get 'em breathing

offlabel said:

Is there some unwritten rule about getting the patient breathing before you ke him up? Suggesting to an SRNA to keep the patient on mechanical ventilation right up to the point that he opens his eyes and then extubate is like denying climate change to Joe Biden...why this poverty of clinical knowlege??

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I feel your pain.  Before I retired, I noticed a lack of attention paid to the "art" of fine tuning your patient.  IMV, the patient should be breathing, extubated and awake when the drapes are pulled off. It's so easy and wasteful to just keep pushing more Propofol at the end rather than aiming for elegant. That's was the endpoint that we learned back in the stone ages.  We aren't there to take up extra, unnecessary OR time. But we had real university affiliated instructors in those days; not random staff people who weren't interested in the best for the students.  My plan is just to avoid to ever going to a hospital again:(

Ha! Indeed.

Working with SRNA's, I just try to show them what's possible. And the reality is, they take the lowest common denominator mostly because it's the surest bet for their level of experience and comfort. Introducing something like extubating the patient right off full mechanical ventilation as long as they're warm and have eye opening to their name is something I really don't expect them to utilize right away. But I really hope it plants a seed for when they're hitting their groove a few years down the line.

offlabel said:

Ha! Indeed.

Working with SRNA's, I just try to show them what's possible. And the reality is, they take the lowest common denominator mostly because it's the surest bet for their level of experience and comfort. Introducing something like extubating the patient right off full mechanical ventilation as long as they're warm and have eye opening to their name is something I really don't expect them to utilize right away. But I really hope it plants a seed for when they're hitting their groove a few years down the line.

It took me a while:(  But I had to learn quickly because my first job was in a non teaching hospital and turnover time was only 20 minutes and the surgeons were breathtakingly quick compared to the teaching hospital I came from.  But thanks for trying to plant the seed:)

Perfect anesthesia, in my opinion, is when the last stitch is put in, the patient is breathing on SIMV with good Vt, ETCO2, and RR and ready to pull the ett/lma. Drapes come down as the dressing is placed and the gurney is brought in. The team moves the patient to gurney and we are off! Efficient OR utilization. 

Qwiigley said:

Perfect anesthesia, in my opinion, is when the last stitch is put in, the patient is breathing on SIMV with good Vt, ETCO2, and RR and ready to pull the ett/lma. Drapes come down as the dressing is placed and the gurney is brought in. The patient moves himself to the gurney and we are off! Efficient OR utilization. 

FTFY

offlabel said:

Ha! Indeed.

Working with SRNA's, I just try to show them what's possible. And the reality is, they take the lowest common denominator mostly because it's the surest bet for their level of experience and comfort. Introducing something like extubating the patient right off full mechanical ventilation as long as they're warm and have eye opening to their name is something I really don't expect them to utilize right away. But I really hope it plants a seed for when they're hitting their groove a few years down the line.

We did and that was back in the 80's.  It was considered very tacky to bring a patient to the PACU intubated for no reason.  This was even before intermediate acting muscle relaxants were available.  All we had was curare and Pavulon. 

subee said:

We did and that was back in the 80's.  It was considered very tacky to bring a patient to the PACU intubated for no reason.  This was even before intermediate acting muscle relaxants were available.  All we had was curare and Pavulon. 

Well now the trend is an opa and a non-rebreather mask to recovery for everything from a crani to a tah...smh.....I gotta retire....

offlabel said:

Well now the trend is an opa and a non-rebreather mask to recovery for everything from a crani to a tah...smh.....I gotta retire....

We have to accommodate the lower performance  with MORE oxygen! The answer to a lack if clinical judgement.  Retirement is awsome.