Techniques for smooth wake-up

If you have an anesthesia machine capable of Pressure Support, I highly recommend using this at the end of your case. You can get them breathing comfortably on PS and titrate your narcotic of choice and they wake up very nicely.

I decide if I want to do a deep or an awake extubation. The most important thing is to do one or the other, not extubate in between. If there is a need for an awake, then I time turning down/off the agent with the progress of the surgery while assuring the muscle relaxation is reversed. Once I'm sure surgery in complete I'll turn off agent while increasing the O2 flow and maybe increasing the minute volume to blow agent off faster. Once they cough I take them off the ventilator and hand ventilate until they respond to commands and demonstrate muscle strength.

If I decide on a deep extubation I'll let the CO2 rise the last 15-20 minutes of the case to the mid40's by reducing the minute ventilation. Usually they will start breathing, and I'll titrate narcotic to the resp rate. (If they need muscle relaxation until the very end, I might shorten this part up) I'll continue to assist ventilation until the procedure is completed and at no time is the agent level reduced. If they start coughing with suctioning, I'll increase agent and let them breath themselves down until they are deep enough. Once they don't cough with suctioning, and have a good respiratory pattern, I pull the tube. Then they need a good jaw lift to keep the airway open and be quiet with the airway until you are sure they are going to maintain respirations (don't be moving the head around, suctioning etc). Some people don't like deep extubations, but it can work well in the right situations.

I pretty much get all of my patients back breathing as soon as it is feasible (after relaxation no longer required, etc...). I like to use SIMV or PS at first, then let them breathe spontaneously. While they are breathing, I titrate my narcotic of choice to achieve a respiratory rate of about 6-10. I have found that if the patient is comfortable and has enough narcotic on board, they tend to wake up much more smoothly.

the tube in their throat or pain is the reason for most rough emergences that can be dealt with by deep extubation or timely narcotics at the end.

Ami,

This is Bryan. I pm'd you a couple of times. Check Pm and get in touch

Thanks!

Brian,

I keep trying to reply to you but for some reason, there is no button that says reply (wierd, huh). Can you just pm me your e-mail address and I will answer your questions that way....I'm so sorry it has taken so long to get back to you...I read your first message a long time ago and completely forgot about it! Anyway, just send me another pm b/c either I am stupid or my pm box is acting wierd.

Ami

P.S....sorry to hijack the thread guys.

TIVA if you arent a cheapskate...Isoflurane can give a nice wake up as opposed to desflurane...gives you a little more time to titrate some narcotics...of course, your attending may have a problem with any of this since you are an SRNA. Best advice...don't worry about how rough the patient wakes up...it is surface level, the important thing is that the tube comes out at the right time...better later than too early if you are still a student. If it gets to a point where the patient is a danger to himself or others, and they are still intubated, don't be afraid to give a few ccs of propofol....

anyone else?

Shut your gas off early and use bumps of propofol. Titrate your propofol with their vital signs. Nice smooth wakeup and you get coverage for nausea as well.

Do any of you CRNAs use Precedex? We've just started using it in our post-op open hearts in a case-by-case basis (those with rough emergence, poor vent tolerance). I like what I've seen so far, but the adverse effects have needed close watching. They say it should decrease the narc need and shorten our post-op extubation times. Any other recommendations for non-anesthesia personnel who extubate?

Get em breathing, titrate some morphine in for RR 8-12, deep extubation they wake up wondering what happened.

Turn off the sevo while the surgeons are closing (you have to know how long your surgeons take to close) go to SIMV, turn on the N2O 1.5L and O2 at 1L. When you want to gas more Sevo off, turn volumes of N2O to 8 and O2 to 6.5. (It will blow off more Sevo). Then after the dressing is on, (your residual Sevo will be low, .2 or .1) then turn the N2O off. Wait for a few min. until nitrous is gone. Then whisper in their ear, "open your eyes" Remove tube and have them move themselves to the gurney. Works like a charm. (you do have to know your surgeons, and use your narcotics judiciously). You don't want any memory of emergence.