Emergence?

[RxBoy]

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So I'm still CA-1, been getting a very good grasp of the bread and butter routine but one thing I still really suck at is emergence. So I have some questions for the pro's.

When is it safe to deeply extubate someone? Obviously aspiration risk, the large BMI, difficult intubations are a no-no. What respiratory parameters during SV are you generally happy with?

At what point in the case do you start dialing down iso? I find it one of the toughest to time compared to sevo/des.

Awake extubations at times are just a cluster f*ck. I try to give iv lido, doesn't help a whole lot. My worst extubations usually consist of me watching the patient wake up, bucking, followed by a 2 minute uncomfortable situation where the OR staff help me talk/wrestle the patient trying to orient them, getting them to raise their head, squeeze my hand, open there mouth to let me suction. THere is always this long lag where the patient is incoherent but bucking and trying to grab at the tube, before they become coherent and follow commands. Any tricks to make it more smooth?

Anyone ever move an intubated patient (of course disconnecting/reconnecting the circuit) on to the stretcher, raise the head before waking and extubating?

Answer one, some, or all. Any advice would be nice.

 

[Bertelman]

Anyone ever move an intubated patient (of course disconnecting/reconnecting the circuit) on to the stretcher, raise the head before waking and extubating?

Frequently. Though as a CA-1 with 2 months under my belt I wouldn't dare unless my attending were present.

 

[fakin' the funk]

At what point in the case do you start dialing down iso? I find it one of the toughest to time compared to sevo/des.

Awake extubations at times are just a cluster f*ck. I try to give iv lido, doesn't help a whole lot. My worst extubations usually consist of me watching the patient wake up, bucking, followed by a 2 minute uncomfortable situation where the OR staff help me talk/wrestle the patient trying to orient them, getting them to raise their head, squeeze my hand, open there mouth to let me suction. THere is always this long lag where the patient is incoherent but bucking and trying to grab at the tube, before they become coherent and follow commands. Any tricks to make it more smooth?

Anyone ever move an intubated patient (of course disconnecting/reconnecting the circuit) on to the stretcher, raise the head before waking and extubating?

No pro here, but I'll share a few of my CA-1 observations and anecdotes:

You can get super-smooth wakeups with lots of opioid on board. Of course, sometimes you overshoot and have to naloxone some peeps.

Some attendings have taught me to use VC -> SIMV-PS during closure -> SV at the very end with late reversal. Weak patients don't cough/buck with much force.

The difficulty you're describing with awake extubations is really just the patient going through Stage 2. Conceptually, you need to make that smoother. Make that stage a little less "quick" by getting the volatile off a little slower (have the pt breathe it off), or smooth it out with opioid. Also you can get the volatile agent off way early and do a nitrous+propofol wakeup (intermittent 10-20mg boluses vs. low-dose infusion).

As far as iso goes, I would give it 30-45 minutes at least. Depending on who you talk to, you may view volatile agents as an "on or off" drug, or as a "slowly dial down the Fi" drug -- your call.

 

[lord_jeebus]

Regarding iso, I think the key for turning off iso is to do it earlier than you feel is necessary - if closure is unexpectedly fast (or iso is coming off unexpectedly slow) you're stuck, but it's easy to prolong an anesthetic as needed.

Exactly when you should feel it necessary really depends on the case length:

From Miller Anesthesia 7th ed.

Other useful tricks for smooth wake-ups include nitrous-narcotic technique and LTAs for short cases. I think telling everyone in the room to be quiet when Stage 2 is impending makes a big difference. This is not a good time to poke around with your yankauer or otherwise disturb your patient.

Recently I have used precedex about 40-20 minutes pre-wakeup with good results, for cases where bucking is really unacceptable, or very likely to happen despite all of the above.

 

[pgg]

OP, smooth wakeups are harder than smooth inductions.


Over time, I've had fewer and fewer angry wakeups. Mostly I attribute that to using 'enough' narcotic.

Not bothering the patient when they're light (not just stage 2, but 'light') helps avoid the bucking and breathholding.

Except for LMA cases, I don't often get the patients breathing spontaneously at the end. I find breathing the gas off with the vent or by manually ventilating gets them through the light period faster. I used to get everyone spontaneous at the end because I thought it would help me 'titrate' opiate to their breathing rate, but now that's just more trouble than it's worth.

We have no purple gas here. I miss the extra smooth isoflurane wakeups - those patients never seemed to wake up pissed off.

I think droperidol (0.625 - 1.25 mg) helps with the high risk wake-up-swinging young males. Unfortunately one of the hospitals where I work just removed it from the formulary because of the black box warning 🙄.


But mostly I think it's just
- enough opiate
- don't poke the oropharynx with the wakeup stick at the wrong time

 

[Idiopathic]

When is it safe to deeply extubate someone? Obviously aspiration risk, the large BMI, difficult intubations are a no-no. What respiratory parameters during SV are you generally happy with?

its safe until it isnt, honestly. i wont deep extubate anyone who is at serious risk of obstruction, who is a full stomach or who was a difficult airway/mask. other than that, get them breathing at 3.0% end tidal sevo, pull the tube and jaw thrust, maybe a little prositive pressure. otherwise, its really not a deep extubation.

if im waking a patient up and they were healthy, easy airway etc then i wait for them to swallow and if they are pulling good volumes, i will extubate, but i do not consider that deep and the two should be differentiated.

i like Vt of 4-5 per kilo and rate 12-15 for deep extubation, for the most part.

At what point in the case do you start dialing down iso? I find it one of the toughest to time compared to sevo/des.

its not tough as long as you dont start dialing it down as they are stapling skin. but it does require more work. ill often add in N2O to cut the iso in half with about 30 minutes to go and typically its easy to get the rest of the iso off after that. i feel that they do wake up smoother and when you get more experience with it, you will like an iso wakeup more.

Awake extubations at times are just a cluster f*ck. I try to give iv lido, doesn't help a whole lot. My worst extubations usually consist of me watching the patient wake up, bucking, followed by a 2 minute uncomfortable situation where the OR staff help me talk/wrestle the patient trying to orient them, getting them to raise their head, squeeze my hand, open there mouth to let me suction. THere is always this long lag where the patient is incoherent but bucking and trying to grab at the tube, before they become coherent and follow commands. Any tricks to make it more smooth?

experience. patients dont have to recite scripture for you and they dont necessarily have to follow commands, they do have to protect their airways and i guarantee you they are doing that while they are bucking. pull the tube. recognizing when a patient is 5-10 seconds from waking up is a lot harder (but more valuable) skill than waiting for them to quit bucking when they have an ETT in, have to pee, are disoriented, and hurting. this is often mistaken as "Stage 2" when its just, in reality, "pissed off"

Anyone ever move an intubated patient (of course disconnecting/reconnecting the circuit) on to the stretcher, raise the head before waking and extubating?

yes, with a caution. if you are concerned at all that the patient is ready to extubate, you should do it on the bed, rather than move them get them more stimulated, maybe pull on the tube, anything that can worsen your situation. also, if they were difficult to mask or intubate, keep them on the OR table.

 

[jwk]

I try to extubate most of my patients deep except for some of the provisos already listed (RSI, difficult airway, etc.) They don't have to be breathing at all, but if I've used NMB's, I want to see a good TOF and sustained tetanus. If they are breathing, I want them around 10-12/min. If they're in the 20's, they need more narcotic. I like lidocaine at emergence as well - LTA's are OK, but if it's a long case, the lidocaine from that is long gone.

If you could mask ventilate them fine with induction, there's no reason to think you can't do so at emergence. If they don't gag with suctioning and then letting down the cuff, they're probably deep enough, and I go ahead and extubate. If they gag with that, it's too late, although you can still give some narcotic at that point.

I love Des because you don't have to lighten up near the end - it comes off quickly. Sevo, especially with obese patients, takes much longer (I don't care what the literature says).

 

[pencan]

shut the gas off early and start bumping with propofol. Most times the patient will lay there with their eyes closed until you call their name and simply ask them to open their mouth take a deep breath and remove the tube. You can also try and utilize LITA tubes which have the med port to utilize for lidocaine into the trachea. Works great for smokers.

 

[Idiopathic]

I'll make the argument that its really not that big a deal if someone coughs prior to extubation...helps with atalectasis

 

[dhb]

This is my advice (clinically replicable over hundred of patients)
YOU CAN PULL THE TUBE ANYTIME PROVIDED THE PATIENT IS NOT IN STAGE 2

This is what i do: get the patient in SV get rate between 8-12 with a long acting narcotic (i've used sufenta for this and invariably patient will complain of pain by the time you hit the pacu).
Blow of the DES (i never use sevo except for mask inductions) and pull it anytime after the Et des is under 1.5 after checking the pupils.

The patient will often react to the stimulus cough or open eyes but will resume SV rapidly. Incidence of laryngospasm: none that i had to break with PP or sux a forceful jaw thrust at most.

 

[behindthadeuce]

Disregarding the patients in which "early" extubation is truly contraindicated (full stomach, difficult airway, etc...) I would say you can pull an ETT at ANY time, including stage 2. Now, I wouldn't recommend that if you can help it, but managing laryngospasm isn't the worst thing in the world. Most can be broken with jaw thrust or positive pressure. If not, 10-20mg Sux will do the trick.

Idiopathic, I partly agree with you that coughing isn't a big deal unless its a carotid or crani you've just completed. But if you have a really obese patient, coughing isn't totally harmless, because they are coughing out their FRC and this will surely make them more hypoxic.

 

[RxBoy]

Wow great advice guys... I never knew there were so many great strategies.

Today I deeply extubated all 3 cases. Its so much smoother than awake, I can't believe I never did it as often. I used some of the strategies mentioned and it made a world of a difference. First case was a ET + sevo. I pulled the ET with sevo still on, it was deep as it could be while still spontaneously breathing. The next 2 cases were with Iso. I started titrating it down while slowly building up CO2 roughly 30 minutes before closing. When they started closing, I pushed the reversal and about 3 minutes later took them off the vent. By the time drapes came down there end tidal mac was 0.3ish and pulling TV in the 300-400s. I just extubated with an oral airway and o2 by mask. By the time they were on the stretcher they started to come back to, and by the time they were in PACU they had no idea how they got there. Great feeling.

Next week I'll try smooth awake extubations strategies for the difficult intubations/obese which I am sure I will get. I'll let you guys know how it goes.

 

[Bertelman]

You can find even more info here.

http://forums.studentdoctor.net/showthread.php?t=703291

 

[Arch Guillotti]

Disregarding the patients in which "early" extubation is truly contraindicated (full stomach, difficult airway, etc...) I would say you can pull an ETT at ANY time, including stage 2.

Uhhh, OK...

Of course you can pull it at any time, you just look like a fool if you are always having to give positive pressure/mask the patient/give sux afterwards. This is what the nurses do.

 

[RickKane]

I'm a big fan of propofol titration. Turn the gas of early...then give mini-boluses of propofol. Think about the surgical stages and level of stimulation. When it comes to closure, treat it just like a MAC case. I give long acting narcs usually Dilaudid, then work in the prop as if it were a prop drip. In my experience patients "wake up" smooth using this combo.

 

[dhb]

First case was a ET + sevo. I pulled the ET with sevo still on, it was deep as it could be while still spontaneously breathing.

Over time you will realize that it's not necessary for the patient to be at 1+mac to do this.
At that level patients have a significant amount of pharyngeal hypotonia and will require an airway +- jaw thrust for longer periods.
During this time secretions will built up in the oropharynx and will make the patient cough. If this happens when the patient is going through stage 2 you'll get your laryngospasm in or on your way to the pacu: not very slick.