lets discuss extubation

i have been working on smoother wakeups. the technique i have been employing is using either morphine or fentanyl and titrating in 2mg per cc of mso4 or 10 mcg of fent to keep respirations about 12- 18 per minute. (obviously in patients that are spont vent.) while doing this i cut back on the gas in increments. when it comes time to extubate they usually will open their eyes to command, wont buck as much and seem more comfortable. i try this in patients that i am not worried about resp depress and airway issues. adn the morphine keeps em more comfortable into postop for obvious reasons.

the question is, do many of you do this? i have worked with some ppl that almost refuse to use narcs near the end of the case on anyone. i dont know if they have been burned in the past or what. this also is adults, not peds where i currently am.

d

I've used MSO4 in the past, but now primarily use Dilaudid. I titrate in 2mg over the last 15-30min (usually in 0.5mg increments) of the case. They do not necessarily have to be spontaneously breathing. I primarily use Sufenta for all of my cases and I wait about 30-45 min. after my last dose of Sufenta before I'll start my Dilaudid. I find the patients are generally comfortable using this technique and they do start breathing without difficulty. I wouldn't worry too much about getting burned. All patients are individual and you can get burned by all techniques, even not titrating in a long acting narc. I'd want narcotic coverage before I woke up. Beats waking up writhing in pain and then having to play catch up.

skipaway

Generally, what I do for most of my cases is give my intubation dose of fentanyl, titrate in additional doses based on hemodynamics, respiratory pattern, etc. and then titrate in additional doses to keep Resps in the low teens right before extubation.

Another technique I find particularly helpful for extubation in longer cases is to get the patient back breathing, shut off my gas, and turn my flow rate to physiologic needs, eg. 400cc/min. Titrate in some narcotics, when the surgery is done, crank my flows, resulting in a smooth quick wake-up.

Brenna's dad

When you crank up your flows at the end are you cranking up nitrous as well as O2 or just O2. I noticed that pt's wake up real fast if the inhalation is turned down before the end of the case, and the Nitrous and O2 are cranked up at the end. I am working on a good wake up technique. Obviously each case is individual but I am looking for a generalized technique that works well.

The reason narcotics are such a great idea toward the end of the case is that they work wonderfully to suppress the cough reflex. If you ever get a horrible upper resp. infection with intractable coughing, have your doctor prescribe a cough syrup with hydrocodone in it and you'll see what I mean. Lidocaine can also suppress the cough reflex as patients lighten at the end of a case, but it will also make them quite sleepy which could prolong your wakeup.

The goal is to keep the patient breathing in a nice smooth pattern right until the moment that you pull the tube. In the absence of narcotic at the end, the patient will blow off the volatile anesthetic and they will eventually get to the stage where they will begin to respond to that big piece of plastic sitting between their vocal cords. They then begin coughing which as you know is not an effective gas exchange. What happens?? - your wakeup comes to a screeching halt because your patient is no longer eliminating their volatile drug via their lungs. Small amounts (25mcg increments of Fentanyl for example) of narcotic once you have a patient back breathing, will allow them to tolerate the tube as they blow off the gas allowing for a much smoother and FASTER wakeup as they can eliminate the volatile drug much more effectively by breathing then you can by squeezing the bag while they're coughing and bucking. The analgesic benefits at the end are also of great value.

This is where the artistry of anesthesia comes into play.

gasspassah -

i likewise love to use fent or dilaudid at the end of the case.....

get em back breathing and titrate in to keep resps 10-12...they wake up wonderfully...i have used lido as well at the end and i must say it was a nice wake as well although the pain control was not there...i have done alot of plastics and do not use nitrous for those so the pain meds are a huge benefit for those patients...

but i love to learn new things...and other different practices??????

I've just recently been a bit more bold with my narcotics usage. I give even short cases big doses of fentanyl on induction, very little gas (Seveo .4 ish) and use nitrous to keep them asleep. When the surgeon is done I turn off the nitrous and up on the o2. I titrate the additional fentanyl for short cases to breathing of 8-10. If I get to 12 they get more. I use demerol for longer more painful cases. I haven't got the hang of sufenta yet, but on longer cases (laminectomies, etc) I've been experimenting). But I graduate in 6 days, so I'll have more freedom coming up very soon!

I've just recently been a bit more bold with my narcotics usage. I give even short cases big doses of fentanyl on induction, very little gas (Seveo .4 ish) and use nitrous to keep them asleep. When the surgeon is done I turn off the nitrous and up on the o2. I titrate the additional fentanyl for short cases to breathing of 8-10. If I get to 12 they get more. I use demerol for longer more painful cases. I haven't got the hang of sufenta yet, but on longer cases (laminectomies, etc) I've been experimenting). But I graduate in 6 days, so I'll have more freedom coming up very soon!

Define a big dose of fentanyl.

No, when I crank up my flows at the end, the surgeon is done or almost done and I am blowing off the rest of their gas.

I don't wake up on Nitrous for obvious reasons. What I do is titrate in narcotics at this pont.

I will preface this with -- In my very short (as of yet) learning experience....

i have found that many are very afraid of higher dose narcotics - i have only worked w/ 1-2 people who utilize this and i have seen it work beautifully...

i will define - as they have to me - the dosages

1-5mcg/kg - low

5-10 - intermediate

10-15 - high to very high....

i like 5mcg/kg on inducation w/ less propofol ....

but again - always willing to learn...

teach me more - teach me more...

athomas, how did your bid for education student rep go?

d

My student role and the shame (lol) of having to use Narcan prevents me from using high dose narcotics in most of my cases. That's why I usually like to "back-load" my narcotics in the last fifteen minutes or so of the case. I titrate in 25-50 mcg until the respirations are less than 10. If the person has a history of narcotic use, I'm usually much more aggressive throughout the case and use long acting narcotics, almost exclusively Hydromorphone. I think Morphine has too great of a side effect profile.

This works very, very well for the majority of my patients. I have had one or two cases where I know the patient needs more narcotics, but for whatever reason (ie. despite being on low amounts of agent), they refuse to breath when given any narcotics. In these one of two cases, the patients wake up in pain and I quickly hit them with narcotics before and on the way to PACU.

gasspassah - lost to a great candidate - so not too upset about it...sure takes alot of work off my back and met great people in the process....thanks for asking