How to do extubation under general anesthesia quietly and without coughing?

General anesthesia is divided into induction, maintenance and resuscitation.
Each process is very important and is also the core technology of anesthesia; but it is necessary to ask which stage best reflects the level of the anesthesiologist, especially the experience of the patient or the experience of the surgeon, and the quality of resuscitation Absolutely the most intuitive; awakening is like "one minute on stage", it requires a solid "ten years off stage", perfect induction and stable maintenance will be exchanged for the final high-quality awakening.

How to achieve high-quality awakening? I think the most intuitive feeling for most people is to extubate the tube under general anesthesia quietly and without coughing; the patient wakes up from his sleep, opens his eyes slowly, breathes regularly and vigorously, cooperates freely, quietly without coughing, and then Easily remove the catheter and draw a successful conclusion to the anesthesia.
Even the patient can move the bed by himself.
This should be the professional pursuit of all anesthesiologists.

It has been reported in the literature that the incidence of coughing during general anesthesia is as high as 76%-96%, of which coughing reactions occur during extubation accounted for the vast majority.

The side effects of coughing reaction are self-evident.
Severe cardiovascular reactions and the embarrassing response of anesthesiologists are the most deadly; the following is a brief summary from the three aspects of the risk identification, prevention and response of coughing reaction to extubation: 01 / Recognition Ⅰ.
Studies have shown that the mu and κ receptors in the brainstem are responsible for regulating the cough reflex, and opioids can inhibit the cough reflex by combining with them; meanwhile, there is a higher availability of mu opioids in women Recipients, so compared with men, women are less likely to cough when using the same opioid.

Ⅱ.
It has been reported that the incidence and severity of cough depends on the residual concentration of the remaining sedatives at the time of extubation; and when the sevoflurane is less than 0.
6%, coughing will occur.
Studies have shown that under the same conditions, the propofol group The indications for extubation appear earlier and have a deeper residual anesthetic effect, resulting in less propofol coughing response.

Ⅲ.
Smoking can cause airway hyperresponsiveness and significantly increase the incidence of coughing.
Studies have shown that in patients undergoing cervical spine surgery under general anesthesia, the incidence of coughing is 50% in smokers and 17% in non-smokers. Therefore, men, ether inhalation, and smoking are high-risk factors for coughing during extubation.

02 / Prevention For the prevention of coughing during extubation, I have briefly summarized [Is there any good way to suppress extubation? 】, mainly the following methods: ⑴Opioid drugs suggest sufentanil (0.
1ug/kg), fentanyl (1ug/kg) 20-30min in advance; continue pumping remifentanil (0.
05) before extubation ug/kg.
min) or TCI maintained at 1.
0~1.
5ng/ml also has a similar effect.
However, it has been found that Refine has stronger respiratory depression in clinical practice, so you should be vigilant.

⑵The most commonly used method of lidocaine is intravenous injection of 1.
0~1.
5mg/kg, but studies have found that the effect is different; spraying 1mg/kg into the trachea 5 minutes before extubation has better effect and better permeability of alkalized lidocaine The filling effect in the cuff is better.

⑶Because dexmedetomidine may affect recovery, start pumping half an hour before the end of the operation, and the dosage is 0.
5ug/kg.

In addition, intravenous injection of tramadol 1 mg/kg 30 minutes before extubation can reduce the occurrence of coughing, and esmolol 1.
5 mg/kg 2-5 minutes before extubation can greatly inhibit the cardiovascular response caused by coughing.
But there is no preventive effect.

03 / Although there are many ways to prevent it, there are still fish that slip through the net from time to time.
When coughing occurs, it must not be extubated at the first time to reduce unnecessary stimulation.
Most coughing reactions can be slow and calm.
Then evaluate consciousness and muscle relaxation residuals.
, Decide the timing of extubation; if there is a strong coughing reaction accompanied by obvious fluctuations in hemodynamics, sedation should be the first time.
It is recommended that the fastest acting propofol 20-50mg is preferred, but the spontaneous respiration should be closely observed.
, And then choose the opportunity to evaluate the extubation.

"Miller's Anesthesiology" suggests that the routine preparations for extubation include: ensuring that neuromuscular blockade is completely reversed or restored, hemodynamic stability, normal body temperature, and adequate analgesia.

In the absence of muscle relaxation monitoring, the cough response greatly interferes with the anesthesiologist’s assessment of residual muscle relaxation; try to avoid high-risk factors, take preventive measures, and reserve a way to suppress the cough response in order to be foolproof .

To sum up, whether it is for patients to wake up quietly or to prevent coughing response, adequate analgesia is the most important, especially for long-term and major trauma operations.
It is recommended that sufentanil and fentai be the first choice.
Ni, second choice dexamethasone, lidocaine; a little experience, welcome to discuss.

Reference: Wu Qiqi, Yue Ziyong.
Research progress on coughing and coughing during extubation under general anesthesia[J].
Medical Review, 2018(1):150-154.
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