Those oh so smooth wakeups... what's your secret?

[morepatience]

How do you get the smooth wakeups? What are you doing with regards to vent settings, gas, opiods, adjuncts, etc? When are you doing it? What's your thought process? Please, give me the secrets. I'm talking everything from the ENT "Oh, don't blow my flap!" cases to the lap chole "Oh, this anesthesiologist is just not that good because their patients always cough or buck when they wake up!" cases.

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[pgg]

Assuming that you aren't looking for glib answers like deep extubation and "do a TIVA" ...

The right mixture of pain control (+/- opiate, +/- regional, +/- local, +/- adjuncts), enough gas, don't wait for the patient to follow directions before extubating (past stage 2 is "awake" enough to pull the tube).

Gas that come off faster (des) needs more of the pain control mix. Gas that comes off slow (iso) needs less because its analgesic effect stays around longer.

The answer is vague because it's different for every patient and surgery. It's simple, not easy. You get a feel for wakeups over time the way you get a feel for the crunchy pop a Tuohy makes when it's tracking midline.

 

[AdmiralChz]

The ultimate in smooth, just try playing it during emergence:



George Michael - Careless Whisper (Official Video) - YouTube

For some reason this immediately came to mind. Unclear why.

 

[DrOwnage]

CA-1 here, along the same lines, how do you guys feel about blowing off the gases prematurely and converting to a semi-TIVA with prop, get the patient adequately breathing and pulling the tube then?

 

[PonyUp]

Appropriately dosed dilaudid or morphine.

Or:

Slow change in ET volatile, instead of going from 1 MAC of inspired gas to 100% oxygen with no volatile as the surgery is being completed, I prefer to wean far ahead of time. Seems like the slower I pull the gas off the smoother emergence goes.

Every patient is different, but I often run a 60% nitrous and 0.4 mac volatile approach near the end of the case, whether I'm pulling the tube when a patient is anesthetized or "waking them up." I like the analgesic from the nitrous prior to the surgeon's inevitable "only at the end of the case" local infiltration. I also love that my tidal volumes improve when weaning the volatile in spontaneously breathing patients. Lastly, emergence for the deep extubated kiddos is much faster when a large portion of what is keeping the kid anesthetized is nitrous. Double edged sword though, if they misbehave...

For CPB cases that I'm going to extubate (asd/vsd/glenn/fontan/Tet) I try not to use volatile at all during or after coming off pump, and if I do it's like 0.2-0.4% iso to drop blood pressures while I'm waiting for the nicardipine to arrive from pharmacy.

There's no secret. No magic formula. Just do what works for you, well.

Or:

One of my coresidents a couple of years ago woke most of his patients up from propofol as opposed to volatile. He would entirely wean volatile off and just dink in propofol when the surgeons were closing. Seemed kind of wasteful to me but it worked well in the knife and gun club trauma patients that were a part of our everyday lives.

 

[Twiggidy]

Anesthesiology is an art. Not all pieces are beautiful, but most of the time they're worth looking at/listening to.

 

[pjl]

CA-1 here, along the same lines, how do you guys feel about blowing off the gases prematurely and converting to a semi-TIVA with prop, get the patient adequately breathing and pulling the tube then?

It is silly. Learn to time your gases.


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[pgg]

CA-1 here, along the same lines, how do you guys feel about blowing off the gases prematurely and converting to a semi-TIVA with prop, get the patient adequately breathing and pulling the tube then?

I always thought that was a lot of extra unnecessary work. If you blow off the gas with an appropriate layer of analgesia underneath it, people wake up smooth enough.

I also don't feel any special need to "get patients breathing again" ... I tend to leave them on the vent as long as possible to keep their MV high. People breathe when they're awake, if they're not overnarcotized.

And be careful with defining "adequately breathing" with volatile on board (which causes rapid shallow respirations)? You titrate narcotic to a RR of 12 in someone breathing off volatile anesthetic, you've probably given too much. On those occasions when I have a spontaneously breathing patient near emergence, I ignore the RR and aim for an ETCO2 in the low 40s. Anecdotally I think MV/ETCO2 is a better barometer of pain than RR in an emerging patient.

 

[DrOwnage]

It is silly. Learn to time your gases.

Thank you for sincere and constructive feedback.

 

[Ronin786]

I always thought that was a lot of extra unnecessary work. If you blow off the gas with an appropriate layer of analgesia underneath it, people wake up smooth enough.

I also don't feel any special need to "get patients breathing again" ... I tend to leave them on the vent as long as possible to keep their MV high. People breathe when they're awake, if they're not overnarcotized.

And be careful with defining "adequately breathing" with volatile on board (which causes rapid shallow respirations)? You titrate narcotic to a RR of 12 in someone breathing off volatile anesthetic, you've probably given too much. On those occasions when I have a spontaneously breathing patient near emergence, I ignore the RR and aim for an ETCO2 in the low 40s. Anecdotally I think MV/ETCO2 is a better barometer of pain than RR in an emerging patient.

While I understand the theory behind a RR of 12 being artificially inflated by the volatile, I also think that line of thought ignores the effect of volatiles on the apnea threshold. The way I see it, opioids are depressing the RR at the same time because of the concomitant volatile (the same reason 100mcg of fentanyl will make an anesthetized patient apneic without having the same effect on an awake patient). I would say there's a wash between those two effects, although most of my patients seem to breathe faster than what they were once the gas blows off.

I also personally like to have patients spontaneously breathing towards the end of a procedure on a bit of PS because I find they tolerate wake-up a little better (might change if they're debilitated vs healthy). Goes to show though how many different ways there are to extubate the cat.

 

[Maverikk]

Now's the time to try different things, you'll get the hang of it and realize that's it's different for the type of case. Once the first layer of fascia is closed they can start breathing, but not bucking or coughing, this should give you a feel of how much narcotic they need. See if you like PS, I personally like it and think it opens atelectatic lung. Try doing low flow, try prop and blowing off the gas, try timing it so all the gas is off by the time they're on skin and see how much time you need until they're awake versus their MAC is 0. It's a combination of surgery, length of surgery and patient. Some places don't want the patient awake at all till the dressings on and some places I've had them flipping themselves out of a prone spine case and they thought that was great. This is what training is for

 

[periopdoc]

how do you guys feel about blowing off the gases prematurely and converting to a semi-TIVA with prop, get the patient adequately breathing and pulling the tube then?

Way too much work, and slows the wakeup. I hate it when we are on short final and the surgeon calls for a go around. A little propofol, and the wakeup gets screwed up. I'm sure that nobody else in the OR notices it, but I certainly do.

Personally, I like to get them through emergence as quickly as possible so I use things like DES, minimal fentanyl, and no long acting opiates or benzos. Others prefer a longer "smoother" emergence time and use longer acting agents. PSV is your friend. I've never found RR to be useful, too many conflicting influences. EtCO2 on the other hand is very useful.

 

[Aether2000]

Dr Ownage, that is exactly what I do for at least 70% of my cases using sevo. The emergence time from Sevo is around 11 min (Desflurane for ambulatory anaesthesia: A comparison with sevoflurane for recovery profile and airway responses. - PubMed - NCBI) whereas from propofol boluses of 50-100mg is around 3-4 minutes, so I shut off sevo in anticipation of subcu or dermal closure (depends on the surgeon's slowness) then pop 50mg boluses of propofol

 

[deleted162650]

A smooth wake-up requires three things.

1: Get rid of the volatile
2: Have enough opioids on board so they will tolerate the ETT
3. Dont f*ck with the patient - let them wake up

There are as many ways to accomplish this as there are anesthesiologists, and finding out your recipe is part of the fun of residency.

 

[ZzzPlz]

Nitrous will only help you. Usually

 

[dhb]

Works every time

 

[Psai]

Dr Ownage, that is exactly what I do for at least 70% of my cases using sevo. The emergence time from Sevo is around 11 min (Desflurane for ambulatory anaesthesia: A comparison with sevoflurane for recovery profile and airway responses. - PubMed - NCBI) whereas from propofol boluses of 50-100mg is around 3-4 minutes, so I shut off sevo in anticipation of subcu or dermal closure (depends on the surgeon's slowness) then pop 50mg boluses of propofol

50-100 mg is 3-4 minutes? I don't believe that for a second

 

[Aether2000]

lol...of course you don't. But having administered it exactly in that manner to over 5,000 patients for pain procedures, that is my experience, but it is given without opioids. Your experience may be different, and is no less valid- the world of anesthesia is not constrained by a single "best way" to achieve a goal, but is manifest by a deliciously bountiful array of options that are used individually or in combination, based on preferences, skills, and most importantly the individual experience of the anesthesiologist.

 

[nimbus]

50-100 mg is 3-4 minutes? I don't believe that for a second

Agree. I often give 40-50mg propofol as a sole agent for cardioversion and it will sometimes last 10min. And I do watch the clock because I'm looking to boogie to my next case.

 

[Aether2000]

Agree propofol can last longer, but the median awakening time from propofol after a full induction dose is 5 min. (The initial clinical experience of 1819 physicians in maintaining anesthesia with propofol: characteristics associated with prolonged time to awake... - PubMed - NCBI) with 6.8% having prolonged awakening. In my surgical cases and many endoscopy cases, 50mg will not be a sufficient induction or in some, even a sedating dosage, but that little amount will be sufficient to augment the anesthesia from sevofluorane, and speed up awakening times.

 

[PainDrain]

I would also add three drugs to the "cocktail" for a smooth wake up. If I am worried about the patient bucking or being wacko on emergence then I will add in 40mcg dexmeditomdine in the last five minutes and dramatically cut back on the gas. Also, ketamine added into the last 30 min of an anesthetic can make a big difference during the tail end and in the pacu. Lastly, a bolus of 100mg lidocaine 30-90 seconds prior to pulling the tube can also help. It's a beautiful thing when the patient opens their eyes and you pull the tube immediately.

 

[D P356]

I've given a chronic pain patient IV haldol prior to emergence. I think I got the idea from @Noyac

It worked beautifully.

If patient is on antipsychotics, I'd think about adding that (depending on QT interval and med allergy). Also helps during the pacu stay.

 

[rakotomazoto]

As a naive resident, I like to believe that out in private practice land, it is easier to time a wake up since the surgeon is actually closing instead of handing the reigns to some surgical intern or MS4 to close the incision. I always try to get the gas off so I don't need other adjuncts like propofol, but I err on the side of getting the gas off and giving them a propofol bolus only if things are dragging on. I have more than once had the patient right where I wanted them, only to have a more senior surgical team member walk back over to the patient and complain about how the skin was closed, resulting in removal of an entire layer of stitches for a redo. Do things like this still happen out in the community setting?

For what it's worth, seems like the propofol bolus works pretty smoothly when I use it, although I don't like making it my primary method because it seems expensive to practice that way routinely. Plus, I like the challenge of timing the gas perfectly, even though I certainly haven't perfected it for every case that I do.

 

[Ezekiel2517]

50-100 mg is 3-4 minutes? I don't believe that for a second

It seems about right to me. Different patients will have different recovery times from prop. I did a GI case today where I gave 200 of prop up front at once and the patient breathed right thru it. Many patients will open their eyes within 2-3 minutes after a 100-150 mg bolus

 

[nimbus]

It seems about right to me. Different patients will have different recovery times from prop. I did a GI case today where I gave 200 of prop up front at once and the patient breathed right thru it. Many patients will open their eyes within 2-3 minutes after a 100-150 mg bolus

Alcoholic crackheads?

 

[deleted59964]

A smooth wake-up requires three things.

1: Get rid of the volatile
2: Have enough opioids on board so they will tolerate the ETT
3. Dont f*ck with the patient - let them wake up

There are as many ways to accomplish this as there are anesthesiologists, and finding out your recipe is part of the fun of residency.

nice post i agree with all 3 points.
for point 2 - any opioid works but remi makes it easy.
for point 3 - leacing them quiet works, and an lma switch works great if no reason not to
if you achieve points 2 and 3, point 1 takes care of itself.

 

[GravelRider]

As a naive resident, I like to believe that out in private practice land, it is easier to time a wake up since the surgeon is actually closing instead of handing the reigns to some surgical intern or MS4 to close the incision. I always try to get the gas off so I don't need other adjuncts like propofol, but I err on the side of getting the gas off and giving them a propofol bolus only if things are dragging on. I have more than once had the patient right where I wanted them, only to have a more senior surgical team member walk back over to the patient and complain about how the skin was closed, resulting in removal of an entire layer of stitches for a redo. Do things like this still happen out in the community setting?

Yup. In private practice land they hand the reigns over to a PA instead. Some PAs are better than others, but some view the closure as their time to shine or are just killing clock until their shift is over.

 

[Swamp Gas]

Lastly, emergence for the deep extubated kiddos is much faster when a large portion of what is keeping the kid anesthetized is nitrous.

No issues with diffusion hypoxia leaving the nitrous on?

 

[anbuitachi]

propofol with remi? i feel like we are slowly moving away from volatiles. at least at my academic institution, there's been more push to do ERAS protocol with TIVA and block if possible. Also tend to do TIVA with young females. And TIVA for cancer patients

 

[Noyac]

No issues with diffusion hypoxia leaving the nitrous on?

Nope. Just make sure they are breathing.
I believe it may be academic dogma. But I never use nitrous so I can't prove my point.

 

[PainDrain]

Nope. Just make sure they are breathing.
I believe it may be academic dogma. But I never use nitrous so I can't prove my point.

I am cautious with nitrous and diffusion hypoxia. I always thought it was BS but I recently had a case of a young man who had significant hypoxia in the PACU following an anesthetic that included nitrous. After ruling everything else out it appeared to be the nitrous.

 

[deleted171991]

I am cautious with nitrous and diffusion hypoxia. I always thought it was BS but I recently had a case of a young man who had significant hypoxia in the PACU following an anesthetic that included nitrous. After ruling everything else out it appeared to be the nitrous.

I avoid that by blowing away nitrous before the final 0.2-0.3 of sevo. The wakeup is as smooth as with nitrous alone.

 

[Noyac]

I avoid that by blowing away nitrous before the final 0.2-0.3 of sevo. The wakeup is as smooth as with nitrous alone.

I blow everything off and give a little propofol for my wake ups. Many ways the skin a cat.

 

[deleted171991]

I blow everything off and give a little propofol for my wake ups. Many ways the skin a cat.

I do that, too, if the sevo is blown away too fast. There aren't that many ways to skin this cat.

 

[ElmerFudd]

How do you get the smooth wakeups? What are you doing with regards to vent settings, gas, opiods, adjuncts, etc? When are you doing it? What's your thought process? Please, give me the secrets. I'm talking everything from the ENT "Oh, don't blow my flap!" cases to the lap chole "Oh, this anesthesiologist is just not that good because their patients always cough or buck when they wake up!" cases.

Don't wake up on gas. TIVAs and narcotic-heavy anesthetics wake up nicely.

Otherwise, just estimate deep as much as possible.

 

[propadope]

I am cautious with nitrous and diffusion hypoxia. I always thought it was BS but I recently had a case of a young man who had significant hypoxia in the PACU following an anesthetic that included nitrous. After ruling everything else out it appeared to be the nitrous.

Its not that diffusion hypoxia is BS. I think it is real but easily mitigated with high FiO2 for a couple of minutes after discontinuation of the nitrous. I am skeptical that it would cause hypoxia by the time the patient is in PACU. Most of the nitrous would have washed out by then.

 

[Swamp Gas]

Nope. Just make sure they are breathing.
I believe it may be academic dogma. But I never use nitrous so I can't prove my point.

I am cautious with nitrous and diffusion hypoxia. I always thought it was BS but I recently had a case of a young man who had significant hypoxia in the PACU following an anesthetic that included nitrous. After ruling everything else out it appeared to be the nitrous.

I avoid that by blowing away nitrous before the final 0.2-0.3 of sevo. The wakeup is as smooth as with nitrous alone.

I do a lot of deep extubations in peds and use a lot of nitrous. I blow off the nitrous the same as ya'll whether it's deep or awake. Just curious if "Ponyup" was leaving it on as he mentioned or if anyone else was for that matter.

I'm in an MD only group, I have no issues with my wake ups but was interested when he mentioned that the kids were waking up faster in PACU. I transport with a Jackson Reece circuit so maybe that would negate any potential hypoxia.

As far as smooth wake ups, when I'm in the ENT room I mix up precedex in the beginning of the day and give them all 0.5 mcg/kg after induction. Been working out nicely.

 

[Hoya11]

propofol with remi? i feel like we are slowly moving away from volatiles. at least at my academic institution, there's been more push to do ERAS protocol with TIVA and block if possible. Also tend to do TIVA with young females. And TIVA for cancer patients

I like a 80-90% prop gtt anesthetic. I run a little gas (0.4-0.7 sevo) to give a little mix. I kill the prop before the gas. I leave the gas on as my residual anesthetic for the end of the case during closing. Then I turn the gas off and wake up. Prop gtt still acts as an antiemetic after turning it off/in pacu, someone should do a study as to how long. This way you dont give high doses of either and get the benefits of both.

 

[Hoya11]

I do a lot of deep extubations in peds and use a lot of nitrous. I blow off the nitrous the same as ya'll whether it's deep or awake. Just curious if "Ponyup" was leaving it on as he mentioned or if anyone else was for that matter.

I'm in an MD only group, I have no issues with my wake ups but was interested when he mentioned that the kids were waking up faster in PACU. I transport with a Jackson Reece circuit so maybe that would negate any potential hypoxia.

As far as smooth wake ups, when I'm in the ENT room I mix up precedex in the beginning of the day and give them all 0.5 mcg/kg after induction. Been working out nicely.

I had lots of calls for bradycardia with the bolus approach to several short cases. it was a PIA and I stopped it. I only now give dex as an infusion, but do believe in it.

 

[Swamp Gas]

I had lots of calls for bradycardia with the bolus approach to several short cases. it was a PIA and I stopped it. I only now give dex as an infusion, but do believe in it.

I hear ya. So the old wise dude in our group who I adapted it from had told me that he use to do 1 mcg/kg but was having occasional bradycardia which prompted him to drop down to 0.5.

The dose has worked well for me thus far and I haven't had any calls from pacu.

 

[periopdoc]

Man, y'all work too hard. Turn the gas off and pull the tube. If you want to do a party trick, have the patient pull their own tube.

Offer does not apply to patients who have received too much opiate.

 

[Psai]

I had lots of calls for bradycardia with the bolus approach to several short cases. it was a PIA and I stopped it. I only now give dex as an infusion, but do believe in it.

How much prop?

 

[Hoya11]

How much prop?

80-150

 

[btbam]

I had lots of calls for bradycardia with the bolus approach to several short cases. it was a PIA and I stopped it. I only now give dex as an infusion, but do believe in it.

I just give 0.2 of glyco with the Dex bolus and it essentially cancels out the bradycardia. Wonder drug for pedi T+As.

 

[DrOwnage]

Does anyone use endotracheal tube cuff lidocaine, or 0.5mg/kg bolus of intravenous lidocaine 5 minutes prior to extubation? I've actually had good results with the latter, but I've only done it around 10 times.

 

[Psai]

Does anyone use endotracheal tube cuff lidocaine, or 0.5kg bolus of intravenous lidocaine 5 minutes prior to extubation? I've actually had good results with the latter, but I've only done it around 10 times.

holy **** 0.5 kg bolus of lido

 

[DrOwnage]

holy **** 0.5 kg bolus of lido

Haha, no wonder it was so smooth . Fixed.

 

[Noyac]

Does anyone use endotracheal tube cuff lidocaine, or 0.5mg/kg bolus of intravenous lidocaine 5 minutes prior to extubation? I've actually had good results with the latter, but I've only done it around 10 times.

Not in the cuff but I do the IV bolus. I give about 40-80mg depending on pt size. Yes, usually 0.5mg/kg.

 

[deleted162650]

IV lidocaine just acts as another hypnotic. Nothing magical about it that reduces coughing/bucking. It's buys you another 5mins of GA, and is equally as efficacious a propofol bolus.

 

[Noyac]

IV lidocaine just acts as another hypnotic. Nothing magical about it that reduces coughing/bucking. It's buys you another 5mins of GA, and is equally as efficacious a propofol bolus.

So true. I actually give both, lidocaine and propofol, at the end of cases that have an ETT. Just propofol if there is an LMA. There is nothing magically special about the lidocaine. Except that it works.