Tweaker Emergence

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I laugh at remi for pretty much any clinical situation, but narcs are a great tool to mellow out the crazies. Dilaudid titrated to a RR of 8 makes everyone wake up like a puppy dog.
 
JobsFan said:
clonidine ... not spending our health $ on meth heads
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while I kind of agree in theory, our hospital carries very little clonidine. I can get dexmedetomidine really easy but the clonidine is almost impossible to track down.
 
I'm a product of hoity toity northeastern hospitals and don't think I have ever taken care of a meth addict - is this something that only happens with them or is it similar to cocaine/pcp etc?
 
They wake up like an uninhibited redheaded teenager--swinging and slinging spit out of their nasty meth mouth.

Anybody have access to the concentrated Precedex? They have this at the children's hospital I rotated at, and we gave 1/2 mcg/kg IM or IV at the beginning of the case. Usually a decent emergence for the cases less than an hour long or so.



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I typically do what Salty said except I also give lots and lots of selective Beta antogonists...
But before I start running really fast I order a troponin so that it makes me look really smart for picking up the myocardial ischemia.
 
In addition to working in enough dilaudid to get the SV pt's rr between 8-12, I pull tube/LMA (if appropriate for patient) with about 0.2-0.4% et sevo, making sure that is not in stage 2. Nasal airway placed at a full MAC if I think they are going to obstruct, avoid guedel airway bc these hopped up little shytes could bite down hard and break their nasty teeth (if they have any at all). Another thing that I'm adamant about is that music is off and I am the only one to speak to the patient if they still freak out and need to be reoriented. In my experience nothing makes the situation worse than enter sandman plus 2 RN's and a surgical resident yelling three different things to the patient while I'm trying to calmly tell them they are safe and that their procedure is over.


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SaltyDog said:
Alright @Noyac, enough teasing - tell us how a Jedi does it.
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You impatient bastard.
Ok, I'll give you my approach. After training in Albuquerque I found that narcotics were not the answer. That's when I moved to Haldol. I give a large dose on "real" narcotics like dilaudid and fentanyl,not that Remi BS that has them writhing 10minutes later.

Remi? Really? Who thinks that's a good idea?

After breathing spontaneously, anywhere below 20 breathes per minute and I'm happy, then I pull the tube and give at least 5mg of Haldol. MAGIC!!!!

I call it the Albuquerque Wake Up
 
Noyac said:
You impatient bastard.
Ok, I'll give you my approach. After training in Albuquerque I found that narcotics were not the answer. That's when I moved to Haldol. I give a large dose on "real" narcotics like dilaudid and fentanyl,not that Remi BS that has them writhing 10minutes later.

Remi? Really? Who thinks that's a good idea?

After breathing spontaneously, anywhere below 20 breathes per minute and I'm happy, then I pull the tube and give at least 5mg of Haldol. MAGIC!!!!

I call it the Albuquerque Wake Up
Click to expand...

The best part is that since they're already so twitchy from the meth, they never even notice the Tardive Dyskinesia!
 
Excellent thread, good combo of clinical acumen and comedy. We had to IM Haldol/Ativan one in PACU when I was a CA-1 after the provider did a remi infusion for the case. The guy was so tweaked out it was sorta scary.

The Haldol idea is a solid one and might be worth a try sometime, especially if we have a repeat customer who we know is an emergence disaster coming in.
 
Noyac said:
You impatient bastard.
Ok, I'll give you my approach. After training in Albuquerque I found that narcotics were not the answer. That's when I moved to Haldol. I give a large dose on "real" narcotics like dilaudid and fentanyl,not that Remi BS that has them writhing 10minutes later.

Remi? Really? Who thinks that's a good idea?

After breathing spontaneously, anywhere below 20 breathes per minute and I'm happy, then I pull the tube and give at least 5mg of Haldol. MAGIC!!!!

I call it the Albuquerque Wake Up
Click to expand...
Tell them the Haldol is for PONV prophylaxis. 😀
 
Precedex 0.5mcg/kg over a few min at least 20-30 min before wakeup. Can go up to 1mcg/kg depending on what else you have on board.

Ketamine 20-30mg if you need to buy 5-10 minutes of safety for you or PACU staff etc.

Never done it in the OR, but putting some seroquel down an OGT while they're asleep would work too
 
Noyac said:
And IMO dexmedetomidine doesn't last long enough. All these newer fancy drugs are great, right up until the point when they suck.
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It lasts forever if you keep the infusion going
 
Noyac said:
You impatient bastard.
Ok, I'll give you my approach. After training in Albuquerque I found that narcotics were not the answer. That's when I moved to Haldol. I give a large dose on "real" narcotics like dilaudid and fentanyl,not that Remi BS that has them writhing 10minutes later.

Remi? Really? Who thinks that's a good idea?

After breathing spontaneously, anywhere below 20 breathes per minute and I'm happy, then I pull the tube and give at least 5mg of Haldol. MAGIC!!!!

I call it the Albuquerque Wake Up
Click to expand...

Haldol is a great idea.

For the dex, I run it at 1mcg/kg/hr for about 30-40 minutes then leave it running at 0.5 for the rest of the case. Turn it off at the very end, sometimes lasts TOO long I find (3 hrs or so of sedation)
 
I think there is a bit of confusion here. I don't find that many of these pts require extended periods of sedation. They just need some sort of calming agent while they recover from the anesthetic and clear their mind enough to understand were they are and what is happening. Usually, they are cooperative enough by the time they leave the PACU.
If they were so out of control you wouldn't have taken them to the OR in the first place unless it was a true emergency and then you may consider keeping them intubated and admit to ICU.
So in this case, I would rather give a quick med IV push rather than start an infusion.
 
One of my partners likes phenergan and Benadryl for these wake ups. I haven't tried it but it could be just as simple and effective.
 
Noyac said:
One of my partners likes phenergan and Benadryl for these wake ups. I haven't tried it but it could be just as simple and effective.
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there are a million ways to skin the cat. You can give them versed after you extubate them to chill them out. I personally find dexmedetomidine to be the most efficacious at maintaining ventilation while providing a calm emergence in this subset of patients that are prone to violent awakenings.
 
Mman said:
there are a million ways to skin the cat. You can give them versed after you extubate them to chill them out. I personally find dexmedetomidine to be the most efficacious at maintaining ventilation while providing a calm emergence in this subset of patients that are prone to violent awakenings.
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I'm not saying precedex is wrong.
 
Noyac said:
One of my partners likes phenergan and Benadryl for these wake ups. I haven't tried it but it could be just as simple and effective.
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I love Benadryl as an adjunct in MAC cases on chronic painers. Even if they are super tolerant/resistant to everything else, Benadryl still puts 'em to sleep and keeps em breathing.
 
I used to use droperidol in these patients (or any anticipated angry wakeup), until every hospital I worked in took it away. Switched to using haloperidol - just as good, but a little more hassle to get in the OR.
 
Noyac said:
Remi? Really? Who thinks that's a good ideal
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There is no better wakeup than remi. The patient is 100% chill AND awake. As the remi wears off, you can talk to the patient and if need be, titrate in other stuff (haldol is prob my go to). But you get over the initial wakeup nicely narcotized and relaxed.
 
facted said:
There is no better wakeup than remi. The patient is 100% chill AND awake. As the remi wears off, you can talk to the patient and if need be, titrate in other stuff (haldol is prob my go to). But you get over the initial wakeup nicely narcotized and relaxed.
Click to expand...
Why not achieve the same goal with something that won't just evaporate?
 
facted said:
There is no better wakeup than remi. The patient is 100% chill AND awake. As the remi wears off, you can talk to the patient and if need be, titrate in other stuff (haldol is prob my go to). But you get over the initial wakeup nicely narcotized and relaxed.
Click to expand...
I totally and completely disagree.
It's a lazy nurse drug. I reserve the right to my opinion here.

And I believe it does our pts very little favors.
 
Haldol has been my go to since I got out of training. Like me, it's cheap and easy and works with multiple routes of administration.
 
Same way I wake up everyone else. Give them some narcotics, don't bother them, pull when ready.
 
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