How to have smooth wake-ups?

[Dantrolene FC]

CA-1 here. I’m trying to make my wake-ups smoother.

I can time a wake up decently without issues, but I keep having about half the patients buck/cough during wake up? Any tips?

I’ve thought it was because the tube was too deep, but then I started putting the tube shallower, then they wake up hoarse presumably because the tube was on the cords.

I’ve considered pushing lidocaine to prevent bucking/coughing. Would that help?

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[Volatile]

Opioid tends to provide pretty good tube tolerance. I do a fair amount of outpatient surgery so I definitely lean on fentanyl more than dilaudid. My general technique is to get them breathing towards the end of the case (usually on pressure support but sometimes off the vent) then titrate in fentanyl until they are breathing ~10/min. Titrate gas down during closure. Once I’m ready to wake up, I turn up flows and as soon as the patient does anything like opens eyes, starts to cough, i pull it. Usually pretty smooth and quick. If I’m worried about airway in say a tonsil or someone was difficult to intubate I’ll have them more awake. If they smoke all bets are off. In general, if you can get them breathing with the tube at the end, it makes things much easier/smoother.

 

[kidthor]

CA-1 here. I’m trying to make my wake-ups smoother.

I can time a wake up decently without issues, but I keep having about half the patients buck/cough during wake up? Any tips?

I’ve thought it was because the tube was too deep, but then I started putting the tube shallower, then they wake up hoarse presumably because the tube was on the cords.

I’ve considered pushing lidocaine to prevent bucking/coughing. Would that help?

In general the thing academics do where you keep yelling at the patient to wake up, continually deep suction, and jaw thrust the patient into coughing agitation will cause an un smooth wake up. None of that is necessary. When they’re awake enough you can just remove the ETT and they’ll be undramatically, safely extubated.

If the patient is well narcotized per Volatile’s suggested technique they’ll probably look good. And as noted some patients will just wake up in a less elegant fashion due to the surgery itself or underlying airway reactivity.

 

[cchoukal]

There have been countless threads about this over the years and a search will likely yield a number of great suggestions. There is no one perfect way, but my observation, in general, has been that people whose gas comes off more slowly tend to be less active on emergence than those who ride at 1 Mac the whole case and blast the flows at the end to quickly come off. But to get gas off slowly, you have to start taking it off earlier, like while the surgeons are still doing stuff. And THAT means you have to cover up the remaining stimulation/stage 2 with something else (e.g., N2O, dexmedetomidine, prop, opiates, etc.). I have not been impressed by IV lidocaine, although I think there's a smattering of evidence supporting it. I believe there was also a trial of dexmedetomidine to reduce emergence "coughing" which showed an effect at 1 mcg/kg, but not 0.5 mcg/kg. That's a lot of dexmedetomidine, and you may find your self babysitting a somnolent, hypotensive patient in PACU longer than you'd like. I like what Volatile said about spontaneously ventilating, narcotized patients. A N2O wake-up also tends to be very smooth, but N2O remains controversial in practice (and on this board). For smokers, you don't stand much of a chance, so just set expectations with the surgeons early, especially for hernias and things where they perceive coughing to be dangerous to their repair.

 

[gratefulgas]

Extubate one breath before they start coughing.

 

[amyl]

Get them spontaneous- titrate some narcs. Gas off earlier. Nitrous with little propofol bumps to keep asleep and help w ponv. Personally I don’t see nausea w nitrous 50/50 but I’m aggressive w ponv… love phenergan… have even woke people up w Benadryl. For combative pts they always get a little p-dex. Lido down the tube is better than iv but have to do it right.

 

[Silo004]

LTA smokers with 100 mg of lidocaine sprayed above and below the cords to prevent coughing. I am assuming airway is easy and no need for an RSI. Also surgery should be <2 hours for it to work. I guess you could use bupi if you needed to make it last longer. Lower dose of course.

I used to do this in residency but the surgeons are way to aggressive about touching patient when I am inducing so I just prop esmolol roc tube.

 

[Silo004]

Extubate one breath before they start coughing.

Also I look to see if patient is swallowing, meaning their airway reflexes have returned and they are less likely to laryngospasm. Although I still have it happen sometimes.

 

[anaesthetic]

All good suggestions in this thread. I have never yelled or screamed at a patient to open their eyes or do multiplication tables prior to extubation like I saw so often in academics. Definitely not necessary, but the only caveat is that you have to be vigilant about post-extubation laryngospasm, bronchospasm, apnea, etc., which can all be very, very subtle (until it’s not).

 

[coffeebythelake]

Getting them off the vent, breathing spontaneously regularly helps a lot.

 

[thinkorswim]

Everyone has their own way of doing it. I personally favor using nitrous and titrating narcotics with spontaneous ventilation, or PSV if required, and having patients open their eyes calmly to my voice for me to remove the tube as soon as the drapes come down. It's all about speed and style.

 

[pocafx]

I find it hard sometimes for laparoscopic cases to have them deep enough and then wake up with fast closing.

 

[narcusprince]

Emergence delirium and smooth wakeups are a function of high inhalational wakeups. Your goal should be to wake patients up to the lowest amount of end tidal agent. You can bridge with Fentanyl, Propofol boluses. Whatever you want that end tidal agent as low as possible when they wakeup.

 

[surgndoc]

Nitrous + adequate amount of narcotic. Spontaneous ventilation preferable, although you can ride the vent 99% of the way then just turn it off at the very end after giving sugammadex.

DO NOT stimulate during emergence - no suction, jaw thrust, moving patient to stretcher etc.

 

[nimbus]

How much narcotic are you guys talking? I typically use fentanyl 50-100mcg for most procedures. None for nonpainful procedures.

 

[narcotics999]

My recipe is nitrous, propofol, and narcotics. 15mins before last stitch, 50% Nitrous, 50% original sevo. 5mins before, 50% nitrous only. 0 minutes, no Nitrous.

Sometimes I take out a 100ml propofol bottle, after the induction dose, finish the rest with a background low dose gtt.

 

[deleted875186]

Everything said above, a little prop while getting gas off.

My biggest pet peeve is no bite block, I don’t understand why no CRNA ever places one, always helpful to be able to suction after pulling tube and in case they do go delirious and start biting the tube. As mentioned above, some patients will just wake up poorly.

 

[thinkorswim]

How much narcotic are you guys talking? I typically use fentanyl 50-100mcg for most procedures. None for nonpainful procedures.

I try to keep it at 100-200mcg of fentanyl for a procedure, give a small dose (25-50mcg) on induction and then nothing until emergence. If it’s a larger procedure, I’ll maybe add 1mg of Dilaudid toward the end or even just give methadone upfront.

 

[Dantrolene FC]

Unfortunately, the vast majority of my attendings are very anti-nitrous.

 

[Morzh]

I feel like low end-tidal volatile agent + stimulation happening at the same time are the key ingredients in the cursed recipe that causes coughing / bucking / ugly wake-ups. You've got to find a way to eliminate one of those two things, or at least separate the timing so they don't happen simultaneously, in order to have consistently smooth extubations.

The stimulation can take many forms: ETT presence (duh), surgical site pain, final sutures, the "one last bovie on the skin real quick here" maneuver, the presence of irritable airways from smoking or recent URI, doing the stuff you see in training hospitals like excessive suctioning, jaw-thrusting, screaming at the patient, etc.

The low end-tidal volatile agent represents a lightly anesthetized mind that's primed to "freak out" at any of the above stimulants. I think there's something particularly irritating about volatile agents that prime a patient for an irritable wake-up, as opposed to emergence from TIVA, for example.

So your choices:

Option A: Let the patient emerge from inhalational general anesthesia land with the ETT still in place, but you've got to come up with some way to cover up the stimulation(s) mentioned above during this phase. Generously titrated narcotic is probably the most reliable way, along with a good regional block when applicable.

Option B: Let the patient emerge from deep inhalational anesthesia, but remove all stimulation prior to them becoming "light". Deep extubate, don't aggressively move the patient, don't suction unnecessarily, don't have loud music blasting, etc. That way you've uncoupled the temporal relationship between the lightly anesthetized mind stage and the stimulators.

Option C: Get the volatile agent nearly completely off prior to extubation, but you have to find something else to anesthetize the brain during this period as a "bridge". Propofol, precedex, nitrous oxide can all be helpful here. This may seem similar to option A, but I think there's an important distinction in philosophy here in that you are technically maintaining a deep plane of anesthesia (as opposed to just cranking up the analgesia). Deep is a state of mind, not an end-tidal sevoflurane number.

I do primarily pediatrics, and the culture and skill-set of our PACU nurses makes Option B very safe and common for most routine cases. This is a traditional deep extubation and is what I do most of the time. I'll usually bolus 1mg/kg propofol right before extubation just to make sure they are truly deep.

For patients I don't feel comfortable extubating on 1.2+ MAC sevoflurane I'll usually do a combination of options A and B. My go-to in these cases is to get the gas off EARLY and essentially convert over to a TIVA with propofol + narcotic for the final 20-30 minutes of the case. As long as the patient's spontaneous ventilation is adequate, the EtSevo is <0.3, and preferably there's some rudimentary signs of airway protective reflex like swallowing, that's all I need to see to be comfortable extubating assuming easy airway on induction.

But it is true that unless you are deep extubating, you can't win them all, especially in smokers or those with reactive airways from intrinsic disease or inflammed tissues from recent URI.

 

[Radetzky]

Who cares? The pt won’t remember it. Don’t stimulate them and use plenty of opiate.

 

[narcusprince]

Who cares? The pt won’t remember it. Don’t stimulate them and use plenty of opiate.

Remember their are people judging your Anesthesia that do not have your understanding of whats going on. All they see is doctor As wakeups are smoother than doctor B. Or what administrators see Dr A takes twice as long as Dr B takes to wake patients up. Its far easier being judged by your peers than by a jury of non peers.

 

[DirtDocMD]

I feel like low end-tidal volatile agent + stimulation happening at the same time are the key ingredients in the cursed recipe that causes coughing / bucking / ugly wake-ups. You've got to find a way to eliminate one of those two things, or at least separate the timing so they don't happen simultaneously, in order to have consistently smooth extubations.

The stimulation can take many forms: ETT presence (duh), surgical site pain, final sutures, the "one last bovie on the skin real quick here" maneuver, the presence of irritable airways from smoking or recent URI, doing the stuff you see in training hospitals like excessive suctioning, jaw-thrusting, screaming at the patient, etc.

The low end-tidal volatile agent represents a lightly anesthetized mind that's primed to "freak out" at any of the above stimulants. I think there's something particularly irritating about volatile agents that prime a patient for an irritable wake-up, as opposed to emergence from TIVA, for example.

So your choices:

Option A: Let the patient emerge from inhalational general anesthesia land with the ETT still in place, but you've got to come up with some way to cover up the stimulation(s) mentioned above during this phase. Generously titrated narcotic is probably the most reliable way, along with a good regional block when applicable.

Option B: Let the patient emerge from deep inhalational anesthesia, but remove all stimulation prior to them becoming "light". Deep extubate, don't aggressively move the patient, don't suction unnecessarily, don't have loud music blasting, etc. That way you've uncoupled the temporal relationship between the lightly anesthetized mind stage and the stimulators.

Option C: Get the volatile agent nearly completely off prior to extubation, but you have to find something else to anesthetize the brain during this period as a "bridge". Propofol, precedex, nitrous oxide can all be helpful here. This may seem similar to option A, but I think there's an important distinction in philosophy here in that you are technically maintaining a deep plane of anesthesia (as opposed to just cranking up the analgesia). Deep is a state of mind, not an end-tidal sevoflurane number.

I do primarily pediatrics, and the culture and skill-set of our PACU nurses makes Option B very safe and common for most routine cases. This is a traditional deep extubation and is what I do most of the time. I'll usually bolus 1mg/kg propofol right before extubation just to make sure they are truly deep.

For patients I don't feel comfortable extubating on 1.2+ MAC sevoflurane I'll usually do a combination of options A and B. My go-to in these cases is to get the gas off EARLY and essentially convert over to a TIVA with propofol + narcotic for the final 20-30 minutes of the case. As long as the patient's spontaneous ventilation is adequate, the EtSevo is <0.3, and preferably there's some rudimentary signs of airway protective reflex like swallowing, that's all I need to see to be comfortable extubating assuming easy airway on induction.

But it is true that unless you are deep extubating, you can't win them all, especially in smokers or those with reactive airways from intrinsic disease or inflammed tissues from recent URI.

Agree with just about all of this.

I do WAY more deep extubations than I used to.

Cutting the volatile, and essentially “waking up” (TIVA) on propofol used to be great when I was doing lots of kids. Titrate the propofol to have a good respiratory rate 10-20, and that wasn’t affected/interrupted by jiggling the tube. This is still a “deep extubation”, but you don’t get laryngospasm on propofol, like you do with volatile.

For adults, as others mentioned, titrate narcs to get resp rate down around 10.

Another thing I’ve noticed (and I wouldn’t do this on COPD or folks with questionable lungs), is that Sugammadex almost reverses TOO well. I notice more bucking/harder coughing, if I reverse early, especially in younger/ middle-aged adults.

I’ll get folks breathing spontaneously, and sometimes extubate, and THEN reverse, immediately after. I DON’T do this on folks who are likely conscious or weak enough to “remember” feeling weak, or folks who aren’t already pulling decent tidal volumes. I wouldn’t do this as a resident, as your academic attending is likely to get ticked off, but as a private practice guy, having folks that are back to 100% full-strength (after sugammadex) with a tube in their throat, seems to lead to more coughing/bucking than neostig/glyco (with maybe 80-90% strength) used to. If nothing else, I’ll wait to give sugammadex until drapes are down, so they don’t spend the last few minutes of the case possibly bucking harder (as mentioned, some folks seem to buck no matter WHAT you do, and the stronger they are, the harder they do it). Others can feel free to disagree with my thoughts on this.

 

[narcusprince]

Agree with just about all of this.

I do WAY more deep extubations than I used to.

Cutting the volatile, and essentially “waking up” (TIVA) on propofol used to be great when I was doing lots of kids. Titrate the propofol to have a good respiratory rate 10-20, and that wasn’t affected/interrupted by jiggling the tube. This is still a “deep extubation”, but you don’t get laryngospasm on propofol, like you do with volatile.

For adults, as others mentioned, titrate narcs to get resp rate down around 10.

Another thing I’ve noticed (and I wouldn’t do this on COPD or folks with questionable lungs), is that Sugammadex almost reverses TOO well. I notice more bucking/harder coughing, if I reverse early, especially in younger/ middle-aged adults.

I’ll get folks breathing spontaneously, and sometimes extubate, and THEN reverse, immediately after. I DON’T do this on folks who are likely conscious or weak enough to “remember” feeling weak, or folks who aren’t already pulling decent tidal volumes. I wouldn’t do this as a resident, as your academic attending is likely to get ticked off, but as a private practice guy, having folks that are back to 100% full-strength (after sugammadex) with a tube in their throat, seems to lead to more coughing/bucking than neostig/glyco (with maybe 80-90% strength) used to. Others can feel free to disagree with my thoughts on this.

Ooowieeee the dream technique…. Deep relaxed extubation then reversal of neuromuscular blockade.

 

[DirtDocMD]

Ooowieeee the dream technique…. Deep relaxed extubation then reversal of neuromuscular blockade.

Like I said, they’re pulling strong TV’s, (and 4 twitches and no appreciable fade). I didn’t use the technique when using Neostig/glyco, but, as I said, the Sugammadex almost works TOO good, and let’s some folks buck really hard, esp young smokers. Not fun on hernia’s and pt’s who just had their sinuses done.

 

[nimbus]

Agree with just about all of this.

I do WAY more deep extubations than I used to.

Cutting the volatile, and essentially “waking up” (TIVA) on propofol used to be great when I was doing lots of kids. Titrate the propofol to have a good respiratory rate 10-20, and that wasn’t affected/interrupted by jiggling the tube. This is still a “deep extubation”, but you don’t get laryngospasm on propofol, like you do with volatile.

For adults, as others mentioned, titrate narcs to get resp rate down around 10.

Another thing I’ve noticed (and I wouldn’t do this on COPD or folks with questionable lungs), is that Sugammadex almost reverses TOO well. I notice more bucking/harder coughing, if I reverse early, especially in younger/ middle-aged adults.

I’ll get folks breathing spontaneously, and sometimes extubate, and THEN reverse, immediately after. I DON’T do this on folks who are likely conscious or weak enough to “remember” feeling weak, or folks who aren’t already pulling decent tidal volumes. I wouldn’t do this as a resident, as your academic attending is likely to get ticked off, but as a private practice guy, having folks that are back to 100% full-strength (after sugammadex) with a tube in their throat, seems to lead to more coughing/bucking than neostig/glyco (with maybe 80-90% strength) used to. If nothing else, I’ll wait to give sugammadex until drapes are down, so they don’t spend the last few minutes of the case possibly bucking harder (as mentioned, some folks seem to buck no matter WHAT you do, and the stronger they are, the harder they do it). Others can feel free to disagree with my thoughts on this.

I do this pretty often nowadays too, sometimes before they take any breaths. No tube=no coughing. Little to no opioids=patients immediately start breathing.

 

[drmwvr]

LTA's last longer than people think...I like 'em for just about every case I'm going to extubate. But the best way to have smooth wakeups is to have a lot of rough ones....

 

[Drwine]

Unfortunately, the vast majority of my attendings are very anti-nitrous.

Nitrous is acceptable as a choice for maintenance with a few exceptions and I won't micromanage that unless a contraindication. However, I insist residents that are using air/ oxygen mixtures for maintenance learn to wake patients up on the same. One MAC of inhalation not necessary to close skin in a patient who had a block or local injected. I am aggressive about turning down sevo during closure. If I misjudge a little propofol goes a long way as does a little fentanyl.

 

[Dantrolene FC]

Nitrous is acceptable as a choice for maintenance with a few exceptions and I won't micromanage that unless a contraindication. However, I insist residents that are using air/ oxygen mixtures for maintenance learn to wake patients up on the same. One MAC of inhalation not necessary to close skin in a patient who had a block or local injected. I am aggressive about turning down sevo during closure. If I misjudge a little propofol goes a long way as does a little fentanyl.

I do oxygen/air mixture with sevo. I usually do the case at 0.7 MAC sevo, unless I’m not paralyzing. Usually, I turn the sevo off when they are about halfway through fascia closure but keep the flows low. By the time they start skin, I usually turn the flows up all the way. Obviously, though this depends on the location of procedure and if patient movement would be bad during closure. For example, I don’t do this on head or neck surgeries.

I have noticed my big laparotomies tend to have smoother wakeups. Maybe this is because I am being more aggressive with opioids when compared to smaller incisions or laparoscopic cases. Also, with laparoscopic cases, it’s kinda more of guess work on appropriate pain control since I don’t have a long time of the patient breathing on their own prior to extubation.

 

[Dantrolene FC]

Nitrous is acceptable as a choice for maintenance with a few exceptions and I won't micromanage that unless a contraindication. However, I insist residents that are using air/ oxygen mixtures for maintenance learn to wake patients up on the same. One MAC of inhalation not necessary to close skin in a patient who had a block or local injected. I am aggressive about turning down sevo during closure. If I misjudge a little propofol goes a long way as does a little fentanyl.

I’ve never used it for maintenance. My attendings won’t even allow me to use it just for wake ups. Some of my attendings don’t even realize we have nitrous on the machines. They are very anti-nitrous and anti-sux. I get that I’m still a CA-1, but it drives me crazy sometimes.

 

[woopedazz]

I know the USA is very anti-opioid, but if you want a patient to wake up smooth, on time and use less opioids in recovery...

I'd be hard-pressed to find a GA case where I don't use at least 100microg of fentanyl intra-op. All these 25-50microg for induction and nothing after seems a bit too nuanced for my simple brain.

 

[2Fast2Des]

Nitrous and des are very potent greenhouse gases, don't really see the need for them when low flow sevo\prop\fent\lido are pretty effective to get a smooth wakeup.

 

[kidthor]

Nitrous and des are very potent greenhouse gases, don't really see the need for them when low flow sevo\prop\fent\lido are pretty effective to get a smooth wakeup.

Yeah I’ve nearly eliminated my use of nitrous and des due to environmental concerns. I used to use nitrous semi regularly too, but now almost never.

 

[IMGASMD]

I’ve never used it for maintenance. My attendings won’t even allow me to use it just for wake ups. Some of my attendings don’t even realize we have nitrous on the machines. They are very anti-nitrous and anti-sux. I get that I’m still a CA-1, but it drives me crazy sometimes.

I was trained under very similar condition. Rarely sux, only time I use nitrous is for inhalation induction on the kiddos. I think it’s fine. It’s good to know what’s out there, it’s better to know how to use what you’ve got very well.

 

[GassYous]

CA-1 here. I’m trying to make my wake-ups smoother.

I can time a wake up decently without issues, but I keep having about half the patients buck/cough during wake up? Any tips?

I’ve thought it was because the tube was too deep, but then I started putting the tube shallower, then they wake up hoarse presumably because the tube was on the cords.

I’ve considered pushing lidocaine to prevent bucking/coughing. Would that help?

Don't put tubes

 

[coffeebythelake]

Don't put tubes

good point
SGA much less likely to cause bucking, and should be considered if the patient doesn't have contraindication
and with the newer generation SGAs w gastric port and good seal i think it is very reasonable to give paralytic drugs with them

 

[anbuitachi]

lots of narcs. i dont reverse until near the end. let them breathe with PSV. near the end i reverse. because if they do buck for whatever reason, i want it to be at the end, and i dont want a huge buck

 

[norski]

lido spray in the trachea and on cords, Reverse on removal of ports, before closing, PSV as soon as possible after reversal, then the tube comes out when the patient's ketamine induced grin appears. I do run TIVAs as often as possible, only run des when I'm lunch breaking a room, and only use sevo for spontaneous breathing LMA GAs or when I think a TIVA is not the right approach, mid case more often than not.

Nice dose of glyco for heavy smokers.

My TIVAs are propofol and remi/fent as maintenance, magnesium and ketamine for wakeups, sometimes lido.

(arch pointed out a chronological error, edited)

 

[nimbus]

Reverse on removal of ports, before closing, lido spray in the trachea and on cords, PSV as soon as possible after reversal, then the tube comes out when the patient's ketamine induced grin appears. I do run TIVAs as often as possible, only run des when I'm lunch breaking a room, and only use sevo for spontaneous breathing LMA GAs or when I think a TIVA is not the right approach, mid case more often than not.

Nice dose of glyco for heavy smokers.

My TIVAs are propofol and remi/fent as maintenance, magnesium and ketamine for wakeups, sometimes lido.

Are the majority of GAs TIVA where you work? Seems like TIVA is more common in Europe than it is in the USA.

 

[Drwine]

Are the majority of GAs TIVA where you work? Seems like TIVA is more common in Europe than it is in the USA.

The US FDA won't accept that the imperfections of the Schnider and Marsh models as well as Eleveld allometric PK model are way better than no model at all so we don't have target controlled infusion pumps in the US. TIVA in the US is way more guess work than doing inhalation anesthesia when we had to use copper kettle and Vernitrol vaporizers. Europeans have had computerized target control pumps for the best part of 20 years. I had been hopeful that the military might have made the push for target controlled pumps but no such luck.

 

[BobLoblaw78]

In long academic cases requiring an ETT, try inserting an LMA over the ETT 30 minutes before the end. Then extubate while deep and let them wake up smoothly with an LMA. It is the only way to end a 12 hour cases that had half the pharmacy thrown at them by 3 different attendings!

 

[nimbus]

In long academic cases requiring an ETT, try inserting an LMA over the ETT 30 minutes before the end. Then extubate while deep and let them wake up smoothly with an LMA. It is the only way to end a 12 hour cases that had half the pharmacy thrown at them by 3 different attendings!

Not in academics but I occasionally do this. But I just extubate and insert the LMA while they’re still deep, often while the patient is still paralyzed.

 

[Arch Guillotti]

In long academic cases requiring an ETT, try inserting an LMA over the ETT 30 minutes before the end. Then extubate while deep and let them wake up smoothly with an LMA. It is the only way to end a 12 hour cases that had half the pharmacy thrown at them by 3 different attendings!

I thought the ETT was not long enough to stick out the end of the LMA?

 

[Arch Guillotti]

Reverse on removal of ports, before closing, lido spray in the trachea and on cords, PSV as soon as possible after reversal, then the tube comes out when the patient's ketamine induced grin appears. I do run TIVAs as often as possible, only run des when I'm lunch breaking a room, and only use sevo for spontaneous breathing LMA GAs or when I think a TIVA is not the right approach, mid case more often than not.

Nice dose of glyco for heavy smokers.

My TIVAs are propofol and remi/fent as maintenance, magnesium and ketamine for wakeups, sometimes lido.

How do you spray lidocaine on the vocal cords while they are still intubated?

 

[narcusprince]

In long academic cases requiring an ETT, try inserting an LMA over the ETT 30 minutes before the end. Then extubate while deep and let them wake up smoothly with an LMA. It is the only way to end a 12 hour cases that had half the pharmacy thrown at them by 3 different attendings!

Gtfoh. The only thing I am doing under the tube is extubating over a tube exchanger….

 

[LaryngoSpazz]

Lots of good suggestions here. There are many ways to accomplish a smooth wake-up but it’s a good idea to learn several as each technique has pros/cons.

One that hasn’t been mentioned yet is a remifentanil wake-up. Give a large dose of remi a few mins before you want to extubate, get all the other anesthetic off and leave the patient alone. They’ll usually open eyes spontaneously looking stunned. At this point you can switch vent off, ask for one spontaneous breath if you insist, or just extubate.

This is particularly nice for cases that you don’t want bucking and you don’t want to give lots of long acting opioids because you want a good neuro exam afterwards, like a crani or carotid.

 

[BobLoblaw78]

Not in academics but I occasionally do this. But I just extubate and insert the LMA while they’re still deep, often while the patient is still paralyzed.

I feel like the LMA slides right down the ETT.

It works so well, that if I am having trouble getting an LMA to seal that I will intubate then I put in the LMA. (jk about the this part)

I thought the ETT was not long enough to stick out the end of the LMA?

Not through the LMA but the LMA actually over the whole ETT without going through the LMA. 2 separate conduits will be sticking out.

Gtfoh. The only thing I am doing under the tube is extubating over a tube exchanger….

This sounds like a joke that I'm too tired to get right now.

 

[narcusprince]

Any concern for laryngeal edema? If you have gone through 3 attendings and multiple pharmacy meds and possibly the blood bank. Why would you push to extubate 12 hrs later at night? Why not send to icu with tube in place and extubate in AM. Instead of having to reintubate this patient in the middle of the night. The real decision is to extubate or not.

 

[abolt18]

I feel like the LMA slides right down the ETT.

It works so well, that if I am having trouble getting an LMA to seal that I will intubate then I put in the LMA. (jk about the this part)

Not through the LMA but the LMA actually over the whole ETT without going through the LMA. 2 separate conduits will be sticking out.

This sounds like a joke that I'm too tired to get right now.

Also referred to as "the Bailey Maneuver".

 

[BobLoblaw78]

Any concern for laryngeal edema? If you have gone through 3 attendings and multiple pharmacy meds and possibly the blood bank. Why would you push to extubate 12 hrs later at night? Why not send to icu with tube in place and extubate in AM. Instead of having to reintubate this patient in the middle of the night. The real decision is to extubate or not.

Ah, I see where you are coming from. I was slightly exaggerating how long it felt like the cases were back then as well as the amount of attendings. Maybe I have PTSD from the surgical equivalent of watching paint dry. But I still would extubate. To be fair, I have always had a lower threshold for extubating after long cases or after hours cases. So even after 12 hours, I would still extubate barring huge amounts of PRBC's and fluid. 12 hours on a tube is still not as bad as 12 days in the ICU on a tube. And many of those get extubated without a tube exchanger in place. I usually reserve tube exchanger for difficult airways that I don't want to eat humble pie or where the patient has other reasons to be edematous.

The LMA trick was great when residents were closing and it could take 10 minutes or 90 minutes. Hard to time the extubation when there was so much variability between residents. Also, we would have hours of isoflurane buildup bc we were trying to save money. (nothing like saving $10 with iso then blowing it by throwing in an LMA!)