Smooth Extubation with Bupivicaine

[jope]

I've always used topical lidocaine to spray the above and below the vocal cords in cases less than 2 hours to try to have a smoother extubation. In longer cases, I have run low-dose remifentanil infusions on wakeup for cases such as neuroanesthesia, carotids, certain ENT cases, etc.

One of my colleagues was taught to use bupivicaine 0.25% and spray about 3-5 mL using a flexible LMA Madgic atomizer. I've tried it out and it seems to help keep the airway topicalized for more than 2 hours. Just wanted to see if anyone else here has tried this out?

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[coffeebythelake]

Haven't heard about this but also interested to learn more

 

[deleted162650]

I find it works better given as an IV bolus. Pretty much zero bucking every time.

 

[deleted171991]

I've always used topical lidocaine to spray the above and below the vocal cords in cases less than 2 hours to try to have a smoother extubation. In longer cases, I have run low-dose remifentanil infusions on wakeup for cases such as neuroanesthesia, carotids, certain ENT cases, etc.

One of my colleagues was taught to use bupivicaine 0.25% and spray about 3-5 mL using a flexible LMA Madgic atomizer. I've tried it out and it seems to help keep the airway topicalized for more than 2 hours. Just wanted to see if anyone else here has tried this out?

I would be curious about the risk of aspiration with this trick. I would really love not to have to rely just on the subglottic receptors. Can they even drink properly in the PACU, with a numb oropharynx?

 

[Noyac]

I would be curious about the risk of aspiration with this trick. I would really love not to have to rely just on the subglottic receptors. Can they even drink properly in the PACU, with a numb oropharynx?

It’s not the oropharynx that’s sprayed. Even though the OP said above and below I believe they mean spraying the cords. And then down the trachea.

 

[vector2]

Used 10cc of 0.5 ropi with a lma magic for a 3-4 hr crani a couple months ago. Worked like a charm. This was for a redo GBM resection in a pt already altered with seizure d/o so I wanted to take it easy on narcotics around extubation. For anything shorter where minimizing bucking is a priority I use a 4% lido LTA.

 

[deleted59964]

I think I'll stick to Remi - thanks

 

[vector2]

I think I'll stick to Remi - thanks

Our hospital is too cheap to buy remi. And even if they weren't it's not like remi plus an LTA are mutually exclusive.

Effect of topical ropivacaine on the response to endotracheal tube during emergence from general anesthesia: a prospective randomized double-blind controlled study

The airway reflex such as cough is common accompanied with severe fluctuations of hemodynamics during emergence. This prospective double-blind randomized controlled trial tested the hypothesis that topical ropivacaine may reduce extubation response and ...

www.ncbi.nlm.nih.gov

 

[dchz]

the smoothest wake up is the ones where they don't think the tube is there.

The best way to do that is make sure there is no tube there when they wake up.

 

[deleted162650]

the smoothest wake up is the ones where they don't think the tube is there.

The best way to do that is make sure there is no tube there when they wake up.

That’s cheating.

 

[PainDrain]

I find it works better given as an IV bolus. Pretty much zero bucking every time.

No need to transport them to PACU either. Just send them straight downstairs to the cooler.

 

[deleted171991]

the smoothest wake up is the ones where they don't think the tube is there.

The best way to do that is make sure there is no tube there when they wake up.

Like this: ?

 

[dchz]

No need to transport them to PACU either. Just send them straight downstairs to the cooler.

ECMO, duh?

Like this: ?

If only there was a natural pouch that you can suction to get all that green stuff out.

 

[Planktonmd]

I find it works better given as an IV bolus. Pretty much zero bucking every time.

This only works if you give the right dose, you want to have convulsions but no cardiovascular effects before extubation, and then you extubate when they are post-ictal ... very elegant technique.

 

[DM27]

This is an interesting idea. I use a 4% Lidocaine LTA for most cases in the 90 min or less range. I had briefly thought about the utility of Bupi or Ropi but something about it just felt like an incident waiting to happen. Now that it seems that people are doing it and there is at least one study I may reconsider this stance.

 

[jope]

It’s not the oropharynx that’s sprayed. Even though the OP said above and below I believe they mean spraying the cords. And then down the trachea.

Yes, sorry for any confusion. I am talking about spraying the vocal cords above and a little bit below, but not the oropharynx. Besides, if they were to try aspirating, it's not like the entire trachea is anesthetized and they should still cough. Finally, this is something I reserve for long cases at least >2+ hours where coughing could theoretically affect the outcome.

 

[Timeoutofmind]

Yes, sorry for any confusion. I am talking about spraying the vocal cords above and a little bit below, but not the oropharynx. Besides, if they were to try aspirating, it's not like the entire trachea is anesthetized and they should still cough. Finally, this is something I reserve for long cases at least >2+ hours where coughing could theoretically affect the outcome.

What is your technique for spraying below the cords with the ETT in place?

 

[deleted162650]

What is your technique for spraying below the cords with the ETT in place?

Before you put the ETT in Einstein.

 

[rakotomazoto]

Before you put the ETT in Einstein.

Nice to see you on SDN, Dr. Einstein.

 

[dhb]

Patients don't like having a numb throat from lidocaine.
Patients are going to cough sooner or later, who cares, just pull the tube before stage 2 to avoid the rodeo.

 

[Hork Bajir]

Or pull the tube in stage two and live dangerously... who’s got the kind of time to wait?

 

[vector2]

Patients don't like having a numb throat from lidocaine.
Patients are going to cough sooner or later, who cares, just pull the tube before stage 2 to avoid the rodeo.

People don’t like having a numb pharynx because it gives them a sensation of throat tightness. But I doubt anyone cares if their trachea, glottis and the inferior aspect of their epiglottis is temporarily lacking sensation.

 

[Twiggidy]

Just extubate like you were taught. I’m over style points

 

[deleted171991]

Before you put the ETT in Einstein.

So you spray the vocal cords and then put the ETT in Einstein?

 

[mdan]

Just extubate like you were taught. I’m over style points

Agreed that in some cases you need to avoid coughing/bucking and spraying may help. But as an aside, I used to care a lot about how smooth I "looked" in the OR when I was a resident/new staff, but now after having a few harrowing, hair rising on the back of the neck situations everyone eventually faces in practice, I'm just happy if at the end of the day, all the patients are alive and without complications. Don't care anymore how smooth I looked. (Although it's nice)

 

[deleted171991]

If they want smooth, they can kiss my behind. I'm in the safety business.

 

[Twiggidy]

If they want smooth, they can kiss my behind. I'm in the safety business.

This visual is going to be stuck in my head all day

 

[deleted162650]

This visual is going to be stuck in my head all day

Funny. I always imagined he was quite hairy.

 

[Twiggidy]

Funny. I always imagined he was quite hairy.

For some reason I did too. Mind blown

 

[nimbus]

If they want smooth, they can kiss my behind. I'm in the safety business.

Funny. I always imagined he was quite hairy.

For some reason I did too. Mind blown

There used to be a waxing salon nearby that advertised the “baseball special” which included the bat, the balls and the dugout.

 

[Twiggidy]

There used to be a waxing salon nearby that advertised the “baseball special” which included the bat, the balls and the dugout.

Aka the Sean Mic....,,nope not gonna go there

 

[deleted162650]

There used to be a waxing salon nearby that advertised the “baseball special” which included the bat, the balls and the dugout.

If you got a hairy bat you got problems.

 

[dhb]

 

[UscGhost]

I've always used topical lidocaine to spray the above and below the vocal cords in cases less than 2 hours to try to have a smoother extubation. In longer cases, I have run low-dose remifentanil infusions on wakeup for cases such as neuroanesthesia, carotids, certain ENT cases, etc.

One of my colleagues was taught to use bupivicaine 0.25% and spray about 3-5 mL using a flexible LMA Madgic atomizer. I've tried it out and it seems to help keep the airway topicalized for more than 2 hours. Just wanted to see if anyone else here has tried this out?

Probably a little overkill to use it for so many cases. Useful if you want to intubate but dont want to give a long acting paralytic (cases with nerve monitoring, breast cases with AXLND), or cases where you want to avoid narcotics.

Otherwise narcotize them to a RR of 8-10 and they will wake up pretty smooth without much else. Pull the tube slowly and gently when the are SV. Pull before stage 2.