No Bucking Allowed

[Gator05]

Ok folks, let's here it. How do you keep YOUR patients from bucking on their tubes?

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[fval28]

deep extubation

 

[Noyac]

deep extubation

Ditto. And if this is not reasonable, narcotics.

 

[rn29306]

One of our Neruosurgeons is always dictating the whole "absolutely no bucking" issue.

It seems to me its either deep gas extubation (forane or sevo) or a deep narcotic wakeup.....neither of which allows a quick post-op neuro check.

At least here, its either one or the other.....can't have it both ways.

Open to suggestions.

 

[Noyac]

One of our Neruosurgeons is always dictating the whole "absolutely no bucking" issue.

It seems to me its either deep gas extubation (forane or sevo) or a deep narcotic wakeup.....neither of which allows a quick post-op neuro check.

At least here, its either one or the other.....can't have it both ways.

Open to suggestions.

Deep extubation on Des or Sevo really doesn't take that long to be ready for neuro checks. The cranium is a little different in that you can't extubate as the surgeon is closing (I usually extubate as the last layer of stitches are getting started). They are generally answering questions as we are moving them to the stretcher or they are moving themselves. Bottom line is that you don't have to wait for the surgery to end always and the field to be cleaned and dressed. You can hold a mask on their face as they spontaneously breath while all this is occurring.

I understand that this practice is not for everyone. But it works for me.

 

[catcolalex]

Precedex load right before emergence.

 

[Monty Python]

Precedex load right before emergence.

Agreed, precedex is a fabulous drug, but are you implying that you use it on all extubations? That's $$$$$.

We only used precedex (at my former place) on CABGS, CEAs, etc.

 

[VolatileAgent]

in addition to what others have said...

relatively short case? LTA at induction.

also, 5cc of 2% lidocaine (ie. 100 mg) IV at emergence when they are getting light... have seen mixed results with this. seems to work better in the average male teen case.

otherwise, if you have a smoker (or any other person with irritable airways) you gotta pull deep.

 

[rn29306]

Deep extubation on Des or Sevo really doesn't take that long to be ready for neuro checks. The cranium is a little different in that you can't extubate as the surgeon is closing (I usually extubate as the last layer of stitches are getting started). They are generally answering questions as we are moving them to the stretcher or they are moving themselves. Bottom line is that you don't have to wait for the surgery to end always and the field to be cleaned and dressed. You can hold a mask on their face as they spontaneously breath while all this is occurring.

I understand that this practice is not for everyone. But it works for me.

Des or remi would make this achievement alot easier. Sadly, we don't have either.

But point taken about sevo. Thanks Noy.

 

[TIVA]

Run a remifentanil infusion at about 0.05 mcg/kg/min. Use the ventilator to breath off all of their agent (i.e. high flows). Keep EtCO2 around 35-40. If they are trying to breath over the vent, run the remifentanil at a slightly higher dose (up to 0.1 mcg/kg/min) until you are doing the breathing for them (in order to facilitate exhalation of all the volatile from their system). Once MAC is down to 0.1 or less, talk to the patient. Ask them to open their eyes. Ask them to take a nice deep breath. And then pull the tube. Voila!

P.S. Be sure to turn the remifentanil infusion off as soon as they are extubated.

 

[catcolalex]

Agreed, precedex is a fabulous drug, but are you implying that you use it on all extubations? That's $$$$$.

We only used precedex (at my former place) on CABGS, CEAs, etc.

Use it only when you dont want the pt to buck, or with a history of emergence delirium. I dont know about you but I never had to pay for any of the anesthetic drugs I use.

 

[militarymd]

Precedex load right before emergence.

How do you load it?

Infusion

Subcutanenous.

small boluses?

 

[VolatileAgent]

How do you load it?

Infusion

Subcutanenous.

small boluses?

it's a 1 mcg/kg infusion over about 10 mins. you can then run it at 0.3-0.5 mcg/kg/hr thereafter.

personally, i've had really mixed results withboth remi and precedex, and they are way too expensive and cumbersome to set-up for routine use.

 

[catcolalex]

just pull up the 1 mcg/kg dose in a syringe push it over 10 min as you come down on gas, done. not too cumbersome.

 

[militarymd]

it's a 1 mcg/kg infusion over about 10 mins. you can then run it at 0.3-0.5 mcg/kg/hr thereafter.

personally, i've had really mixed results withboth remi and precedex, and they are way too expensive and cumbersome to set-up for routine use.

I thought maybe he had a novel way of loading it.

That's what the package insert says...I think..

I've always loaded over 20 minutes to minimize some of the side effects what you see during the load.

I've loaded with small boluses and subcutaneously.....both work well ....but off-label....but I've only loaded pre-induction for awake intubations...or early after induction for maintenance...

I was hoping to hear of a new way of loading for emergeence.

 

[VentdependenT]

remi has worked great for my CEA's. Keep in mind that my experience with the drug is limited. However the patients wake up smooth. Plus you can use the stuff to control pressure during the case instead of running vasoactive drips.

Havent used precedex yet but thats comming.

For yer average case some people are gonna buck no matter what the hell you do outside of smackin em with narcs. I usually get em spont ventilating, even prone (at the end o the case...I aint that nuts) and titrate narcs to respirs. Works great and more often than not patients wake up very nicely.

 

[Tenesma]

for the guy who posted about the neurosurgeon who insists on no bucking....

my response:
1) If he is SOOOO worried about bucking then we should just go ahead and put in a ventriculostomy....
2) No ventriculostomy? then I ask him how he plans on stopping coughing against a closed glottis when the patient is in the PACU, Neuro-ICU, home???
3) and then I point out that technically as long as the ET tube is in the trachea, and remains patent (solid bite block), even if the patient bucks, very unlikely that the ICP would increase to a dangerous point
4) and then I point out that I am running remi in the background as a good cough suppressant
5) and then I point out that he is a ******* for insisting on no bucking... unless he wants me to insist on prep-times <3 hours

 

[catcolalex]

for the guy who posted about the neurosurgeon who insists on no bucking....

my response:
1) If he is SOOOO worried about bucking then we should just go ahead and put in a ventriculostomy....
2) No ventriculostomy? then I ask him how he plans on stopping coughing against a closed glottis when the patient is in the PACU, Neuro-ICU, home???
3) and then I point out that technically as long as the ET tube is in the trachea, and remains patent (solid bite block), even if the patient bucks, very unlikely that the ICP would increase to a dangerous point
4) and then I point out that I am running remi in the background as a good cough suppressant
5) and then I point out that he is a ******* for insisting on no bucking... unless he wants me to insist on prep-times <3 hours

I want to be able to say that to my surgeons when I grow up.