Waking a patient up

[Swim123]

Hey guys,

I'm going to be a new CA-1 in a few days, and I have to say I'm really excited...but also very nervous. Our program gives us a lot of independence, which is a good thing, but early on it can get pretty scary.

For the most part, I think I'll be OK to do a basic case on day 1, but I'm still a little concerned about ending the case and waking the patient up from anesthesia.

I was wondering if you guys can give me any advice on how you approach this....ex: when is the best time to start pushing the reversal meds, how do you wean the gas off (do you switch to SIMV mode and decrease the rate, or do you take them off the vent completely and bag whenever the pt needs a breath, do you turn the gas off completely or do you slowly turn it down, etc), how much reversal do you give if the patient has 1 vs 4 twitches, etc.

Any advice would be appreciated. Thanks.

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[Planktonmd]

I am not convinced that you will be doing a case alone on day one!
Are you in the United States or somewhere else?
Emergence from general anesthesia is an art and there is many ways to do it, so, you will have to see more experienced people do it first and try to develop your own style.
If they are planning to let you do a case alone on day one and expect you to know how to do that safely, then you might be in the wrong residency program.

 

[lvspro]

I am not convinced that you will be doing a case alone on day one!
Are you in the United States or somewhere else?
Emergence from general anesthesia is an art and there is many ways to do it, so, you will have to see more experienced people do it first and try to develop your own style.
If they are planning to let you do a case alone on day one and expect you to know how to do that safely, then you might be in the wrong residency program.

It happens. I was alone on day 1. Maybe his program is organized like ours.
Our last mo of internship is an anesthesia mo. We read the first 15-18 chapters of morgan, and do a hardcore intro to the OR program. We are taught how to do the basics of the daily grind, and how to approach any issues ranging from hypoxia to post-op delirium.
It's pretty much you and an attending as usual, but they keep a closer eye on u. If you seem weak during this mo, they pair you up with a senior until u catch on.

Back to the OP. Emergence is an art form, as plank mentioned. Pay close attention to your peers, and get an idea of what they do. With time you'll develop a style, and different approaches to different pathology/surgeries.

 

[Josh L.Ac.]

Just a hypothetical, but if the patient has to be restrained from getting off the table and walking to PACU, they definitely meet extubation criteria and it is safe to take the tube out.


Not that it happened to anyone I know...

 

[Licoricestick]

Just a hypothetical, but if the patient has to be restrained from getting off the table and walking to PACU, they definitely meet extubation criteria and it is safe to take the tube out.


Not that it happened to anyone I know...

Didn't get quite that far but the first time I ever extubated a patient on my own I'd been in anaesthesia for about 2-3 months and my boss decided that he was going to go home and I was going to finish the case. As this was about 10pm and in a smallish hospital that left me as the only person from the anaesthesia dept in the hospital... ie, the only person with ANY sort of airway skills (the emergency dept depends on us for airway stuff and there is no ICU). It's safe to say that I warned my anaesthetic nurse that we were going to stand there for as long as it took before I was happy to pull the tube - there was no way I was going to have her go into laryngospasm or need to be reintubated.

 

[Frank Rizzo]

Turn the dial on the vaporizer clockwise until you here it 'click' at zero. Usually works for me.

Last day of residency today... fuukn awesome.

 

[geauxg8rs]

To the OP,
waking up is an art so you will see different ways to do it from different attendings. Each one will tell you their way is the best way. Look toward the attendings who are flexible in their anesthetic plan (from preop to post op to ICU to Pain). These ones who are flexible are the ones you should look to mentor. When you get out in practice you will need to know more than one way to do every part of your anesthetic plan (in real life as well as on the oral boards).
The annoying part is once you are 6 months or so into CA-1 year and beyond and you start hearing from your attending "Doctor, do you really think it is safe to do a deep extubation on this patient? Maybe you need to read more chapters in Miller." Then the next attending comes in to take over the case and says "Why are we not doing a deep extubation?"
The art is flexibility, in how you plan your cases and in how you deal with the attendings/colleagues.

 

[Jeff05]

my rule of thumb - try not to wake them up on just potent volatile. they wake up like $hit. have a smoothing agent - i like opioids. propofol is good. lidocaine is neither here nor there, but can't hurt. nitrous chills most out.

the key is also to make sure that with all this stuff on board they will have adequate respiratory function and stable hemodynamics once you pull whatever you have jammed in their mouth hole.

try not to yank the tube when one of the patient's eyes is looking at the clock behind the surgeon and the other at your left shoulder.