What is emergence? The time from discontinuation of an anesthetic to when the patient can make a non-reflex response to verbal command
Maneuvers to improve the elimination of inhaled anesthetics:
- Increase FiO2
- Increase gas flow rate
- Increase PEEP to prevent atelectasis
Factors that affect emergence:
- Patient factors (e.g. obesity, advanced age, hepatic or renal insufficiency)
- Drug factors (e.g. dosage, time of administration, metabolism, excretion)
- Surgical factors (e.g. length/type of surgery)
Reversal of neuromuscular blockade:
- Acetylcholinesterase inhibitor (e.g. neostigmine): increases amount of acetylcholine at the neuromuscular junction to reverse paralysis; also increases acetylcholine in the parasympathetic nervous system
- Muscarinic receptor antagonist (e.g. glycopyrrolate): inhibits the parasympathetic effects of neostigmine
Postoperative considerations:
- Antiemetics: ondansetron, dexamethasone, aprepitant
- Postoperative pain medications: long-acting narcotics, NSAIDs (e.g. ketorolac), acetaminophen
Extubation criteria:
- Hemodynamically stable
- Respiratory rate between 8-35
- Adequate oxygenation (PaO2 at least 60 mmHg with FiO2 <50%, or PaCO2 < 50 mmHg)
- Tidal volume > 5 ml/kg
- Negative inspiratory force of at least 25 mmHg, and vital capacity of 15 mL/kg
- Can also look for purposeful movements such as opening eyes or following commands
Respiratory complications are about 3 times more likely to occur during extubation than intubation
Steps to extubation:
- Deflate the cuff
- Gently remove tube
- Have suction ready, clear secretions prior to extubation and afterwards
- Have oxygenation equipment ready
- Remove monitors from the patient when appropriate (typically remove the oxygen saturation probe last)
Extubation complications:
- Airway obstruction
- Early postoperative hypoxemia
- Heightened cardiovascular response
- Aspiration
- Emergence delirium
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