Efficient Wake-Ups

[DrRobert]

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After reading through the discussion about deep vs. awake extubation in the "academic attending" thread, I was hoping some attendings could share their regimens for smooth, quick wakeups that help speed up turnover.

I've recently been trying one recipe: get patient breathing spontaneously, give reversal, and turn off agent about 20 minutes before wakeup... then turn on N2O/O2 70%/30%... then titrate fentanyl and propofol to respiratory rate of 10-14... turn off N2O as dressing is being applied... extubate awake moments later.


I have run into a couple problems with this:

1. Sometimes I get burned by giving too much fentanyl... even though the patient is breathing 10-14/min they can sometimes be a little too narcotized and take longer to wake up... any advice to prevent this and still have them wake up comfortable?

2. You really have to be vigilant because the patient can cough, buck out of nowhere and then you have to give propofol to knock them back down, which can delay wakeup.

3. Haven't tried deep extubation with ETT because I'm at an academic center... when do you pull the tube and how do you titrate narcotics, etc?

 

[Jeff05]

they take longer to wake up because of the nitrous (ET usually needs to be under 10 for a minute or two...) and the prop.
if fentanyl is the only thing on board and they are breathing 14 times a min, they will be awake (unless they are ancient).

no need to titrate in the prop. slap a bis on them if it makes you feel better. the nitrous and VA fumes are enough to keep them asleep.

a patient does not need to be awake to pull the tube. if not a difficult airway, not obese, not a truly full stomach - do what you're doing. pull the tube with at least a half a mac of gas on. suction them out really well. put an oral airway in. if they're properly narcotized they will NOT buck.

 

[Bertelman]

I go easy on the fentanyl at the end of the case, especially within the last half hour prior to extubation. Maybe 25 mcg, 50 if they are no stranger to narcotics. Tend to use more morphine/dilaudid, I think it gives less respiratory depression in the immediate period. And I don't always shoot for some magical 10-14 breaths if it means loading with 4 mg morphine and 50 mcg fentanyl while the surgeon is laying sutures. You're asking for trouble like that. I've got no problems waking them up comfortably, then asking them in PACU if they need a little more.

I tend to turn my gas down to 0.2 or so, with ET around 0.4 or 0.5, with N2O at the end. Keep flows low, turn off agent as they are suturing final layer. As soon as I drop the drapes, crank the flows. Maybe turn off N2O if it's a quick dressing and patient is supine. Little stimulus via suctioning the oropharynx, maybe transfer to the stretcher, then ready to extubate.

 

[Planktonmd]

There are many ways to skin this cat like everything else in this business.
One thing I want to add to what have been already mentioned:
In my experience Sufentanyl gives a much better awakening than Fentanyl if you are extubating awake (this is anecdotal and based on personal experience), they just open their eyes when you call their name and wait for you to pull the tube out.
One note about deep extubation:
Real deep extubation means that close to the end of surgery you don't turn down the vapor, actually if you are less than 1 MAC you increase it and you pull the tube out while the patient is deeply anesthetized, you place an oral airway then you finish the case as a face mask case, the advantage to this is that when they reach light levels of anesthesia they don't have an ETT that makes them cough.
The deep extubation many people here are referring to is extubation under light anesthesia but not fully awake, it requires more vigilance and many people consider it unacceptable especially in academia but it could be great in the right hands.

 

[ChrisA]

Lots of ways to do wake ups.

The vent you have can change your wake up as well.

For instance, I have worked in one OR where the Vent had pressure support. So, you could get the pt breathing even with substantial gas still on and pop on pressure support to supplement the TV in order to breath the gas off faster.

However, most places im at only have Ventilation & pressure control. for these pts I usually keep the paralyzed with 1-2 twitches running low gas with nitrous then in the last 10-15 min of the case turn off the gas up nitrous to 70/30 with higher flows. That way i let the vent blow off the gas so i dont have slow wake ups and reverse them when it hits about 5-7 minutes prior to the end of the case. Titrate in a little narcotic to respiration and they generally wake up when i tap em on the forehead lightly.

works for me anyway.

 

[huktonfonix]

Lots of ways to do wake ups.

The vent you have can change your wake up as well.

For instance, I have worked in one OR where the Vent had pressure support. So, you could get the pt breathing even with substantial gas still on and pop on pressure support to supplement the TV in order to breath the gas off faster.

However, most places im at only have Ventilation & pressure control. for these pts I usually keep the paralyzed with 1-2 twitches running low gas with nitrous then in the last 10-15 min of the case turn off the gas up nitrous to 70/30 with higher flows. That way i let the vent blow off the gas so i dont have slow wake ups and reverse them when it hits about 5-7 minutes prior to the end of the case. Titrate in a little narcotic to respiration and they generally wake up when i tap em on the forehead lightly.

works for me anyway.

You can also do manual pressure support, just takes a little more work.

 

[ChrisA]

Good point. Yes, ive done that too but as you say, it ties up a hand.

 

[OB1🤙]

Plenty of gold in this old thread- http://forums.studentdoctor.net/showthread.php?t=213500

Count me in the pressure support/N20/whiff of volatile/dilaudid titration camp for emergence.

I'm figuring out which attendings are cool with deep extubation and trying to learn it- I definitely love it.

 

[Idiopathic]

Im a fan of extubating with the drapes up as the last sutures/staples are going in

 

[dfk]

There are many ways to skin this cat like everything else in this business.
One thing I want to add to what have been already mentioned:
In my experience Sufentanyl gives a much better awakening than Fentanyl if you are extubating awake (this is anecdotal and based on personal experience), they just open their eyes when you call their name and wait for you to pull the tube out.
One note about deep extubation:
Real deep extubation means that close to the end of surgery you don't turn down the vapor, actually if you are less than 1 MAC you increase it and you pull the tube out while the patient is deeply anesthetized, you place an oral airway then you finish the case as a face mask case, the advantage to this is that when they reach light levels of anesthesia they don't have an ETT that makes them cough.
The deep extubation many people here are referring to is extubation under light anesthesia but not fully awake, it requires more vigilance and many people consider it unacceptable especially in academia but it could be great in the right hands.

this is what i do. for the most part, adults are extubated around 1-1.2 MAC, depending on age and sex (young buck males get the heavier end of agent), and kids are near 1.3-1.4 MAC. i have encountered laryngospasm (albeit not too often) when pulling deep with MAC at anything less than 0.8 (as long as the pt isn't 80 yrs old or the like).
if spasm is encountered, i usually mask (with OPA) with the pop-off around 5-10-ish.

oh, and what also helps is to think of it like this...
compare fentanyl to washing a car, and morphine/dilaudid to waxing the car. works wonders and wakeups are great.

 

[SleepIsGood]

Here's what I do...

I pull them semi deep. I make sure everyone is reversed. Then 1 minte or two before pulling the tube semi deep while they are breathing on their own, I give 1 mg/kg prophylactically for spasm...

So far no troubles...

Of course if pt is obese or has OSA, no way I'm doing any of this.

 

[Bertelman]

Here's what I do...

I pull them semi deep. I make sure everyone is reversed. Then 1 minte or two before pulling the tube semi deep while they are breathing on their own, I give 1 mg/kg prophylactically for spasm...

So far no troubles...

Of course if pt is obese or has OSA, no way I'm doing any of this.

You give what? sux?

 

[dhb]

Lidocaine more likely

 

[HalO'Thane]

Great discussion. For those that do give dilaudid/morphine intraop...do you tend to work it in throughout the course of a case or do wait until you get the patient spontaneously breathing towards the end of the case?

 

[Bertelman]

Great discussion. For those that do give dilaudid/morphine intraop...do you tend to work it in throughout the course of a case or do wait until you get the patient spontaneously breathing towards the end of the case?

Depends on the case. If I know they'll need it (colectomy), I work it in. If I'm not sure, I wait until the end.

 

[HalO'Thane]

That is pretty much what I do...reverse paralytics when the fascia is closed (or 10-15 minutes before the end); spontaneously breathing with psv 10/5, gas down, 50% nitrous/02, and titrate dilaudid (either rr < 20 or ETC02 45). For those that only stick to fentanyl intraop, is it due to any anecdotal evidence of delayed respiratory in the PACU? Some of the attendings at my institution feel that the PACU nurses already snow the patients with too much dilaudid in the PACU so they want to "give the patient a fighting chance" by laying off the dilaudid intraop, especially at the end of the case.