Wake Ups

[2ndyear]

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Well, I'm almost done with 3 months of CA-1 training. I can get through a basic general anesthetic on mostly healthy people. My problem is that my wake ups are on the slow side, or just not real pretty. I've tried gas switching if I'm using Iso (to sevo or des), tried to turn off the agent real early and get by on nitrous and/or propofol, but I still get burnt. Most commonly there will be a big incision, I see that they're closing fascia, but then they bust out the staple gun and I'm sitting with a MAC of iso on board and then sitting in the OR for 30 minutes. Or I think I have a well timed wake up going, and then they decide to let the MS-3 try to close. They usually end up trying to suture a moving target on that one... I've also been playing with the BIS once in a while but I find myself reacting to the numbers a bit too much and scaring myself into giving drugs. 70! Get some propoflol out quick they're waking up! and so on, a viscious circle.

Hints, tips, techniques?

 

[VolatileAgent]

in the words of led zeppelin, communication breakdown. if they don't tell you when they're going to finish, they can just wait. you can help train the surg resident that he/she needs to remember there's another doctor in the room running his/her end of the case too. personally i find the ob/gyns to be the worst.

and my advice is don't rely on the bis so early in your training. my ideal anesthetic is the patient waking up just as the drapes are coming down. some patients just are not going to wake up pretty. but usually a narcotic issue i find. learning the art of anesthesia takes time. don't be too hard on yourself. i'm not on myself. they should be reversed and breathing by closure anyway. gently titrating fentanyl to control rate (without snowing them) will ease your wake-ups too. by the end of the case you should have a good idea how your patient is going to respond to narcs.

my technique: peeking over the curtain and 'guesstimating' when they're going to finish closing helps. 1/2 hour before the case ends, iso dial goes down to 0.6%. stay low flows and let 'em rebreathe, pad with some nitrous (even if it's a belly case), and if they start to move too early blast them with some diprivan (but not too much). as soon as that last stitch goes in, shut the iso and nitrous off and crank the dial to 100% O2. squeeze the bag as they're breathing in. they still gotta take the drapes off, clean the patient, get the stretcher in the room,etc. start pulling your monitors off, except the pulse ox (of course). put the patient on the stretcher with the tube in, if necessary. even wheel them to the PACU with the tube in. this saves time, which is all the ancillaries really care about anyway. that seems to have worked for me. or, you can always switch to des about 1/2 hour before the case is going to end. this has worked well too. it's an art form, dude. it takes time.

 

[VolatileAgent]

and, just to keep some perspective, i actually had a SICU nurse say to me the other day, 'why is this patient so awake?' can you believe it? she tried to give me **** about delivering a perfect anesthetic. i told her, "i brought this dude back exactly they way i found him." which was true. problem is, an awake patient is more work for her.

 

[UTSouthwestern]

Take a look at tips and tricks sticky above. Click on the "Emergence" thread.

I now get my patients breathing first, titrate narcotics in to get the RR to 16-20 so my surgeon isn seeing a belly jiggle, turn off gas 5-10 minutes before end time with 70% nitrous running. Last stitch in, nitrous off -> 100% oxygen. Patient breathing already, last bit of gas running off and patient extubated with or without oral airway in place.

I did five gastric bands yesterday by 11:30 AM with turnover between cases less than 10 minutes (wake up, pt to PACU, next pt in room asleep) doing that. You will experiment with a number of methods, but communication is critical so ask your colleagues how/when they will finish.

 

[powermd]

I too have been having difficulty with timely, smooth wakeups for similar reasons. One additional factor that complicates things, in addition to timing the drugs, is getting my attending in the room at the right moment for extubation. Some are better than others, but I can never seem to trust that my attending will definitely show up on time for extubation unless I just wait to shut off the gas until he or she arrives. I would be willing to extubate the patient alone if I knew an attending would be available at a minute's notice if things went bad. Most of the time my attendings take a few minutes to answer a page, if they answer at all (oh, you paged?). A call for stat anesthesia to the room just looks bad, and can also take a few critical minutes. On top of all that- we're not supposed to extubate without an attending in the room, adding additional pressure to keep the patient asleep longer than necessary.

To UT- a 10 minute turnover? WOW.. At Columbia we can't sign out a patient to the PACU nurses in less than 10 minutes. If our next patient still hasn't been "checked in" by nursing, that'll add at least another 20 minutes... I hope I can work at a private hospital one day where things run more smoothly.

 

[Noyac]

Powermd, do the CA2's & 3's have to wait for the attending to arrive also? Is this a billing issue? Are the rest of you having to wait for the attending? This is ridiculous. Where are they when you page them? If in another room then ok. If they are in the lounge then wake the patient up. I can't imagine how inefficient it must be to have to wait for the attending. Hang in there. It gets better.

 

[UTSouthwestern]

I too have been having difficulty with timely, smooth wakeups for similar reasons. One additional factor that complicates things, in addition to timing the drugs, is getting my attending in the room at the right moment for extubation. Some are better than others, but I can never seem to trust that my attending will definitely show up on time for extubation unless I just wait to shut off the gas until he or she arrives. I would be willing to extubate the patient alone if I knew an attending would be available at a minute's notice if things went bad. Most of the time my attendings take a few minutes to answer a page, if they answer at all (oh, you paged?). A call for stat anesthesia to the room just looks bad, and can also take a few critical minutes. On top of all that- we're not supposed to extubate without an attending in the room, adding additional pressure to keep the patient asleep longer than necessary.

To UT- a 10 minute turnover? WOW.. At Columbia we can't sign out a patient to the PACU nurses in less than 10 minutes. If our next patient still hasn't been "checked in" by nursing, that'll add at least another 20 minutes... I hope I can work at a private hospital one day where things run more smoothly.

You will find that efficiency varies in the private practice world, but the surgery programs that understand the economical sense it makes to be efficient are the ones you will truly enjoy working at both personally and financially. At the center I was at yesterday, the OR team that finished the cases with me by 11:30 AM got to eat a free lunch at noon and went home for the day, or went to another site to pick up extra work. Win win situation for everyone, but especially the patient if the anesthesiologist knows how to appropriately manage the anesthetic to allow optimum pain control without prolonging PACU time or causing PONV.

By the time I was a second year, most of my attendings were comfortable letting me run my own cases from start to finish. If they felt a resident was not ready, they would insist being present to finish off a case, but if you are ready, you are ready and they gave you autonomy.

 

[jetproppilot]

Well, I'm almost done with 3 months of CA-1 training. I can get through a basic general anesthetic on mostly healthy people. My problem is that my wake ups are on the slow side, or just not real pretty. I've tried gas switching if I'm using Iso (to sevo or des), tried to turn off the agent real early and get by on nitrous and/or propofol, but I still get burnt. Most commonly there will be a big incision, I see that they're closing fascia, but then they bust out the staple gun and I'm sitting with a MAC of iso on board and then sitting in the OR for 30 minutes. Or I think I have a well timed wake up going, and then they decide to let the MS-3 try to close. They usually end up trying to suture a moving target on that one... I've also been playing with the BIS once in a while but I find myself reacting to the numbers a bit too much and scaring myself into giving drugs. 70! Get some propoflol out quick they're waking up! and so on, a viscious circle.

Hints, tips, techniques?

If you could do everything smooth after 3 months, 2ndyear, us veterans would be threatened!

All kidding aside, it'll come with experience and increasing case load.

I think I'd stop using iso, though. Of course you can use it, and use it well, but because of its solubility issues compared to des/sevo your planning has to be WAY in advance, and the PACU sequelae may be higher (prolonged sleepiness, increased n/v, etc). An inferior volatile compared to des/sevo.

 

[VentdependenT]

Thats why your the friggen man UT.

I feel that I'm still slowly growing every day in terms of emergence and especially when to extubate. Some attendings do it when the pt is a little deep while others wait till the pt is basically lifting all their extremities off the table. There is a middle ground there but it completely varies with the individual pt. Some of these people are just a friggen mess. I can't believe how psych issues manifest themselves in their interactions with anesthestics. A little extra propofol burn goes a long way.

I'm trying to critically evaluate each emergence situation and take something away from it. I just go by what UT says and it seems to work well. Last Fascial layer? Gas down but not off, vent em down, no2 up, see dip on capnograph with a low mac then APL to bag, gas off, breathing, fentanyl blips sometimes for rate, propofol on hand for a buck, no2 off, air and o2 up way high, page attending, extubate. Or sit there and wonder what the F*$K is still on board while drawing up some narcan for those itty bitty pupils.

 

[jetproppilot]

If you could do everything smooth after 3 months, 2ndyear, us veterans would be threatened!

All kidding aside, it'll come with experience and increasing case load.

I think I'd stop using iso, though. Of course you can use it, and use it well, but because of its solubility issues compared to des/sevo your planning has to be WAY in advance, and the PACU sequelae may be higher (prolonged sleepiness, increased n/v, etc). An inferior volatile compared to des/sevo.

And like UT said, check out the emergence thread under the procedures sticky at the top of the forum. Good stuff.

 

[davvid2700]

Well, I'm almost done with 3 months of CA-1 training. I can get through a basic general anesthetic on mostly healthy people. My problem is that my wake ups are on the slow side, or just not real pretty. I've tried gas switching if I'm using Iso (to sevo or des), tried to turn off the agent real early and get by on nitrous and/or propofol, but I still get burnt. Most commonly there will be a big incision, I see that they're closing fascia, but then they bust out the staple gun and I'm sitting with a MAC of iso on board and then sitting in the OR for 30 minutes. Or I think I have a well timed wake up going, and then they decide to let the MS-3 try to close. They usually end up trying to suture a moving target on that one... I've also been playing with the BIS once in a while but I find myself reacting to the numbers a bit too much and scaring myself into giving drugs. 70! Get some propoflol out quick they're waking up! and so on, a viscious circle.

Hints, tips, techniques?

Dont ever switch volatile agents at the end.. makes you look like an amateur.. which you are...

your wakes up will get better the more you do..... be patient... think.. think.. keep on asking questions .. and read the book

 

[davvid2700]

and, just to keep some perspective, i actually had a SICU nurse say to me the other day, 'why is this patient so awake?' can you believe it? she tried to give me **** about delivering a perfect anesthetic. i told her, "i brought this dude back exactly they way i found him." which was true. problem is, an awake patient is more work for her.

bitch slap the next nurse who says something like that to you

 

[davvid2700]

I too have been having difficulty with timely, smooth wakeups for similar reasons. One additional factor that complicates things, in addition to timing the drugs, is getting my attending in the room at the right moment for extubation. Some are better than others, but I can never seem to trust that my attending will definitely show up on time for extubation unless I just wait to shut off the gas until he or she arrives. I would be willing to extubate the patient alone if I knew an attending would be available at a minute's notice if things went bad. Most of the time my attendings take a few minutes to answer a page, if they answer at all (oh, you paged?). A call for stat anesthesia to the room just looks bad, and can also take a few critical minutes. On top of all that- we're not supposed to extubate without an attending in the room, adding additional pressure to keep the patient asleep longer than necessary.

To UT- a 10 minute turnover? WOW.. At Columbia we can't sign out a patient to the PACU nurses in less than 10 minutes. If our next patient still hasn't been "checked in" by nursing, that'll add at least another 20 minutes... I hope I can work at a private hospital one day where things run more smoothly.

if your attending is not around after you called him.. call him again.. if he is still not around.. wake the patient up on your own...

 

[tx082md]

if your attending is not around after you called him.. call him again.. if he is still not around.. wake the patient up on your own...

I totally agree. I call my attending a few minutes before I wake up the patient. If he/she doesn't show the patient gets extubated and they can see the patient in the PACU.

 

[Lonestar]

I find that having the pt breathing (if they didn't get much relaxant) 30 min before surgery is finished helps a lot. I have had smoother wake ups with that. This is all from 3 months of experience so take it with a grain of salt. Oh and turnover time at our hospital is terrible. One of the CA1s at our hospital got yelled at for extubating a pt after waiting fifteen minutes for the attending (after 3 pages). This particular attending is a crazy bit$h and no one likes anyway. Ahhh, just the things we have to do to get to the promise land.

 

[UTSouthwestern]

Nimbex/cisatracurium is your friend. I have used it almost exclusively as my relaxant of choice because after the first 30 minutes of surgical dissection, the stimulus level is much lower and the patient is much less likely to buck or move. By that time, the patient has reached an anesthetic threshhold and keeping them anesthetized is much less effort intensive. The cis breaks itself down and I have rarely had to reverse any of my patients and have thus avoided the SE's of glyco/neostigmine. From a cost analysis standpoint, not having to use glyco and neostig also provides a cost saving compared to using other NMB's that may still leave a patient with significant residual paralysis if reversal is not given. Just another preference and one of many that you will hear.

 

[2ndyear]

Thanks for the tips all!
My wake ups got a ton better this past week. I think part of it is just paying more attention to where the surgery process is at and having a plan for wake ups. I like the getting the patient breathing part, this wasn't as hard as I thought it was. I had a great attending yesterday who told me from the outset "Just pull tube when patient ready, no need to call", awesome older Indian fellow; I got them breathing real early, gas off when closing started, snuck in a little propofol for good measure and when the last dressing was on I had the tube out. That was my best overall experience so far as a CA-1, but I know everything won't go that smoothly that often, it was an easy gyn case, healthy pt, easy tube, etc. Anyways, thanks.

 

[jetproppilot]

and when the last dressing was on I had the tube out.

Excellent! Keep up the good work.

 

[powermd]

Excellent! Keep up the good work.

Friday was a big day for me. I had my first two solo extubations... terrifying, but exhilerating at the same time. I've been using the techniques talked about here- off with the paralysis, reverse early, get the patient breathing, lidocaine, off with the gas. It may be dumb luck, but I'm starting to become a big believer in the lidocaine = smooth emergence dogma. I've had attending surgeons comment several times on how smooth the wakeup was. Thanks to everyone here- this forum has really developed into a wonderful professional community.

 

[UTSouthwestern]

Friday was a big day for me. I had my first two solo extubations... terrifying, but exhilerating at the same time. I've been using the techniques talked about here- off with the paralysis, reverse early, get the patient breathing, lidocaine, off with the gas. It may be dumb luck, but I'm starting to become a big believer in the lidocaine = smooth emergence dogma. I've had attending surgeons comment several times on how smooth the wakeup was. Thanks to everyone here- this forum has really developed into a wonderful professional community.

The lidocaine really does work. Timing is a big part of it, but I've had the most compliments from the neurosurgeons who are happy that I can wake the patient and extubate them without them gagging or bearing down. They just open their eyes, open their mouths, and let you pull the tube out without a blink.