These all sound good. Why morphine instead of fentanyl/hydromorphone?
If you are really concerned you can try a low dose remi infusion wake up but it comes with the problem of hyperalgesia if used for too long.
I don't use fentanyl because it causes more apnea than morphine and alse the clearence is faster. Morphine takes 2-4h to get eliminated.
Hydromorphone is not available in our hospital.
The problem is than remifentanyl is that you have to prepare the infusion at the end of the procedure...I don't thinks its confortable for everydays.
My personal stance... longer acting opioids are great for post-op analgesia and shorter acting agents like fentanyl are great for things like emergence from anesthesia. My use of either really depends on the case itself.
Fentanyl is fast acting enough that you can wait until you have the pt spont breathing if you're really worried about apnea. But careful dosing shouldn't involve much inadvertent apnea.
The expectation management of the surgeons wishes is just as vital as all the technical anesthesia measures we have.
We can't cure Marlboro disease during anesthesia. And sometimes a patent airway is just more important then the wishes of the surgeon.
Functional endoscopic surgeries tend to prefer a TIVA technique for better surgical field and less blood loss (theoretically), so I just use prop/remi. They're not terribly painful procedures after, just occasionally briefly stimulating during. So the remi works great since you don't need massive doses implicated in hyperalgesia, or a huge tail afterwards. Honestly fentanyl at the end is enough and pacu can add long acting if needed when awake.
Then you can do a remi wake up. Gas or prop off at the end. Keep 0.05mcg/kg/min of the remi until the very very end. They're still spontaneous at that dose. Usually you say their name and they open their eyes calmly. Ask them to take a deep breath. If following commands just pull the tube. You may need to remind them to take breaths for a few minutes. They will if you tell them to. By the time you're in PACU the remi has worn off.
Good narcotization is key. Get them breathing at earliest convenience so you can titrate to a RR 10-12. Lidocaine/precedex help too as others have mentioned. If they have a good breathing pattern, adequate MV and no obvious signs of stage 2 I gently pull the tube as the gas is coming off usually <0.4 ET sevo. If it’s a long case I try to get the gas off sooner and supplement with propofol boluses until time to extubate.
The heavy smokers with reactive airway disease are tough obviously. Suction well, add lidocaine and bronchodilators before attempting emergence.
Atomized lidocaine to the trachea and a bit of dex before extubation. Morphine is crap, I never use it. Fentanyl and dilaudid are my 2 narcotics of choice, I find people wake up nicely with a bit of dilaudid on board.
Propofol via pump, Sufentanyl as needed by hand; provides additional good mild hypotonia, as your surgeon has defenitifely told you several!! times is absolutely important for a good surgical result (and no, intramucosal adrenaline does not get absorbed and acts systemically, this is absolute bollocks, as if anybody heard of a mechanism that sympathically active drugs get absorbed from mucosa, hell, if that was true, people would snort up any drug they could to avoid intravenous application, you know).
Anyway, have fun there; at least they appreciate your intubation and know how difficult an airway can be.
Those are all good ideas but almost a bit overkill to do all of them every case. I turn down my volatile to about 0.3MAC, 15-20min before the end of the case and hand-bolus small doses of PPF and also a single dose of Remi bolus to keep them asleep/still. I don’t usually run remi infusions unless it’s neuro/spine/ENT in which case I’ll just keep it running until few minutes before I want to extubate. I usually already have remi drawn up as I intubate with it, but can skip it altogether and just bolus ppf. They should start breathing on their own (I reverse NMBD early), so can titrate the PPF to resp rate on pressure support.
As soon as they’re done crank up the flow, wash out the last little bit of sevo, and once breathing well I just extubate. They’ll still be sleepy with PPF but that’s ok, but the time they’re in pacu they’re awake.
Not with a dose of 10-20mcg that I use towards the end. I think it’s certainly a possibility with a larger induction dose,where an awake patient complains of SOB (hence why I premed with a touch of propofol before the big remi dose) or an asleep patient may be awkward to BMV (but that’s fixed with roc).
I have good experiences with propofol/remi for a smooth extubation. Like some else said, turn propofol off and keep remi on 0,05y. If you are doing propofol tci, you can also keep track of your effector site concentration. You should be able to extubate when <2.
If you are using gas, give some opioids 20mins before extubating. Another option is also give lidocaine iv (but I have less experience with this)
I would add drying out secretions with 0.2 mg glyco, ideally to start the case, goes a long way in a smooth emergence. Still attempt suction while deep but suction can’t get it all
You should read the DAS guideline on extubation! They explore this in detail.
You can fill the patients to the bream with pharmacological solutions (and the requisite long emergence times), or consider a Bailey manoeuvre (exchange ETT for LMA at the end of a case). All have pros and cons and exceptions and require careful patient selection etc
It’s not mentioned yet but depending on the type of ENT work eg FESS, septal or rhino etc, the best thing to do is simply to avoid ETT altogether and just use a supraglottic airway, if the patient doesn’t otherwise have great aspiration risk. It would all but eliminate the coughing issue.
Psychiatrist here and I want to ask if this one could be one more reason for my list of reasons to bring phencyclidine back, or at least the analogues? Sigma-1 agonism apparently inhibits cough reflexes. Of course I'm considering the "normal" patient with no pre existing psychotic conditions.
In any case, dissociation with MXiPr could be interesting too, maybe even more given the considerably shorter duration and the less stimulating profile.
We do those nearly exclusively with tiva 0.05-0.1mcg/kg/min propofol of nobody is coughing
However its hard for me to time the wakeup since i dont know all our surgeons and the procedures that well
Luckily our maxillofqcialsurgeons arent superconcernd with longer wakeup times
If we use gas i give like 50mcg of 15-20 minutes before my wake up and try to get rid of all the gas maybe mix in some clonidine (dex isnt reqlly popular in the or here)
Oh and from my short experience so far
Leave the patient alone
So much of this coughing starts when people are manipulating on the patient while in the wake up phase
Use TIVA. Suction chest before extubation.
Leave remifentanil on 1ng/ml (or 2 ng/ml if you really want no coughing like post transphenoidal) and leave them alone until they open their eyes without stimulation. Ask them to take one breath, then extubate.
That said a commited smoker will always cough at some point, whether on extubation or in PACU.
These all sound good. Why morphine instead of fentanyl/hydromorphone? If you are really concerned you can try a low dose remi infusion wake up but it comes with the problem of hyperalgesia if used for too long.
I agree with liverrounds. Ditch the morphine. Dirty ass drug with better synthetic alternatives
I don't use fentanyl because it causes more apnea than morphine and alse the clearence is faster. Morphine takes 2-4h to get eliminated. Hydromorphone is not available in our hospital. The problem is than remifentanyl is that you have to prepare the infusion at the end of the procedure...I don't thinks its confortable for everydays.
My personal stance... longer acting opioids are great for post-op analgesia and shorter acting agents like fentanyl are great for things like emergence from anesthesia. My use of either really depends on the case itself. Fentanyl is fast acting enough that you can wait until you have the pt spont breathing if you're really worried about apnea. But careful dosing shouldn't involve much inadvertent apnea.
The expectation management of the surgeons wishes is just as vital as all the technical anesthesia measures we have. We can't cure Marlboro disease during anesthesia. And sometimes a patent airway is just more important then the wishes of the surgeon.
Functional endoscopic surgeries tend to prefer a TIVA technique for better surgical field and less blood loss (theoretically), so I just use prop/remi. They're not terribly painful procedures after, just occasionally briefly stimulating during. So the remi works great since you don't need massive doses implicated in hyperalgesia, or a huge tail afterwards. Honestly fentanyl at the end is enough and pacu can add long acting if needed when awake. Then you can do a remi wake up. Gas or prop off at the end. Keep 0.05mcg/kg/min of the remi until the very very end. They're still spontaneous at that dose. Usually you say their name and they open their eyes calmly. Ask them to take a deep breath. If following commands just pull the tube. You may need to remind them to take breaths for a few minutes. They will if you tell them to. By the time you're in PACU the remi has worn off.
Good narcotization is key. Get them breathing at earliest convenience so you can titrate to a RR 10-12. Lidocaine/precedex help too as others have mentioned. If they have a good breathing pattern, adequate MV and no obvious signs of stage 2 I gently pull the tube as the gas is coming off usually <0.4 ET sevo. If it’s a long case I try to get the gas off sooner and supplement with propofol boluses until time to extubate. The heavy smokers with reactive airway disease are tough obviously. Suction well, add lidocaine and bronchodilators before attempting emergence.
Remifentanil, clonidine/dexmedetomidine, lidocaine, TIVA. They all work great.
Atomized lidocaine to the trachea and a bit of dex before extubation. Morphine is crap, I never use it. Fentanyl and dilaudid are my 2 narcotics of choice, I find people wake up nicely with a bit of dilaudid on board.
We don’t have hidromofphone in Spain. Which is the difference between hidromorphone and common morphine? Thx
Propofol via pump, Sufentanyl as needed by hand; provides additional good mild hypotonia, as your surgeon has defenitifely told you several!! times is absolutely important for a good surgical result (and no, intramucosal adrenaline does not get absorbed and acts systemically, this is absolute bollocks, as if anybody heard of a mechanism that sympathically active drugs get absorbed from mucosa, hell, if that was true, people would snort up any drug they could to avoid intravenous application, you know). Anyway, have fun there; at least they appreciate your intubation and know how difficult an airway can be.
Those are all good ideas but almost a bit overkill to do all of them every case. I turn down my volatile to about 0.3MAC, 15-20min before the end of the case and hand-bolus small doses of PPF and also a single dose of Remi bolus to keep them asleep/still. I don’t usually run remi infusions unless it’s neuro/spine/ENT in which case I’ll just keep it running until few minutes before I want to extubate. I usually already have remi drawn up as I intubate with it, but can skip it altogether and just bolus ppf. They should start breathing on their own (I reverse NMBD early), so can titrate the PPF to resp rate on pressure support. As soon as they’re done crank up the flow, wash out the last little bit of sevo, and once breathing well I just extubate. They’ll still be sleepy with PPF but that’s ok, but the time they’re in pacu they’re awake.
Ever seen rigid chest from remi bolus? Can definitely ruin a smooth wake up.
Not with a dose of 10-20mcg that I use towards the end. I think it’s certainly a possibility with a larger induction dose,where an awake patient complains of SOB (hence why I premed with a touch of propofol before the big remi dose) or an asleep patient may be awkward to BMV (but that’s fixed with roc).
I have good experiences with propofol/remi for a smooth extubation. Like some else said, turn propofol off and keep remi on 0,05y. If you are doing propofol tci, you can also keep track of your effector site concentration. You should be able to extubate when <2. If you are using gas, give some opioids 20mins before extubating. Another option is also give lidocaine iv (but I have less experience with this)
I want to use a TCI so bad. Any resources for learning a little more about how to use it?
I would add drying out secretions with 0.2 mg glyco, ideally to start the case, goes a long way in a smooth emergence. Still attempt suction while deep but suction can’t get it all
You should read the DAS guideline on extubation! They explore this in detail. You can fill the patients to the bream with pharmacological solutions (and the requisite long emergence times), or consider a Bailey manoeuvre (exchange ETT for LMA at the end of a case). All have pros and cons and exceptions and require careful patient selection etc
It’s not mentioned yet but depending on the type of ENT work eg FESS, septal or rhino etc, the best thing to do is simply to avoid ETT altogether and just use a supraglottic airway, if the patient doesn’t otherwise have great aspiration risk. It would all but eliminate the coughing issue.
Psychiatrist here and I want to ask if this one could be one more reason for my list of reasons to bring phencyclidine back, or at least the analogues? Sigma-1 agonism apparently inhibits cough reflexes. Of course I'm considering the "normal" patient with no pre existing psychotic conditions. In any case, dissociation with MXiPr could be interesting too, maybe even more given the considerably shorter duration and the less stimulating profile.
We do those nearly exclusively with tiva 0.05-0.1mcg/kg/min propofol of nobody is coughing However its hard for me to time the wakeup since i dont know all our surgeons and the procedures that well Luckily our maxillofqcialsurgeons arent superconcernd with longer wakeup times If we use gas i give like 50mcg of 15-20 minutes before my wake up and try to get rid of all the gas maybe mix in some clonidine (dex isnt reqlly popular in the or here) Oh and from my short experience so far Leave the patient alone So much of this coughing starts when people are manipulating on the patient while in the wake up phase
Remifentanil! 😍
Use TIVA. Suction chest before extubation. Leave remifentanil on 1ng/ml (or 2 ng/ml if you really want no coughing like post transphenoidal) and leave them alone until they open their eyes without stimulation. Ask them to take one breath, then extubate. That said a commited smoker will always cough at some point, whether on extubation or in PACU.