoother wakeups. I got to try haldol a couple nights ago. 1 mg given just after induction for a 30 minute case on a 30M strong angry unreasonable IVDU with a shooter's abscess - Woke up very flat and drowsy, much easier to control. I'll definitely consider haldol more in the future. I like its antiemetic component too.

I also did find a strategy I'm going to use a lot more now:
I did some calculations and found that 1 cc boluses of propofol every time the cuff cycles (q3min) on a 70 kg patient is equivalent to a propofol infusion of ~50 mcg/kg/min (47 to be more precise).

It makes calculations in the head really easy for deviations in various ways: If you want 100 mcg/kg/min, double it every cuff cycle. If patient weighs 100 kilos (1.5x 70kg), divide 50 mcg/kg/min by 1.5 gives you a rate of ~35 mcg/kg/m. If you make the cuff cycle q2m instead of q3m it will make it 50 mcg/kg/m again. Having a supplemental propofol "gtt" like this has been super - I've used it a bunch of times now on ambulatory and people seem to emerge very smooth.

Haven't tried precedex yet, I am hesitant to use precedex in general because my program really pushes being cost-conscious and I have yet to find a situation where I desperately needed precedex (or remi) where I couldn't get away with propofol or sufentanil. Precedex is also not as available as propofol, obviously.

 

[narcusprince]

Thanks for all the advice, everyone. I've been really focusing on it this last week and analyzing how to get smooth wakeups. My main hope was to get something that was easily accessible and convenient while giving smoother wakeups. I got to try haldol a couple nights ago. 1 mg given just after induction for a 30 minute case on a 30M strong angry unreasonable IVDU with a shooter's abscess - Woke up very flat and drowsy, much easier to control. I'll definitely consider haldol more in the future. I like its antiemetic component too.

I also did find a strategy I'm going to use a lot more now:
I did some calculations and found that 1 cc boluses of propofol every time the cuff cycles (q3min) on a 70 kg patient is equivalent to a propofol infusion of ~50 mcg/kg/min (47 to be more precise).

It makes calculations in the head really easy for deviations in various ways: If you want 100 mcg/kg/min, double it every cuff cycle. If patient weighs 100 kilos (1.5x 70kg), divide 50 mcg/kg/min by 1.5 gives you a rate of ~35 mcg/kg/m. If you make the cuff cycle q2m instead of q3m it will make it 50 mcg/kg/m again. Having a supplemental propofol "gtt" like this has been super - I've used it a bunch of times now on ambulatory and people seem to emerge very smooth.

Haven't tried precedex yet, I am hesitant to use precedex in general because my program really pushes being cost-conscious and I have yet to find a situation where I desperately needed precedex (or remi) where I couldn't get away with propofol or sufentanil. Precedex is also not as available as propofol, obviously.

I dont need to do all that..... I am one with the force and propofol.

 

[sigrhoillusion]

I dont need to do all that..... I am one with the force and propofol.

I hear rectal brevital on emergence does wonders... 🙄