1. Dismiss Notice
  2. Download free Tapatalk for iPhone or Tapatalk for Android for your phone and follow the SDN forums with push notifications.
    Dismiss Notice

Smooth emergence after ETT GA

Discussion in 'Anesthesiology' started by apma77, Jun 1, 2008.

  1. apma77

    apma77 Senior Member
    10+ Year Member

    Joined:
    Feb 27, 2003
    Messages:
    435
    Likes Received:
    0
    What is ya'll' s concoction for smooth emergence:

    IV lidocaine prior to extubation
    precedex infusion thru the case
    LTA lidocaine at intubation
    fill the cuff with 4% lido

    any other options???
     
  2. Note: SDN Members do not see this ad.

  3. huktonfonix

    huktonfonix board certified!
    7+ Year Member

    Joined:
    Oct 3, 2003
    Messages:
    733
    Likes Received:
    2
    Status:
    Attending Physician
    IV lido helps some, but is hit or miss. LTA works great for short cases. Precedex is too expensive to use for a smooth emergence in most cases. My usual thing is deep extubation and/or adequate narcotics. If I didnt need to rapid sequence a patient or worry about a difficult airway, then they almost all get extubated deep.
     
  4. jwk

    jwk CAA, ASA-PAC Contributor
    10+ Year Member

    Joined:
    Apr 30, 2004
    Messages:
    3,513
    Likes Received:
    583
    IV lidocaine - sometimes

    Precedex - not even on formulary here and way to expensive for this simple problem

    LTA lidocaine at intubation - seems to be finding favor again in our practice, but if the case lasts much more than an hour or so, it doesn't help much.

    Fill the cuff with 4% lido - as in inflate your cuff with a fluid rather than air? NOPE! - not unless it's for the fancy laser ETT with the blue dye in the cuff.
     
  5. jetproppilot

    jetproppilot Turboprop Driver
    10+ Year Member

    Joined:
    Mar 12, 2005
    Messages:
    5,861
    Likes Received:
    103
    JWK has responded to your question.

    But the dudes been doing this gig longer than I've had a drivers license.

    I'd bet theres alot more going into JWKs smooth emergences than your simple list.
     
  6. coprolalia

    coprolalia Bored Certified
    2+ Year Member

    Joined:
    Aug 5, 2007
    Messages:
    3,084
    Likes Received:
    17
    Status:
    Attending Physician
    I think HookedOnPhonics covered it nicely. I'm a big fan of the LTA, when I remember to use it. Also, a little propofol as you're titrating off the anesthetic works wonders, especially in kids. I rarely have a bucking, angry, inconsolable kid in the PACU anymore with this technique.

    -copro
     
  7. cchoukal

    cchoukal Senior Member
    Moderator 10+ Year Member

    Joined:
    Jul 10, 2001
    Messages:
    2,013
    Likes Received:
    153
    Status:
    Attending Physician
    When and how do you dose the propofol in this setting?
     
  8. coprolalia

    coprolalia Bored Certified
    2+ Year Member

    Joined:
    Aug 5, 2007
    Messages:
    3,084
    Likes Received:
    17
    Status:
    Attending Physician
    As the case is ending, breathe the vapors down to 0.3 MAC. Maintain your high flows. Give a 0.5-1mg/kg bolus. Pull the tube when they wrinkle their brow and/or reach for the tube. No bucking. No thrashing. Smooth as silk. Kids are less "dysphoric" in the PACU as well.

    This does not work for a heavy smoker with an irritable airway, but that excludes most 5-year-olds fortunately.

    -copro
     
  9. Jeff05

    Jeff05 Senior Member
    10+ Year Member

    Joined:
    May 30, 2001
    Messages:
    1,059
    Likes Received:
    2
    Status:
    Attending Physician
    get a good spray with the LTA - tetrac. is good makes them numb for 4-6 hrs.

    run remi with nitrous (70%) and a touch of prop - 30mcg/kg/min.

    if you're running remi at 0.25mcg/kg/min turn it down to 0.03-0.05mcg/kg/min about 10 min prior to emergence.

    about 5 min prior to emergence turn off prop.

    when ready to roll turn off nitrous and blow it off under 10. if patient is under 10 and sleeping, turn off remi at this time.

    they will open their eyes - tell them that surgery is over and to take a deep breath. you do not need to get them to breath spontaneously prior to this. pull the tube.

    02 nc on and actively encourage them to breathe for the next 5 min.

    i have times the technique so that the patient is extubated and moving over to bed within 3-5 min after procedure finish.

    every wakeup is a comfortable, compliant patient. i like to wake up huge dudes like this - so they don't go ape$hit on emergence. works like a charm.


    i have done this technique on airway and neuro cases and have NEVER had bucking or a rough emergence. never confusion. always comfortable, compliant patients.

    this may not be feasible in pp.
     
  10. coprolalia

    coprolalia Bored Certified
    2+ Year Member

    Joined:
    Aug 5, 2007
    Messages:
    3,084
    Likes Received:
    17
    Status:
    Attending Physician
    It's a good technique if you have someone who absolutely cannot cough at the end of the procedure, but you're right. Probably too expensive for PP land.

    Where do you get the tetracaine LTA? Do you make it up yourself with regular 0.2% tetracaine? (I ask because we have nifty pre-made lidocaine 4% LTA kits.)

    -copro
     
  11. Planktonmd

    Moderator Emeritus Lifetime Donor Classifieds Approved 10+ Year Member

    Joined:
    Nov 2, 2006
    Messages:
    6,819
    Likes Received:
    1,795
    Status:
    Attending Physician
    Or just do deep extubation ;)
     
  12. Jeff05

    Jeff05 Senior Member
    10+ Year Member

    Joined:
    May 30, 2001
    Messages:
    1,059
    Likes Received:
    2
    Status:
    Attending Physician
    we have lidocaine LTAs. i splash out half of the lido and add the tetra. total volume is about 5 ml - half and half.
     
  13. 2win

    10+ Year Member

    Joined:
    Apr 25, 2008
    Messages:
    1,178
    Likes Received:
    32
    Status:
    Attending Physician
    Plus Lido cream 4% lubricate the cuff. Filling the cuff with lido? How does it work?
     
  14. coprolalia

    coprolalia Bored Certified
    2+ Year Member

    Joined:
    Aug 5, 2007
    Messages:
    3,084
    Likes Received:
    17
    Status:
    Attending Physician
    2win,

    No offense. But, I don't believe you are an anesthesia attending. Sorry.

    -copro
     
  15. 2win

    10+ Year Member

    Joined:
    Apr 25, 2008
    Messages:
    1,178
    Likes Received:
    32
    Status:
    Attending Physician
    No problem coprolalia - thanks God that you were not on the board. Regarding the "sorry" part I couldn't care less.
    Look at this
    http://bja.oxfordjournals.org/cgi/content/full/93/3/477
    we are talking about alkalinization of the lido...
    "Sodium bicarbonate is necessary to transform lidocaine hydrochloride into lidocaine base to potentiate diffusion across the ETT; 65% of diffusion occurs over 6 h with the hydrophobic neutral form but only 1% with ionized lidocaine hydrochloride.4"
    REGARDING THE STUDY WITH LIDO ONLY - BS
     
    #14 2win, Jun 3, 2008
    Last edited: Jun 3, 2008
  16. coprolalia

    coprolalia Bored Certified
    2+ Year Member

    Joined:
    Aug 5, 2007
    Messages:
    3,084
    Likes Received:
    17
    Status:
    Attending Physician
    Your posts are very confusing and/or leading. I guess I should assume that English isn't your first language then.

    Everyone I know understands the theory behind putting lidocaine in the ETT cuff. No one I know does it. The only time anyone puts anything in the cuff other than air is during a laser case, and even then we use special tubes.

    I would presume that all anesthesia attendings should know that. I further assume that there would be no point for an attending to ask such a question. So, in my deduction, you either (a) are an anesthesia attending and didn't initially know the answer (scary), (b) aren't an anesthesia attending, or (c) are playing an Internet game. Which is it?

    -copro
     
  17. 2win

    10+ Year Member

    Joined:
    Apr 25, 2008
    Messages:
    1,178
    Likes Received:
    32
    Status:
    Attending Physician
    :laugh:
    That's funny the way that you read an article. So you know that lidocaine somehow gets outside of the cuff, u dont have any ideea how, what concentration or if the tube has to be kept for an hour in warm water before, u dont know the rate of diffusion, u never tried but u are sure that's working...don't assume to much without to be a little humble coprolalia. u choosed right your name - and seems that u're happy with this condition.
     
  18. coprolalia

    coprolalia Bored Certified
    2+ Year Member

    Joined:
    Aug 5, 2007
    Messages:
    3,084
    Likes Received:
    17
    Status:
    Attending Physician
    2win,

    Stay with me here: No one puts lidocaine in the cuff. No one puts lidocaine+bicarb in the cuff. People know that it's possible to do this. People even surmise that it may work. Still, no one does it. Understand?

    Again, I'm having an incredibly difficult time following your what-probably-only-makes-sense-to-you stream of consciousness. You are playing a game, and therefore are a TROLL.

    -copro
     
  19. dhb

    dhb Member
    Lifetime Donor Classifieds Approved 10+ Year Member

    Joined:
    Jul 12, 2006
    Messages:
    3,529
    Likes Received:
    737
    Status:
    Attending Physician
    +1
     
  20. Pooh & Annie

    Pooh & Annie Member
    10+ Year Member

    Joined:
    Jul 15, 2005
    Messages:
    1,374
    Likes Received:
    569
    Status:
    Attending Physician
    This would blunt they're gag too though, wouldn't it? It seems like if they puke they'd be more likely to aspirate.
     
  21. jetproppilot

    jetproppilot Turboprop Driver
    10+ Year Member

    Joined:
    Mar 12, 2005
    Messages:
    5,861
    Likes Received:
    103
    Dude speaks da truth.
     
  22. urge

    10+ Year Member

    Joined:
    Jun 23, 2007
    Messages:
    3,625
    Likes Received:
    1,006
    Status:
    Attending Physician
    Posted via Mobile DeviceI push 20 of potassium and extubate. Do cpr until pt awakes. No bucking ever.
     
  23. jetproppilot

    jetproppilot Turboprop Driver
    10+ Year Member

    Joined:
    Mar 12, 2005
    Messages:
    5,861
    Likes Received:
    103

    .
     
    #22 jetproppilot, Jun 5, 2008
    Last edited: Jun 6, 2008

Share This Page