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This all sounds like an overly complicated way to lose and airway eventually. It’s essentially indefensible with little upside.
How to have smooth wake-ups?
Started by Dantrolene FC
how practical and safe is it to pull the tube and then reverse with sugammadex. or LMA exchange and then reverse?
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deleted87051
If the patient has a normal airway, it’s very safe. I would not do it with a difficult airway.
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Disagree wholeheartedly. It is actually safer than any deep extubation. It is extubating deep to a SGA. To take it even further, if you extubated any airway and needed to reintubate but couldn’t, what would you do? SGA. I’m not advocating doing it for a full stomach or any case that LMA is inappropriate. Funny how it can be seen that differently
How much ketamine and when?
Why would you extubate and then put an lma? Or pull the tube then reverse? Sounds unnecessary. It really isn't that hard to extubate smoothly in most patients. And if they buck? Buck it.
Mixed bag. Some run gas for 90% of their cases, I'm at 20 gas/80 TIVA. Others 50/50, depending on the case.
I run prop+remi/fent/alfent without TCI protocols every once in a while, but I have to admit I wouldn't be super comfortable doing it without the knowledge/experience base granted me by running tons of TCIs.
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0.5mg/kg/hr the last hour.
Often augmented with magnesium, given no contraindications.
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With magic, of course.
Erm, I see that I should've put that first. Do you have lidocaine spray bottles with long, 25-30cm nozzles in the US? I use one of those, spray one puff with the nozzle 2cm from cords, then advance just inside the cords, one more puff,then the tube goes in,all in the same laryngoscopy. This for elective cases when I have five extra seconds for intubation.
I like the idea of remi bolus wakeups, but how much do you administer? For a remi(nmb free) intubation, I go between 3-4mcg/kg, give that 90 seconds, then tube, but other than letting the remi run (tci at 250-350 mcg/hr), never bolused it for extubation. Share, please!
Did you place your LMA over a tube? So you intubated with a 6.0 tube? All that plastic on plastic. Unnecessary and dangerous in this case. Would never do this on a 12 hour case. Indefensible….
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Why bolus it? Just as easy to wake them up on it without a bolus.
PGY4 here from Iraq...
My simple technique : -
1- Good analgesia perioperatively
2- Once skin sutured or 10 minutes at the end of the operation, off the Volatile - if Isoflurane you know when, if Desflurane you know when
3- Patient have spontaneous breathing, switch to SIMV - VC or PC or PSV; do you know how to play with it? Then switch to PSVpro and gently monitor your patient until 5/5 is achieved with good tidal volume. Talk to your patient, do NOT overstimulate, and never leave the patient without PSV, never let your patient breath spontaneously on manual (just when you check his reservoir bag) especially early during the end of the case, this will make the patient more tachypenic, exhausted; always on a mode of ventilation.
See your signs of recovery, especially opening the eye, can lift the head,,, etc means away from stage 2 laryngospasm
Then extubation with a jaw thurst and listen closely to the sound of air.... Here you go!
Excellent job!
My simple technique : -
1- Good analgesia perioperatively
2- Once skin sutured or 10 minutes at the end of the operation, off the Volatile - if Isoflurane you know when, if Desflurane you know when
3- Patient have spontaneous breathing, switch to SIMV - VC or PC or PSV; do you know how to play with it? Then switch to PSVpro and gently monitor your patient until 5/5 is achieved with good tidal volume. Talk to your patient, do NOT overstimulate, and never leave the patient without PSV, never let your patient breath spontaneously on manual (just when you check his reservoir bag) especially early during the end of the case, this will make the patient more tachypenic, exhausted; always on a mode of ventilation.
See your signs of recovery, especially opening the eye, can lift the head,,, etc means away from stage 2 laryngospasm
Then extubation with a jaw thurst and listen closely to the sound of air.... Here you go!
Excellent job!
No. ETT doesn't go through the LMA. LMA is placed posterior to the ETT. It is Bailey maneuver as mentioned above and the image below. I haven't used this maneuver since being in PP and haven't used it for ages. But I still defend its use as it works great if needed.
I don't see how a patient can get exhausted from breathing.... Every human breathes for the entirety of their existence.
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I have seen patient were put once they are getting spontaneous breathing on manual non mode ventilation and the tidal volume were like 10 to 25 ml and respiratory rate exceeding 40; probably we don't have TOF like you over there, and we just as said off volatiles and let him breath on his own. I have found those patients were having issues of anxiety, and tachypneic; unlike those who I woke them up with PSVpro slowly and as I said above; I remember I had three post cesarean section GA patients were put in the hallway waiting to go to the ward, and they were calm enough, unlike others and I got questioned from the OBs what did you give them? I said "nothing, just smooth recovery". I have said before "these my own opinion, and reflect my practice and how I learnt, and many wrong stuff I had learnt, I've could correct them here - so so many; but this technique of extubation, I have been practice them over almost two years now, and haven't seen any issue; It happens I used to switch to manual breath and telling the patient to breath more and with suction, , , etc, and one day an Attending at Baghdad Medical City shouted at me and said "what are you doing?"; I said "I am doing extubation", and he starts explaining the proper way of how to extubate the patient on a Mode of Ventilation even VC and not PSV or those weaning modes, and during the third year, I had that Attending who was very weird smart in his approach, and he shoveled up our thoughts and taught us the PSVpro. I can tell you a thing, even some cases - elective - we use PSVpro during induction on mask before intubation to synchronize with his hypopnea and always get supported breath (it is like delayed sequence induction). So, you have said it right "Every human breaths for the entirely of their existence".... we exchange thoughts !
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Because when your breathing is obstructed, it increases the work of breathing
I mean isn't that obvious?
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Through a straw?
D
deleted87051
Even when I preoxygenate with a mask, many patients tell me it feels difficult to breathe through the breathing circuit.
Yes, Dr. Nimbus,
I personally seen this, and found to switch to nasal cannula or face mask (non rebreather) is better during preoxygenation - same rules of DSI.
3 to 5 minutes of good tidal breathing is the standard I believe; away from 8 VC breathing.
This right here. Sounds like a lot of people are trying to re-invent the wheel.
Just basic Poiseuille's law. People sleeping through physics class again lol
Not for the entirety of the case, I mean on emergence. I can't see someone being tired of coming off the vent for the brief period of emergence.. especially if psv is being utilized with appropriate support. What is the emergence time? 5 to 10 minutes? I don't use TOF anymore since sugammadex anyway
These days I primarily use remi as an infusion in certain cases. For wake-up I go up on infusion and turn everything else off 10-15 mins early. Then a couple minutes before I want to extubate I shut the remi off too. I rarely bolus anymore as my hospital only stocks it in 2mg vials. I used to have access to 100mcg syringes which for most patients was a good amount for a bolus during emergence. For someone with high opioid requirements that might not be enough and for a little old lady probably more than you need. The biggest problem with bolusing too much is that you’re likely to have bradycardia and hypotension.
Having to formulate\mix remi, bolus a tiny amount, and then waste the rest with the OR RN, doesn't seem too efficient, for a case that you haven't used remi on to begin with, and then do that for every case? I mean yes remi makes for great wakeup, and for select cases I can see it being worth the while, but not as a routine though
"How to have smooth wake-ups?"
You can't (consistently). Just the way it crumbles....
Deep extubation works most times with a TIVA.
Sufenta infusion consistently works well.
Droperidol was an excellent "smooth awakening" agent. I haven't used it in many years.
You can't (consistently). Just the way it crumbles....
Deep extubation works most times with a TIVA.
Sufenta infusion consistently works well.
Droperidol was an excellent "smooth awakening" agent. I haven't used it in many years.
I mainly use remifentanil as an infusion but would like to know how to bolus it for these situations. How much exactly are you giving and when? Is this after reversal and 50mcg at a time?
The key is to have as little as your volatile agent off when they are emerging. You can do it slow or you can do it fast . If you do it slow your patient will be bucking and exhibiting crazy **** prior to extubation for a longer period of time. I do not titrate narcotics to RR. Have not since residency. I have learned thats a good way of overdosing patients with narcotics. GIve them what you think they need and thats it. Anesthetizing trachea is a good move with LTA, 5 percent lidocaine ointment is good. Precedex and Ketamine are the devil.
We’re giving droperidol to most patients now as an anti-emetic. As far as I know it’s mildly “sedating” but haven’t noticed a big change in wake ups.
My go to is ride the vent, nitrous+ narcotic, Wean the sevo over 10 mins during closure then once they react turn off the vent, see a few spontaneous breaths and extubate. Works well 95% of the time.
I see many residents only using PSV, and constantly lowering the support level for their wakeups. Seems to be a new trend. The wakeups consistently take forever in this fashion. Seems to be what’s taught nowadays.
My go to is ride the vent, nitrous+ narcotic, Wean the sevo over 10 mins during closure then once they react turn off the vent, see a few spontaneous breaths and extubate. Works well 95% of the time.
I see many residents only using PSV, and constantly lowering the support level for their wakeups. Seems to be a new trend. The wakeups consistently take forever in this fashion. Seems to be what’s taught nowadays.
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I use psv to emerge, no issues here. I pull the tube as the drapes go down or immediately after, no time for doing calculus or head lifts, pt either comes to as we roll out or in PACU
My go to as well. 5 minutes or so left, high flows, sevo off nitrous on. Nitrous off 2 minutes before drapes down. Bridge with propofol 10-20mg as needed. Let the vent get all the volatile/nitrous off. Have to watch the patient closely. Always scenarios where I wouldnt do this but it works well for most cases. Watching patients breathe their way through stage 2 is painful and takes forever.
It's potency is ~1:1 with fentanyl. So if you want to get an effect equal to "50mcg of fentanyl" you can give 50mcg of remi.
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deleted875186
Disagree, I beleive it’s almost 2:1 potency as fentanyl. It is hard to compare as the onset time is so much quicker for Remi.
They must think you're the bees knees
Exceptionally smooth extubation overrated for most cases. Some exceptions: for hernias I do the typical private practice "pull tube when just before I see any signs of life" extubation with a goal of 10 RR using opioids. For breast/gynecomastia cases I pull it deep z(> 1.2 MAC), sit the pt up and jaw thrust as they're wrapping the pt up. For thyroids I stop the Remi after most of the gas is off and wait for their eyes to open. For carotids I start a precedex infusion after they unclamp.
For all the rest I might give ~0.25 precedex towards the end and wake them all the way up, replacing a bunch of the sevo with nitrous at the end. I honestly use a little less opioid than I used to. I target RR ~ 16 instead of 10.
They might cough, buck, or even sit up suddenly. But then they're awake and I can frequently chat with them and even have them move themselves to the other bed. Last week one of the circulating RNs saw that and said I could do her anesthesia anytime. A "cough less" extubation isn't the only way to look smooth.
For all the rest I might give ~0.25 precedex towards the end and wake them all the way up, replacing a bunch of the sevo with nitrous at the end. I honestly use a little less opioid than I used to. I target RR ~ 16 instead of 10.
They might cough, buck, or even sit up suddenly. But then they're awake and I can frequently chat with them and even have them move themselves to the other bed. Last week one of the circulating RNs saw that and said I could do her anesthesia anytime. A "cough less" extubation isn't the only way to look smooth.
You can do all these cases with no coughing without deep extubation, remi, nitrous or precedex. It's just about timing. Get the gas off slowly and early.
I still enjoy using Nitrous for wake-ups and I consider it an 'inhaled propofol'. I understand it's a potent Greenhouse Gas, however, why compromise my wake-ups when there are massive industries that are far worse emitters than the entirety of Anesthesiology? Is there good evidence to suggest that our small contribution will make giants leaps in reducing our footprint?
you don't need it for good wake-ups
Nitrous has gotten a bad rap but I still use it almost always. Why? It contributes significantly to mac.And thats what I want. I want an amnestic, asleep patient. I do not want to risk awareness. Risk of nausea? pfffft. Ill take that anyday over some patient telling me Im not nauseous but i remember the entire thing. PLus I think narcotic, ketamine, precedex all have a major hand in nausea even moreso than nitrous oxide.
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deleted875186
Nitrous is well established as causing nausea. It’s a terrible greenhouse gas. It is convenient to use for wake ups, but that’s it, I would argue volatile plus or minus prop achieves as fast a wake up without downsides of nitrous.
Ketamine in large doses contributes to nausea, not small doses though. Precedex never causes nausea. Opioids cause nausea but at least they bring some analgesia, more than can be said for nitrous.
I think it is a mistake to throw nitrous oxide by the wayside. Again, it contributes significantly to MAC, and the risk of nausea is there but not significantly higher than not using nitrous in the enigma2 trial. You wont make the newspapers because your patient has nausea but you will if she has awareness. Greenhouse mehh
PONV from nitrous is less than 1% if used for less than 1 hour.
And what's the incidence of intraop awareness when running 0.7MAC of volatile or higher? Less than 0.01%? I am not opposed to the use of nitrous, especially at the end of a case. I just don't understand the reasoning for it from @OptionOffense . Awareness is SO low on my list of concerns.
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I don't get it.
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When you’re in academics, nitrous at the end of a case makes it much easier to time a wake-up. Especially when you’re doing 3 hour EGDs under general with a 2 minute heads up of when they’ll be done.
D
deleted875186
As opposed to cranking flows and pushing some prop if they get a bit light???
Having a case of awareness is devastating to all those involved. I notice a trend that people(trainees and midlevels) forego gas (all gases) especially nitrous for TIVA protocols . I have also seen protocols that call for "no gases" in the name of ERAS. I have also witnessed us foregoing the use of gases to facilitate neuromonitoring. This is short-sighted especially how devastating a case of awareness is and how easy it is to prevent with a little bit of nitrous and or volatile agent . Part of me thinks there is a conspiracy by the precedex sales force to demonize nitrous and the volatile agents in favor of precedex infusions. Not to mention the climate freaks who say if I turn on a bit of desflurane I am the ****in' devil. Interesting times. It is only a matter of time where we see a well covered case of awareness under anesthesia amongst the many.
my only point was, why abandon the use of a fantastic agent because "it causes nausea" when the risk is higher but not 100 percent higher especially when the use of narcotics is still in full force use.
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No gas, no awareness if you know what you are doing.
