Here's my recipe for fast and smooth emergences:
1. Induction with propofol
2. Run propofol infusion (for hypnosis). Start at 100-150 mcg/kg/min and titrate from there.
3. Start the remifentanil infusion (for pain). Start at 0.1 mcg/kg/min. Titrate from there, no higher than .2 mcg/kg/min if you can avoid it in order to prevent opioid-induced hyperalgesia.
4. Give 0.1 mg/kg morphine IV at the beginning of the case (no matter how short or how long the case will be). This will serve as your background narcotic as well as smooth out your emergence; not to mention take care of postoperative pain.
5. Keep patient on 60% oxygen/40% air mixture (less postop nausea, improved sense of well being if you believe the studies). NO VOLATILES.
6. Keep end tidal CO2 around 40+ (this will tell you how well you've titrated your narcotic in a non-paralyzed patient).
7. As surgery draws to a close, start titrating down the propofol (e.g. down to 75 mcg/kg/min during suturing, or 50 mcg/kg/min during dressings).
8. Give whatever other drugs you want to (Zofran, Toradol, etc.)
9. With the last few minutes of surgical time left, turn off the propofol but keep the remifentanil going at 0.05 mcg/kgmin to 0.1 mcg/kg/min.
10. Nine times out of 10, the patient will wake up within 60-90 seconds of the surgeon taking off his gloves. The patient will be rousable to voice. No coughing or gagging or bucking. You simply ask the patient to open their mouths, and you pull the tube ... all the while the remifentanil is running at a low rate. Once the tube is out, stop the remifentanil and keep morphine or fentanyl in your pocket for any post-op pain in the PACU.
11. The other one time out of ten times, the patient will waken within four minutes.
This recipe works awesomely for every type of surgery except cardiac surgeries (since volatiles have been shown to improve ischemic preconditioning, and thus you put your patient at a disadvantage by withholding gases from him) and certain orthopedic surgeries (e.g. external fixation). For everything else, from general to kidney transplants to spine cases to ENT to neurosurgery, this anesthetic will impress the surgeons, the OR staff, the PACU nurses, and even your anesthesia attending with respect to the speed and gracefulness of the emergence. And less nausea (because of the propofol and no gases).
Oh, yeah, this technique is a little difficult in tykes less than five years old cuz they have larger volumes of distribution and they metabolize the drugs much quicker.
I've had patients wake up euphoric and crying out of joy with this cocktail.
Although it's taken me 2 years to streamline it, and as good as it is in my hands, I'm always looking to improve it.
I think volatiles are harder to titrate and work with in terms of producing a smooth emergence because it's the narcotics which will prevent coughing and bucking, but then these very agents will also drive down the respiratory centers, thus taking the patient longer to blow out the gases, and thus causing greather time to emergence.
