get off all of the volatile before extubation?

[phillyfornia]

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so i came across the post on smooth wakeups while looking through the procedures sticky. it's a great post with a lot of helpful stuff for a CA-1 like myself.

personally, for my wake ups so far i have been getting the pt breathing spontaneously before the case ends and then titrating in some fentanyl to their respiratory rate. at the end of the case, they usually wake up with a little bit of volatile on board (e.g. 0.2 of sevo). it's worked okay for me so far.

i saw that some people like to use the vent to get off all of the volatile before extubation. in order to do this, they use little bumps of propofol to keep the pt asleep. i've been trying this out recently but i just can't get it to work. my big problem is that i can't time the propofol correctly. the patient always ends up bucking or moving or doing something else embarrassing before i give the bump of propofol.

so for those of you who get off all of the volatile before extubation, how do you time the propofol? do you look at the HR? BP? or is it something that you just get a feel for as you progress?

or do you guys run a propofol drip? or just give prophylactic doses (e.g. 2 cc every 5 minutes)?

any help would be appreciated. im new to this anesthesia thing and i want to try out different things. thanks.

 

[2ndyear]

This is a great question because everyone does it a little bit differently. I personally like to keep the vent on until the agent is off or they buck a bit at which point I will let them breathe. But our new machines also have SIMV and PSV modes. I'll routinely switch to SIMV with pressure support towards the end of the case. I can watch the waveforms then and see when respirations have resumed and they tolerate the vent well. Turn up the flows, agent off and there you go. The propofol thing is really just buying you time. If your expired agent is very low and there isn't much for narcotics on board then your patient will wake up, right? So give a little propofol. The BIS monitor can be quite helpful in this regard, and as a resident you don't have to worry about spending money as much so if you have a toy like the BIS, try it out. I'd also try using desflurane if you have it.

 

[pjl]

I have been doing one of a few things with varied, but typically alright success. Here is my most common:
Drop volatile to about 0.5 MAC during suturing. If des, then I rarely turn on NO2 if it wasn't on for the case, if other agent then I most often do turn NO2 on. If using NO2 then combined MAC is a little higher. Turn off gas based on timing for speed of intern/med student. Often this is the last stitch because people get all huffy if the patient "wakes up" while they are putting a bandaid on. From the time suturing starts I drop the tidal volumes way off and turn the rate up, with a goal of CO2 ~40. Then I wait. As soon as I see them cough, I turn off the vent and then I wait a 20 count and ask them to open their eyes. If they are ready, out comes the tube. This typically happens with about 0.1-0.2 MAC or so left on board. If not, then I move them to the other bed with the tube in and they are often ready by then. If not, they get the walk of shame and go to the PACU intubated (only happened a few times, and I figure I am a beginner so they can deal with it)
I dont use propofol very often unless stopping the vent doesn't solve the coughing issue.

 

[Bougie]

Just be patient with it. You just have to learn how the gases come off with various age groups, narcotic loads, etc. This just takes doing lots of cases. I think the bumping with propofol thing is a bad idea, too much work and can burn you if the patient gets too many doses.

 

[Jeff05]

i use lidocaine as a smooth landing tool.
get patient to breathe spont. and titrate narcotic to RR of about 10.
keep 0.6 mac of gas until about 3-5 min prior to extubation.
lidocaine IV bolus about 1-1.5mg/kg. gas off. flows up.
lido keeps patient down and makes them tolerate tube until all gas comes off.
very smooth wakeups.

however, if not full stomach, tube comes out right after bolus of lido. they can blow off the gas with an oral airway and mask.

 

[IceDoc]

Often this is the last stitch because people get all huffy if the patient "wakes up" while they are putting a bandaid on.

At a private hospital I've now twice heard an emphatic "Keep letting em wake up!" as they quickly finish without me having to reanesthetize for 10mins.

 

[Bertelman]

I've got no problem sending a Pt. to recovery exhaling 0.2 of sevo or iso, particularly in the longer cases.

 

[Mman]

If your case runs several hours, anything other than a skinny patient is going to be blowing off Sevo or Iso for quite some time in PACU even if the gas monitor read 0.00 in the OR. They just can't calibrate to read that low and the patient will be leaking volatile from their fat to their blood and exhaling it for a while.

I just try to have the patient breathing spontaneously with narcotics titrated in for respiratory rate and get the MAC down to maybe 0.2 or 0.3 while they are suturing and then shut it off just before the last stitch is in. If they wake up while dressings are going on, the tube comes out. Heck, I'll pull the tube out if they are awake while the last suture is going on. They usually stop moving as soon as you extubate them since the gag stimulus is no longer there.

If I have a patient spontaneously breathing through an LMA, I'll just pull the LMA deep while the surgeons are closing skin and let the patient wake up breathing oxygen via facemask.

If I need to temporize for a minute or two just before extubating I like Lidocaine or maybe 20 mg propofol. Just enough to get them to hold still for a minute and hopefully not delay wakeup for 10 minutes.

 

[jwk]

Too much mental masturbation trying to time it perfectly. Long cases take a little longer to wake up, short cases a little quicker. And I don't care what any study or sales rep says, but they take longer to wake up with sevo after a long case than des. I reverse NMB as early as possible, rarely cut back on the des (but I will cut back on sevo) until stapling, and dink in a little morphine or dilaudid to keep their respiratory rate under 20. If they're not quite ready to extubate and everyone's looking at me, we can move to the stretcher. If I have ANY question about the airway, potential for vomiting, did an RSI, etc., the patient doesn't get moved till I'm ready. That may be 2 minutes, it may be 15. Most of mine will be on the way to PACU five minutes after the last staple goes in. I have no problem extubating deep on appropriate patients, and in a previous gig with stellar PACU nurses, had no problem taking patients to PACU with the ETT and letting them extubate (my current PACU wants an Aldrete score of 10 on arrival to decrease their workload 😉 ).

 

[proman]

Doesn't anybody use nitrous? I found that opioids are your friend, and a nitrous/opioid wakeup (ie no other volatile anesthetic on board) is very smooth and rapid.