Waking up cranis..

[rn29306]

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Given the wealth of knowledge and varying experience on this board, I was hoping some of you would share your wake up techniques for cranis.

We are a university setting and not private practice so keep that in mind, but I see two schools of thought on waking this category of patients up.

School one: Regular wakeup with varying attempts at keeping pt from bucking on tube, such as IV lidocaine, and promptly extubate and attempt to be as smooth as possible.

School two: Some form of deep extubation (assuming an easy mask upon induction), either narcotic based or inhalational gas at time of extubation.

The goal is a smooth, efficient wakeup with no bucking I realize on cranis or clippings, but one of our neuro surgs prances around just waiting for a potential bucking and he gives a lashing that has to be witnessed to believe. He favors deep extubation with narcs or gas on board and to PACU with OA. I have seen this done with success and I have also seen complications from this and I realize potential pitfalls with hypoventilation and hypercarbia on these such patients with deep extubations. One of our attendings goes toe to toe with him all the time regarding how coughing on an OETT with an open pop off valve does not allow the intra-abdominal or intrathoracic buildup of pressure that regular coughing or pulling against a closed epiglottis allows and the coughing on a tube is actually worse looking than it is. And that a normal wakeup allows a faster post-op eval of neuro status and is much better than taking a chance on losing an airway and having the patient pull on a closed epiglotis. Most of these patients smoke anyway which doesn't help matters.

I also realize a quick wakeup is essential and a goal, but this guy doesn't seem to consider this optimal over a deep wakeup. We don't have des or remi at our facility.

My question is how do you smoothly and efficiently wake these patients up?
Thanks in advance for the clinical pointers. Hopefully you won't mind a SRNA asking clinical questions.

 

[UTSouthwestern]

Sufentanil can be used just as efficiently as remi as long as you shut it off approximately 35-45 minutes before the end of the case. I have frequently used remi or sufentanil throughout a crani, used either des or sevo, turned off the gas 15 minutes before the end of the case so that I can get most of the gas off before wakeup. I have used small boluses of propofol as a bridge and an IV lido bolus 5-10 minutes before my anticipated extubation time. Usually my patients just open their eyes and look around before opening their mouth for me to take the ETT out. I lubricate the tube with lido jelly as well.

Alternatively, I have done deep extubations after using conventional anesthetic techniques (morphine, fentanyl, etc.), with a deep extubation strategy as you have discussed above. It tends to be less dependable than the above, but with the lubricated ETT and bolus of lido at the end, the bucking that can happen even with deep extubation, tends not to occur.

 

[militarymd]

Tell your attending that coughing on a ETT is just as bad as coughing without an ETT.

Your glottis maybe open, but various other parts of the airway can and will collapse during a Valsalva manuever when you cough.

How do I know? During bronchoscopies, I have watched airways completely collapse below the ETT when the patient coughs.....so your attending is full of it.

However, no matter how good you are, some patients will cough....either before, during, or after extubation, no matter how you do it......just part of the process.

 

[Noyac]

Sheridan tubes work quite well. For those unfamiliar with the tubes, they are typical ETT's with an additional port for injection of lido. at the end of the case. If not available, you can fill the cuff of the ETT with 4% lido. and I am told that it will diffuse out during the case to topicalize the airway. I have not done this, however and I have my doubts.
I tend to do a narcotic wakeup. I haven't been a big fan of the IV lido. It just seems a little more unpredictable in my hands.

 

[militarymd]

Sheridan tubes work quite well. For those unfamiliar with the tubes, they are typical ETT's with an additional port for injection of lido. at the end of the case. If not available, you can fill the cuff of the ETT with 4% lido. and I am told that it will diffuse out during the case to topicalize the airway. I have not done this, however and I have my doubts.
I tend to do a narcotic wakeup. I haven't been a big fan of the IV lido. It just seems a little more unpredictable in my hands.

I agree with the IV lidocaine.....doesn't work for me....and I've been trying it on and off since 1993.

Fentanyl in 5 to 10 mcg doses does much better.

 

[refreshingred]

Sheridan tubes work quite well. For those unfamiliar with the tubes, they are typical ETT's with an additional port for injection of lido. at the end of the case. If not available, you can fill the cuff of the ETT with 4% lido. and I am told that it will diffuse out during the case to topicalize the airway. I have not done this, however and I have my doubts.
I tend to do a narcotic wakeup. I haven't been a big fan of the IV lido. It just seems a little more unpredictable in my hands.

I don't see how filling a cuff w/ lidocaine could ever 'diffuse' out. The thing is impermeable to air, so there is no way lidocaine can diffuse out. Has anybody tried this and seen it have an effect?

 

[heartICU]

I don't see how filling a cuff w/ lidocaine could ever 'diffuse' out. The thing is impermeable to air, so there is no way lidocaine can diffuse out.

Never seen lido diffuse out of it, but it is definitely permeable to air. Ever check your cuff after using nitrous for several hours? The 5cc or whatever you put in turns into 7 or 8cc to take out. You can actually transduce your cuff pressure and watch it rise throughout the case.

An attending of mine teaches about the amount of pressure an overinflated cuff places on the tracheal mucosa. Think about the end of your case, when you place a 10cc syringe on the cuff port and the plunger slowly moves on its own and lets out a few cc of air. Now take that 10cc syringe with the plunger fully inside, and attempt to blow on the end and move the plunger a few cc. I have to assume I have normal lungs at 25 years old, and I can only move it about 0.75cc. It is a lot harder than it looks. Give you a idea of how much pressure an overfilled cuff generates on the trachea.

Sorry - this got a little off topic. 🙄

 

[Noyac]

I don't see how filling a cuff w/ lidocaine could ever 'diffuse' out. The thing is impermeable to air, so there is no way lidocaine can diffuse out. Has anybody tried this and seen it have an effect?

The guy in my practice that does this, trained at Stanford and was an attending at Dartmouth b/4 joining my group. I will ask him tomorrow but if any one from these programs has heard of this or has tried this then let us know.

 

[Tenesma]

remifentanil all the way.... i usually extubate them as soon as they take their first breath.... however it may only be 1-3 breaths/minute for the next 2 minutes or so 🙂

 

[Noyac]

remifentanil all the way.... i usually extubate them as soon as they take their first breath.... however it may only be 1-3 breaths/minute for the next 2 minutes or so 🙂

Absolutely, but the poster stated that they don't have Remi. Too bad. Great drug for this type of case. Not having Des is no big deal, however. I wonder if they have Precedex? This also would work.

 

[UTSouthwestern]

Absolutely, but the poster stated that they don't have Remi. Too bad. Great drug for this type of case. Not having Des is no big deal, however. I wonder if they have Precedex? This also would work.

If they don't have remi, I doubt they have Precedex.

 

[rn29306]

If they don't have remi, I doubt they have Precedex.

We just started using it on very few select cases, does that officially make us a dino or what? I believe the cause of bringing it to us is rumored to be just these types of cases.

Tank you all very much for your responses.

 

[jetproppilot]

We just started using it on very few select cases, does that officially make us a dino or what? I believe the cause of bringing it to us is rumored to be just these types of cases.

Tank you all very much for your responses.

Whats funny after you've been in this business for a while is that you figure out its very rare for a pharmaceutical agent to have literature-backed influence on perioperative outcome. Does the agent really shorten wakeup times? Reduce post-operative problems (N/V, etc)? Or can a skilled clinician use thiopental/fentanyl/pancuronium/isoflurane and have the same results?

I think propofol/des&sevo/Precedex are the most influential agents I've seen in my career. All the others, one can substitute something else (i.e. fentanyl vs remi) without difference, for pennies on the dollar.

One could argue Zofran et al is more effective than previous antiemetics, and I use it myself, but if the big droperidol scare wasnt here, could we do without them and provide similar clinical outcomes?

I guess I'm pondering how much of our industry is powered by hype by the very profitable drug companies verses old school stuff...fentanyl, sufentanyl, vecuronium, etc....

 

[zippy2u]

Ok, ole Zip'll walk you through it. Use sevo not des or forane. Have pt breathing so don't use much opioid throughout case.RR should be around 8. 2% lido on ett when you intubate. Have the neuro dude reinject the pt's head with LA where the pins are that secure his head in the halo thing. You extubate the pt DEEP when he's still in the halo. place in an Lma then let the neuro dude take head out of halo and wrap the head with the gauze. Turn off the sevo and continue with micro boluses of opiod to keep RR at 8. Pt. doesn't buck because now he's emerging with an LMA in and not the garden hose in the trachea. regards, ---Zippy

 

[rn29306]

Whats funny after you've been in this business for a while is that you figure out its very rare for a pharmaceutical agent to have literature-backed influence on perioperative outcome. Does the agent really shorten wakeup times? Reduce post-operative problems (N/V, etc)? Or can a skilled clinician use thiopental/fentanyl/pancuronium/isoflurane and have the same results?

I think propofol/des&sevo/Precedex are the most influential agents I've seen in my career. All the others, one can substitute something else (i.e. fentanyl vs remi) without difference, for pennies on the dollar.

I guess I'm pondering how much of our industry is powered by hype by the very profitable drug companies verses old school stuff...fentanyl, sufentanyl, vecuronium, etc....

Like I mentioned before, we are an academic teaching level 1 peds and adult and a rotation site for med students and residents, with a CRNA program. Our anesthesia is based on vec/iso/fent believe it or not, a belief held by our docs and CRNAs. We don't even have des on our machines. If my doc found sevo being used, I better have damn good reason. We also are heavy narc based, esp front loaded. Yes, we are much different than a quick priv practice, but I honestly have seen no longer turn arounds than the priv practice. Our people are good at using the old standbys and it works quite well, for chumpchange compared to what some practices run. I would put any of our iso CRNAs up against sevo CRNAs any day and I promise the actual room turn around is not prolonged.
Fent/vec/iso have indeed been around for a long time, but with that age comes tested and proven results. These drugs are extremely predictable and thus easy to use.
I guess that is why the anesthesiologist that owns the group is very adament about using the old school drugs. Not sure about your costs and agreements with reps, but iso for us is reportedly about $24 per bottle and sevo is $92-95 or so. From a cost standpoint, that is remarkable.
I agree with your statement about des/sevo/prop/precedex. One of my docs was saying that the most dramatic changes in the future of anesthesia will be by IV drug mfgs and I think that propofol and precedex are examples of this. It is all about the Benjamins and drug companies know this, thus all the expensive marketing and initial research that has to be questioned about the origions and potential bias when reading these reports.

 

[jetproppilot]

Ok, ole Zip'll walk you through it. Use sevo not des or forane. Have pt breathing so don't use much opioid throughout case.RR should be around 8. 2% lido on ett when you intubate. Have the neuro dude reinject the pt's head with LA where the pins are that secure his head in the halo thing. You extubate the pt DEEP when he's still in the halo. place in an Lma then let the neuro dude take head out of halo and wrap the head with the gauze. Turn off the sevo and continue with micro boluses of opiod to keep RR at 8. Pt. doesn't buck because now he's emerging with an LMA in and not the garden hose in the trachea. regards, ---Zippy

GEEZ, ZIP, WHERE YA BEEN?

You're kinda like a Navy SEAL....you pop in, take care of business, and you're out.

Kinda surprised, though, by the Zippy-Crani-technique....C'mon, Dude, you're a franchise player! We've gotta pay 4 mil plus incentives to retain you next year!

And no franchise player would go to all that trouble switching airways for a crani, when you can wake them up on a tube, albeit with some agent still on board, with no problem!!!

You're benched until further notice. Ricky Williams has given up The Bud and he'll be starting in your position.

 

[zippy2u]

Fook that "old school drug" anesthesiologist- He ain't buyin' the drugs so tell him to shove it. You're experimentin' with anesthetic techniques and agents which trumps any of his reasons. Reminds me of those dingus docs in private practice who lock the docs lunch room so the nondocs can't get a bite to eat. The docs didn't buy the food... dumb phucks! ---Regards, Zippy

 

[zippy2u]

Yo Jetman, the shiite I spill on ya don't come from all them high fallutin' anesthesia rags that you and military man read. They come from them deep dark anesthesia trenches that I've trudged through on many a weary night... Warmest regards, --Zip

 

[jetproppilot]

Yo Jetman, the shiite I spill on ya don't come from all them high fallutin' anesthesia rags that you and military man read. They come from them deep dark anesthesia trenches that I've trudged through on many a weary night... Warmest regards, --Zip

Your posts are not discounted. But I, and Mil for that matter, are in the trenches with you.

Warmest regards, --Jet

 

[militarymd]

Your posts are not discounted. But I, and Mil for that matter, are in the trenches with you.

Warmest regards, --Jet

I'm in a deep trench.

 

[refreshingred]

Never seen lido diffuse out of it, but it is definitely permeable to air. Ever check your cuff after using nitrous for several hours? The 5cc or whatever you put in turns into 7 or 8cc to take out. You can actually transduce your cuff pressure and watch it rise throughout the case.

An attending of mine teaches about the amount of pressure an overinflated cuff places on the tracheal mucosa. Think about the end of your case, when you place a 10cc syringe on the cuff port and the plunger slowly moves on its own and lets out a few cc of air. Now take that 10cc syringe with the plunger fully inside, and attempt to blow on the end and move the plunger a few cc. I have to assume I have normal lungs at 25 years old, and I can only move it about 0.75cc. It is a lot harder than it looks. Give you a idea of how much pressure an overfilled cuff generates on the trachea.

Sorry - this got a little off topic. 🙄

Well, I guess it's N20 that's diffusing IN, (not air diffusing out). But that isn't surprising, N20 seems to have the potential to diffuse through many a membrane. But the next time I use N20 on a long case I'll see if I can transduce the cuff and see if this actually happens.

 

[refreshingred]

Sheridan tubes work quite well. For those unfamiliar with the tubes, they are typical ETT's with an additional port for injection of lido. at the end of the case. If not available, you can fill the cuff of the ETT with 4% lido. and I am told that it will diffuse out during the case to topicalize the airway. I have not done this, however and I have my doubts.
I tend to do a narcotic wakeup. I haven't been a big fan of the IV lido. It just seems a little more unpredictable in my hands.

Yeah I found that Sheridan tube on the company's website it's called the Sheridan LITA. Has 8 microscopic ports above plus 2 microscopic ports below the cuff that you can spray a mist of lidocaine through. Pretty ingenious, but do you actually notice less couging and bucking when you use it?

 

[Noyac]

Yeah I found that Sheridan tube on the company's website it's called the Sheridan LITA. Has 8 microscopic ports above plus 2 microscopic ports below the cuff that you can spray a mist of lidocaine through. Pretty ingenious, but do you actually notice less couging and bucking when you use it?

Absolutely!!!!
I use it on all the cervical cases. Never had one buck on emergence. I know, I haven't done enough. Or as Volatile would say, I don't even practice anesth. and especially not spines in the prone position.

Hey Volatile, I got some memory, Huh? 😀

 

[beezar]

Everyone at my place seems to use iso/nitrous/fentanyl/vec and it works great. Large fentanyl bolus up front, and usually fentanyl drip, titrated down every 1/2 hr to hr, turning it off like 45mins-1hr prior to wakeup. For example, for a crani that you think will be 4 hrs, bolus up front something like 250-500mcg fentanyl, start a drip at 5mcg/kg/hr, cut it in half each hour, then off for the last hour. Make sure all the iso is gone by the end of the case (not too hard if you're used to doing it.) Pts seem to always have that smooth narcotic wakeup where they don't buck, follow cmds, and fall asleep whenever you don't stimulate them.

 

[refreshingred]

The guy in my practice that does this, trained at Stanford and was an attending at Dartmouth b/4 joining my group. I will ask him tomorrow but if any one from these programs has heard of this or has tried this then let us know.

So, did you ask your buddy about using lidocaine in the cuff? I'm really interested to know how he knows that this is working and actually diffusing out.