Fastest Way To Wake Up A Patient

One thing that anesthesiology residency doesn't teach you is how to quickly and efficiently wake up a patient from general anesthesia. Sure, we all get grilled on the SAFEST method for emergence and extubation. However, in the real world, safe emergence is a given. Therefore to a surgeon what differentiates one anesthesiologist from another is how quickly the patient is transferred to recovery after a case is over. If the patient is still asleep after the surgeon has written the postop orders and finished talking to the patient's family, then you, my friend, are a slow anesthesiologist.

I've noticed this lack of exactitude results in two different philosophies (and possibly three which I will get to later) on how best to quickly wake up a patient. When I come in to the OR in the morning, I do my anesthesia machine check and I can easily see what the anesthesiologist who last used it was thinking about how to awaken the patient.  The machine usually has the last ventilatory setting of the previous patient still in place. From this, I can deduce two methods that are generally followed by anesthesiologists at the end of a case.

One is the slow and go idea for emergence. The vent settings on the machine will show a respiratory rate of about five with tidal volumes below five hundred. I presume the anesthesiologist is attempting to revive the patient's spontaneous respiration by allowing the patient's pCO2 levels to rise quickly. Once the patient is breathing on his own then the endotracheal tube can be removed.

The other method is the fast and furious approach. The vent setting will have the respiratory rate set in the high teens with large tidal volumes. The anesthesiologist was apparently trying to wake up the patient by swiftly blowing off the inhalational agents accumulated in the blood stream and lungs.  Once the patient is conscious, then the ETT can be safely taken out.

I don't think there has been a study on which process for emergence is better. There are just too many variables and either one works satisfactorily.  During residency I had attendings who advocated one or the other technique and the patients did just fine either way. Again the goal of residency training is safety first. But now in the real job market there is no real consensus on the best and fastest plan for emergence. So some unfortunate anesthesiologists get labeled as "slow."

So finally let me tell you about one colleague's practice for achieving fast emergence. I don't advocate his methods but it sure gets the job done. During surgery he gives absolutely no narcotics. He doesn't believe in preemptive analgesia. He thinks any narcotics given during the case will slow down emergence, which is true. His patients wake up in blinding pain from surgery whereupon he gives liberal doses of pain meds. Unfortunately the narcs rarely work rapidly enough before the patient is transferred to recovery. You can imagine the anesthesiologist is not one of the recovery room nurses' favorites when they are confronted with a miserable postop patient. But he gets the room turned over quickly and is thus well liked by the surgeons. Try it if you dare.