Smooth emergence after ETT GA

[apma77]

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???

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[huktonfonix]

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.

 

[jwk]

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???

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.

 

[jetproppilot]

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.

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.

 

[coprolalia]

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

 

[cchoukal]

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

When and how do you dose the propofol in this setting?

 

[coprolalia]

When and how do you dose the propofol in this setting?

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

 

[Jeff05]

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.

 

[coprolalia]

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.

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

 

[Planktonmd]

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.

Or just do deep extubation

 

[Jeff05]

we have lidocaine LTAs. i splash out half of the lido and add the tetra. total volume is about 5 ml - half and half.

 

[2win]

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???

Plus Lido cream 4% lubricate the cuff. Filling the cuff with lido? How does it work?

 

[coprolalia]

Plus Lido cream 4% lubricate the cuff. Filling the cuff with lido? How does it work?

2win,

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

-copro

 

[2win]

2win,

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

-copro

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

 

[coprolalia]

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

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

 

[2win]

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

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.

 

[coprolalia]

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.

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

 

[dhb]

You Are Playing A Game, And Therefore Are A Troll.

-copro

+1

 

[Pooh & Annie]

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

This would blunt they're gag too though, wouldn't it? It seems like if they puke they'd be more likely to aspirate.

 

[jetproppilot]

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, NOONE 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

Dude speaks da truth.

 

[urge]

Posted via Mobile DeviceI push 20 of potassium and extubate. Do cpr until pt awakes. No bucking ever.

 

[jetproppilot]

Posted via Mobile DeviceI push 20 of potassium and extubate. Do cpr until pt awakes. No bucking ever.

.