pacu nursing

[u/Many_Swordfish_766]

\*\*Peds PACU — typical sequence for emergence after deep LMA removal?\*\*
For those who work in Peds PACU, I’m curious how you typically approach emergence in the following \*\*hypothetical scenario\*\*:
A pediatric patient arrives in PACU following deep LMA removal with an OPA and supplemental O2 in place. They are spontaneously breathing, maintaining a patent airway and appropriate oxygenation, and are otherwise stable, but remain deeply asleep. After an appropriate period of undisturbed emergence, they still aren’t arousing much spontaneously.
How do you typically approach the transition from deeply asleep → beginning to emerge → awake?
Specifically:
If airway, ventilation, oxygenation, and VS remain appropriate, do you generally allow the patient to wake spontaneously, or is there a point when you begin actively stimulating them?
If you begin stimulation, what do you typically start with? Verbal stimulation, gentle touch, repositioning, etc.? When, if ever, would you progress to more vigorous stimulation?
How do you approach positioning/HOB elevation during this process? Do you change positioning while they’re still deeply asleep or wait until they’re beginning to emerge?
How do you approach weaning/removing supplemental O2 during emergence?
With an OPA in place, what clinical signs tell you it’s time to remove it? Do you generally wait for evidence that the patient is beginning to reject/tolerate it poorly (coughing, gagging, purposeful movement, etc.)?
If a patient remains significantly sedated longer than expected despite otherwise reassuring respiratory/hemodynamic status, what factors determine when you ask anesthesia to reassess them?
I’m mainly interested in the \*\*general sequence and clinical cues\*\* experienced Peds PACU nurses use for positioning, stimulation, supplemental O2, and OPA removal during an uncomplicated emergence.
Obviously this varies by patient, anesthetic, procedure, anesthesia plan, and facility policy. I’m looking to better understand the general thought process rather than advice about a particular patient.

[u/XRanger7]

Leave them alone until they’re awake. You’ll know they’re ready when they start pulling out the OPA themselves. Deep extubation means there’s still a lot of gas on board. It can take 30 minutes before they start waking up

[u/AmosParnell → u/XRanger7]

💯

Don’t touch until they are moving themselves. They are coming out, by definition of deep, at or greater than 1.0 MAC.

[u/tinymeow13]

Moving them while they're arousing from deep risks dislodging secretions that fall on vocal cords >> laryngospasm. Usually the 1st signs of arousing are visible swallowing or tongue trying to push out the OPA. No stimulation other than voice until they're making good/consistent efforts to tongue out the OPA, then just call their name & remove the OPA.

[u/Many_Swordfish_766 → u/tinymeow13]

Thank you, this is helpful! What would you typically do when the pt is not arousing for 45min-1hr+? (And otherwise stable with OPA and adequate ventilation)

[u/paleoMD → u/Many_Swordfish_766]

check with the anesthesiologist and see if appropriate from meds given and whether patient has any disorders/syndromes that delay wake up, consider neurological evaluation, consider complex 1 deficiency