24 y.o. male, 220lb., no known medical problems, NPO for 6.5 hours, open foot fracture after a steel bar fell on it. Ortho to do I&D and possible ORIF.
RSI with 200mg propofol, 80mg lido, 150mg fentanyl, 5mg roc for defasc, 200mg succ. Tube went in easily. Anesthesia maintained on 1.3 mac sevo, no additional muscle relaxant.
Ortho does I&D, pinning of great toe, and closes. Procedure time around 1.5hrs (yeah university hospital and waiting for attending to show up to decide whether to pin or amputate great toe). Anyway turned off gas about 2 minutes before the splint goes on. Total narcotic given 400mcg (Pt's HR periodically increased to 90s).
Upper level resident comes into room. Wants to give additional 20mg of lidocaine to blunt laryngeal reponse.
Splint done setting, patient does not respond to name with sevo at Mac of 0.3. We move patient over to bed. Patient bucks on tube several times.
Attending anesthesiologist walks into room. Asks why patient is still not responding to name. Upper level says it's the fentanyl. Looked at patient's pupils and not pinpoint (~3mm). But still no response to name. At this time RR 14, TV 600, ETCO2~mid 40s. Attending says patient is still in stage 2, not safe to extubate because patient are prone to develop laryngospasm....
I was tempted to yank the tube as the patient was bucking after we transferred to bed. But the final decision was to T-piece him.
Of course on the way to PACU patient starts coughing and bucking HARD. Once in the PACU patient self extubated. Patient complains of discomfort in his foot (hence not too much narcotic)
So my question is, how safe is it to extubate a patient in "Stage 2". Also I was hoping someone can give me a definition of stage 2. Do patients tend to develop larynospasm at this point? I've been in cases where pediatric patients with LMAs get extubated in "stage 2" all the time.
Thanks for reading/reply to this long post.
RSI with 200mg propofol, 80mg lido, 150mg fentanyl, 5mg roc for defasc, 200mg succ. Tube went in easily. Anesthesia maintained on 1.3 mac sevo, no additional muscle relaxant.
Ortho does I&D, pinning of great toe, and closes. Procedure time around 1.5hrs (yeah university hospital and waiting for attending to show up to decide whether to pin or amputate great toe). Anyway turned off gas about 2 minutes before the splint goes on. Total narcotic given 400mcg (Pt's HR periodically increased to 90s).
Upper level resident comes into room. Wants to give additional 20mg of lidocaine to blunt laryngeal reponse.
Splint done setting, patient does not respond to name with sevo at Mac of 0.3. We move patient over to bed. Patient bucks on tube several times.
Attending anesthesiologist walks into room. Asks why patient is still not responding to name. Upper level says it's the fentanyl. Looked at patient's pupils and not pinpoint (~3mm). But still no response to name. At this time RR 14, TV 600, ETCO2~mid 40s. Attending says patient is still in stage 2, not safe to extubate because patient are prone to develop laryngospasm....
I was tempted to yank the tube as the patient was bucking after we transferred to bed. But the final decision was to T-piece him.
Of course on the way to PACU patient starts coughing and bucking HARD. Once in the PACU patient self extubated. Patient complains of discomfort in his foot (hence not too much narcotic)
So my question is, how safe is it to extubate a patient in "Stage 2". Also I was hoping someone can give me a definition of stage 2. Do patients tend to develop larynospasm at this point? I've been in cases where pediatric patients with LMAs get extubated in "stage 2" all the time.
Thanks for reading/reply to this long post.
