S2E7 - Emergence

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 FiO2Increase gas flow rateIncrease PEEP to prevent atelectasisFactors 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, aprepitantPostoperative pain medications: long-acting narcotics, NSAIDs (e.g. ketorolac), acetaminophen Extubation criteria:Hemodynamically stableRespiratory rate between 8-35Adequate oxygenation (PaO2 at least 60 mmHg with FiO2 <50%, or PaCO2 < 50 mmHg)Tidal volume > 5 ml/kgNegative inspiratory force of at least 25 mmHg, and vital capacity of 15 mL/kgCan also look for purposeful movements such as opening eyes or following commandsRespiratory complications are about 3 times more likely to occur during extubation than intubation Steps to extubation:Deflate the cuffGently remove tubeHave suction ready, clear secretions prior to extubation and afterwardsHave oxygenation equipment readyRemove monitors from the patient when appropriate (typically remove the oxygen saturation probe last) Extubation complications:Airway obstructionEarly postoperative hypoxemiaHeightened cardiovascular responseAspirationEmergence deliriumSupport the show

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