Tips for fast turnover/start of cases

[BobBarker]

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I dont think that situation is what they are talking about...

 

[Bertelman]

There seems to be a late infusion of attitude in this thread.

 

[psychbender]

My question to you.... Standard CA1 case: 250 pounder for robotic hys BSO 3 hour in with iso at mac 1.0 in steep trendelenberg... estimated 30 minutes to go but who knows, maybe they'll have to do a cysto. You know out of steep trendelenberg to closure of lap sites takes them 10 minutes. What would be your strategy for a fast wake up?

I actually had nearly this exact case the other day when I got pulled into the general OR to help out (and had never worked with any of these residents/staff, as this is not my home institution, and I am on cardiac). At the announcement of "30 minutes," respiratory rate decreased to build up CO2, iso dialed way down, flows kept <1 lpm, still 1/4 twitch, OGT and oropharynx suctioned dry (lots of drool). Flipped her to PSV just before being taken out of T-berg, and worked in fentanyl to RR 8-10. While the resident was closing, surprise, they want to do a cysto! ET iso 0.4%, RR 10, TV on PS 10 400. Propofol in line, just in case (ended up not needing it). The staff was doing the cysto, so flows turned way up, reversal given, additional fentanyl worked in. Once the cysto was complete, and the table taken down from neuro height, pt off PSV, taking spontaneous 300-400mL TV breaths at rate of 10, with ET iso 0.1%. She moved her leg when one of the residents started putting a dressing on, which freaked her out (oh my God, the patient is moving!), and I had the patient extubated by the time the last dressing was applied.

I use Iso almost exclusively on long cases, partly because only a few machines back home have Des vaporizers, so had to figure out how to get fast wake ups with it. For me, turning the gas down/off well before closure, and resuming spontaneous (PSV) breathing early is the ticket. I sometimes have to supplement with some propofol that I didn't use from induction, or turn on a bit of nitrous, but my staff and the surgeons seem to be satisfied with my technique, as the patient doesn't move during their closure, and we are out of the room not long after the dressings are applied, and the skin cleaned of dry prep solution.

 

[Arch Guillotti]

-If I Titrate opiates, I do it early. Near the start of slow skin closure (or when I think I have 10 or so minutes left), I use EtCO2 to assess how deep someone is, in that I keep it constant (32-34) as I wash out gas with agent off and high flows until they buck (I always make sure I have at least 1 good twitch). Most of the time its around a ET of 0.3ish (true reading using low flow).
-I use mech ventilation as long as possible. Only when the case truly is at the very end I reverse and switch to SV.

If someone is on mechanical ventilation how does ETCO2 tell you how deep someone is?

 

[proman]

Flipped her to PSV just before being taken out of T-berg, and worked in fentanyl to RR 8-10. While the resident was closing, surprise, they want to do a cysto! ET iso 0.4%, RR 10, TV on PS 10 400. Propofol in line, just in case (ended up not needing it).

The adverse effects of opioids include bradypnea/apnea and hypercarbia from rightward shift of the CO2 response threshold. I've never understood the practice of titrating drugs to their adverse effect. RR of 8 is very close to 0 after extubation. I do give opioid timed so that the peak effect of the drug coincides when the patient will be awake. I realize my practice is probably in the minority but patients are just as comfortable and I think it's a safer approach.

 

[RxBoy]

If someone is on mechanical ventilation how does ETCO2 tell you how deep someone is?

If they can initiate a breath (try to breath over the vent) at a PaCO2 near normal, that means most of the anesthetic has a\worn off because the PaCO2 response curve has normalized. If however PaCO2 needs to build up to say 50 (in a normal non COPD/OSA pt) and then they start rebreathing, considering the dose dependent response of the volatile, they still have a lot of agent on board which will take them quite some time to blow off if its been a long case.

Edit: Before I get flamed and get called a nurse again because I fail to realize that strong cortical activity such as surgical stimulation can over come the apneic threshold and allow the pt to intiate a breath... This is why I work in opiate early and reverse later (to avoid drastic movement). If weak stimulus such as suture causes an initiation of a breath, that is also an indicator to me that most of the gas has worn off.

 

[RxBoy]

I had the patient extubated by the time the last dressing was applied.

Nice....THe nice thing about Iso is that you have a lot of slack to dial it down early because it takes so long to wash out which also makes it one of the biggest weaknesses.

 

[pgg]

My question to you.... Standard CA1 case: 250 pounder for robotic hys BSO 3 hour in with iso at mac 1.0 in steep trendelenberg... estimated 30 minutes to go but who knows, maybe they'll have to do a cysto. You know out of steep trendelenberg to closure of lap sites takes them 10 minutes. What would be your strategy for a fast wake up?

Option 1) Use the blue gas instead. 😀

Option 2) Turn the iso down/off early. That's the answer. You can fudge it with some propofol, or using some nitrous, or more narcs, or fewer twitches closer to the end ... but the answer is you just have to shut it off early. I know you know this and I'm not trying to be sarcastic. It is harder to time it, especially with inconsistent surgeons, or ones who aren't able (or can't be bothered) to tell you if they're going to do the cysto or not with some warning. The cases that are high-stim to abruptly no-stim with short/no closing time are tough.

Isoflurane is a fine gas. Consider though that longer cases like this in obese patients are why desflurane was developed in the first place. I think there is learning value in mastering iso wakeups, but I don't see the point in permanently handicapping yourself with a marginally cheaper but pharmacokinetically inferior drug.

We don't have isoflurane any more, and I don't really miss it. Ten consecutive beautiful, smooth, classic iso wakeups aren't worth the one time the surgeon abruptly announces he's done and we sit in the OR an extra 10 or 15 minutes. Because that's the wakeup everyone will remember.

Embrace the blue gas. You know you want to. 🙂

 

[proman]

Option 1) Use the blue gas instead. 😀

Embrace the blue gas. You know you want to. 🙂

Probably not what you meant 😉

 

[Bertelman]

If they can initiate a breath (try to breath over the vent) at a PaCO2 near normal, that means most of the anesthetic has a\worn off because the PaCO2 response curve has normalized. If however PaCO2 needs to build up to say 50 (in a normal non COPD/OSA pt) and then they start rebreathing, considering the dose dependent response of the volatile, they still have a lot of agent on board which will take them quite some time to blow off if its been a long

I have found little correlation in my experience with depth of anesthetic to the ETCO2 at which they begin to breath over the vent. Too many other variables.

 

[BLADEMDA]

I have found little correlation in my experience with depth of anesthetic to the ETCO2 at which they begin to breath over the vent. Too many other variables.

 

[BLADEMDA]

 

[BLADEMDA]

 

[BLADEMDA]

Always remember to keep in mind who exactly are you waking up.

Fentanyl patch? Drinker? Drug user? Elderly? Young and healthy?

These variables place just as important a role as the type of vapor and ETCo2 level.

 

[fakin' the funk]

The adverse effects of opioids include bradypnea/apnea and hypercarbia from rightward shift of the CO2 response threshold. I've never understood the practice of titrating drugs to their adverse effect. RR of 8 is very close to 0 after extubation. I do give opioid timed so that the peak effect of the drug coincides when the patient will be awake. I realize my practice is probably in the minority but patients are just as comfortable and I think it's a safer approach.

You make an excellent point, and I agree with you.

But to play devil's advocate, this principle is certainly widespread:
1) titration of po beta-blockers to fatigue or HR ~50 or AV block
2) titration of po alpha-blocker in a pheo pt preop until they have nasal congestion

 

[fakin' the funk]

She moved her leg when one of the residents started putting a dressing on, which freaked her out (oh my God, the patient is moving!), and I had the patient extubated by the time the last dressing was applied. ...as the patient doesn't move during their closure, and we are out of the room not long after the dressings are applied, and the skin cleaned of dry prep solution.

Having the pt buck/cough, or just loudly talking to a just-awakened but comfortable and not-yet-extubated pt, is a great way to get the surgeons (i.e. junior resident/med student) to hurry the f*ck up and finish the dressings. I personally don't care if this makes them happy or not, it doesn't hurt the pt, and we all the know the pt is still amnestic at this point.

 

[Gasworks]

Having the pt buck/cough, or just loudly talking to a just-awakened but comfortable and not-yet-extubated pt, is a great way to get the surgeons (i.e. junior resident/med student) to hurry the f*ck up and finish the dressings. I personally don't care if this makes them happy or not, it doesn't hurt the pt, and we all the know the pt is still amnestic at this point.

I hope you realize that this doesn't happen in the real world outside of crybaby infested university OR's. Most of the surgeons I work with in hospitals and surgery centers work as fast as they possibly can as do all of the nurses, techs and even the people mopping the floors. Speed is always an asset if it means I get to spend an extra 30 minutes chilling in the yard with the dogs vs. wasting that time moving in slow motion at the hospital. Here are a couple of my personal tips - I didnt read the whole thread so some of it might have been said before:

1. Learn to do a quick and thorough preop. The admitting nurse usually does and detailed intake and just about anything that can be said about the pt is condensed into a couple of sheets. People hate repeating the same questions from 50 different people and if they are telling you the same things they told the last 3 people it doesn't necessarily make you look smart.

2. Have the nurses start the IV's. Usually I have them come back with a saline lock as the bag tends to slow down the transport process.

3. Already mentioned - learned the art of balancing the mask on a pt's face using the christmas tree. Put the pt to sleep by yourself. Why should the nurse have to stand there like a statue when he/she could be prepping the pt? The surgeons are happy to hold cricoid, pass the tube, start another IV or even an A-line if you just ask nicely.

4. Instill a culture of rapid turnover in your workplace... which is a fancy way of saying that you should stay on top of the staff to flip the rooms in a timely manner. When working at surgery centers we usually can't leave until the last pt has left the parking lot so it them becomes my job to ride the pacu nurses to get the pts out. You don't have to be mean about it - a little positive reinforcement goes a long way with people who are used to getting screamed at all day.

5. Extubate deep. Get them breathing as soon as possible, cut the gas, a few breaths of 100% 02 and pull the tube as long as tidal volumes are compatible with life. Educate the pacu nurses on proper use of oral and nasal airways. Usually this is as simple as telling the nurses to leave them in until the pt pulls them out. If you can also teach them how to insert airways and give a little jaw lift you'll be in deep extubation heaven.

6. Don't drop the ETCO2 too low on anyone who is a smoker, obese, has OSA or COPD. You'll just wind up waiting that much longer for it to climb back up.

7. Go easy on the narcs, especially if you like to extubate deep. Let the pacu nurses give them as the pt is blowing off the last 1/2 mac of anesthesia.

8. Learn how to give meaningful and fast acting IV sedation. Listening to some barely conscious pt ramble on and on does wonders for a surgeons concentration. In a healthy pt my sedation starts with 2 versed 100 fent and 50 of prop. Make sure you have narcan handy and a circuit/mask ready to go if needed. Use a CO2 sampling nasal cannula. We don't have ETCO2 on some offsite machines and the pt's seem to have significantly wider swings into over/under sedation without it. Pt moving and pt turning blue will usually slow things down.

9. Help the room when you can. Tie the surgeons, plug in the suction and bovie, inflate the tourniquet, grab sutures while the circulator is out of the room, answer the phone, check surgeons beeper for them, do what you can to help troubleshoot equipment (we need more male OR nurses lol). I get tired of feeling the glory of my pre-rush hour drive home fade away as a nurse thats been on her feet all day slowly shuffles back and forth across the room.

Remember.. at the end of the day, you are basically the only person that benefits from picking up all of these extra minutes. The nurses are on the clock and the surgeons either have rounds, clinic or another OR waiting for them. I on the other hand, am still enjoying the last couple of weeks of convertible weather on my way home.

 

[epidural man]

I hope you realize that this doesn't happen in the real world outside of crybaby infested university OR's. Most of the surgeons I work with in hospitals and surgery centers work as fast as they possibly can as do all of the nurses, techs and even the people mopping the floors. Speed is always an asset if it means I get to spend an extra 30 minutes chilling in the yard with the dogs vs. wasting that time moving in slow motion at the hospital. Here are a couple of my personal tips - I didnt read the whole thread so some of it might have been said before:

1. Learn to do a quick and thorough preop. The admitting nurse usually does and detailed intake and just about anything that can be said about the pt is condensed into a couple of sheets. People hate repeating the same questions from 50 different people and if they are telling you the same things they told the last 3 people it doesn't necessarily make you look smart.

2. Have the nurses start the IV's. Usually I have them come back with a saline lock as the bag tends to slow down the transport process.

3. Already mentioned - learned the art of balancing the mask on a pt's face using the christmas tree. Put the pt to sleep by yourself. Why should the nurse have to stand there like a statue when he/she could be prepping the pt? The surgeons are happy to hold cricoid, pass the tube, start another IV or even an A-line if you just ask nicely.

4. Instill a culture of rapid turnover in your workplace... which is a fancy way of saying that you should stay on top of the staff to flip the rooms in a timely manner. When working at surgery centers we usually can't leave until the last pt has left the parking lot so it them becomes my job to ride the pacu nurses to get the pts out. You don't have to be mean about it - a little positive reinforcement goes a long way with people who are used to getting screamed at all day.

5. Extubate deep. Get them breathing as soon as possible, cut the gas, a few breaths of 100% 02 and pull the tube as long as tidal volumes are compatible with life. Educate the pacu nurses on proper use of oral and nasal airways. Usually this is as simple as telling the nurses to leave them in until the pt pulls them out. If you can also teach them how to insert airways and give a little jaw lift you'll be in deep extubation heaven.

6. Don't drop the ETCO2 too low on anyone who is a smoker, obese, has OSA or COPD. You'll just wind up waiting that much longer for it to climb back up.

7. Go easy on the narcs, especially if you like to extubate deep. Let the pacu nurses give them as the pt is blowing off the last 1/2 mac of anesthesia.

8. Learn how to give meaningful and fast acting IV sedation. Listening to some barely conscious pt ramble on and on does wonders for a surgeons concentration. In a healthy pt my sedation starts with 2 versed 100 fent and 50 of prop. Make sure you have narcan handy and a circuit/mask ready to go if needed. Use a CO2 sampling nasal cannula. We don't have ETCO2 on some offsite machines and the pt's seem to have significantly wider swings into over/under sedation without it. Pt moving and pt turning blue will usually slow things down.

9. Help the room when you can. Tie the surgeons, plug in the suction and bovie, inflate the tourniquet, grab sutures while the circulator is out of the room, answer the phone, check surgeons beeper for them, do what you can to help troubleshoot equipment (we need more male OR nurses lol). I get tired of feeling the glory of my pre-rush hour drive home fade away as a nurse thats been on her feet all day slowly shuffles back and forth across the room.

Remember.. at the end of the day, you are basically the only person that benefits from picking up all of these extra minutes. The nurses are on the clock and the surgeons either have rounds, clinic or another OR waiting for them. I on the other hand, am still enjoying the last couple of weeks of convertible weather on my way home.

👍

 

[jwk]

I hope you realize that this doesn't happen in the real world outside of crybaby infested university OR's. Most of the surgeons I work with in hospitals and surgery centers work as fast as they possibly can as do all of the nurses, techs and even the people mopping the floors. Speed is always an asset if it means I get to spend an extra 30 minutes chilling in the yard with the dogs vs. wasting that time moving in slow motion at the hospital. Here are a couple of my personal tips - I didnt read the whole thread so some of it might have been said before:

2. Have the nurses start the IV's. Usually I have them come back with a saline lock as the bag tends to slow down the transport process.
5. Extubate deep. Get them breathing as soon as possible, cut the gas, a few breaths of 100% 02 and pull the tube as long as tidal volumes are compatible with life. Educate the pacu nurses on proper use of oral and nasal airways. Usually this is as simple as telling the nurses to leave them in until the pt pulls them out. If you can also teach them how to insert airways and give a little jaw lift you'll be in deep extubation heaven.

6. Don't drop the ETCO2 too low on anyone who is a smoker, obese, has OSA or COPD. You'll just wind up waiting that much longer for it to climb back up.

7. Go easy on the narcs, especially if you like to extubate deep. Let the pacu nurses give them as the pt is blowing off the last 1/2 mac of anesthesia.

8. Learn how to give meaningful and fast acting IV sedation. Listening to some barely conscious pt ramble on and on does wonders for a surgeons concentration. In a healthy pt my sedation starts with 2 versed 100 fent and 50 of prop. Make sure you have narcan handy and a circuit/mask ready to go if needed. Use a CO2 sampling nasal cannula. We don't have ETCO2 on some offsite machines and the pt's seem to have significantly wider swings into over/under sedation without it. Pt moving and pt turning blue will usually slow things down.

I agree with most of your statements. You're totally correct that being outside a teaching environment that speed and efficiency are huge commodities, even moreso in ASC's than hospitals.

All our patients come to the OR with IV's running. No reason not to - that's what pre-op is usually for. With all the SCIP paranoia, the "appropriate" antibiotic is usually hanging and ready to go (or vanco already on the pump and running). The only thing that still drives me nuts is everyone asking the same questions over and over. Totally absurd. If the pre-op nurse asks about NPO status, loose teeth, piercings, yada, yada, yada, then the OR nurse shouldn't need to come in and spend five minutes asking the same questions all over again. Redundancy for operative side/site/procedure is fine - all the rest just wastes time.

I use tons of narcs and still extubate deep. I would prefer to pre-empt their pain rather than waiting to react to it in PACU. We encourage our surgeons to use lots of local. I do indeed titrate my narcs using respiratory rate as a guide towards the end of the case. I don't do it down to a rate of 8-10 as some apparently do, but if they're huffing along at 25-30/min, and your agents on the way down, ya gotta give em something.

I've paid a lot more attention in the last few years to my ventilation practices. Running everyone into the low 30's used to be the norm, and PEEP used to be evil. Now if I'm using controlled ventilation, I'm perfectly happy with ETCO2's in the high 30's-low 40's, and almost always use PC with a little PEEP and keep my PIP's as low as I can to keep ventilation and oxygenation where I want it. The various PSV-PRO, SIMV, etc., modes on the newer ventilators make everything so much easier. Staying near-normocarbic helps with fast wakeups as well.

The only thing that made me raise an eyebrow was your mentioning keeping Narcan handy. That's a drug I use perhaps twice a year, and I do a boatload of MAC cases. If you're using it (as opposed to just having it) with any frequency at all, I'd question how you're dosing your narcotics.

 

[pgg]

One of the things I love most about SDN is seeing how others do things.

5. Extubate deep. Get them breathing as soon as possible, cut the gas, a few breaths of 100% 02 and pull the tube as long as tidal volumes are compatible with life. Educate the pacu nurses on proper use of oral and nasal airways. Usually this is as simple as telling the nurses to leave them in until the pt pulls them out. If you can also teach them how to insert airways and give a little jaw lift you'll be in deep extubation heaven.

[...]

7. Go easy on the narcs, especially if you like to extubate deep. Let the pacu nurses give them as the pt is blowing off the last 1/2 mac of anesthesia.

I tried this general approach but could never get it to work to my satisfaction, especially with regard to minimizing PACU time. I found that with deep extubations and minimal narcs, there were more PACU issues. Well, not so much "issues" in the PACU as "more time" in the PACU.

Now I take almost the opposite approach. I extubate awake in the OR after being fairly generous with opiates. I rarely attempt to get patients spontaneously breathing prior to the end of the case, instead using the ventilator to blow off as much gas as possible, keeping ETCO2 in the low 40s. With a sufficient narc load, they'll stay still for closing with 2-3% or so ET desflurane (about 0.8% sevo), open their eyes around 0.8% ET desflurane (or 0.2-0.3 ET sevo), I'll pull the tube, and they breathe. They're awake, many of them move themselves to the gurney, if they need more opiate at that point it's obvious, and I can start getting on top of their pain before they hit the PACU.

I love desflurane, and not just because it makes fast in-OR wakeups super easy. I think they continue to wake up faster, and have shorter PACU times as well.


Not at all a criticism of your technique, I just posted this to illustrate that very different approaches work, and there's a lot of hard-to-quantify art to what we do.

 

[RxBoy]

Now I take almost the opposite approach. I extubate awake in the OR after being fairly generous with opiates. I rarely attempt to get patients spontaneously breathing prior to the end of the case, instead using the ventilator to blow off as much gas as possible, keeping ETCO2 in the low 40s. With a sufficient narc load, they'll stay still for closing with 2-3% or so ET desflurane (about 0.8% sevo), open their eyes around 0.8% ET desflurane (or 0.2-0.3 ET sevo), I'll pull the tube, and they breathe. They're awake, many of them move themselves to the gurney, if they need more opiate at that point it's obvious, and I can start getting on top of their pain before they hit the PACU.

👍👍👍👍👍 I have the exact same approach if you read some of my earlier posts in the forum (which got a lot flame).

I think people who have not tried this approach yet, should at least try it 3 or 4 times and see the difference. Especially fellow residents who are learning all the different ways to skin a cat.

 

[hoyden]

Running everyone into the low 30's used to be the norm, and PEEP used to be evil. Now if I'm using controlled ventilation, I'm perfectly happy with ETCO2's in the high 30's-low 40's, and almost always use PC with a little PEEP and keep my PIP's as low as I can to keep ventilation and oxygenation where I want it. The various PSV-PRO, SIMV, etc., modes on the newer ventilators make everything so much easier. Staying near-normocarbic helps with fast wakeups as well.

 

[treasurefull2]

bumpty bump

 

[ssmallz]

If the pt is still blowing off gas, get the gurney into the room and transfer the pt before you extubate. It beats standing around and watching the pt breath on his own, then waking up and transferring him. The stimulation of the movement from bed to gurney will also wake the pt a bit and get the ready for extubation sooner.

 

[divinemsm]

I'm a big fan of deep extubation unless contraindications are present including but not necessarily limited to-

Difficult airway
Morbid obesity
Parturient or immediately post partum
Full stomachs or the equivalents

Always with an oral airway
Always JUST prior to skin closure
Any volatile agent works
I place nasal cannula 02 on every.single.patient while deep before the lma or tube comes out and turn it ON
Everyone with paralytic other than six gets reversal-except maybe bad asthmatics.

There is other stuff- but as is the case with patients-it is an individual case by case basis.