Different ways of waking up patients after long laparoscopic surgeries

[beezar]

hey all,

This question is for all you residents/attendings out there. Say you are doing a long (4hr) laparoscopic case on like a 45 y/o person, like bariatric surgery or something. And you are runnning isoflurane at like 1.0-1.2% in air/O2 (avoiding nitrous to avoid bowel distention) for the entire case, along with fentanyl and muscle relaxant PRN. Now when they pull out the trocars, they can quickly close all the holes.

Now my question is, how do you get that damn iso down quickly enough for wakeup? I mean, you can't turn down the iso really until they start deflating the abdomen, at which point you have like 15 minutes until you have to wake them up.

I've been switching to desflurane or sevo like 45 mins before the end of the case in order to wake them up in time, but others tell me I don't need to do this, so I was wondering how you guys do it.

I know prolonged wakeups has to do with how much narcotic I use as well, so if you guys can also give me a more detailed approach of how much narcotic you would use (in the beginning, when the last dose would be, typically how much you would use, if you would try to titrate it at the end according to respiratory rate [which incidentally seems difficult to do if you are trying to blow off the gas]), and when you turn off the gas, etc. I know it varies from patient to patient, but just if you could give me an example of a typical patient, that would be greatly appreciated.

thanks

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[jwk]

hey all,

This question is for all you residents/attendings out there. Say you are doing a long (4hr) laparoscopic case on like a 45 y/o person, like bariatric surgery or something. And you are runnning isoflurane at like 1.0-1.2% in air/O2 (avoiding nitrous to avoid bowel distention) for the entire case, along with fentanyl and muscle relaxant PRN. Now when they pull out the trocars, they can quickly close all the holes.

Now my question is, how do you get that damn iso down quickly enough for wakeup? I mean, you can't turn down the iso really until they start deflating the abdomen, at which point you have like 15 minutes until you have to wake them up.

I've been switching to desflurane or sevo like 45 mins before the end of the case in order to wake them up in time, but others tell me I don't need to do this, so I was wondering how you guys do it.

I know prolonged wakeups has to do with how much narcotic I use as well, so if you guys can also give me a more detailed approach of how much narcotic you would use (in the beginning, when the last dose would be, typically how much you would use, if you would try to titrate it at the end according to respiratory rate [which incidentally seems difficult to do if you are trying to blow off the gas]), and when you turn off the gas, etc. I know it varies from patient to patient, but just if you could give me an example of a typical patient, that would be greatly appreciated.

thanks

Don't use iso

 

[UTSouthwestern]

You have to communicate with the surgeons to find out how far they are from being ready to remove the trocars. You can switch off the Iso an hour before that time and go with a shorter acting volatile but you can also turn off the Iso 20 minutes before the end of the case and titrate in some propofol to bridge the gap and/or turn on some nitrous once all of the intracavitary electrocautery is done at high flows with high flow O2 to both maintain a reasonable anesthetic depth and help to flush out the Iso.

You have alternatives to narcotics at the end of the case and if no contraindication exists, I would use some Toradol to cover analgesia over the last 45 minutes to an hour of the case.

IV lidocaine 1-1.5 mg/kg 10-15 minutes before planned extubation time can also potentiate analgesia and sedation up until the time you plan to extubate and should sufficiently blunt the airway reflexes to allow for a VERY smooth wake up and extubation. I use this technique routinely for extubating aneurysm clipping patients and it has yet to fail to give me a patient who just opens his/her mouth and nods his/her head yes when I ask them if they would like that tube out.

 

[NaeBlis]

hey all,

This question is for all you residents/attendings out there. Say you are doing a long (4hr) laparoscopic case on like a 45 y/o person, like bariatric surgery or something. And you are runnning isoflurane at like 1.0-1.2% in air/O2 (avoiding nitrous to avoid bowel distention) for the entire case, along with fentanyl and muscle relaxant PRN. Now when they pull out the trocars, they can quickly close all the holes.

Now my question is, how do you get that damn iso down quickly enough for wakeup? I mean, you can't turn down the iso really until they start deflating the abdomen, at which point you have like 15 minutes until you have to wake them up.

I've been switching to desflurane or sevo like 45 mins before the end of the case in order to wake them up in time, but others tell me I don't need to do this, so I was wondering how you guys do it.

I know prolonged wakeups has to do with how much narcotic I use as well, so if you guys can also give me a more detailed approach of how much narcotic you would use (in the beginning, when the last dose would be, typically how much you would use, if you would try to titrate it at the end according to respiratory rate [which incidentally seems difficult to do if you are trying to blow off the gas]), and when you turn off the gas, etc. I know it varies from patient to patient, but just if you could give me an example of a typical patient, that would be greatly appreciated.

thanks

Switching to another agent is the best strategy i can think of, but i use nitrous instead of des in the last half hour or so. It won't expand the bowel enough to cause any problem in just a half hour, or even an hour really. And if you get to low an iso level, it doesn't take very long to get it back on, or u can use small doses of prop or fentanyl to keep them down enough to tollerate the end of the case. From what I have heard, private practice surgeons are fairly tolerant of the pt starting to to move a bit at the end of the case because they know that will mean a quicker wake up and turn over. On the other hand I once ahd a 5th year surg resident ask if a perfectly still pt was relaxed enough because he was having trouble approximating the edges of a one of the trocar incisions.

 

[NaeBlis]

IV lidocaine 1-1.5 mg/kg 10-15 minutes before planned extubation time can also potentiate analgesia and sedation up until the time you plan to extubate and should sufficiently blunt the airway reflexes to allow for a VERY smooth wake up and extubation. I use this technique routinely for extubating aneurysm clipping patients and it has yet to fail to give me a patient who just opens his/her mouth and nods his/her head yes when I ask them if they would like that tube out.

Never really tried this before, I suppose if you leave all other thing the same, adding the lidocaine would keep them asleep a bit longer too? Since you are decreasing some of their stimulation.

 

[jwk]

Switching to another agent is the best strategy i can think of, but i use nitrous instead of des in the last half hour or so. It won't expand the bowel enough to cause any problem in just a half hour, or even an hour really. And if you get to low an iso level, it doesn't take very long to get it back on, or u can use small doses of prop or fentanyl to keep them down enough to tollerate the end of the case. From what I have heard, private practice surgeons are fairly tolerant of the pt starting to to move a bit at the end of the case because they know that will mean a quicker wake up and turn over. On the other hand I once ahd a 5th year surg resident ask if a perfectly still pt was relaxed enough because he was having trouble approximating the edges of a one of the trocar incisions.

Most private practice surgeons I know are NOT happy when patients move a little at the end.

And if a 5th year resident can't close trocar sites in a patient with little or no NMB on board, maybe he needs........oh, never mind. Of course that goes along nicely with a few of the OB/GYN docs at my institution who want more muscle relaxation in C/S and other epidural cases. Duh........

 

[UTSouthwestern]

Never really tried this before, I suppose if you leave all other thing the same, adding the lidocaine would keep them asleep a bit longer too? Since you are decreasing some of their stimulation.

It can add to their current level of sedation but the patient remains easily arousable. It may also add a minimal amount of analgesia as well.

 

[NaeBlis]

Most private practice surgeons I know are NOT happy when patients move a little at the end.

And if a 5th year resident can't close trocar sites in a patient with little or no NMB on board, maybe he needs........oh, never mind. Of course that goes along nicely with a few of the OB/GYN docs at my institution who want more muscle relaxation in C/S and other epidural cases. Duh........

Happy would be to strong a word, they tolerate it becase it gives them what the want, but this is second hand from attendings who work part time at surgi centers or private hospitals. That resident was a shocker, he looked young and i figured he was probably and intern or pgy2, when we were transporting the pt to pacu i asked him what year he was, and i hope i didn't look to shocked when he said he was a 5th year.

 

[jetproppilot]

Great question. We do lap-bariatric cases at our hospital so I feel your pain. First off, I know its probably something you can't control at the residency level, but using Des or Sevo for the whole case will help your wake ups drastically.. I came out of residency in 1996 so most of my traing was on iso, with des and sevo emerging later. And I'm telling you, des and sevo are better if you are having trouble with wakeups.
Keep your opiods to a minimum (250mcg or less). Use desflurane or sevo and rapidly titrate up for any rise in hemodynamics. Remember, if you are satisfied with anesthetic depth and the BP and heart rate start to rise, use something to treat the hemodynamics, not the anesthetic depth, i.e. labetelol.
Got 'em breathing at the end but the respiratory rate is kinda high? My opinion is wait on opiod administration- you can always give morphine/fentanyl after extubation. Your main objective at the end of the operation is to get the tube out and have a self-maintaining airway- you can only hose yourself by titrating opiods to respiratory rate at the end- because invariably you'll be concerned about respiration when thinking of pulling the tube. So wait 'til the tube is out, then titrate opiods on the way to the PACU.

Precedex is also a great route to take for cases as you described- long cases where you need to extubate them at the end- bolus precedex in the holding area, run a basal infusion intra-op...drastic reduction in volatile anesthetic and opiod requirements.

hey all,

This question is for all you residents/attendings out there. Say you are doing a long (4hr) laparoscopic case on like a 45 y/o person, like bariatric surgery or something. And you are runnning isoflurane at like 1.0-1.2% in air/O2 (avoiding nitrous to avoid bowel distention) for the entire case, along with fentanyl and muscle relaxant PRN. Now when they pull out the trocars, they can quickly close all the holes.

Now my question is, how do you get that damn iso down quickly enough for wakeup? I mean, you can't turn down the iso really until they start deflating the abdomen, at which point you have like 15 minutes until you have to wake them up.

I've been switching to desflurane or sevo like 45 mins before the end of the case in order to wake them up in time, but others tell me I don't need to do this, so I was wondering how you guys do it.

I know prolonged wakeups has to do with how much narcotic I use as well, so if you guys can also give me a more detailed approach of how much narcotic you would use (in the beginning, when the last dose would be, typically how much you would use, if you would try to titrate it at the end according to respiratory rate [which incidentally seems difficult to do if you are trying to blow off the gas]), and when you turn off the gas, etc. I know it varies from patient to patient, but just if you could give me an example of a typical patient, that would be greatly appreciated.

thanks

 

[UTSouthwestern]

Great question. We do lap-bariatric cases at our hospital so I feel your pain. First off, I know its probably something you can't control at the residency level, but using Des or Sevo for the whole case will help your wake ups drastically.. I came out of residency in 1996 so most of my traing was on iso, with des and sevo emerging later. And I'm telling you, des and sevo are better if you are having trouble with wakeups.
Keep your opiods to a minimum (250mcg or less). Use desflurane or sevo and rapidly titrate up for any rise in hemodynamics. Remember, if you are satisfied with anesthetic depth and the BP and heart rate start to rise, use something to treat the hemodynamics, not the anesthetic depth, i.e. labetelol.
Got 'em breathing at the end but the respiratory rate is kinda high? My opinion is wait on opiod administration- you can always give morphine/fentanyl after extubation. Your main objective at the end of the operation is to get the tube out and have a self-maintaining airway- you can only hose yourself by titrating opiods to respiratory rate at the end- because invariably you'll be concerned about respiration when thinking of pulling the tube. So wait 'til the tube is out, then titrate opiods on the way to the PACU.

Precedex is also a great route to take for cases as you described- long cases where you need to extubate them at the end- bolus precedex in the holding area, run a basal infusion intra-op...drastic reduction in volatile anesthetic and opiod requirements.

Precedex is an excellent choice if it's available at your institution. All of our bariatric cases get a Precedex infusion but the expense can be prohibitive in some institutions.

 

[apma77]

great question.........

i will basically keep the patient at 2 twitches (train of four) and turn my ISO way down 15 min before case ends..once they pull out with the trocars i will turn on the nitrous . To make sure i am not having awareness under anesthesia i will apply my BIS monitor at the beginning of the case. This way the patient is relaxed and not bucking on the tube and you can reverse them within 5 min.

If you cant or dont have access to DES or SEVO you may wanna try this strategy

goodluck