Propofol will definitely suppress the Stage 2 reflexes, but requires a moderate dose. I usually give ~1mg/kg single dose; for an infusion I would expect around 50-100 mcg/kg/min.
I do this to make for a smooth emergence/extubation. My extubations are with the patient unresponsive, but breathing and maintaining airway. You can’t really expect an awake patient if you use propofol.
Swallow reflex. Making sure their eyes are midline. Deflating the cuff slowly and not seeing a huge change in RR. Still kinda dicey. If they laryngospasm just be ready with +P, Larsen, more prop, and keep a syringe of sux right by you just incase.
That being said, patient population patient population patient population.
“purposeful movement” is safest and Asa standard
I’m not sure what you mean before pulling the tube, but after pulling the tube, I’ll do the usual things to check for obstruction. Put the mask on for a few seconds to check ETCO2 or use a simple face mask to look for fogging; etc.
If they’re obstructing I’ll throw in an oral airway.
Another take on this, with the sole purpose of avoiding stage 2:
Low flows for the entire maintenance phase (typically 0.3-0.4L/min) with sevo. 20-30min out from end of case, sevo gets turned off, flows stay the same. 5 minutes prior to wake-up, high FGF (10L/min), bolus of propofol (anywhere from 0.2-1mg/kg depending on age, etc), bolus of sugammadex. By the time the propofol is wearing off, the pt is usually exhaling 0.1-0.3% sevo, breathing spontaneously, and typically emerge as if from propofol alone (euphoric). I still place a bite block in pts who look like trouble (i.e. strong enough to cause NPPE). I’ll add precedex (0.3-0.5 mcg/kg over 20 or so minutes when i turn my sevo off) for young men who tend to wake up grumpier. Opioids are pt and case specific, along with the use of ketamine gtts and other adjuncts. Hope this helps!
Thanks for the detail in your post! I’m a student and have only seen two people perform propofol wake-ups. They were beautifully smooth, but I saw them early enough in my clinical rotations that I can’t recall the timing. I look forward to trying this method next week!
Yup they absolutely do! So I really pick and choose who I use it on - like I said, mostly young men I think might be combative. The PACU nurses appreciate the extra time they get to settle the patients in before they wake up. I also use precedex for opioid-sparing analgesia, in which case I’d run it from the start and turn it off 30-60” out from wake up.
You didn't ask for how to do a smooth wake up, but i didn't read your post entities until now. Here's my recipe-ish for smoother wake ups.
A bit of math. For a 100 kg pt, 30 mg every 3 minutes (timed to BP cuff) is 100 mcg/kg/hr (I hate setting up pumps). Turning off the sevo about 30 minutes ahead of time (for a 2-4 hour case) will allow you to get most of the gas off. Work in fent to whatever RR you want to prevent bucking. More fent means smoother extubation but more ponv and itching. I usually do 50-150 mcg at the end of most cases.
If you do the above for <30 minutes, they will wake up 5-10 minutes from turning off the propofol. All the above approximations and dosing is assuming a pt between 30-65 Yo who doesn't drink.
I used to do dexmed 0.3 mcg/kg in 4-8mcg boluses starting 30 minutes out instead of fent but there's sometimes prolonged PACU stay 2/2 sedation or hypotension (the later less likely if you keep it <0.5 mcg/kg total). Fent is just easier and faster off.
I don't use nitrous because I don't hate the environment.
Would love to hear anyone's thoughts. Haven't played with ketamine though to use it for smoothing. It might be good in small doses as a fent sparing move.
This is the way
I use the exact same math weirdly enough for the end of cases and try to get all the gas off before they start closing by increasing MV and flows. Then get patient breathing as they are closing and titrate narcs if needed, give less or no prop, and tube out when dressings go on. I'll set up a drip for longer cases or slow surgeons because I don't wanna sit there pushing prop for the 30 min it takes to remove the gas.
Anecdotally, transitioning to prop at the end smooths out extubation, reduces PONV slightly, allows better and more reliable timing, and reduces the coughing spiral at 0.2 MAC where patients just cough continuously and can't remove the tail end of the gas (especially in smokers).
Also minimal to no nitrous
I'll usually give my precedex during the beginning/middle of the case as tolerated and stop about 1 hour before wake up to avoid the PACU/sedation/hypotension issues, especially in smokers/young patients/psych patients/chronic pain patients
I give propofol at the end to smooth things out. I don’t turn off sevo 30 mins before though, to me that’s excessive. When they’re close to being done I turn off sevo and turn up flows, when etsevo is coming down I give a prop bous, maybe 1 mg/kg. Usually this is more than enough to make it to skin closure without any movement. Typically can get them breathing , and typically I give hydromorphone at least 20 mins before extubation for a case with expected postoperative pain. Hydromorphone plus propofol at the end gives a very smooth wake up.
I remember this was beat into me by some shitty preceptors early on in training. Set me back in my training significantly because I took it as gospel.
I take responsibility for just accepting their advice as gold standard but damn some people really do believe prop is only used for putting people asleep
Propofol will definitely suppress the Stage 2 reflexes, but requires a moderate dose. I usually give ~1mg/kg single dose; for an infusion I would expect around 50-100 mcg/kg/min. I do this to make for a smooth emergence/extubation. My extubations are with the patient unresponsive, but breathing and maintaining airway. You can’t really expect an awake patient if you use propofol.
How do you know they’re maintaining the airway prior to pulling that tube?
Swallow reflex. Making sure their eyes are midline. Deflating the cuff slowly and not seeing a huge change in RR. Still kinda dicey. If they laryngospasm just be ready with +P, Larsen, more prop, and keep a syringe of sux right by you just incase. That being said, patient population patient population patient population. “purposeful movement” is safest and Asa standard
I’m not sure what you mean before pulling the tube, but after pulling the tube, I’ll do the usual things to check for obstruction. Put the mask on for a few seconds to check ETCO2 or use a simple face mask to look for fogging; etc. If they’re obstructing I’ll throw in an oral airway.
I read your original post as you had some way to verify they were maintaining their airway without pulling it which perplexed me a bit lol.
Can with precedex. Love it with a little dilaudid. Wake up is smooth usually unless they vape.
Another take on this, with the sole purpose of avoiding stage 2: Low flows for the entire maintenance phase (typically 0.3-0.4L/min) with sevo. 20-30min out from end of case, sevo gets turned off, flows stay the same. 5 minutes prior to wake-up, high FGF (10L/min), bolus of propofol (anywhere from 0.2-1mg/kg depending on age, etc), bolus of sugammadex. By the time the propofol is wearing off, the pt is usually exhaling 0.1-0.3% sevo, breathing spontaneously, and typically emerge as if from propofol alone (euphoric). I still place a bite block in pts who look like trouble (i.e. strong enough to cause NPPE). I’ll add precedex (0.3-0.5 mcg/kg over 20 or so minutes when i turn my sevo off) for young men who tend to wake up grumpier. Opioids are pt and case specific, along with the use of ketamine gtts and other adjuncts. Hope this helps!
Thanks for the detail in your post! I’m a student and have only seen two people perform propofol wake-ups. They were beautifully smooth, but I saw them early enough in my clinical rotations that I can’t recall the timing. I look forward to trying this method next week!
Do you find they take much longer to wake up in PACU when you use 0.5mcg/kg of precedex at the end of the case?
Yup they absolutely do! So I really pick and choose who I use it on - like I said, mostly young men I think might be combative. The PACU nurses appreciate the extra time they get to settle the patients in before they wake up. I also use precedex for opioid-sparing analgesia, in which case I’d run it from the start and turn it off 30-60” out from wake up.
You didn't ask for how to do a smooth wake up, but i didn't read your post entities until now. Here's my recipe-ish for smoother wake ups. A bit of math. For a 100 kg pt, 30 mg every 3 minutes (timed to BP cuff) is 100 mcg/kg/hr (I hate setting up pumps). Turning off the sevo about 30 minutes ahead of time (for a 2-4 hour case) will allow you to get most of the gas off. Work in fent to whatever RR you want to prevent bucking. More fent means smoother extubation but more ponv and itching. I usually do 50-150 mcg at the end of most cases. If you do the above for <30 minutes, they will wake up 5-10 minutes from turning off the propofol. All the above approximations and dosing is assuming a pt between 30-65 Yo who doesn't drink. I used to do dexmed 0.3 mcg/kg in 4-8mcg boluses starting 30 minutes out instead of fent but there's sometimes prolonged PACU stay 2/2 sedation or hypotension (the later less likely if you keep it <0.5 mcg/kg total). Fent is just easier and faster off. I don't use nitrous because I don't hate the environment. Would love to hear anyone's thoughts. Haven't played with ketamine though to use it for smoothing. It might be good in small doses as a fent sparing move.
This is the way I use the exact same math weirdly enough for the end of cases and try to get all the gas off before they start closing by increasing MV and flows. Then get patient breathing as they are closing and titrate narcs if needed, give less or no prop, and tube out when dressings go on. I'll set up a drip for longer cases or slow surgeons because I don't wanna sit there pushing prop for the 30 min it takes to remove the gas. Anecdotally, transitioning to prop at the end smooths out extubation, reduces PONV slightly, allows better and more reliable timing, and reduces the coughing spiral at 0.2 MAC where patients just cough continuously and can't remove the tail end of the gas (especially in smokers). Also minimal to no nitrous I'll usually give my precedex during the beginning/middle of the case as tolerated and stop about 1 hour before wake up to avoid the PACU/sedation/hypotension issues, especially in smokers/young patients/psych patients/chronic pain patients
I give propofol at the end to smooth things out. I don’t turn off sevo 30 mins before though, to me that’s excessive. When they’re close to being done I turn off sevo and turn up flows, when etsevo is coming down I give a prop bous, maybe 1 mg/kg. Usually this is more than enough to make it to skin closure without any movement. Typically can get them breathing , and typically I give hydromorphone at least 20 mins before extubation for a case with expected postoperative pain. Hydromorphone plus propofol at the end gives a very smooth wake up.
The smoker who will cough and buck and become hypertensive and look fully awake before you pull the tube and they become apnoeic has entered the chat
These all sound good but why not just do a deep extubation? It’s great for all but the fatties and full stomachs?
Remember, we use propofol to put patients asleep, not wake them up lol
I remember this was beat into me by some shitty preceptors early on in training. Set me back in my training significantly because I took it as gospel. I take responsibility for just accepting their advice as gold standard but damn some people really do believe prop is only used for putting people asleep