Your experience with pre-extubation hypertension?

[DrAmir0078]

Hi SDN Anesthesia,
I am bringing up this for discussion, a adult case, you are trying to extubate him (I extubate using the technique of PSVPro mode, and never on spontaneous breathing), and without train of four and those fancy stuff - I am in Iraq - sometime the patient develops hypertension, and you only have the following medication (It is a brief period of 5 - 10 minutes, until he start obey command to open his eyes or at least moves his eyebrows up indicating good airway reflexes - then I proceed with reversal agents "only atropine + neostigmine"):
Medication I only have sometimes:
- Metoprolol 5 mg
- GTN Angsid 100 mcq
So, from your experience, what will you do? In case, the patient is with upper limit hypertension presentation preop (145/92), and the operation (If Lap Choley - remember it is Lap, CO2, , , etc), how will you manage the hypertension? My patient today reached 182/125 and then extubate her (she was calm, opened her eyes, protrude her tongue, able to lift her neck), and Bp post extubation was 165/93; you may say how was her Bp during the lap choley? we were trying to control it with Metorprolol 1mg every time it peaks, and on remifentanyl drip 4 mcg/ml (according to the need).
Thanks a lot for sharing your thoughts...
Truly,
Amir

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[JoelJoel84]

I would have them spontaneously breathing without ventilator support, to start…

But as to your question, you can certainly give more than 1 mg Metoprolol (eg. 5 mg at a time), or a faster and shorter acting agent like Esmolol.

 

[deleted697127]

This is likely sympathetic response to not liking the endo tracheal tube +/- inadequate analgesia +\- hyperalgesia from remi. I would use literally any other opiate than remifentanyl.

Lido jelly on the ETT before intubation helps reduce the stimulus of the tube at the end. If you don’t have this, 1cc of 2% lido and however much air to inflate cuff may help. Maybe 0.5-1mg/kg of lido IV to decrease airway reactivity prior to extubation just like it works prior to laryngoscopy and intubation. I would lower this dose in elderly.

If this is a lap chole for symptomatic cholelithiasis without acute cholecystitis and my index of suspicion for residual fluid in the stomach from an upset GI tract is low, I would get them breathing on their own and extubate deep with an oral airway in once taking adequate tidal volumes.

 

[DrAmir0078]

I would have them spontaneously breathing without ventilator support, to start…

But as to your question, you can certainly give more than 1 mg Metoprolol (eg. 5 mg at a time), or a faster and shorter acting agent like Esmolol.

Thanks,
But how would you leave a patient breathing spontaneously on a RR of 40 and Tv of 50? would this change your "I would", beside why you don't want to leave your patient on Pressure support?
Ok, you suggested to give Metoprolol 5 mg prior to extubation? like ? 20 minutes (onset of action) ?
Unfortunately, I haven't seen Emolol in my practice, but I would answer an MCQ in regard to this drug!

 

[DrAmir0078]

This is likely sympathetic response to not liking the endo tracheal tube +/- inadequate analgesia +\- hyperalgesia from remi. I would use literally any other opiate than remifentanyl.

Lido jelly on the ETT before intubation helps reduce the stimulus of the tube at the end. If you don’t have this, 1cc of 2% lido and however much air to inflate cuff may help. Maybe 0.5-1mg/kg of lido IV to decrease airway reactivity prior to extubation just like it works prior to laryngoscopy and intubation. I would lower this dose in elderly.

If this is a lap chole for symptomatic cholelithiasis without acute cholecystitis and my index of suspicion for residual fluid in the stomach from an upset GI tract is low, I would get them breathing on their own and extubate deep with an oral airway in once taking adequate tidal volumes.

Thanks,
Yup it is definitely, a sympathetic response from ETT, I am not sure about inadequate analgesia (she got remi + paracetamol and acupan during the op - only we got), no other opiate handy!
Lido jelly is here, and I am not sure if they used it, some Attending likes it, and I do actually (it helps). Would you please elaborate regarding Lido 2% inserted in the pilot cuff with extra air, I heard of such thing but never practice it, because I fear of cuff rupture from the fluid, but is it Ok and does it works?
Well, IV Lido, I think they gave her prior to intubate, but one of our Attendings (I think a Professor), he doesn't like the idea of giving Lidocaine in regard of airway reflexes, is it approved by ASA?
Yes, she got empyema of GB - it was elective op.
Well, extubate deep is a good idea too, but any references for deep extubation school? There is another Attending when I was at Baghdad Medical City, he was against the idea of deep, and per his say "there is always awake extubation, deep extubation is a myth and try not to do it, if you have no experience in it - Mandelson is on its way" ....

 

[DrOwnage]

I'm sorry that you don't have a lot of medications readily available. It sounds like you have to make a lot of adjustments to take care of your patients due to medication shortages (I've seen you saying you don't have phenylephrine in the past).

However, someone who is emerging with rapid shallow breathing at 40 and hypertensive has an autonomic nervous system that is pissed off.

There are a lot of qualitative and quantitative cues that will tell you how comfortable a patient is prior to extubation. Some people go off of ETCO2, some go off of RR. HR, breathing pattern, response to suctioning are others.

I almost always have patient spontaneously breathing for a little while before I pull the tube. I usually aim to have them breathing somewhere between 10-15 RR. I cant really explain the reason physiologically, but I've noticed patients who breathe spontaneously on the tube and have more regular breathing patterns with adequate TVs tend to keep breathing after the tube is pulled and have less chance of laryngospasm. Its when you're playing with pressure support or making changes to their breathing pattern right before you extubate I see patients breath hold or do weird things after the tube is pulled.

For bread and butter general cases like a lap chole, I will usually dose my long acting opioid (hydromorphone) 0.4mg-0.8mg like 30 minutes before I know the case is going to be done. I'll usually be down titrating the gas sometime before they remove the ports. Reverse once fascia is closed. Usually add 50-60% nitrous and turn your sevo down to like 0.4 while they're closing or turn the gas down and feed them a little prop (10-20mg here and there). Then I just turn up the flows 100% as their cleaning and dressing. Have them spontaneous breathing, if they start to react around 0.3% ET you can give them 1mg/kg of lidocaine IV. Once they start breathing again you can pull the tube and its pretty smooth. Waiting all the way until they open their eyes and follow commands I only do with fat patients, difficult airways, or NPO status questionable (with the head of bed up).

 

[GassYous]

I'm sorry that you don't have a lot of medications readily available. It sounds like you have to make a lot of adjustments to take care of your patients due to medication shortages (I've seen you saying you don't have phenylephrine in the past).

However, someone who is emerging with rapid shallow breathing at 40 and hypertensive has an autonomic nervous system that is pissed off.

There are a lot of qualitative and quantitative cues that will tell you how comfortable a patient is prior to extubation. Some people go off of ETCO2, some go off of RR. HR, breathing pattern, response to suctioning are others.

I almost always have patient spontaneously breathing for a little while before I pull the tube. I usually aim to have them breathing somewhere between 10-15 RR. I cant really explain the reason physiologically, but I've noticed patients who breathe spontaneously on the tube and have more regular breathing patterns with adequate TVs tend to keep breathing after the tube is pulled and have less chance of laryngospasm. Its when you're playing with pressure support or making changes to their breathing pattern right before you extubate I see patients breath hold or do weird things after the tube is pulled.

For bread and butter general cases like a lap chole, I will usually dose my long acting opioid (hydromorphone) 0.4mg-0.8mg like 30 minutes before I know the case is going to be done. I'll usually be down titrating the gas sometime before they remove the ports. Reverse once fascia is closed. Usually add 50-60% nitrous and turn your sevo down to like 0.4 while they're closing or turn the gas down and feed them a little prop (10-20mg here and there). Then I just turn up the flows 100% as their cleaning and dressing. Have them spontaneous breathing, if they start to react around 0.3% ET you can give them 1mg/kg of lidocaine IV. Once they start breathing again you can pull the tube and its pretty smooth. Waiting all the way until they open their eyes and follow commands I only do with fat patients, difficult airways, or NPO status questionable (with the head of bed up).

Same. Small opioid 30 minutes before, get the gas off early and slowly, sv is key. I always thought leaving them gas on and then turning the flows to 20 L at the end was stupid. Once the tv is ok I pull the tube. I don't wait for them to buck all over the place and be doing calculus before I pull the tube.

Btw for the vast majority of cases I don't care if their bp is 180/100. Unless I'm doing carotid work or something I let the patient ride it out and by the time they leave recovery they are chillin

 

[deleted697127]

Thanks,
Yup it is definitely, a sympathetic response from ETT, I am not sure about inadequate analgesia (she got remi + paracetamol and acupan during the op - only we got), no other opiate handy!
Lido jelly is here, and I am not sure if they used it, some Attending likes it, and I do actually (it helps). Would you please elaborate regarding Lido 2% inserted in the pilot cuff with extra air, I heard of such thing but never practice it, because I fear of cuff rupture from the fluid, but is it Ok and does it works?
Well, IV Lido, I think they gave her prior to intubate, but one of our Attendings (I think a Professor), he doesn't like the idea of giving Lidocaine in regard of airway reflexes, is it approved by ASA?
Yes, she got empyema of GB - it was elective op.
Well, extubate deep is a good idea too, but any references for deep extubation school? There is another Attending when I was at Baghdad Medical City, he was against the idea of deep, and per his say "there is always awake extubation, deep extubation is a myth and try not to do it, if you have no experience in it - Mandelson is on its way" ....

The full review article summarizing the evidence for intracuff lidocaine for reducing coughing at extubation should be available in this link.

I don’t like giving lidocaine unless i think the patient will benefit for some specific reason. For instance, patients i don’t want to buck at the end because they’ll bleed like neck dissections, or sinuses. I’ll give nebulized lidocaine right after extubation for patients with reactive airways during a case, after bronchs, or for patients with laryngomalacia that i expect to cough their brains out in pacu. I try not to give it to people with low heart rates going for procedures that trigger vagal responses like insufflation. There’s some evidence that lidocaine infusions may help males wake up more comfortably after urology procedures so I’m more inclined to give it there. Maybe worth it for tiny hand veins in patients i expect to be wimpy as opposed to more stoic patients with free flowing AC IVs…more so to make the propofol hurt less than to aid in blunting laryngoscopy.

I likely agree with your attending that it’s not wise to give it to everyone blindly. In your case, I would consider it for the specific reason of limited alternative opiates and the specific problem you’re trying to address of sympathetic stimulation from the tube at the end of the procedure.

I personally think oral opiates work better than IV opiates. Slower onset, lower peak, less respiratory depression. You often see dramatically lower oral daily opiate requirements converting someone from PCA to oral meds. If you have it available and the patient is tolerating PO (not nauseous in preop) I would consider giving 5mg of oxycodone prior to the procedure.

Efficacy of intracuff lidocaine in reducing coughing on tube: a systematic review and meta-analysis

To investigate the efficacy of intracuff lidocaine in reducing coughing and other endotracheal tube side effects and so ensure a smooth extubation process.PubMed, EMBASE, and Cochrane Library databases were systematically searched for all randomised controlled ...

www.ncbi.nlm.nih.gov

Efficacy of intracuff lidocaine in reducing coughing on tube: a systematic review and meta-analysis​

Fei Peng, Maohua Wang, [...], and Menghong Long

Additional article information

Short abstract​

Objective​

To investigate the efficacy of intracuff lidocaine in reducing coughing and other endotracheal tube side effects and so ensure a smooth extubation process.

Method​

PubMed, EMBASE, and Cochrane Library databases were systematically searched for all randomised controlled trials (RCTs) published before June 30, 2019 that investigated the efficacy of intracuff lidocaine, with or without sodium bicarbonate, in reducing coughing and other complications related to endotracheal intubation. A random-effects model was used to conduct a meta-analysis to assess the relative risks (RRs) of the incidence of these intubation-related side effects.

Results​

11 studies involving 843 patients were included in the meta-analysis. Compared with control groups (i.e., saline or air), intracuff lidocaine groups (alkalinized or non-alkalinized) had a significantly reduced incidence of coughing on tube. Similarly, intracuff lidocaine groups were more effective than control groups in reducing the incidence of other intubation-related complications.

Conclusion​

Intracuff alkalinized or non-alkalinized lidocaine significantly reduced coughing and other intubation-related complications during the extubation process.
Keywords: Endotracheal tube, coughing, dysphonia, hoarseness, agitation, lidocaine, sodium bicarbonate, meta-analysis

 

[Lidolover]

Give nitrous …. Will equilibrate everything

 

[deleted875186]

Agree with above.

I would also suggest if reversing with neostigmine to make sure to reverse early, some shallow rapid breathing could be from a weak patient.

 

[GassYous]

I don't use lido and I can barely the last time I had a patient buck. It's just about timing and judgment.

 

[deleted697127]

I don't use lido and I can barely the last time I had a patient buck. It's just about timing and judgment.

Yea but he’s not working with the same equipment or meds we are. Lido was a suggestion because it’s usually ubiquitous.

Sugammadex is obviously a game changer. A lot of coughing and obstruction post extubation is from weak muscles causing airway tissue to close or trigger reflexes.

 

[DrAmir0078]

I'm sorry that you don't have a lot of medications readily available. It sounds like you have to make a lot of adjustments to take care of your patients due to medication shortages (I've seen you saying you don't have phenylephrine in the past).

However, someone who is emerging with rapid shallow breathing at 40 and hypertensive has an autonomic nervous system that is pissed off.

There are a lot of qualitative and quantitative cues that will tell you how comfortable a patient is prior to extubation. Some people go off of ETCO2, some go off of RR. HR, breathing pattern, response to suctioning are others.

I almost always have patient spontaneously breathing for a little while before I pull the tube. I usually aim to have them breathing somewhere between 10-15 RR. I cant really explain the reason physiologically, but I've noticed patients who breathe spontaneously on the tube and have more regular breathing patterns with adequate TVs tend to keep breathing after the tube is pulled and have less chance of laryngospasm. Its when you're playing with pressure support or making changes to their breathing pattern right before you extubate I see patients breath hold or do weird things after the tube is pulled.

For bread and butter general cases like a lap chole, I will usually dose my long acting opioid (hydromorphone) 0.4mg-0.8mg like 30 minutes before I know the case is going to be done. I'll usually be down titrating the gas sometime before they remove the ports. Reverse once fascia is closed. Usually add 50-60% nitrous and turn your sevo down to like 0.4 while they're closing or turn the gas down and feed them a little prop (10-20mg here and there). Then I just turn up the flows 100% as their cleaning and dressing. Have them spontaneous breathing, if they start to react around 0.3% ET you can give them 1mg/kg of lidocaine IV. Once they start breathing again you can pull the tube and its pretty smooth. Waiting all the way until they open their eyes and follow commands I only do with fat patients, difficult airways, or NPO status questionable (with the head of bed up).

Thanks DrOwnage,
I can build up some extra knowledge from your perspective, and just to address the extubation on pressure support, I have been using this technique the last 6 months and had no case of laryngeospasm encountered, they all wake up calm, and I sometime use prop prior to extubation too, sometime also use metopropolol too as 1 mg.
Today, I was supervise a PGY1 resident who was with an over confidence anesthesia tech who helped her in extubating a case of again an obese lab choley, they let her spontaneously breath on a Tv of 100 and RR of over 30, and gave her reversal based on her spontanesous breathing and extubate it her, the patient then started to vomit after 2 minutes of extubation with that golden yellowish vomits; we managed suction, NG tube her, and then she was OK wih SPO2 98% and sent to recovery. I was a bit mad, regarding the timing of extubation (I only extubate once the patient can elevate their eye brows and even lift their head on ETT, even open their eyes, but on PSVPro or SIMV-PC), then remove the tube easily (It works the best, if the patient had 50 mcg Fentanyl 30 minutes prior to extubation). I didn't like the way the tech was explaining "she won't get aspirated, because she was fully awake and vomits", no dear, she was not, she was even disoriented and way after 5 minutes she became fully awake, and not to mention the patient position was reverse Trendelenburg not lateral recumbent too.
My this post - patient was difficult airway!

 

[DrAmir0078]

Same. Small opioid 30 minutes before, get the gas off early and slowly, sv is key. I always thought leaving them gas on and then turning the flows to 20 L at the end was stupid. Once the tv is ok I pull the tube. I don't wait for them to buck all over the place and be doing calculus before I pull the tube.

Btw for the vast majority of cases I don't care if their bp is 180/100. Unless I'm doing carotid work or something I let the patient ride it out and by the time they leave recovery they are chillin

Thanks DrGassYours,
I can now having a cut off Bp of 180/100 and not to worry.
in my above reply to Dr. Ownage, about a patient today, she vomits lots after extubation, I was closely monitoring her Bp, she was hypertensive too, and I gave her intraoperatively 2mg metoprolol and 40 mg of Lidocaine, and she was very Ok with her Bp and never became hypertensive (It reached 170/125), and the surgeon was scared, but unfortunately, I wasn't there at the time of preparing the extubation, I reached them while they were giving the reversal and extubating - yet I was watching - she was Ok, and I left the theater to another one as I am monitoring other cases, but then I heard somebody said "where is the Attending, they need help with a patient who is vomiting", my heart was telling me about that patient !
I am building up knowledge here !

 

[DrAmir0078]

The full review article summarizing the evidence for intracuff lidocaine for reducing coughing at extubation should be available in this link.

I don’t like giving lidocaine unless i think the patient will benefit for some specific reason. For instance, patients i don’t want to buck at the end because they’ll bleed like neck dissections, or sinuses. I’ll give nebulized lidocaine right after extubation for patients with reactive airways during a case, after bronchs, or for patients with laryngomalacia that i expect to cough their brains out in pacu. I try not to give it to people with low heart rates going for procedures that trigger vagal responses like insufflation. There’s some evidence that lidocaine infusions may help males wake up more comfortably after urology procedures so I’m more inclined to give it there. Maybe worth it for tiny hand veins in patients i expect to be wimpy as opposed to more stoic patients with free flowing AC IVs…more so to make the propofol hurt less than to aid in blunting laryngoscopy.

I likely agree with your attending that it’s not wise to give it to everyone blindly. In your case, I would consider it for the specific reason of limited alternative opiates and the specific problem you’re trying to address of sympathetic stimulation from the tube at the end of the procedure.

I personally think oral opiates work better than IV opiates. Slower onset, lower peak, less respiratory depression. You often see dramatically lower oral daily opiate requirements converting someone from PCA to oral meds. If you have it available and the patient is tolerating PO (not nauseous in preop) I would consider giving 5mg of oxycodone prior to the procedure.

Efficacy of intracuff lidocaine in reducing coughing on tube: a systematic review and meta-analysis

To investigate the efficacy of intracuff lidocaine in reducing coughing and other endotracheal tube side effects and so ensure a smooth extubation process.PubMed, EMBASE, and Cochrane Library databases were systematically searched for all randomised controlled ...

www.ncbi.nlm.nih.gov

Efficacy of intracuff lidocaine in reducing coughing on tube: a systematic review and meta-analysis​

Fei Peng, Maohua Wang, [...], and Menghong Long

Additional article information

Short abstract​

Objective​

To investigate the efficacy of intracuff lidocaine in reducing coughing and other endotracheal tube side effects and so ensure a smooth extubation process.

Method​

PubMed, EMBASE, and Cochrane Library databases were systematically searched for all randomised controlled trials (RCTs) published before June 30, 2019 that investigated the efficacy of intracuff lidocaine, with or without sodium bicarbonate, in reducing coughing and other complications related to endotracheal intubation. A random-effects model was used to conduct a meta-analysis to assess the relative risks (RRs) of the incidence of these intubation-related side effects.

Results​

11 studies involving 843 patients were included in the meta-analysis. Compared with control groups (i.e., saline or air), intracuff lidocaine groups (alkalinized or non-alkalinized) had a significantly reduced incidence of coughing on tube. Similarly, intracuff lidocaine groups were more effective than control groups in reducing the incidence of other intubation-related complications.

Conclusion​

Intracuff alkalinized or non-alkalinized lidocaine significantly reduced coughing and other intubation-related complications during the extubation process.
Keywords: Endotracheal tube, coughing, dysphonia, hoarseness, agitation, lidocaine, sodium bicarbonate, meta-analysis

Thanks,
I am pleased to see this metanalysis, I just want to touch base with you, I can use 2% IV/IM Lidocaine 2 ml (40 mg), and inserted in the cuff through the pilot tube, and the rest air or Normal Saline to provide protection?

 

[DrAmir0078]

Give nitrous …. Will equilibrate everything

What is nitrous?
I can answer MCQs in regard, but never seen it in practice or training in Iraq, it was gone over 10 years ago from hospitals !

 

[DrAmir0078]

Agree with above.

I would also suggest if reversing with neostigmine to make sure to reverse early, some shallow rapid breathing could be from a weak patient.

Dr. DipriMan,
Thanks, you know how we make reversal, we mix Neo + Atropine in one syringe (10 ml), and I am sure it is not the best practice, but how would you tell me to do it for better practice?

 

[deleted697127]

Thanks,
I am pleased to see this metanalysis, I just want to touch base with you, I can use 2% IV/IM Lidocaine 2 ml (40 mg), and inserted in the cuff through the pilot tube, and the rest air or Normal Saline to provide protection?

A lot of the studies use both higher volumes and concentrations of lido. I don’t know what tubes you guys use but there is warranted skepticism that much lidocaine even crosses through the balloon. As long as the cuff pressure is high enough to give you a seal for adequate ventilation and protect from aspiration and low enough that you are not causing ischemia, i do not think any combination of lidocaine or air would cause an issue. This should not be an issue unless you are using a low volume high pressure cuff.

 

[GassYous]

Yea but he’s not working with the same equipment or meds we are. Lido was a suggestion because it’s usually ubiquitous.

Sugammadex is obviously a game changer. A lot of coughing and obstruction post extubation is from weak muscles causing airway tissue to close or trigger reflexes.

True. Sugammadex is definitely a game changer. But you can get to a similar place by minimizing paralytic and reversing early with heavier opioid.

 

[deleted697535]

Lap chole extubation BP? Never even measured it, nor cared.
Ive basically never seen brief episodes of hypertension to cause harm outside of very acute neuro/cardiac cases

Yea but he’s not working with the same equipment or meds we are. Lido was a suggestion because it’s usually ubiquitous.

Sugammadex is obviously a game changer. A lot of coughing and obstruction post extubation is from weak muscles causing airway tissue to close or trigger reflexes.

Lap chole is the exact same 6 simple drugs for every single case?

 

[deleted875186]

Dr. DipriMan,
Thanks, you know how we make reversal, we mix Neo + Atropine in one syringe (10 ml), and I am sure it is not the best practice, but how would you tell me to do it for better practice?

The dose of neostigmine you are using is probably correct.

My point was make sure you give neostigmine at least 15-20 mins before you are going to wake them up, and don’t let them breath spontaneously or wake up before getting full muscle strength back. Hypertension could be from increased work of breathing in the setting of waking up with residual weakness.

 

[DrAmir0078]

The dose of neostigmine you are using is probably correct.

My point was make sure you give neostigmine at least 15-20 mins before you are going to wake them up, and don’t let them breath spontaneously or wake up before getting full muscle strength back. Hypertension could be from increased work of breathing in the setting of waking up with residual weakness.

So, Dr. DipriMan, are you saying to give Neostigmine before getting spontaneous breathing? and is it alone without Atropine? How about the side effect of Neostigmine Bradycardia, secretions ???

That is reasonable explaining the hypertension and work of breathing !
Thanks

 

[GassYous]

Thanks DrGassYours,
I can now having a cut off Bp of 180/100 and not to worry.
in my above reply to Dr. Ownage, about a patient today, she vomits lots after extubation, I was closely monitoring her Bp, she was hypertensive too, and I gave her intraoperatively 2mg metoprolol and 40 mg of Lidocaine, and she was very Ok with her Bp and never became hypertensive (It reached 170/125), and the surgeon was scared, but unfortunately, I wasn't there at the time of preparing the extubation, I reached them while they were giving the reversal and extubating - yet I was watching - she was Ok, and I left the theater to another one as I am monitoring other cases, but then I heard somebody said "where is the Attending, they need help with a patient who is vomiting", my heart was telling me about that patient !
I am building up knowledge here !

I actually don't care that much about that level of bp. The reason why I treat that is because that's the level at which the pacu nurses will say the patient is not acceptable to go home or to the floor, even if that's where they are all the time.

You don't need spontaneous breathing to give neostigmine, only twitches on train of four. You can give neostigmine alone (although some of the stupider attendings I've had would tell me that it would certainly kill the patient). It does cause bradycardia, increased secretions and I've also had a patient perform a code brown on the table.

 

[DrAmir0078]

I actually don't care that much about that level of bp. The reason why I treat that is because that's the level at which the pacu nurses will say the patient is not acceptable to go home or to the floor, even if that's where they are all the time.

You don't need spontaneous breathing to give neostigmine, only twitches on train of four. You can give neostigmine alone (although some of the stupider attendings I've had would tell me that it would certainly kill the patient). It does cause bradycardia, increased secretions and I've also had a patient perform a code brown on the table.

Interesting, but I have no TOF ! !
Well, without Atropine, how brief the secretions and Bradycardia ?

 

[deleted697127]

Lap chole extubation BP? Never even measured it, nor cared.
Ive basically never seen brief episodes of hypertension to cause harm outside of very acute neuro/cardiac cases

Lap chole is the exact same 6 simple drugs for every single case?

Lol. I don’t disagree with any of this. At the same time i still try to avoid swings of BP and bucking which again no one is arguing is a difficult task to accomplish for a lap chole. 99% of the time bucking doesn’t matter to anyone other than the judging eyes of the OR staff. Patients more than likely won’t remember or care. I also only elaborated because OP asked for stuff to try out.

 

[deleted697127]

Interesting, but I have no TOF ! !
Well, without Atropine, how brief the secretions and Bradycardia ?

I don’t have the balls to travel to Iraq for leisure but am definitely curious what the working conditions are like based on some of your posts.

 

[DrAmir0078]

I don’t have the balls to travel to Iraq for leisure but am definitely curious what the working conditions are like based on some of your posts.

No need for balls, just come and live 3 days with us at our Teaching Center - I assure you, you will be fully protected from my side, I am a US citizen too and Iraqi too.
One adventure at a time, but don't come these days, unless you want to get hyponatremia from sweating - at least 110 F at noon...

 

[deleted875186]

I

So, Dr. DipriMan, are you saying to give Neostigmine before getting spontaneous breathing? and is it alone without Atropine? How about the side effect of Neostigmine Bradycardia, secretions ???

That is reasonable explaining the hypertension and work of breathing !
Thanks

i would give neostigmine/atropine at least 15 mins before planned wake up, ok to let them breath on PSV with support if they are trying to initiate breathes, but no spontaneous breathing until strength has fully returned.

I honestly find it easier to not PSV people and just leave them on full vent support until they are reversed, gas is off, and then switch to spontaneous or PSV with minimal support, I think it’s faster and simplifies things.

 

[DrAmir0078]

I

i would give neostigmine/atropine at least 15 mins before planned wake up, ok to let them breath on PSV with support if they are trying to initiate breathes, but no spontaneous breathing until strength has fully returned.

I honestly find it easier to not PSV people and just leave them on full vent support until they are reversed, gas is off, and then switch to spontaneous or PSV with minimal support, I think it’s faster and simplifies things.

Oh Ok, that is awesome 15 minutes before planned wake up... Once the diaphragm works you mean - it is interesting, hopefully the surgeon is quick to close!
Yes, I start with SIMV-PC then once I see them getting their own breath with good Tv on Psupport of 10 cmH2O, I switch to PSVpro as it is a protective against apnea... I always monitor the machine fixing the support, when I reach 5 CmH2O and got like 450 Tv, then it is the time to check the patient status, if just elevate their eye brows on command or open their eyes, I extubate...

 

[GassYous]

What do you mean psv is protective against apnea? It's just augmenting the breaths the patient is taking themselves.

 

[DrAmir0078]

What do you mean psv is protective against apnea? It's just augmenting the breaths the patient is taking themselves.

Yes, it is PSVPro, that means it support the ventilation, but if apnea happened, the control part works... It is like this
Pinsp
RR
Tinsp
Peep
Psupport

So, the control part won't work unless there is apnea...

Unlike the SIMV-PC or SIMV-VC or SIMV-PS, where if there is apnea, only the set RR on the control part will work!

In SIMV, I can reduce the RR to like 3 and depends on patient RR like 12 (this is a process to lower RR of the control part), but if apnea happened, it will only give RR set on the control part.

Unlike PSVPro, I always set RR to 12 for peace of mind!

Do you have it in your anesthesia machine?

 

[GassYous]

Oh I see what you mean, that there's a backup setting.

 

[DrAmir0078]

Oh I see what you mean, that there's a backup setting.

Yes Sir, it is a backup that is why called PSVPro - pro means protection...

 

[deleted697535]

Lol. I don’t disagree with any of this. At the same time i still try to avoid swings of BP and bucking which again no one is arguing is a difficult task to accomplish for a lap chole. 99% of the time bucking doesn’t matter to anyone other than the judging eyes of the OR staff. Patients more than likely won’t remember or care. I also only elaborated because OP asked for stuff to try out.

Agree with what? I didnt mention bucking at all i dont think?

i also avoid bucking /hypertension as it does look ugly i agree, but i just never have it tbh cause i extubate deep pretty much all the time.
I just dont think htn matters in the slightest mostly

 

[vector2]

Me as a resident: "Wow psvpro and simv-pcvvg are so cool"

Me as anesthesia/CCM staff years later: "just give me volume control and the bag"

 

[drmwvr]

LTA +/- iv lidocaine, narc as appropriate, mechanically ventilate until purposeful movement/eye opening to voice...extubate...routine htn on emergence means extubating too late routinely.