The Beginning and End of Things

I've blogged much on the start of anesthesia, but very little on the end of cases. Ending an anesthetic gracefully is really an art. The perfect anesthetic awakes the patient the moment the last surgical dressing is on in a smooth manner without any pain or coughing. That rarely happens. Occasionally we are too optimistic and the patient lightens before the surgeons are completely finished. Other times, we are too conservative and the surgeons wait while we get all the anesthetic gas off. Nobody is happy if the patient wakes up in severe discomfort or agitated or hypertensive. The art of the perfect wake-up is a combination of knowing the surgeons, titrating the anesthetic off carefully, and balancing oversedation from pain medications with the anticipated painfulness of the surgery.

Today, I had a case which did not end well. The patient was too weak upon extubation and although he could initiate breaths, his tidal volumes were simply too low. Prior to removing the breathing tube, he looked like he would fly; he was following commands with stable vitals; he was warm, reversed, and comfortable. Nevertheless, after taking the tube out, he wasn't looking fantastic so we reintubated him to give him extra time. Although it is a step backwards, we have to do what is safest for the patient.