waking up a kid

[Jeff05]

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i've been an anesthesia resident for almost 2 years now and have NEVER seen anyone wake up a kid without bucking on the tube. i mean, is there a better way than having the circulator and surgeon holding down the kid as they are bucking around and you're looking like a total douche?! (deep extubation would be nice, but my attendings are not really down with that).

 

[militarymd]

more fentanyl

 

[nutmegs]

clonidine?

 

[Gator05]

No tube, no bucking.

Lots and lots of morphine. I'm starting to think this has something to do with opioid subtypes; sometimes I'll get folks spont breathing with ETCO2 at 50+, RR 6-8, but once the gas comes off they buck if the only opiod I've used is fentanyl. Same patient, but with morphine/dilaudid worked in, no problem. Remember, codeine/morphine/dilaudid are wonderful cough suppressants, but ?? about phenylpiperidines.

 

[Planktonmd]

There are many ways to that (like everything in anesthesia) and unfortunately there is no magic solution that fits all.
Here is one way:
1- Avoid desflurane: In my experience it makes them cough more.
2- Get the kid to breath spontaneously early then turn your fresh gas flow way down to something like 150cc/min of O2, close the pop off valve and shut down your vaporizer, congratulations, you are now doing closed circuit anesthesia.(don't do this with small infants).
3- Titrate small doses of your narcotic of choice to keep the respiratory rate under 10 BPM.
4- When they are putting the dressing on give Lidocaine IV 0.5 mg/kg.
5- Open the pop off valve and turn your fresh gas flow up.
6- In a couple of minutes the kid Will start moving, once they do purposeful movements extubate.
If you time everything correctly they Will wake up nicely most of the times.

 

[kidmd44]

Precedex, baby! Yeah!

BTW, the worst thing to do is get tired of watching the kid buck (stage 2), decide to yank the tube, then watch the kid laryngospasm.

 

[jwk]

Just extubate deep - I can never figure out why this is such a big deal. Just remember deep means deep - no lightening up while the med student closes. You can lighten up after the tube is out.

 

[Planktonmd]

Just extubate deep - I can never figure out why this is such a big deal. Just remember deep means deep - no lightening up while the med student closes. You can lighten up after the tube is out.

He can't!
He has attendings that will B**** slap him if he does.

 

[jwk]

He can't!
He has attendings that will B**** slap him if he does.

I know, I know - but - he's asking is there a better way? Yes, there is. I know he can't do it against what his attendings are telling him. But like I said - I've never understood why this is such a big deal. After nearly 30 years, I still prefer extubating every possible patient deep, kid, adult, whoever. I want an indication to extubate awake, not an indication to extubate deep. Wanna be slick in private practice like Jet is always talking about? Having the patient extubated, breathing, comfortable, and ready to go to PACU before the drapes come off goes a long way.

 

[bigeyedfish]

Get all the volatile off and keep them down with N2O and bumps of the white stuff (or an infusion.) Use plenty of narcs, RR 12. Like someone said, a little lidocaine at the appropriate time will smooth things out too.

The propofol wake up with kids is smoother for me than the volatile wakeup.

My staff refuse to extubate deep too.

 

[coprolalia]

Here's what you do. Premix a syringe of 1mg/kg of propofol plus 1mg/kg of lidocaine. As the end-tidal of Sevo (or whatever agent you're using) hits about 0.3 MAC, just push that slowly through the line. 20kg kid? That's 2mL of propofol and 1mL of 2% lidocaine. Not much.

I used to fight through the bucking too. And, the crabby kids in the PACU. No more. 🙂

-copro

 

[Planktonmd]

Here's what you do. Premix a syringe of 1mg/kg of propofol plus 1mg/kg of lidocaine. As the end-tidal of Sevo (or whatever agent you're using) hits about 0.3 MAC, just push that slowly through the line. 20kg kid? That's 2mL of propofol and 1mL of 2% lidocaine. Not much.

I used to fight through the bucking too. And, the crabby kids in the PACU. No more. 🙂

-copro

Here comes Copro with his Propofol/ Lidocaine prophecy.
You are starting to remind me of the minimally invasive anesthesia guy 🙂

 

[urge]

For all deep extubaters,

Is there a limit in Kg or age where you would not do a deep extubation? Less than 2 yrs, 1 yr, 6 mo, 3 mo, neonate?

 

[Noyac]

Precedex, baby! Yeah!

Are you f*cking kidding me.

 

[deleted77919]

Here comes Copro with his Propofol/ Lidocaine prophecy.
You are starting to remind me of the minimally invasive anesthesia guy 🙂

I was just waiting for aghast to jump in.

 

[kidmd44]

Are you f*cking kidding me.

Nope, ain't kidding. Bolus around 0.2-0.4 mcg/kg as Sevo comes off. They go through stage 2 as usual, tube comes out afterward, and they stay asleep with no respiratory depression. If delirium, give a little more.

 

[UTSouthwestern]

Morphine or Demerrol. Get them breathing at the end, titrate in up to 0.1 mg/kg morphine or 1 mg/kg Demerrol, or until the RR is less than 20. No Des, make sure the OP is thoroughly suctioned well before planned extubation, drop the cuff well before extubation time, and you are off and running. I would still extubate them deep, but on the occasions I felt compelled to let them wake up with the tube, there was minimal bucking.

 

[Noyac]

Nope, ain't kidding. Bolus around 0.2-0.4 mcg/kg as Sevo comes off. They go through stage 2 as usual, tube comes out afterward, and they stay asleep with no respiratory depression. If delirium, give a little more.

Ok, welcome to the forum. I understand that you are a resident and all these swanky drugs are alluring to you but you gotta consider a few things.
1) ease of use. Precedex is not one I consider easy to use since I have to mix it up and check it out from the Pixis.
2) Cost. Do you know what Precedex costs? It ain't cheap.
3) availability. Once you leave your residency, you are not going to find Precedex at any ASC. And this is where you will do the vast majority of your peds cases.

So go ahead and play with the drug but be sure you know how to do cases without it as well. This is not a very good use of Precedex IMHO.

Try what UT just described. Thats exactly how I do these cases, 0.1mg MS and maybe a little bump of propofol b/4 extubation.

And to all those afraid of laryngospasm. You know how to treat it right? I extubate almost every kid deep. On a rare occasion they are a little tight when they take their first breath. I automatically give a little positive pressure until I am happy with their respirations. No problems. If they are obstructing then place an oral airway and put them on their side. Roll them to the PACU and the nurses will love you cause they get their first assessment, vitals and all. Then within a few minutes (maybe 2-4 min) the kids slowly opens his eyes and starts to look around. Go get Mom.

 

[kidmd44]

Ok, welcome to the forum. I understand that you are a resident and all these swanky drugs are alluring to you but you gotta consider a few things.
1) ease of use. Precedex is not one I consider easy to use since I have to mix it up and check it out from the Pixis.
2) Cost. Do you know what Precedex costs? It ain't cheap.
3) availability. Once you leave your residency, you are not going to find Precedex at any ASC. And this is where you will do the vast majority of your peds cases.

So go ahead and play with the drug but be sure you know how to do cases without it as well. This is not a very good use of Precedex IMHO.

Try what UT just described. Thats exactly how I do these cases, 0.1mg MS and maybe a little bump of propofol b/4 extubation.

And to all those afraid of laryngospasm. You know how to treat it right? I extubate almost every kid deep. On a rare occasion they are a little tight when they take their first breath. I automatically give a little positive pressure until I am happy with their respirations. No problems. If they are obstructing then place an oral airway and put them on their side. Roll them to the PACU and the nurses will love you cause they get their first assessment, vitals and all. Then within a few minutes (maybe 2-4 min) the kids slowly opens his eyes and starts to look around. Go get Mom.

I appreciate your thoughts Noyac. I agree with everything you said. I have tried the cocktail you mentioned and it works well.

As far as Precedex goes, not everything you say is accurate. We are fortunate in that our pharmacy has pre-made syringes of it. Our attendings use it like "water" (their words, not mine). Price is always a concern, indeed. And the availability is a thing of the future. I suspect that most children's hospitals will have it in pre-made syringes in the next couple of years. If you are a peds anesthesiologist, Noyac, I'm sure you're familiar with Dr. Joe Tobias' papers. Precedex is promising. And in my limited experience, it works very well, particularly for emergence delirium.