Happens frequently

[Fadiology]

I am 1 year anesthesia resident, i like the speciality, or and everything
But i have one problem that i cant figure a solution for till this moment, smooth emergence
Today i had this 50 yo female pt, breast reduction, after stopping, reversing muscle relaxant, i extubated the pt then she clenched her teeth i tried jaw thrust and failed , mask ventilation failed also. I called a senior but before he arrived she started breathing it happened to me twice be4 i need explanation

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[coffeebythelake]

I am 1 year anesthesia resident, i like the speciality, or and everything
But i have one problem that i cant figure a solution for till this moment, smooth emergence
Today i had this 50 yo female pt, breast reduction, after stopping, reversing muscle relaxant, i extubated the pt then she clenched her teeth i tried jaw thrust and failed , mask ventilation failed also. I called a senior but before he arrived she started breathing it happened to me twice be4 i need explanation

Are you pulling the tube too early?
Clenching teeth or laryngospasm?

 

[Robotic Wis-Hipple]

See stage 2.
See soft bite block.

 

[DrOwnage]

First of all, if you're a first year, its pretty rare you would be extubating without a faculty member there at most institutions. Any patient who gets sux for intubation gets a soft bite block after the tube goes in, same goes for during reversal before the tube comes out. My guess is you might have extubated too early, even though she was spontaneously breathing, you might have still had >0.3% sevo on board and she hadn't fully settled out yet. I find the patients that seem uncomfortable on the vent, aka breathing >15 RPM with high minute ventilation seem to do this more often for obvious reasons. Sometimes people will extubate on pressure support and then this will happen also due to change in respiratory dynamics.

 

[Hoya11]

First of all, if you're a first year, its pretty rare you would be extubating without a faculty member there at most institutions. Any patient who gets sux for intubation gets a soft bite block after the tube goes in, same goes for during reversal before the tube comes out. My guess is you might have extubated too early, even though she was spontaneously breathing, you might have still had >0.3% sevo on board and she hadn't fully settled out yet. I find the patients that seem uncomfortable on the vent, aka breathing >15 RPM with high minute ventilation seem to do this more often for obvious reasons. Sometimes people will extubate on pressure support and then this will happen also due to change in respiratory dynamics.

Agree with above.

When the case is over and they are breathing on their own, give narcotic to get their rate down to 12-14 or so. Then let the gas come down as far as they tolerate, pull tube at <.3% sevo once narcotized and while in their breathing rhythm.

 

[dhb]

I've never used a bite block.
Laryngospasme notch and vigourous jaw thrust are your friends.
Extubate anytime except when in stage 2.

 

[UscGhost]

No need for a bite block until the end of the case. Not sure you want to create the risk of a hidden pressure point in the oropharynx for several hours.

Place bite block in towards the end before reversal. Give a bit if fent to get rate down to 8-12. Turn off gas and push a few 1-3ml doses of propofol as gas is wearing off (or nitrous). Slowly let down cuff and pull.

If patient HR starts to climb or RR changes abruptly...they are likely stage 2 so dont pull it..leave them be until it's time to pull.

And dont worry about it. Takes years to get the hang of it..and some never do Haha

 

[2Fast2Des]

Any use of Ketamine, lidocaine, or precedex also works great smoothen emergence

 

[deleted875186]

All of the above is good advice.

Alternatively, wait until the person is fully awake and following commands and extubate. Always the safest thing to do.

 

[2Fast2Des]

All of the above is good advice.

Alternatively, wait until the person is fully awake and following commands and extubate. Always the safest thing to do.

Too much work... Just get em spontaneous, blow off the gas, give something to blunt emergence, pull it out. Less talky pts better 😛😎

 

[Fadiology]

I've never used a bite block.
Laryngospasme notch and vigourous jaw thrust are your friends.
Extubate anytime except when in stage 2.

I tried to open her mouth but it was cemented

 

[deleted875186]

I tried to open her mouth but it was cemented

To me this says you extubated too soon. I’ve had people clench their jaw, but if you extubated while they are breathing adequately and apply some jaw thrust, they should still be breathing adequately after extubation. Either you couldn’t ventilate because they laryngospasmed, or they obstructed, either way they weren’t ready to have the tube out.

 

[deleted59964]

too much pain - not enough opioid

 

[Fadiology]

To me this says you extubated too soon. I’ve had people clench their jaw, but if you extubated while they are breathing adequately and apply some jaw thrust, they should still be breathing adequately after extubation. Either you couldn’t ventilate because they laryngospasmed, or they obstructed, either way they weren’t ready to have the tube out.

Actually she started breathing after like 20 seconds of breath holding, my question was why she closed her mouth , as u said it happened to u

 

[skypilot]

I put a plastic oral airway in at the end of the case. Wastes a lot of plastic but I find it very helpful. I never worry about anyone biting my fingers either.

 

[Robotic Wis-Hipple]

Actually she started breathing after like 20 seconds of breath holding, my question was why she closed her mouth , as u said it happened to u

Everyone has been telling you. Here, from wiki;

Stage 2
Stage 2, also known as the excitement stage, is the period following loss of consciousness and marked by excited and delirious activity. During this stage, the patient's respiration and heart rate may become irregular. In addition, there may be uncontrolled movements, vomiting, suspension of breathing, and pupillary dilation. Because the combination of spastic movements, vomiting, and irregular respiration may compromise the patient's airway, rapidly acting drugs are used to minimize time in this stage and reach Stage 3 as fast as possible.


This is written as if you are going from awake—> induced into general anesthesia. But upon emergence your patient must come through stage 2 to get into stage 1 and full consciousness. In stage 2 patients may be breathing, their vitals may appear at baseline, but they also may not and they are very sensitive to stimulation. My guess, and most others agree, is that you are pulling the tube during stage 2. At that point it could be anything that stimulates the patient into breath holding or clenching their teeth or even laryngospasm (secretions stimulating the glottis, pain, movement, etc).

The fact that you’re asking this question, and not understanding the replies as a 1st year resident implies you need to read more and have closer supervision. I also am curious if you are in a place that does all TIVA anesthetics?

 

[icecoldstar]

Everyone has been telling you. Here, from wiki;

Stage 2
Stage 2, also known as the excitement stage, is the period following loss of consciousness and marked by excited and delirious activity. During this stage, the patient's respiration and heart rate may become irregular. In addition, there may be uncontrolled movements, vomiting, suspension of breathing, and pupillary dilation. Because the combination of spastic movements, vomiting, and irregular respiration may compromise the patient's airway, rapidly acting drugs are used to minimize time in this stage and reach Stage 3 as fast as possible.


This is written as if you are going from awake—> induced into general anesthesia. But upon emergence your patient must come through stage 2 to get into stage 1 and full consciousness. In stage 2 patients may be breathing, their vitals may appear at baseline, but they also may not and they are very sensitive to stimulation. My guess, and most others agree, is that you are pulling the tube during stage 2. At that point it could be anything that stimulates the patient into breath holding or clenching their teeth or even laryngospasm (secretions stimulating the glottis, pain, movement, etc).

The fact that you’re asking this question, and not understanding the replies as a 1st year resident implies you need to read more and have closer supervision. I also am curious if you are in a place that does all TIVA anesthetics?

While I really appreciate people like you posting helpful tidbits like this, was last paragraph really necessary? I mean who doesn't need to read more? Plus, CA1s literally started 2 days ago...

 

[coffeebythelake]

While I really appreciate people like you posting helpful tidbits like this, was last paragraph really necessary? I mean who doesn't need to read more? Plus, CA1s literally started 2 days ago...

Maybe he is a rising CA2?

 

[deleted875186]

Actually she started breathing after like 20 seconds of breath holding, my question was why she closed her mouth , as u said it happened to u

It’s hard to tell without being in the situation. I am only guessing it was extubation during light anesthesia rather than fully awake.

My only point is that if someone is fully awake, normal respiratory mechanics before the case, they shouldn’t breath hold or stop breathing or obstruct etc. I think we as anesthesiologists are very used to extubating when not fully awake and it works most of the time.

 

[Robotic Wis-Hipple]

While I really appreciate people like you posting helpful tidbits like this, was last paragraph really necessary? I mean who doesn't need to read more? Plus, CA1s literally started 2 days ago...

Look, if he’s a 2 day into anesthesia training CA-1 he shouldn’t be pulling tubes without staff in the room. I’d argue, if he’s a rising CA-2 he probably shouldn’t be either. Either way, he asked multiple times why or what was happening and at least 3 or 4 attending level posters told him it was likely pulling the tube early, and specifically likely related to the physiology of stage 2. Which, honestly should be pre-day 1 reading.

I’m all for asking questions and I’m all for seeking advice from the experienced gurus here, I myself am quite junior and know that there is much I don’t know or have experienced. But when you ask a question, listen to the answers.

And finally, my question about TIVA was trying to ascertain if the cases were being done and thus emerged from an IV anesthetic which doesn’t allow you to just look at your etAgent.

 

[lizzers729]

And finally, my question about TIVA was trying to ascertain if the cases were being done and thus emerged from an IV anesthetic which doesn’t allow you to just look at your etAgent.

Do people emerging from TIVA go through stage 2? The classification system was originally designed based on straight volatile anesthetic (ether). In general, TIVA patients seem to awaken calmly and smoothly, without the agitation/excitement of emergence from volatiles, IMO.

 

[Mikkel]

Do people emerging from TIVA go through stage 2? The classification system was originally designed based on straight volatile anesthetic (ether). In general, TIVA patients seem to awaken calmly and smoothly, without the agitation/excitement of emergence from volatiles, IMO.

I think there are elements to stage 2 in TIVA, they're just much much less susceptible to certain elements (like tendency toward laryngospasm... They just never have laryngospasm without volatile in system).

 

[pgg]

While I really appreciate people like you posting helpful tidbits like this, was last paragraph really necessary? I mean who doesn't need to read more? Plus, CA1s literally started 2 days ago...

We should all remember that not every anesthesia trainee who posts here is a US grad in a US program with US supervision norms for whom English is their first language ...

 

[illaqueable]

(like tendency toward laryngospasm... They just never have laryngospasm without volatile in system).

I appreciate your optimism, but I have absolutely had patients laryngospasm on TIVA. Certainly the tendency is greater with volatiles, but to say it never happens with TIVA is not true--any time secretions or other foreign debris fall on the cords a patient can laryngospasm.