Deep v Awake T&A Extubation

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Me. 🙂

I just make sure they are past stage 2 and breathing well in the lateral position before heading out of the OR. Out of habit I always have one hand on the crib/bed and the other with my fingers over their chin/palm of my hand over their mouth assessing ventilation on the way to pacu. Always suction blood out of the stomach before waking up.

Never had a problem.
 
One of my partners does it all the time with healthy kids at the ASCs. I do not. Though I have considered it from time to time as there are no trainees out there and the field is always bone dry.
It's not outside the standard of care, but I think that it does add risk. If they go into laryngospasm in the PACU, I'll probably be in the middle of the next induction. Not ideal patient care.
 
How does extubating deep increase your chances of laryngospasm in pacu?
 
I don't, not the way I was raised.

Also, I don't trust the PACU nurses with a kid who hasn't passed through stage 2 yet. If I'm going to wait in the OR until they're past stage 2 then one of the big advantages of deep extubation (reduced turnover time) is nearly moot.


sevoflurane said:
How does extubating deep increase your chances of laryngospasm in pacu?
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Mainly RN harassment.

*pat* *pat* *pat* "TAKE SOME DEEP BREATHS!" *pat* *pat* *pat* *sternal rub* "TIME TO WAKE UP YOU'RE GOING TO MISS THE BUS AND HAVE TO WALK TO SCHOOL!"
 
Wow, wow.... wait a minute now:

The situation you guys are describing is that of a patient being dropped off in pacu while they are transitioning through stage 2 + someone who is hypoventilating needing to get stimulated in order to breath. That is just silly, certainly not ideal patient care and is not the definition of a deep extubation. NONE of my patients go through this... ever.

I'm not dogging awake extubations but have you guys ever wondered if you could have prevented a post tonsillar bleed because your patient wakes up chocking on the tube increasing tonsillar capillary bed pressure.? I have. i certainly have had post tonsillar bleeds come back at 2:00am to get cauterized. And this coupled with the fact that even a small amount of blood can cause N/V is the reason I extubate deep.

Tube comes out deep with good TV, a little jaw thrust + hand on the bag until they are reaching up to pull the mask off of their face + good TV and respiratory pattern +/- phonation. Safely beyond stage 2 and no disconjugate gaze. I don't use narcs anymore which may change things for you guys. I see no problem with this technique and i certainly don't think it's "riskier".

Just my 2 cents dudes. 🙂
 
I don't think there's anything wrong with deep extubations and emergence in the OR.

At the peds hospital where I rotated as a resident, there were a couple attendings who would pull the tube deep, take to the PACU, and let them emerge there with the PACU nurse while they went to see their next patient. I don't do that because I think it's nuts.

I don't do deep extubations + emergence in the OR for T&A cases because honestly I find I have faster emergences and turnover times if I vent them myself at a reasonable MV until they're awake rather than get them spontaneously breathing at some lower MV. Your point about a smoother wakeup with less rebleed potential is well taken but I'm basically happy with my awake extubations. You don't give them narcotics; I do.
 
When I extubate deep, I don't wait around in the room for them to come through stage 2. They are deep, but spontaneously ventilating. They go through stage 2 in the PACU, often with an OPA. Our nurses are capable of handling emergencies and stage 2. They do it every day. However, at the ASCs, where the healthy patients tend to go, there is not usually anyone available to go to an emergency in the PACU so I don't do it.
There's no increased risk of deep extubation and emergence in the OR, but I don't do that. Our need to go back to sleep for a bleed on emergence is very rare. Bucking on the tube doesn't seem to increase bleeding.
I usually give them 0.1 mg/kg morphine unless they have OSA. I would think they would be pretty unhappy with no opiates in the OR. Are they not screaming in the pacu? I'd rather give them a good base of opiate in the OR and lightly tune them post op for discharge. Clogging beds in the ASCs is a no go here.
 
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A lot of these kids have snot running down their nose, maybe getting over a mild lower/upper/ AW bug... etc. Honestly I worry more about pulling a tube wide awake in these (often asthmatic) kids calling into action robust AW reflexes... the kind that may cause laryngospasm and/or bronchospasm. I think these kids are ideal for a deep extubation. It's just smoother IMO.

A bit of pressure behind the jaw is a great way to get rid of your volatile + since this is a 20 minute case, these kids get rid of sevo/des like lightning quick... A little pressure behind the mandible and your TV will increase + you can assist these kidos to help them along the way and speed things up. I honestly think deep extubation + waiting in the room past stage 2 doesn't take any longer than removing the tube. I think it is probably still faster IMHO. It's not like when you extubate awake you remove the ETT and immediately head out...

For pain, we've started to use IV paracetamol. We add to that precedex.

Once the tonsils are torched, the surgeon applies 4x4's soaked in marcaine and epi for 2 minutes on each tonsillar bed. This maneuver, although likely not long lasting, does provide analgesia well into the post-operative period.

No respiratory depressants intra-op. All my kids are sleeping comfortably when they get to pacu. Once they wake up, if they need it, nurses can give them narcotics. This is usually not necessary once mom shows up with an ice popsicle. 😀

I'm 100% sure IlD has pulled tons more T&A's than I have. I trust in his experience. But really, it's dealers choice and either way is 100% acceptable IMHO.

🙂
 
I am still working on my T&A "recipe" so I don't have a lot to add (but since when has that stopped me from posting)?

Sevo, do you pass an OG to suction the stomach on all your tonsils?

I tried the no narc technique and neither I nor my PACU nurses were happy. I just ended up with more screaming kids that did not get out of PACU any earlier. This may be because I do not use any premeds and my surgeons inject local but do not soak the bed like Sevo was talking about. Who knows? This is one of the areas of anesthesia that is an art, not a science. I have seen a pretty even split between awake vs deep in my short career so deep extubation is not a breech of standard of care.

I don't think that every deep extubation needs to be fully awake in the OR. If you have a patient with no airway concerns (save laryngospasm), en empty stomach, a good working IV, good ventilatory pattern etc, I see no problem taking them to PACU to complete emergence. I think that there should be a properly equipped anesthesiologist at their side until they have completed emergence, but I don't see why that can't be done in the PACU while the anesthesiologist is giving report etc.

When I am working with peds T&A's I do carry a syringe of SUX with a small IM dose in my pocket. If one of those buggers ever laryngospasms on me on induction or in transport, I won't be stuck scrambling for some SUX.


- pod
 
All,

Just a little note to say this thread rox.

This is one of those threads that gets the young'ins critically thinking. At first, be you a pre-med, med student, CA-0, you might think, "Why would an anesthesiologist EVER extubate these kids deep. Like what could the physio/medico/legalo (new word) benefit be to that? Isn't it more dangerous? Sounds more dangerous! Why take a chance? Are you EVEN TAKING a chance?"

Then, you read all the reasons WHY one might extubate one of these T&A kiddies deep!
And you learn. A-ha moments follow.

Then you think, what about all the dogma herein taught during training?

Then you think, well maybe this is one of those times you should use your BRAIN instead of, or at least, in conjunction with a textbook.

Really highlights how CREATIVE medicine really is. So when people tell me, "Why go from tv writing to medicine, they are so different," I always say, no, they're not. They both utilize your MIND. Be they same side of the brain, or alternate sides. Big whoop.

And then we hear a couple counterpoints to each argument.

And a few more reasons why you guys DO WHAT YOU DO.

All without shouting, or kicking, or screaming. From leaders on this board.

REAL. WORLD. ANESTHESIA. Discussing a topic that is palatable for the curious peeps out here. Whether we get it all or not. It's SO amazing to read.

Really appreciate and love the way you went about this thread.

The subtext within this thread, that it states there are...

a) many ways to skin a cat
b) surely pros and cons to many of the pathways one takes
c) methods specific to certain workplaces
d) sharing knowledge creates knowledge

is really important IMHO.

So, thanks!

D712

p.s. Just read this from PERIOP, "This is one of the areas of anesthesia that is an art, not a science." YES. And I would imagine being a great artist
in the OR is what makes the Jets and Sevos and UTs and Periops and IlDs and PGGs so good and unique at what they do.
 
sevoflurane said:
Wow, wow.... wait a minute now:

The situation you guys are describing is that of a patient being dropped off in pacu while they are transitioning through stage 2 + someone who is hypoventilating needing to get stimulated in order to breath. That is just silly, certainly not ideal patient care and is not the definition of a deep extubation. NONE of my patients go through this... ever.

I’m not dogging awake extubations but have you guys ever wondered if you could have prevented a post tonsillar bleed because your patient wakes up chocking on the tube increasing tonsillar capillary bed pressure.? I have. i certainly have had post tonsillar bleeds come back at 2:00am to get cauterized. And this coupled with the fact that even a small amount of blood can cause N/V is the reason I extubate deep.

Tube comes out deep with good TV, a little jaw thrust + hand on the bag until they are reaching up to pull the mask off of their face + good TV and respiratory pattern +/- phonation. Safely beyond stage 2 and no disconjugate gaze. I don’t use narcs anymore which may change things for you guys. I see no problem with this technique and i certainly don’t think it’s “riskier”.

Just my 2 cents dudes. 🙂
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I am not averse for any anesthesiologists extubating deep post tonsillectomy at all as long as they are with the patient at all times until the kid is awake screaming and eyes open. Anything less than that I believe is not ideal. I personally would not extubate deep because i dont believe it adds benefit and it is more risky and i just dont feel like breaking laryngospasm in a child.

I dont believe the coughing has anything to do with post tonsillectomy bleeding or very minimal. IT has more to do with the method the surgeon used to cauterize the vessel. Some of them use alternate methods to minimize the post op pain. and those alternate methods lend themselves to post tonsillectomy bleeds.
 
I almost always extubate T&A's deep. I don't use any muscle relaxant on kiddie T&A's - get em deep, a couple mg/kg of lidocaine, and tube. While we're doing our IV/ETT thing, the circulator pops in a tylenol suppository. Most of these cases are about 15 minutes tops in our private practice. I'm +/- on the narcs, but I have no problem using them. I frequently have the surgeon remove the tube when they pull out the mouth gag. I make no attempt to lighten them up before that point. We put them on their side on the stretcher, and off we go. With sevo/des, these kids wake up quick, and most of the time they're rousing before we get to PACU, but if not, our nurses are used to handling these kids, and there is always someone free if there is a problem. I firmly believe that coughing and straining DOES increase bleeding, and have always found deep extubation a great benefit for most ENT cases, peds or adult.
 
jwk said:
I firmly believe that coughing and straining DOES increase bleeding, and have always found deep extubation a great benefit for most ENT cases, peds or adult.
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When you say this, do you mean acute bleeding at extubation/immediate post op or late bleeding. The former may make sense to me, but the latter does not.
I can only speak from my own experience/surgeons, but all of mine wake up straining and bucking on the tube after a vigorous suction, including running an OG down to suck up the oral premed (never any blood). I can count the number of times they've had to go back to sleep for an immediate bleed in the last few years on one hand. (and I do a lot of T&A's)
Do your surgeons use ultrasound coblation? Ours do not due to increased post op bleeding risk which they confirmed themselves when they trialed it for a while. Of course electrocautery has more post op pain.
Many ways to skin this cat, and they are influenced by the surgical practice as well. For example, ours don't use any local, if they did, maybe I could skip the opiates.👍
 
I have done them both ways due to attendings' preferences. Most of ped attendings give Vec and run the case with a little bit Sevo. We extubate these kids awake after full reveral. The little bit of sevo can be blown away fast and kids get off stage 2 very quickly.

If we are not using muscle relaxant, we usually deep extubate the kids. We make sure there is no airway reflex before taking the tube out. If in doubt, we inform the surgeon and extubate them awake.
 
Mac4 said:
I have done them both ways due to attendings' preferences. Most of ped attendings give Vec and run the case with a little bit Sevo. We extubate these kids awake after full reveral. The little bit of sevo can be blown away fast and kids get off stage 2 very quickly.

If we are not using muscle relaxant, we usually deep extubate the kids. We make sure there is no airway reflex before taking the tube out. If in doubt, we inform the surgeon and extubate them awake.
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😕😕 Why I wonder? Slower onset, longer duration.

I don't paralyze. After the 1st tonsil is out the propofol has worn off and I get them to resume spontaneous breathing. Before then, I might supplement with a couple of propy boluses.
 
jwk said:
I almost always extubate T&A's deep. I don't use any muscle relaxant on kiddie T&A's - get em deep, a couple mg/kg of lidocaine, and tube. While we're doing our IV/ETT thing, the circulator pops in a tylenol suppository. Most of these cases are about 15 minutes tops in our private practice. I'm +/- on the narcs, but I have no problem using them. I frequently have the surgeon remove the tube when they pull out the mouth gag. I make no attempt to lighten them up before that point. We put them on their side on the stretcher, and off we go. With sevo/des, these kids wake up quick, and most of the time they're rousing before we get to PACU, but if not, our nurses are used to handling these kids, and there is always someone free if there is a problem. I firmly believe that coughing and straining DOES increase bleeding, and have always found deep extubation a great benefit for most ENT cases, peds or adult.
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Niceeee....😉

👍
 
I am going into my last week of a peds rotation where I have been doing 20-30 ENT cases per day (ASC). All T&A's get a N2O/Sevo mask induction, followed by propofol and fentanyl (1mcg/kg) before intubation. Gas is kept relatively light until patient is SV and then titrated to effect. The surgeon's last act is to suction the patient. We then kill the gas and go 100% O2 after flushing the circuit, turn the table, re-suction the patient and pull the tube. Patient is then assisted on O2 until breathing is deep and regular and then transported to the PACU. The PACU nurses here are great and they all use precordials to monitor respiration until the patient is awake. Problems are identified early and the design of the place is such that an attending is never more than about 50ft away. We use toradol in the PACU to great effect on our patients, but none of the tonsils get any.

I believe all of the airway complications I have seen have been with patients who were light at extubation and therefore predictably at risk for laryngospasm.
 
jwk said:
I almost always extubate T&A's deep. I don't use any muscle relaxant on kiddie T&A's - get em deep, a couple mg/kg of lidocaine, and tube. While we're doing our IV/ETT thing, the circulator pops in a tylenol suppository. Most of these cases are about 15 minutes tops in our private practice. I'm +/- on the narcs, but I have no problem using them. I frequently have the surgeon remove the tube when they pull out the mouth gag. I make no attempt to lighten them up before that point. We put them on their side on the stretcher, and off we go. With sevo/des, these kids wake up quick, and most of the time they're rousing before we get to PACU, but if not, our nurses are used to handling these kids, and there is always someone free if there is a problem. I firmly believe that coughing and straining DOES increase bleeding, and have always found deep extubation a great benefit for most ENT cases, peds or adult.
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The above is fine if you dont let the nurses in the pacu emerge the patient. The ideal situation is when you emerge the child yourself.

I personally extubate these kids awake and certainly dont leave the room until they are awake. I dont like to worrry about the kid in the hallway or the pacu.

If coughing increases bleeding there is something wrong with the hemostatic method..
 
I was a CRNA in a past lifetime and was taught to pull the tube routinely at the first sign of bucking (the worst time ever). I don't know, looking back, what they were thinking when they taught us to do that. We had to deal with spasm not daily but a few times each week for sure. At the same time I did learn how to extubate deep at other times.

I say that if the surgeons, on a case like tonsils or hernia repairs, haven't done their job well enough to stand up to some bucking they aren't doing it correctly. The first time the kid cries or coughs or strains postop we are going to be heading back to the OR so the surgeon can do the job correctly the second time.

Any suture line or cautery job should be done well enough to let the pt cough and strain without undoing the surgery. Early extubation is fraught with a danger that, if the surgeon does his part correctly, you don't have to risk.

Why even take the small risk. Get the surgeon to do his job.

Just my humble opinion.
 
Dejavu said:
I was a CRNA in a past lifetime and was taught to pull the tube routinely at the first sign of bucking (the worst time ever). I don't know, looking back, what they were thinking when they taught us to do that. We had to deal with spasm not daily but a few times each week for sure. At the same time I did learn how to extubate deep at other times.

I say that if the surgeons, on a case like tonsils or hernia repairs, haven't done their job well enough to stand up to some bucking they aren't doing it correctly. The first time the kid cries or coughs or strains postop we are going to be heading back to the OR so the surgeon can do the job correctly the second time.

Any suture line or cautery job should be done well enough to let the pt cough and strain without undoing the surgery. Early extubation is fraught with a danger that, if the surgeon does his part correctly, you don't have to risk.

Why even take the small risk. Get the surgeon to do his job.

Just my humble opinion.
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👍

I agree with everybody on this thread regarding surgeons technique and surgical bleeding. We do about 3-4 bring back tonsils a year (heavy ENT service). These 3 or 4 I wonder about. Is there anything I could have done differently to avoid this complication?

Looks good at the end of the case...? then heavy bucking + increase in capillary bed pressure, maybe dislodgment of hemostatic plug or small area of the torched tonsilar bed leading to a small but persistent bleed that is not recognized post-op....?

For you medical students out here there is this thing called Law of La Place. Although it is typically used describing abdominal aortic aneurysms, it may have some applicability here:

La Place's law describes the relationship between the transmural pressure difference and the tension, radius, and thickness of the vessel wall. The higher the pressure difference the more tension there will be. On the other hand, the thicker the wall the less tension there is (torched tonsillar beds). Also, the larger the radius the more tension there is (ie AAA's). These three rules culminate into one equation:
T = ( P * R ) / M
Where T is the tension in the walls, P is the pressure difference across the wall, R is the radius of the cylinder, and M is the thickness of the wall.

We have some rockstar ENT dudes over here... but we still see tonsillar bleeds from time to time. I'm of the belief that these small isolated cases may have benefited from a deep extubation... It certainly does not hurt and may be protective... but who knows maybe they would have bled anyways....

🙂
 
Dejavu said:
I was a CRNA in a past lifetime and was taught to pull the tube routinely at the first sign of bucking (the worst time ever). I don't know, looking back, what they were thinking when they taught us to do that. We had to deal with spasm not daily but a few times each week for sure. At the same time I did learn how to extubate deep at other times.

I say that if the surgeons, on a case like tonsils or hernia repairs, haven't done their job well enough to stand up to some bucking they aren't doing it correctly. The first time the kid cries or coughs or strains postop we are going to be heading back to the OR so the surgeon can do the job correctly the second time.

Any suture line or cautery job should be done well enough to let the pt cough and strain without undoing the surgery. Early extubation is fraught with a danger that, if the surgeon does his part correctly, you don't have to risk.

Why even take the small risk. Get the surgeon to do his job.

Just my humble opinion.
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agreed 10o percent.. frown on deep extubation and certainly early extubation( on first bucking) are you kidding me? thats what they taught you?
 
sevoflurane said:
😕😕 Why I wonder? Slower onset, longer duration.

I don't paralyze. After the 1st tonsil is out the propofol has worn off and I get them to resume spontaneous breathing. Before then, I might supplement with a couple of propy boluses.
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The reason these ped guys chose vec is that they feel they can reliably fully reverse the kids even 10-15 minutes after giving vec at moderate dosage (0.05-0.08 mg/kg). Roc is still relatively new and a little unpredictable sometimes.

By giving vec, they can run gas low and get off stage 2 quickly at the end. In addition, they normally wait until sevo at 0.4 to give full reversal. This little bit vec at the end can prevent bucking if some kids start waking up at high sevo and going into stage 2 eariler.
 
hivoltage said:
agreed 10o percent.. frown on deep extubation and certainly early extubation( on first bucking) are you kidding me? thats what they taught you?
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Yeah, honest to God, but it was 34 yrs ago. But, I suppose, we have all gotten smarter since 34 yrs ago, right?
 
I keep em spontaneously breathing ~12/min w/narcotic, sev ~ 1% 50/50 nitrous. Put the cuff down and if they don't move pull the tube. Seems to work ok and they wake up really quick
 
imfrankie said:
Wondering who extubates kiddies deep s/p tonsillectomy
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Let's see...trying to figure out the numbers of how many tonsils I've done...previous gig (where we had a hospital and surgery center) at the surgery center we probably did 20 pedi tonsils a week, thats 80 a month, 960 in a year, times 8 years there= 7680 tonsils, divided between 5 partners is around 1500.

OK, I've done around fifteen hundred pedi tonsils.

Every single one of them was extubated deep.

We were blessed to work with highly skilled ENT surgeons who took...literally...fifteen minutes to do the procedure.

The beauty of our biz is there's many, many ways to accomplish the same goal.

I can proudly report our recipe worked well. We chose to Keep It Simple, Stupid.

The K.I.S.S. technique.

WHATS THE KISS TECHNIQUE FOR PEDI TONSILS?

Sevoflurane. And an intra-op tylenol suppository.

That's it.

Lemme 'splain:

We had three ROKKSTAR ENT surgeons. Fast. Great. No drama.

Turnover time between these cases averaged eight minutes.😱

Kid would be rolled in, transferred to OR table, monitors on, sevo wide open,kid goes to sleep, tylenol suppository placed by RN, intubated, table turned, procedure performed..with very predictable surgeons you learn when to reduce the volatile and get the kid breathing on his own again...with these surgeons, five minutes into the case the volatile is being turned down, anticipating the return of spontaneous ventilation..which of course always happened since we used NO muscle relaxants, NO opioids... table turned back, kid breathing well, suctioned, extubated DEEP,mask on, still breathing well, monitors off, kid moved to stretcher and to PACU.

For the operation we used

NO PARALYTICS (yes, you can intubate a kid easily without relaxant if your sevo is deep enough).

NO OPIOIDS (really no need...the sevo supplied all that was needed).

JUST GAS. AND A TYLENOL SUPPOSITORY.

We got good at it. Really good at it. Removing the question marks (concerning wake up) of paralytics and narcs made our anesthetic very predictable.

In the PACU it was rare for us to have a problem.

KEEP IT SIMPLE.

When you're new to this business, you tend to contrive all these ELABORATE ANESTHETICS WITH MULTIPLE DRUGS...

Amazing that when you're new you ask yourself

WHAT CAN I GIVE?

Remarkable after you've done this gig for a while you ask yourself, pharmacologically speaking,

WHAT CAN I DO WITHOUT???
 
MRW said:
What do you use for post-op pain? Just wondering if the acetaminophen dose is close to maxing out on your patients...
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Was rare to give anything else. You'd be surprised how well kids do with no opioid. On the rare occasion thatta kid was ranting we gave a small intravenous fentanyl dose.
 
Jet three questions.

When do you place the IV?

What if any are your premeds?

What are/ were the surgeons doing for local (injection, soaking the bed, ???)


Still thinking about giving the no narc technique another try. I almost never use paralytics in peds (I infrequently use it in adults for that matter, KISS) so that is not an issue for me. I have been giving ~0.015 mg/kg dilaudid and I have been very happy. Fast wakeups, no side effects, happy kids in PACU (better than fentanyl or morphine IMHO). I don't use premeds.

My basic technique crank the sevo to max and turn the flows up to 5-8 LPM prior to patient entering the room (really speeds induction if the circuit is saturated). Mask. PIV by circulator. ~ 1 mg/kg propofol (probably un-necessary). Intubate. If she misses twice I intubate then place the PIV. Turn table. Patient is usually spontaneously ventilating by this point. Hydromorphone as the mouth gag is going in. If the patient holds his breath at this point I might hand ventilate for 30 sec to 1 min. Decadron and ondansetron. Sevo off and flows up usually right as the surgeon gives me a 5 minute warning. Turn the table back and extubate. If the patient is too light at the end I will give ~0.5 mg/kg propofol (knocks out the airway reflexes, but keeps them breathing.) Onto the stretcher and off to PACU. Arousable/ awake before I am done with giving my report, but I feel like they spend too much time in PACU (which may or may not have any correlation to my anesthetic.)

- pod
 
periopdoc said:
Jet three questions.

When do you place the IV?

After induction. Had great RNs back then who could do most of the IVs. If they failed (which was rare) we used the MD/CRNA model meaning I could start the IV if needed.

What if any are your premeds?

Every kid got oral midazolam.

What are/ were the surgeons doing for local (injection, soaking the bed, ???)

They all did their injection thing to the peritonsillar area. Can't remember concentration/volume.


Still thinking about giving the no narc technique another try. I almost never use paralytics in peds (I infrequently use it in adults for that matter, KISS) so that is not an issue for me. I have been giving ~0.015 mg/kg dilaudid and I have been very happy. Fast wakeups, no side effects, happy kids in PACU (better than fentanyl or morphine IMHO). I don't use premeds.

My basic technique crank the sevo to max and turn the flows up to 5-8 LPM prior to patient entering the room (really speeds induction if the circuit is saturated). Mask. PIV by circulator. ~ 1 mg/kg propofol (probably un-necessary). Intubate. If she misses twice I intubate then place the PIV. Turn table. Patient is usually spontaneously ventilating by this point. Hydromorphone as the mouth gag is going in. If the patient holds his breath at this point I might hand ventilate for 30 sec to 1 min. Decadron and ondansetron. Sevo off and flows up usually right as the surgeon gives me a 5 minute warning. Turn the table back and extubate. If the patient is too light at the end I will give ~0.5 mg/kg propofol (knocks out the airway reflexes, but keeps them breathing.) Onto the stretcher and off to PACU. Arousable/ awake before I am done with giving my report, but I feel like they spend too much time in PACU (which may or may not have any correlation to my anesthetic.)

Sounds like you've worked out a pretty sweet protocol for yourself. I GUARANTEE if you simplify it, you will be able to discharge kids faster than you are accomplishing current day. I don't know all the answers. What I CAN relay to you is....My partner's and I decided we needed to practice ALIKE...and we adopted a FORMULA....and the formula I described enabled us to keep a feverous pace at a busy surgery center, concomitant with patient safety and high patient (parental, in these cases) satisfaction.

- pod
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.
 
jetproppilot said:
Sounds like you've worked out a pretty sweet protocol for yourself. I GUARANTEE if you simplify it, you will be able to discharge kids faster than you are accomplishing current day. I don't know all the answers. What I CAN relay to you is....My partner's and I decided we needed to practice ALIKE...and we adopted a FORMULA....and the formula I described enabled us to keep a feverous pace at a busy surgery center, concomitant with patient safety and high patient (parental, in these cases) satisfaction.
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👍👍👍

I believe I can make it better.

- pod
 
Resume SV + turn off vapor after the first tonsil is out. .5-1 l/m fresh gas flow to blow off vapor slowly. Still extubate deep with this way.

I'm all about no paralytics/opiods. Very predictable as Jet mentioned above. I also like precedex which doesn't mess with your resp. drive and is comparable to intraop morphine in regards to pain.

http://www.anesthesia-analgesia.org/content/111/2/490.abstract

Good thread home-E's :highfive:

:horns:.
 
jetproppilot said:
We were blessed to work with highly skilled ENT surgeons who took...literally...fifteen minutes to do the procedure.

The beauty of our biz is there's many, many ways to accomplish the same goal.
Click to expand...

And the many ways are sometimes dictated by the way the surgeon works.
I often say that the limit of anesthesia is the surgeon: you can do anything with a ROCKSTAR not so much with an average dude.
 
jetproppilot said:
Let's see...trying to figure out the numbers of how many tonsils I've done...previous gig (where we had a hospital and surgery center) at the surgery center we probably did 20 pedi tonsils a week, thats 80 a month, 960 in a year, times 8 years there= 7680 tonsils, divided between 5 partners is around 1500.

OK, I've done around fifteen hundred pedi tonsils.

Every single one of them was extubated deep.

We were blessed to work with highly skilled ENT surgeons who took...literally...fifteen minutes to do the procedure.

The beauty of our biz is there's many, many ways to accomplish the same goal.

I can proudly report our recipe worked well. We chose to Keep It Simple, Stupid.

The K.I.S.S. technique.

WHATS THE KISS TECHNIQUE FOR PEDI TONSILS?

Sevoflurane. And an intra-op tylenol suppository.

That's it.

Lemme 'splain:

We had three ROKKSTAR ENT surgeons. Fast. Great. No drama.

Turnover time between these cases averaged eight minutes.😱

Kid would be rolled in, transferred to OR table, monitors on, sevo wide open,kid goes to sleep, tylenol suppository placed by RN, intubated, table turned, procedure performed..with very predictable surgeons you learn when to reduce the volatile and get the kid breathing on his own again...with these surgeons, five minutes into the case the volatile is being turned down, anticipating the return of spontaneous ventilation..which of course always happened since we used NO muscle relaxants, NO opioids... table turned back, kid breathing well, suctioned, extubated DEEP,mask on, still breathing well, monitors off, kid moved to stretcher and to PACU.

For the operation we used

NO PARALYTICS (yes, you can intubate a kid easily without relaxant if your sevo is deep enough).

NO OPIOIDS (really no need...the sevo supplied all that was needed).

JUST GAS. AND A TYLENOL SUPPOSITORY.

We got good at it. Really good at it. Removing the question marks (concerning wake up) of paralytics and narcs made our anesthetic very predictable.

In the PACU it was rare for us to have a problem.

KEEP IT SIMPLE.

When you're new to this business, you tend to contrive all these ELABORATE ANESTHETICS WITH MULTIPLE DRUGS...

Amazing that when you're new you ask yourself

WHAT CAN I GIVE?

Remarkable after you've done this gig for a while you ask yourself, pharmacologically speaking,

WHAT CAN I DO WITHOUT???
Click to expand...

When do you think the kids were going through Stage 2? I think the problem I am having with my deep extubations in T+A's is that I am frequently moving the kids over to the stretcher at precisely the wrong time, flipping them into laryngospasm. I have probably done somewhere around 50-75 of these cases, and have run into at least 5 cases of laryngospasm, usually occurring as I described (ie the kids were plenty deep at extubation (sevo on 5% or so), nice SV, suctioned, but either on the OR table or stretcher go into laryngospasm). Just wondering if maybe I need to move them over to the stretcher quickly and keep all RN hands off them for a while...

Otherwise, if I allow them to fully emerge on the table, I agree with other posters that I might as well extubate awake.
 
jetproppilot said:
Let's see...trying to figure out the numbers of how many tonsils I've done...previous gig (where we had a hospital and surgery center) at the surgery center we probably did 20 pedi tonsils a week, thats 80 a month, 960 in a year, times 8 years there= 7680 tonsils, divided between 5 partners is around 1500.

OK, I've done around fifteen hundred pedi tonsils.

Every single one of them was extubated deep.

We were blessed to work with highly skilled ENT surgeons who took...literally...fifteen minutes to do the procedure.

The beauty of our biz is there's many, many ways to accomplish the same goal.

I can proudly report our recipe worked well. We chose to Keep It Simple, Stupid.

The K.I.S.S. technique.

WHATS THE KISS TECHNIQUE FOR PEDI TONSILS?

Sevoflurane. And an intra-op tylenol suppository.

That's it.

Lemme 'splain:

We had three ROKKSTAR ENT surgeons. Fast. Great. No drama.

Turnover time between these cases averaged eight minutes.😱

Kid would be rolled in, transferred to OR table, monitors on, sevo wide open,kid goes to sleep, tylenol suppository placed by RN, intubated, table turned, procedure performed..with very predictable surgeons you learn when to reduce the volatile and get the kid breathing on his own again...with these surgeons, five minutes into the case the volatile is being turned down, anticipating the return of spontaneous ventilation..which of course always happened since we used NO muscle relaxants, NO opioids... table turned back, kid breathing well, suctioned, extubated DEEP,mask on, still breathing well, monitors off, kid moved to stretcher and to PACU.

For the operation we used

NO PARALYTICS (yes, you can intubate a kid easily without relaxant if your sevo is deep enough).

NO OPIOIDS (really no need...the sevo supplied all that was needed).

JUST GAS. AND A TYLENOL SUPPOSITORY.

We got good at it. Really good at it. Removing the question marks (concerning wake up) of paralytics and narcs made our anesthetic very predictable.

In the PACU it was rare for us to have a problem.

KEEP IT SIMPLE.

When you're new to this business, you tend to contrive all these ELABORATE ANESTHETICS WITH MULTIPLE DRUGS...

Amazing that when you're new you ask yourself

WHAT CAN I GIVE?

Remarkable after you've done this gig for a while you ask yourself, pharmacologically speaking,

WHAT CAN I DO WITHOUT???
Click to expand...

My peds rotations are coming up in a few months. Def looking forward to working with the kids.

Jet, the more of your posts I read, the more I want to go where you are. Your PP sounds like a paradise -- physician concierge, 8-min turnovers, 15-min T&A's, awesome surgeons... 👍
 
dhb said:
wtf 😕
i guess if you get them at 8% they'll sleep through the stretcher part...
Click to expand...

Why does this shock you? I usually run these kids with dial somewhere between 3 and 5% for the case. I like to be on the higher end prior to extubation. I don't believe 1 MAC is deep enough for deep extubations...

I think a lot people run into trouble thinking that a MAC of 1 is deep enough for extubation.
 
Multifidus said:
Why does this shock you? I usually run these kids with dial somewhere between 3 and 5% for the case. I like to be on the higher end prior to extubation. I don't believe 1 MAC is deep enough for deep extubations...

I think a lot people run into trouble thinking that a MAC of 1 is deep enough for extubation.
Click to expand...

I don't think it is deep enough either for kiddos, esp. those who haven't had narcs.
 
Great thread.

I think T&A's are something we all can do safely, but to do it with style and quickly, you need to do a lot of them.

I don't get to do that many, and the last one I did, I felt like a bafoon.

I think mostly at our hospital, we extubate awake for these cases. Many of the physicians that do the cases like it better. I think they feel like the kids (or young adults) are going to cough at some point (in the PACU, in the car going home, or whenever) and they WANT to test the coughing (and suture job) with the tube in place in the OR. As a resident, I remember a few cases where after coughing, the pharynx was pretty wet with suctioning. More propopfol, another look, some more caudery, maybe a suture or two...then back to extubation.
 
I couldn't tell you the last time I've seen an immediate post-op bleed in private practice. The only post-op bleeding tonsils we see are 7-10 days out.

KISS and extubating deep works.
 
Multifidus said:
I don't believe 1 MAC is deep enough for deep extubations...
Click to expand...

If you're not giving narcs then i understand why you are running high on the sevo. I agree that without narcs kids (even adults) will be much more susceptible to laryngospasm.
My definition of deep extubation is in fact "not awake extubation" i strongly believe that you can pull the tube at any moment provided the patient is not in stage 2.
 
dhb said:
If you're not giving narcs then i understand why you are running high on the sevo. I agree that without narcs kids (even adults) will be much more susceptible to laryngospasm.
My definition of deep extubation is in fact "not awake extubation" i strongly believe that you can pull the tube at any moment provided the patient is not in stage 2.
Click to expand...

Totally agree w/you on this point. The key thing is to get em breathing early and titrate the narcs to a resp of 10-12. I like to give .1 mg/kg of morphine right after the tube goes in. Once the pt gets turned to side so the surgeon can operate, the ventilator goes off to build up CO2. Once they start breathing I turn down the gas 1% sevo 50% N20 and keep giving narcs, to maintain that solid low and slow resp rate. When the surgeon is just about finished you can turn off the gas and crank up the flows. If you've timed it right the surgeon will turn the bed to you and you let down the cuff, get no coughing and yank the tube. Kiddie will be awake by the time the stretcher hits the door. If the kids cough when I let down the cuff then they get an awake extubation. The narcs usually help w/a smoother wake up when you've gotta do it awake but the key is to be extra vigilant about maintaining that low and slow rate while not overnarcatizing them
 
ssmallz said:
Totally agree w/you on this point. The key thing is to get em breathing early and titrate the narcs to a resp of 10-12. I like to give .1 mg/kg of morphine right after the tube goes in. Once the pt gets turned to side so the surgeon can operate, the ventilator goes off to build up CO2. Once they start breathing I turn down the gas 1% sevo 50% N20 and keep giving narcs, to maintain that solid low and slow resp rate. When the surgeon is just about finished you can turn off the gas and crank up the flows. If you've timed it right the surgeon will turn the bed to you and you let down the cuff, get no coughing and yank the tube. Kiddie will be awake by the time the stretcher hits the door. If the kids cough when I let down the cuff then they get an awake extubation. The narcs usually help w/a smoother wake up when you've gotta do it awake but the key is to be extra vigilant about maintaining that low and slow rate while not overnarcatizing them
Click to expand...

Sounds smooth. I would worry a respiratory rate of 10 with the mouth gag thing in would equal a respiratory rate of squat when the stimulation ended, but maybe I will try this next time.
 
Multifidus said:
Sounds smooth. I would worry a respiratory rate of 10 with the mouth gag thing in would equal a respiratory rate of squat when the stimulation ended, but maybe I will try this next time.
Click to expand...

And if that happens, you just wait to pull the tube, no biggie. Always remember you can reverse narcotics very easily w/a touch of narcan. You don't have to give em much to get em to breath and if you titrate it correctly they will not wake up screaming. Also, I like to give 0.1mg/kg of morphine and titrate the rest w/fentanyl b/c it lasts less time than morphine giving you more of a safety net in case you overdose em
 
RxBoy said:
http://www.outpatientsurgery.net/news/2011/08/4-Nasal-Dressing-Death-Lawsuit-Settled-for-350K


To all you deep extubators out there.
Click to expand...

I don't deep extubate T&As, but ...

Among their charges were that Dr. Sanders had performed an ill-advised deep extubation in spite of the patient's obesity, difficult airway and aspiration risks; dislodged the nasal pack and suture during extubation; failed to exercise prudent care and remove all the dressing after aspiration became a threat; and failed to notify the attending surgeon before manipulating it himself. These missteps, the family claimed, delayed proper treatment and hastened the patient's death.
Click to expand...

You have to take the plaintiff's claims with a great big grain of salt, but this wasn't your typical pediatric or adolescent T&A.
 
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