Remifentanil wake-ups

[ButterButter]

I often hear people talk about remi wakeups but haven't come across a recipe that I've had consistent success with. If you use remifentanil for smooth wakeups after cranis, carotids, bronchs, etc. what's your dose range? Are you running higher doses toward the end of the case and then shutting it off to allow them to wake up? Are you extubating on low-dose remi? What's your recipe?

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[FiO2@21]

Extubate on low dose remi. 0.03-0.08. But it’s not 100% sadly.

 

[coffeebythelake]

I often hear people talk about remi wakeups but haven't come across a recipe that I've had consistent success with. If you use remifentanil for smooth wakeups after cranis, carotids, bronchs, etc. what's your dose range? Are you running higher doses toward the end of the case and then shutting it off to allow them to wake up? Are you extubating on low-dose remi? What's your recipe?

Nothing works 100%. You can always start slow and titeate down as needed. Turn off your other anesthetics early and go up on your remi during that time to ensure the patient remains anesthetized, then as you approach your time of emergence go down on the remi. Take advantage of its very short half life. I've had pretty good success in the 0.03 to 0.05 range.

 

[GassYous]

Usually around 0.05. I stopped using remi altogether though. I think smooth wakeups are over valued by surgeons who know nothing about what we do. But if you want a smooth wakeup, be generous with the opioids, time it well and don't reverse until all the volatile is off. I also do everything gradually. As the case ends, go down on the prop gtt and the volatile as the nitrous is slowly titrated up. Use sugammadex, not neo. Also I've been using simv instead of prvc or whatever.

I reverse when almost all the gas is off and let them wake up slowly. As soon as the tidal volume is acceptable, I extubate right before they stage 2. If I miss the timing I just let em buck. Buck it.

 

[IMGASMD]

Usually around 0.05. I stopped using remi altogether though. I think smooth wakeups are over valued by surgeons who know nothing about what we do. But if you want a smooth wakeup, be generous with the opioids, time it well and don't reverse until all the volatile is off. I also do everything gradually. As the case ends, go down on the prop gtt and the volatile as the nitrous is slowly titrated up. Use sugammadex, not neo. Also I've been using simv instead of prvc or whatever.

I reverse when almost all the gas is off and let them wake up slowly. As soon as the tidal volume is acceptable, I extubate right before they stage 2. If I miss the timing I just let em buck. Buck it.

Perception is reality

 

[DrZzZz]

Usually around 0.05. I stopped using remi altogether though. I think smooth wakeups are over valued by surgeons who know nothing about what we do. But if you want a smooth wakeup, be generous with the opioids, time it well and don't reverse until all the volatile is off. I also do everything gradually. As the case ends, go down on the prop gtt and the volatile as the nitrous is slowly titrated up. Use sugammadex, not neo. Also I've been using simv instead of prvc or whatever.

I reverse when almost all the gas is off and let them wake up slowly. As soon as the tidal volume is acceptable, I extubate right before they stage 2. If I miss the timing I just let em buck. Buck it.

Strongly disagree on the reversing late, when almost all the gas is off. Particularly if using sugammadex like you suggest. If it works for you, I'm not going to try and convince you to change your practice. But to me, having a nearly awake but still relaxed patient is a recipe for anything but a smooth wakeup. Reverse relaxant deep and titrate opioid to respiratory rate for smooth wakeup. Giving sugammadex closer to gas being off has been suggested as a main cause of the bradycardia side effect due to patients valsalva-ing upon reversal too late in the process. Not to mention patients bucking as soon as they're physically able to if you didn't titrate opioid properly.

 

[GassYous]

Strongly disagree on the reversing late, when almost all the gas is off. Particularly if using sugammadex like you suggest. If it works for you, I'm not going to try and convince you to change your practice. But to me, having a nearly awake but still relaxed patient is a recipe for anything but a smooth wakeup. Reverse relaxant deep and titrate opioid to respiratory rate for smooth wakeup. Giving sugammadex closer to gas being off has been suggested as a main cause of the bradycardia side effect due to patients valsalva-ing upon reversal too late in the process. Not to mention patients bucking as soon as they're physically able to if you didn't titrate opioid properly.

Have zero bucking, zero bradycardia, zero valsalvas. Nothing but smooth extubations for the last several hundred patients. As in most things in our field I think the key is getting the timing right.

 

[coffeebythelake]

I do think that bucking is overrated. If the surgeon is so afraid that the patient would buck when breathing spontaneously with an ETT during emergence they should also be damned scared if the patient coughs when they are at home. Rarely is it actual important. A lot of the time it is a stupid request and more telling of their inadequate hemostasis and surgical technique.

 

[anaesthetic]

.

 

[nimbus]

For nonpainful procedures (ICDs, ablations, etc), I give no opioids, turn off gas at the end, suction and extubate while they’re still paralyzed and on PPV. Then I give sugammadex. No tube=no coughing and they breathe right away because I gave no opioids during the case.

 

[woopedazz]

I'm with the above. I blow off a little bit of gas and wait until BIS is 90-100 and HR is 220-age and then give sugammadex for a smooth wakeup.

 

[vector2]

I often hear people talk about remi wakeups but haven't come across a recipe that I've had consistent success with. If you use remifentanil for smooth wakeups after cranis, carotids, bronchs, etc. what's your dose range? Are you running higher doses toward the end of the case and then shutting it off to allow them to wake up? Are you extubating on low-dose remi? What's your recipe?

Remi is overused and unnecessary imo. Just pull more people deep. But if you can't do that, start using more 4% lido LTAs. For longer cases, get one of these guys

and anesthetize the trachea with a bunch of 0.5 or 0.75 ropi. Then make sure the surgeon used local in the incision and give more opioid (+- a small adjunct dose of ketamine like even 20 mg). Emerging pts don't buck if their trachea is numb and their surgical site doesn't hurt.

 

[Hoya11]

Strongly disagree on the reversing late, when almost all the gas is off. Particularly if using sugammadex like you suggest. If it works for you, I'm not going to try and convince you to change your practice. But to me, having a nearly awake but still relaxed patient is a recipe for anything but a smooth wakeup. Reverse relaxant deep and titrate opioid to respiratory rate for smooth wakeup. Giving sugammadex closer to gas being off has been suggested as a main cause of the bradycardia side effect due to patients valsalva-ing upon reversal too late in the process. Not to mention patients bucking as soon as they're physically able to if you didn't titrate opioid properly.

Right. A smooth wake-up in my mind is best done on a patient already breathing well and in a regular, slow pattern, while deep. Generous opiate as others have suggested to get that RR rate down to 12ish or below - even if the surgery not painful. I'm not going to wait to get them back breathing at the very end. I want to check that off my list early and titrate opiate to a resp rate of <12 before the emergence process. Once they are breathing and deep, you just come down on the gas gradually. I always like to wake up on gas, and if I'm doing a mixed anesthetic i turn off the drips early but leave on just a little sevo like 0.8 until closure is complete. Then gas off and flows up. Nice , smooth, safe, timely.

Keeping the guy paralyzed until the end is a strategy I have seen when most patients are undernarcotized intra-op, its easier but not optimal. If you give enough opiate you dont have to keep them paralyzed until the very end. They will be still and cooperative and already breathing sufficiently and ready for extubation, which I do once sevo has been under 0.4 for a few breaths. Plus that opiate on board is likely to reduce any coughing or bucking by decreasing airway reactivity.

 

[Greenbayslacker]

After propofol, remifentanil is my second favorite drug of all time. Followed by sugammadex. You can see a common trend, I enjoy the “titratability” of fast-on/fast-off drugs, which sevo does not provide. This does require a hands on approach and watchful eye.

My formula for the past ~1500 or so GA cases has brought me great success, fast and smooth extubations, and patient satisfaction. The key is to get the gas off early. Having sevo on board invariably leads to some degree to emergence delirium and PONV. I strive to have Et sevo at 0.0 prior to reversal. In those cases I may leave remi on at 0.03-0.05 if I have it going as others have mentioned, but more importantly give small boluses of propofol 20-40mg and fentanyl 25-50mcg at a time titrated to effect. If I have a BIS on it’s helpful but usually I’m just titrating to BP & HR. By having the gas off early, I don’t need high MV after the drapes come down in a desperate attempt to get as much gas off as possible. Instead I can slowly let the EtCO2 rise to >45. As soon as the drapes come down, hit them with the sugammadex, pressure support, and they’re comfortably extubatable with Vt >350 within minutes. In my N of ~1500 for the past two years, I’ve had really good success that everyone is happy with, including myself, room staff, surgeon, and most importantly the patient with absolutely zero recall.

 

[pgg]

I almost never "titrate narcotics to respiratory rate". Given that volatiles increase RR all by themselves I've seen others give waaay too much narcotic to achieve that normal RR of 12 or 15. Which becomes 6 when the gas is gone and they're stoned out of their gourds on blue stuff. If one is going to titrate that way, an ETCO2 in the 40s is probably a better target.

But anyway, I generally leave them paralyzed and on the vent as long as possible. Lighten the gas as much as possible toward the end. Reverse and extubate. People breathe when they're awake if you don't overnarcotize them. By the time you've done a bunch of cases you ought to be able to predict how much narcotic a given patient will need. And you can always give more when they're awake.

I just find RR under GETA with volatile is a bad parameter for titration. But obviously lots of people do it and make it work.

 

[secretasianman]

Don’t really use Remi much. I like fentanylz

 

[anaesthetic]

.

 

[dhb]

I'm surprised with all the red tape involved you guys are so willing to give narcotics.
I have to go to the safe to get them and sign a pink sheet at the end of the week and that's already too much for my taste.
Also RR is kind of a myth, sure 10-15 will work but i wake up people with 30+ often with no noticeable difference in PACU.

 

[deleted875186]

Usually around 0.05. I stopped using remi altogether though. I think smooth wakeups are over valued by surgeons who know nothing about what we do. But if you want a smooth wakeup, be generous with the opioids, time it well and don't reverse until all the volatile is off. I also do everything gradually. As the case ends, go down on the prop gtt and the volatile as the nitrous is slowly titrated up. Use sugammadex, not neo. Also I've been using simv instead of prvc or whatever.

I reverse when almost all the gas is off and let them wake up slowly. As soon as the tidal volume is acceptable, I extubate right before they stage 2. If I miss the timing I just let em buck. Buck it.

Extubating before stage 2 with volatiles sounds like a deep extubation, should be acheviable with any combo of meds.

 

[deleted875186]

Have zero bucking, zero bradycardia, zero valsalvas. Nothing but smooth extubations for the last several hundred patients. As in most things in our field I think the key is getting the timing right.

I also like to reverse late, only possible with sugga. Prevents bucking big time.

 

[deleted875186]

I almost never "titrate narcotics to respiratory rate". Given that volatiles increase RR all by themselves I've seen others give waaay too much narcotic to achieve that normal RR of 12 or 15. Which becomes 6 when the gas is gone and they're stoned out of their gourds on blue stuff. If one is going to titrate that way, an ETCO2 in the 40s is probably a better target.

But anyway, I generally leave them paralyzed and on the vent as long as possible. Lighten the gas as much as possible toward the end. Reverse and extubate. People breathe when they're awake if you don't overnarcotize them. By the time you've done a bunch of cases you ought to be able to predict how much narcotic a given patient will need. And you can always give more when they're awake.

I just find RR under GETA with volatile is a bad parameter for titration. But obviously lots of people do it and make it work.

100%, dose opioids primarily on anticipated pain based off the surgery, not off RR. I prefer long acting hydromorphone during the case, skip the short acting massive doses and most people will be breathing g pretty easily at the end.

 

[linkin06]

Is everyone really doing 4 and 2 mg/kg of suggamadex? Seems like a waste since its such a good drug

 

[coffeebythelake]

I'm with the above. I blow off a little bit of gas and wait until BIS is 90-100 and HR is 220-age and then give sugammadex for a smooth wakeup.

U forgot to pull the ett first before giving the sugammadex

 

[coffeebythelake]

Is everyone really doing 4 and 2 mg/kg of suggamadex? Seems like a waste since its such a good drug

Well that really depends on how deeply relaxed the patient is...

 

[coffeebythelake]

Another problem when not using super short acting rx.. surgeon wants a smooth wake up but also wants it to be done quickly. Can't have it both ways.

 

[vector2]

Another thing to consider when talking about “RR” is are we talking about using PSV during wakeup? As a “titrate narcotic to RR” guy I personally think PSV is absolute trash. The boost in Vt from PSV and the variation that comes from messing with the flow trigger will absolutely throw off the RR you’re titrating to. The “true” RR for me is what the pt does on the bag (with the popoff closed just a bit to provide about 5 of PEEP). I’ve never had a situation where I was titrating opioids to the RR on the bag but then once I pulled the tube and the gas blew off their rate was drastically different enough for me to worry about it.

 

[FiO2@21]

Another thing to consider when talking about “RR” is are we talking about using PSV during wakeup? As a “titrate narcotic to RR” guy I personally think PSV is absolute trash. The boost in Vt from PSV and the variation that comes from messing with the flow trigger will absolutely throw off the RR you’re titrating to. The “true” RR for me is what the pt does on the bag (with the popoff closed just a bit to provide about 5 of PEEP). I’ve never had a situation where I was titrating opioids to the RR on the bag but then once I pulled the tube and the gas blew off their rate was drastically different enough for me to worry about it.

I’ve played around with no support and just peep on PSV mode. Didn’t seem to vary the RR in a way that’s significant. Almost never decrease the flow trigger. I like to use it get the gas off a little faster.

 

[zizzer]

Is everyone really doing 4 and 2 mg/kg of suggamadex? Seems like a waste since its such a good drug

Are you suggesting using less than the recommended amount? If so, why? I know a lot of people seem to judge adequate reversal by whether you can successfully extubate but neglect the nonrespiratory effects of residual paralysis we don't see such as pharyngeal muscle weakness (most susecptible to NMBAs) and aspiration pneumonia.

 

[deleted875186]

Is everyone really doing 4 and 2 mg/kg of suggamadex? Seems like a waste since its such a good drug

I give the 2 mg/kg recommended dose, if I think the block is mostly off and there’s 4 TOF then I’ll given neostigmine.

why give less than 2 mg/kg? Are you splitting vials between patients? Otherwise I see no benefit.

 

[Urzuz]

Remifentanil is the quintessential “the patient looks good right now as I’m dropping them off in pacu, therefore I’ve done a good job” drug. Other drugs In this same family include naloxone, flumazenil, and my personal favorite, a hit of phenylephrine/ephedrine right before hooking them up to monitors.

Remi a good drug with a niche use that gets used way too much.

 

[GassYous]

One of the attendings at my program decreased the flow trigger. He was an idiot so I think it's a stupid thing to do.

Titrating to respiratory rate also doesn't make much sense. The other day I had a patient taking tvs of 100s at a rate of 30 with an occasional tv of 800 and after waiting for 15 minutes (4/4 twitches, all numbers look good) I just bit the bullet and extubated (fat but easy airway). As soon as I pulled the tube, she was breathing at 800s at a rate of 10 and did really well in pacu. If they need more, well that's what pacu is for.

For sugammadex I just give 200 cause that's what's in the vial.

 

[nimbus]

After propofol, remifentanil is my second favorite drug of all time. Followed by sugammadex. You can see a common trend, I enjoy the “titratability” of fast-on/fast-off drugs, which sevo does not provide. This does require a hands on approach and watchful eye.

My formula for the past ~1500 or so GA cases has brought me great success, fast and smooth extubations, and patient satisfaction. The key is to get the gas off early. Having sevo on board invariably leads to some degree to emergence delirium and PONV. I strive to have Et sevo at 0.0 prior to reversal. In those cases I may leave remi on at 0.03-0.05 if I have it going as others have mentioned, but more importantly give small boluses of propofol 20-40mg and fentanyl 25-50mcg at a time titrated to effect. If I have a BIS on it’s helpful but usually I’m just titrating to BP & HR. By having the gas off early, I don’t need high MV after the drapes come down in a desperate attempt to get as much gas off as possible. Instead I can slowly let the EtCO2 rise to >45. As soon as the drapes come down, hit them with the sugammadex, pressure support, and they’re comfortably extubatable with Vt >350 within minutes. In my N of ~1500 for the past two years, I’ve had really good success that everyone is happy with, including myself, room staff, surgeon, and most importantly the patient with absolutely zero recall.

Sevo gets blamed for a lot of stuff that it doesn’t cause when you don’t engage in polypharmacy. If you use sevo alone, with no benzos and opioids, you get less intraop hypotension and smooth fast wakeups with no delirium or PONV. I often get 90 year olds who are fully conversant enroute to PACU using this technique.

 

[abolt18]

One of the attendings at my program decreased the flow trigger. He was an idiot so I think it's a stupid thing to do.

Titrating to respiratory rate also doesn't make much sense. The other day I had a patient taking tvs of 100s at a rate of 30 with an occasional tv of 800 and after waiting for 15 minutes (4/4 twitches, all numbers look good) I just bit the bullet and extubated (fat but easy airway). As soon as I pulled the tube, she was breathing at 800s at a rate of 10 and did really well in pacu. If they need more, well that's what pacu is for.

For sugammadex I just give 200 cause that's what's in the vial.

I'll often decrease the flow trigger initially just untill they start pulling, then make small intermittent increases in the trigger.

 

[GassYous]

I'll often decrease the flow trigger initially just untill they start pulling, then make small intermittent increases in the trigger.

Why?

 

[abolt18]

Why?

They start breathing sooner.

 

[GassYous]

You can do the same thing by decreasing the mv and letting the etco2 go up.

 

[coffeebythelake]

If you use sevo alone, with no benzos and opioids, you get less intraop hypotension and smooth fast wakeups with no delirium or PONV.

Good luck using this strategy with a painful case

 

[vector2]

One of the attendings at my program decreased the flow trigger. He was an idiot so I think it's a stupid thing to do.

Titrating to respiratory rate also doesn't make much sense. The other day I had a patient taking tvs of 100s at a rate of 30 with an occasional tv of 800 and after waiting for 15 minutes (4/4 twitches, all numbers look good) I just bit the bullet and extubated (fat but easy airway). As soon as I pulled the tube, she was breathing at 800s at a rate of 10 and did really well in pacu. If they need more, well that's what pacu is for.

For sugammadex I just give 200 cause that's what's in the vial.

If she was taking 100cc volumes with a high rate interspersed with random 800cc breaths then it sounds like she was in between stages and I wouldn't be titrating opioid there either. People who are deep (1+ mac volatile on board) or people who are about to emerge (~0 volatile on board) usually have regular respiration patterns and volumes in my experience, which can be used (along with the rest of the clinical picture) to titrate opioid or adjuncts for a smooth wakeup.

 

[nimbus]

Good luck using this strategy with a painful case

Yeah it only works with nonpainful procedures or with a good block. I use it mostly in long EP lab cases.

 

[coffeebythelake]

Remifentanil is the quintessential “the patient looks good right now as I’m dropping them off in pacu, therefore I’ve done a good job” drug. Other drugs In this same family include naloxone, flumazenil, and my personal favorite, a hit of phenylephrine/ephedrine right before hooking them up to monitors.

Remi a good drug with a niche use that gets used way too much.

Agree. It is expensive and it should be used for niche indications (many of which involve neuromoniyoring and avoidance of rocuronium). I would not give patient remifentanil solely for the purpose of smooth wake up

 

[Volatile]

After propofol, remifentanil is my second favorite drug of all time. Followed by sugammadex. You can see a common trend, I enjoy the “titratability” of fast-on/fast-off drugs, which sevo does not provide. This does require a hands on approach and watchful eye.

My formula for the past ~1500 or so GA cases has brought me great success, fast and smooth extubations, and patient satisfaction. The key is to get the gas off early. Having sevo on board invariably leads to some degree to emergence delirium and PONV. I strive to have Et sevo at 0.0 prior to reversal. In those cases I may leave remi on at 0.03-0.05 if I have it going as others have mentioned, but more importantly give small boluses of propofol 20-40mg and fentanyl 25-50mcg at a time titrated to effect. If I have a BIS on it’s helpful but usually I’m just titrating to BP & HR. By having the gas off early, I don’t need high MV after the drapes come down in a desperate attempt to get as much gas off as possible. Instead I can slowly let the EtCO2 rise to >45. As soon as the drapes come down, hit them with the sugammadex, pressure support, and they’re comfortably extubatable with Vt >350 within minutes. In my N of ~1500 for the past two years, I’ve had really good success that everyone is happy with, including myself, room staff, surgeon, and most importantly the patient with absolutely zero recall.

Prop/ remi ggt’s w/ sugammadex for last ~1500 cases, you better hope your hospital never looks at the cost of your anesthetics

I rarely use remi nowadays, basically just for crani’s. It seems our surgeons care less and less about neuromonitoring so I don’t find myself needing it very often.

To the original question, it’s never going to be 100%. But the better “remi” wake ups I’ve done/seen are when the patient is waking up only on remi, no volatile/ propofol/ ketamine etc. if you time it correctly you really shouldn’t need all that. With that being said, I wake up plenty of patients with a little volatile left over and they can be just as smooth. Smokers are ****ed and I’ll usually let the surgeon know they’re going to cough at some point.

 

[Modoc]

I typically run Remi at 0.2-0.3mcg/kg/min after intubation. I maintain dose until surgeon begins closing, dose dialudid and stop the remi when dressing is being applied to surgical wounds.

 

[D P356]

@Noyac wrote earlier to give haldol IV prior to emergence. That works well if there is a pt with a significant psych history.

I give propfol or short acting opioid as well. For those with significant cardiac dz I’ll usually give esmolol.

Yes, The 2ppd, DM, CHF vasculopath getting the CEA is coughing. It’s a good thing they won’t cough at home....

 

[pgg]

@Noyac wrote earlier to give haldol IV prior to emergence. That works well if there is a pt with a significant psych history.

Definitely

When we had droperidol, I'd give some to every person with PTSD, and every young strong male who looked like he might be belligerent when he woke up. Now, I use haloperidol for the same thing, but admittedly less often because it's not stocked in the ORs. It's a great anti-emetic too, 0.5 mg prior to emergence or as rescue in the PACU.

 

[nimbus]

Definitely

When we had droperidol, I'd give some to every person with PTSD, and every young strong male who looked like he might be belligerent when he woke up. Now, I use haloperidol for the same thing, but admittedly less often because it's not stocked in the ORs. It's a great anti-emetic too, 0.5 mg prior to emergence or as rescue in the PACU.

+1 for drop. Wish we still had it.

Anyone use precedex to prevent emergence delirium and agitation in this population? I haven’t used it enough to form an impression.

 

[Ronin786]

I almost never "titrate narcotics to respiratory rate". Given that volatiles increase RR all by themselves I've seen others give waaay too much narcotic to achieve that normal RR of 12 or 15. Which becomes 6 when the gas is gone and they're stoned out of their gourds on blue stuff. If one is going to titrate that way, an ETCO2 in the 40s is probably a better target.

But anyway, I generally leave them paralyzed and on the vent as long as possible. Lighten the gas as much as possible toward the end. Reverse and extubate. People breathe when they're awake if you don't overnarcotize them. By the time you've done a bunch of cases you ought to be able to predict how much narcotic a given patient will need. And you can always give more when they're awake.

I just find RR under GETA with volatile is a bad parameter for titration. But obviously lots of people do it and make it work.

While I do think titrating religiously to RR is stupid, I disagree about the volatile vs RR thing.

While volatiles do increase your RR, they also increase your apneic threshold and sensitivity to narcotics. IMO the two outweigh if you pay attention.

 

[Mehd School]

I only use remi for spine cases and the occasional crani. I'm excited to not be in an academic setting much longer so I can stop interacting with neuromonitoring technicians that make an otherwise easy day challenging for no good reason besides a nervous surgeon.

 

[deleted162650]

I only use remi for spine cases

Stop it

I can stop interacting with neuromonitoring technicians

Not to burst your bubble, but we have them in PP too.

 

[GassYous]

Definitely

When we had droperidol, I'd give some to every person with PTSD, and every young strong male who looked like he might be belligerent when he woke up. Now, I use haloperidol for the same thing, but admittedly less often because it's not stocked in the ORs. It's a great anti-emetic too, 0.5 mg prior to emergence or as rescue in the PACU.

hmm I really wish we had some antipsychotics stocked. I can think of a few patients who would have benefitted greatly

Not to burst your bubble, but we have them in PP too.

Yeah but the difference is I do what I want and all they say is thank you when I run the ketamine

 

[Mehd School]

Stop it




Not to burst your bubble, but we have them in PP too.

I'm sure, but there are 15 private hospitals in my city and the neuromonitoring guys I talk to say that they only regularly work at 3 of them. I like those odds.

Would you like me to start using remi for TKA's and penile prosthetics?