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Two patients arrive simultaneously in the recovery room following general endotracheal anesthetics. One patient is unresponsive and requires an oral airway to maintain adequate respiration. In the next bed, the second patient is awake, comfortable and conversant. How can this be? It occurs because different anesthetists practice differently. Some can wake up patients promptly, and some cannot.
Does it matter if a patient wakes up promptly after general anesthesia? It does. An awake, alert patient will have minimal airway or breathing problems. When it’s time to walk away from your patient in the recovery room, you’ll worry less if your patient is already talking to you and has minimal residual effects of general anesthesia. Whether the surgery was a radical neck dissection, a carotid endarterectomy, a laparotomy, or a facelift, it’s preferable to have your patient as awake as possible in the recovery room.
What can you do to assure your patients wake up promptly? A Pubmed search will give you little guidance. There’s a paucity of data or evidence in the medical literature on how to wake patients faster. You’ll find data on ultra-short acting drugs such as propofol and remifentanil. This data helps, but the skill of waking up a patient on demand is more an art than a science. Textbooks give you little advice. Anesthesiologist’s Manual of Surgical Procedures, (4th Edition, 2009), edited by Jaffe and Samuels, has an Appendix that lists Standard Adult Anesthetic Protocols, but there is little specific information on how to titrate the drugs to ensure a timely wakeup.
Based on 29 years of administering over 20,000 anesthetics, this is my advice on how to wake patients promptly from general anesthesia:
- Propofol. Use propofol for induction of anesthesia. You may or may not choose to infuse propofol during maintenance anesthesia (e.g. at a rate of 50 mcg/kg/min) but if you do, I recommend turning off the infusion at least 10 minutes before planned wakeup. This allows adequate time for the drug to redistribute and for serum propofol levels to decrease enough to avoid residual sleepiness.
- Sevoflurane. Sevoflurane is relatively insoluble and its effects wear off quickly when the drug is ventilated out of the lungs at the conclusion of surgery. I recommend a maintenance concentration of 1.5% inspired sevoflurane in most patients. I drop this concentration to 1% while the surgeon is applying the dressings. When the dressings are finished, I turn off the sevoflurane and continue ventilation to pump the sevoflurane out of the patient’s lungs and bloodstream. The expired concentration will usually drop to 0.2% within 5-10 minutes, a level at which most patients will open their eyes.
- Nitrous oxide. Unless there is a contraindication (e.g. laparoscopy or thoractomy) I recommend you use 50% nitrous oxide. It’s relatively insoluble, and adding nitrous oxide will permit you to utilize less sevoflurane. I recommend turning off nitrous oxide when the surgeon is applying the dressings at the end of the case, and turning the oxygen flow rate up to 10 liters/minute while maintaining ventilation to wash out the remaining nitrous oxide.
- Narcotics. Use narcotics sparingly and wisely. I see overzealous use of narcotics as a problem. Prior to inserting an endotracheal tube, it’s reasonable to administer 50 – 100 mcg of fentanyl to a healthy adult or 0 -50 mcg of fentanyl to a geriatric patient. A small dose serves to blunt the hemodynamic responses of tachycardia or hypertension associated with larynogoscopy and intubation. Bolusing 250 mcg of fentanyl prior to intubation is an unnecessary overdose. The use of ongoing doses of narcotics during an anesthetic depends on the amount of surgical stimulation and the anticipated amount of post-operative pain. You may administer intermittent increments of narcotic (I may give a 50-100 mcg dose of fentanyl every hour) but I recommend your final narcotic bolus be given no less than 30 minutes prior to the anticipated wakeup. Undesired high levels of narcotic at the conclusion of surgery contribute to oversedation and slow awakening. If your patient complains of pain at wakeup, further narcotic is titrated intravenously to control the pain. Your patient’s verbal responses are your best monitor regarding how much narcotic is needed. Your goal at wakeup should be to have adequate narcotic levels and effect, but no more narcotic than needed.
- Intra-tracheal lidocaine. I recommend spraying 4 ml of 4% lidocaine into the larynx and trachea at laryngoscopy prior to inserting the endotracheal tube. I can’t cite you any data, but it’s my impression that patients demonstrate less bucking on endotracheal tubes at awakening when lidocaine was sprayed into their tracheas. Less bucking enables you to decrease anesthetic levels further while the endotracheal tube is still in situ.
- Local anesthetics. Local anesthetics are your friends at the conclusion of surgery. If the surgeon is able to blunt post-operative pain with local anesthesia or if you are able to blunt post-operative pain with a neuroaxial block or a regional block, your patient will require zero or minimal intravenous narcotics, and your patient will wake up more quickly.
- Muscle relaxants. Use muscle relaxants sparingly. Nothing will slow a wakeup more than a patient in whom you cannot reverse the paralysis with a standard dose of neostigmine. This necessitates a delay in extubation until muscle strength returns. Muscle relaxation is necessary when you choose to insert an endotracheal tube at the beginning of an anesthetic, but many cases do not require paralysis for the duration of the surgery. When you must administer muscle relaxation throughout surgery, use a nerve stimulator and be careful not to abolish all twitch responses. Avoid long-acting paralyzing drugs such as pancuronium, as you will have difficulty reversing the paralysis if surgery concludes soon after you’ve administered a dose. Use rocuronium instead. Avoid administering a dose of rocuronium if you believe the surgery will conclude within the next 30 minutes—it may be difficult to reverse the paralysis, and this will delay wakeup.
- Laryngeal Mask Airway (LMA). When possible, substitute an LMA for an endotracheal tube. Wakeups will be smoother, muscle relaxants are unnecessary, and narcotic doses can be titrated with the aim of keeping the patient’s spontaneous respiratory rate between 15- 20 breaths per minute.
- Temperature monitoring and forced air warming. Cold is an anesthetic. Strive to keep your patient normothermic by using forced air warming. If your patient’s core temperature is low, wakeup will be delayed.
10. Consider remaining in the operating room after surgery until your patient is awake enough to respond to verbal commands. This is my practice, and I recommend it for safety reasons. In the operating room you have all your airway equipment, drugs, and suction at your fingertips. If an unexpected emergence event occurs, you’re prepared. If an unexpected emergence event occurs in an obtunded patient in the recovery room, your resuscitation equipment will not be as readily available. If your patient is responsive to verbal commands in the operating room, your patient will be wakeful on arrival in the recovery room.
Is this protocol a recipe? Yes, it is. You’ll have your own recipe, and your ingredients may vary from mine. You may choose to administer desflurane instead of sevoflurane. You may choose sufentanil, morphine, or meperidine instead of fentanyl. My advice still applies. Use as little narcotic as is necessary, and try not to administer intravenous narcotic during the last 30 minutes of surgery. If you use a remifentanil infusion, taper the infusion off early enough so the patient is wakeful at the conclusion of surgery.
The principles I’ve recommended here are time-tested and practical. Follow these guidelines and you’ll experience two heartwarming scenarios from time to time: 1) Patients in the recovery room will ask you, “You mean the surgery is done already? I can’t believe it,” and 2) Recovery room nurses will ask you, “Did this patient really have a general anesthetic? She’s so awake!”
Your chest will swell with pride, and you’ll feel like an artist. Good luck.
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Published in September 2017: The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.
KIRKUS REVIEW
In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.
Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.
Nuanced characterization and crafty details help this debut soar.
Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:
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Just stumbled upon your blog. Very informative. Like you said, you won’t learn this in a text book. For me, running over a MAC of propofol for a 7 hour facelift I literally have to turn the propofol 1 hour before the end of the case for the patient to wake up on the dime.
How do you prevent patients from moving or being stimulated at only 1.5% sevoflurane? Are you using nitrous with it? I’ve had cases where I’ve been at 2.5% end tidal and the patient still reacts during stimulation, and during periods of non-stimulation I have to turn it down. I am a 2nd year resident trying to learn.
Yes, I routinely use 50% nitrous oxide as well as 1.5% sevoflurane.
Some surgeries have minimal pain because of local anesthetic infiltration by the surgeon, or because of a regional anesthetic. These patients will need minimal or no IV narcotics.
Most other surgeries require incremental IV narcotic for analgesia. For an intra-abdominal case, I may utilize 100 mcq of fentanyl IV every hour for analgesia. The combination of 50% nitrous oxide and 1.5% sevoflurane gives you approximately 1.2 MAC equivalents (depending on the patient’s age), and supplementing with local anesthetic or IV narcotic is usually sufficient to keep patients from being too light or moving.
Every case is a titration, and you may wind up giving less or more depending on the patient and the surgery.
You should not have to routinely paralyze patients who do not need muscle relaxation, just to guarantee they do not move during surgery.
“You should not have to routinely paralyze patients who do not need muscle relaxation, just to guarantee they do not move during surgery.”
As aforementioned, since (if) we don’t use NMBA, how abut your ventilator setting strategy to encounter the spontaneous respiration that will always come up during maintenance of anesthesia? From what I’ve learnt, it always ruin my ventilator setting. Thank you in advance
Always good to learn a new technique for waking up patients. Thanks!
My mother was in the “wake-up” room after carpal tunnel out-patient surgery. She vividly reports a male nurse pinching her neck/shoulder muscle so hard. As she grimaced in such pain, he said he would stop if she would communicate to the nurses. Is this actually a wake-up technique?
No.
If a patient is very sleepy after a general anesthetic, the Post Anesthesia Recovery Unit nurse may make efforts to arouse the patient to take deep breaths, if that is deemed necessary to keep the patient’s oxygen saturation at a safe level. These efforts may include verbal requests, gentle traction on the jaw to pull the airway open, or mild rubs on the sternum. No one is taught to pinch a neck or a shoulder muscle hard.
Anesthesia was practiced much differently in 1973.
Today Darvon is not on the market, and it’s unlikely anyone would inject you with Demerol while waiting in the hallway. The modern anesthetics wear off much more quickly than the anesthetics (Pentothal and halothane) that were used 45 years ago. If you have an anesthetic in the future you can share your past story with the anesthesiologist, but be reassured that your experiences of 45 years ago are unlikely to be repeated with modern techniques.
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For as long as I can recall my body seems to take huge amounts of these meds to sedate me. My last endoscopy I had the Dr. record the amounts and time. The procedure took 21 minutes from initial administration of 6mg of Versed, 100mcg Fentanyl and 750 Propofol. I am 50 years old and weigh 250. I also wake extremely fast without any side effects. Others have tried less and I had injured one Dr. by hitting him because I woke confused in the middle of a procedure. Can you give me any reason why it takes so much to keep me down?
Randy,
First off, you are a big man. You weigh twice as much as some adult female patients. IV drug doses are given based on the weight and age of a patient. It is not unusual for you to require 2X doses of IV drugs when compared to a 125 pound patient for that reason. In addition, patients vary in their sensitivity or tolerance to IV anesthetic drugs. Patients who are accustomed to regular alcohol or cannabis use require higher doses.
Per your history, you are tolerant and require higher doses. Tell your anesthesiologist prior to your procedures, and they will take this into account so that you receive adequate doses. Whenever a patient tells me they require “higher doses to keep me down,” they are always correct.
Hi..Glad to found your precious experiences of world of anesthesiology here!
I am the anesthesiology resident, 2nd year. During maintenance of anesthesia on patients with endotracheal tube using NMDA before surgery end, what is the best method to allow spontaneous breathing to come without allowing them to move from surgical stimulus, i.e wound suturing? For most of the time, I was unable to use any neuromuscular blocking monitor device due to its availability.
There are multiple ways to handle this issue.
One common method is to decrease the ventilator rate or turn the ventilator off, so that the CO2 will climb enough for the patient to begin spontaneous breathing while still anesthetized.
Another preference is to keep the patient under light general anesthesia on the ventilator, while the surgeons close. Turn off inhaled anesthesia just as the final sutures are going in, and leave the patient on the ventilator to “pump” the inhaled anesthetic out of the patient’s body. In 5 – 10 minutes the patient should awaken. This method is most effective if no narcotics are given in the final 45 minutes of the anesthetic.
I recently observed an anesthesiologist push a taped ETT in and out of the airway to “stimulate” the baby to breathe and or cough post op in an effort to see if she would wake. Is this standard practice or to be avoided? I tend to agree with the latter.
This is not a standard of care practice.