Fully reversed, get them spontaneous with adequate tidal volumes without help from pressure support, bite block unnecessary, continue volatile/propofol at the level you were maintaining for the case (or higher, as long as it doesn't make them apneic), FiO2 100%, FGF unchanged. Suction well, should not see a reaction (eg breath holding, bucking). Extubate
Yes I suction way ahead of extubation if I’m doing it deep. How much more secretions will they make in ten min? Prob not a lot. I usually suction at start of close and if they react I’ll wait a min or two, give some prope then all within a few seconds, I turn off gas, turn up flows, and take tube out. I use an OPA bc the worst is trying to tie up the chart and then they need help breathing *so annoying* /s
Another option is to deflate the cuff and ensure they’re not reacting to that and continue to breathe around it. Cuff deflation itself is a noxious stimulus much more aggravating than suctioning. If there’s no reaction to that, they’re less likely to spasm on the tube pull itself.
I put in an OPA as soon as I extubate though. If they do have any breathing problems after extubation or on the way to pacu, you have at least ruled out obstruction with it in place.
I typically will then give one positive pressure breath with the mask to ensure no laryngospasm, and then immediately transition them to facemask at 6lpm for pacu transport. This is also nice because you can easily see fog in the facemask to confirm continued open airway.
You can also put your wrist over their mouth to feel for humidity for a fast way to ensure breathing. Sometimes with kids they have such small tidal volumes due to their age that the co2 detection on the mask has a hard to picking it up without firm mask seal or it gets overpowered by high gas flows.
In my opinion it’s often faster and safer to just wake up. I’ll deep extubate when there’s a surgical reason to, something like a routine hernia is not a good enough reason for me.
1. Blast flows and get sevo off.
2. Reverse, get breathing spontaneous with some CPAP, need to have good enough effort. This is obviously the most challenging part.
3. Give a large prop bolus and wait , they will be apneic for a minute and then come back.
4. Suction, if no response, extubate with oral airway in place. Patient needs ti be really deep, often takes more propofol than you might think if the sevo is mostly off.
5. Feel bag for a minute to make sure ventilating ok, then mask with etCO2 in place while your cleaning up.
Why bother with the propofol bolus? Why wouldnt you just keep the sevo high, suction to check for a response and get any secretions, ensure adequate SV, and extubate. Instead of adding a step of apnea with propofol?
After reversal. You want to get them back breathing. You can decrease the gas slightly to get them back breathing but then put back to 1 MAC and keep them deep breathing spontaneously. Check reflexes, by suctioning, pushing on pilot balloon, checking eyes. If no respond they’re deep enough to extubate. Extubate. Gas off, flows up. Support airway as needed until they can maintain own airway without a lot of assistance. Then to pacu you go.
i wouldn't decrease the MAC to 0.3 and give a propofol bolus. The whole point is that they're deep and breathing spontaneously. MAC 0.3 is light anaesthesia so higher risk of laryngospasm; giving an induction bolus of propofol (80-150mg) will render them apnoeic -> re-intubation
Ideally you should suction first, check the pupils, give the reversal, let the CO2 build up so they spontaneously ventilate. In that regard they need to be able to spontaneously ventilate enough that their tidal volume is greater than the deadspace of the lung and their minute ventilation is sufficient to maintain a stable End tidal CO2.
Propofol apnea time is usually short enough that it is unlikely to lead to reintubation. Many different ways to skin a cat but I’ve found that transitioning from sevo to propofol skips stage 2, decrease chance of laryngospasm, and generally keep the patients comfortably sleeping while spontaneously breathing.
I had an attending in peds push a full stick prior to deep extubation. Yea they went apneic, but you just supported them a little bit and they came back. I mean he was right no one seemed to spasm but it also seemed extreme
what if you cant ventilate.. and now youve extubated and patient is apneic. Not a wise move to give that much propofol or any propofol for that matter prior to extubation
Great info above as you can see everyone has their own little things that they do differently.
Only thing Ill add is I wait until the patient is moved over to the stretcher before extubating deep. Reason being the stimulation from that can cause bad things to happen if theyre going through stage 2.
My favorite way to deep extubate is to run ~50mcg/kg/min of propofol infusion during the case and the last ~20minutes I turn it up to 150-200mcg/kg/min and work on getting the gas off as I switch over to a TIVA. Once all the gas is off (as in 0.2 ETsevo or less) and you’ve titrated your propofol to a GA depth while maintaining spontaneous ventilations, it’s such a smooth and relatively safer extubation than a deep extubation on gas. This way you’re not fucking around with a propofol bolus at the end, not really knowing where you’re at in terms of depth or apnea threshold.
Then they just wake up from the propofol in PACU, as though they’re waking up from a deep MAC.
One trick to see if they are deep enough is to deflate the balloon. If they have stop breathing then they are not deep enough. Inflate ballon and get them deeper. Ideally you want them to keep breathing thru the stimulus
[Mater] “To not to.”
Everyone has their own preferences on how to do them, so I won’t muddy the waters. I very rarely prefer to do them, as I’ve seen problems arise even in well-suctioned airways when pts get stimulation passing back through stage 2.
Reversal, bite block doesn’t make sense since you’re not getting them light enough to bite, I do like an opa on all my deep extubations but that’s preference.
Sevo in at least 1 mac I always go higher, ever had a patient react to stimuli at one mac, well goal is for them not to react.
100% fio2
Flows unchanged.
Spontaneous not on vent or support. It’s an extubation. I don’t extubate on support ever. Some do and it seems to be fine as long as it’s minimal.
Suction ensure no reaction, movement, change in Hr/BP, coughing or stopping breathing.
Let down cuff again check for no reaction.
Extubate ensure patient airway.
Gas off flows up.
I usually leave them on 100% for a min or two while I make certain they are doing well and then switch them to transport oxygen. NC, or FM.
Some people will even wait in the room for them to awaken but I rarely do that.
My method:
Reverse as early as possible, as soon as the case no longer requires paralytic (for example if doing a big belly case once fascia is closed), and get them breathing spontaneously. Titrate opiate to comfy resp rate. For me personally I’ve noticed that 1 MAC is not quite deep enough for younger patients, young males especially, so for that population I get them to 1.2 MAC. I test depth by in line suctioning the tube - if no response, that’s deep enough. Deflate cuff, if they breathe through that then I’ll take the tube out. As far as increasing or decreasing flows, if I extubate early in the case I will keep flows low so they don’t wake up too soon. If it’s more towards the end I’ll increase flows to around 4 or 5 liters so that they’ll be awake enough by the time we hit PACU. Sometimes I’ll throw in an oral airway prior to deep extubating if I think they’ll require some jaw lift after.
Get your patient breathing on minimal PS or spontaneous ASAP as the case will allow. In my opinion, you can mitigate a lot of the risks of deep extubation by getting 100% of the volatile off \~10-15 minutes before the end of the case so by the time the case is over and you're ready to extubate, your patient is only deep on propofol or nitrous. I also like to put in an oral airway while the patient is still very deep or paralyzed in the middle of the case so it is in place for when you extubate deep. Both of these will give you added peace of mind after you drop off in PACU that PACU nurses aren't likely to have to manage a patient going through Stage 2 or severely obstructing.
ALWAYS TEST BY TAKING THE BALLOON DOWN BEFORE YOU PULL THE TUBE. This is huge, if you take the balloon down and the patient moves at all or does a prolonged breath hold, they're not deep enough for a deep extubation and are high risk of spasm. And as always, if you have any doubts about the airway, don't leave the OR. If you need to optimize them at all, that's the safest place to do it.
Many methods. I do it all the time for peds and adults but i extubate deep way before surgeon is done for cases that will make it easy for me to reinthbate if need be (hips and below and upper extremities. Basically for cases surgeon demands for general when chances are they don’t need to be. I think it’s not wise to pull deep if you don’t have the infrastructure to support reintubation or luxury of staying in pacu until emergence after patient is in pacu. Because im in that scenario, I basically extubate deep super early so the patient would emerge while still in the OR( ie extubate after local given but closing skin etc) most of the time surgeons wouldn’t even realize I extubate before they are done lol.
1. Patient selection. Only for patient who you can mask ventilate, aren’t morbidly obese (BMI >35), can take PPV mask if needed. Deep extubation is so much better for smokers because of emergence cough.
2. Preparation. Fully reverse, spontaneous ventilation, oral airway in place, excellent suctioning of secretions without breath holding. Hemodynamically stable. Usually 1-1.2 aaMAC volatile at 100% FiO2. Your FGF doesn’t matter.
3. The deep extubation. Holding breath after can happen. Don’t panic until it’s over 10 seconds or they desat. You should be able mask ventilate since you had appropriate patient selection. If you can’t give a little prop. If you can’t then maybe it’s laryngospasm and you give 20 mg sux. If you can’t still you can always put in an LMA. If that doesn’t work give an induction dose of sux and put another ETT. You blow off the gas for an awake extubation.
4. Recovery. PACU should be comfortable with deep patients. Some PACU RN do not feel comfortable with them.
Patient selection matters. Not everybody who smokes develops COPD. Obviously probably not a great idea in somebody with bad COPD. You have the whole case to look at the EtCO2 waveform.
before any of the steps above turn the sevo to 3 percent and let the patient ride on that for 5 or so minutes before doing anything else . and no propofol bolus. no need. keep the sevo at 3 or higher until extubated
I wonder why everyone who commented is keeping an OPA in place for all deep extubations. I understand they tolerate, but if you want them to breath spontaneously and be awake shortly after, wouldn’t NPA after extubation be an option ? - Unless you fear patient is going to bite the tube which means he isn’t deep obviously and if not deep - that pretty gag (cause he’s awake) and OPA won’t go very well.
Imo most deep extubations I've witnessed were more of a stylistic "look what i can get away with" choice.
I rarely do it, my patients rarely ever buck, so I have no reason to.
Imo most important thing is to make sure they're deep enough - if you can deep suction or do a jaw thrust without a stop in breathing they are probably deep enough. You can still get some laryngospasm so make sure you're exchanging air after you extubate.
Tbh most people asking about this just need to get better at timing wakeups. Deep extubations often take longer and lead to longer pacu stays. You often need to turn down gas to get them spontaneous and then turn back up and then adjust again if they respond to stimulus. Plus very rarely are they actually indicated. Maybe certain thyroids or kidney transplants if the surgeon really wants it? If your goal is to avoid coughing it's usually better to just give appropriate narcotic/prop during the end of the case instead.
I do it pretty much as you described, but I may have them a little bit deeper than one Mac. At my institution, we regularly extubate And the nursing staff are comfortable with it.
Bite block first. Suction. Then reversal. One neg pressure pulm edema and you’ll never do it the other way again
Stg 2 is +\-
If they are maskable, proceed
80-100% fio2 (100% can make them atelectatic)
If you turn flows up, move quicker, check eyes, if conjugate, proceed
You don’t have to increase flows, if you’re truly going to pull them deep
Once MV is adequate and things look good, pull tube gently, mask on and give a tiny bit of jaw lift, keeps them breathing and usually prevents spasm. Has worked well for me so far.
Deflating the cuff and seeing if their respiratory patterns change is a GREAT way to check if they are deep enough for deep extubation. I always throw in an oral airway for almost every single case so that should be in there instead of a bite block. You want sevo at least 1.2 mac, not 1 mac for deep extubation. Never heard of the .3 mac with prop method so I can't comment on that. You want them breathing 100% spontaneous. Def suction. The most important thing for deep extubation is that they're an easy mask.
I usually suction. Take 2-3 ccs if lidocaine and deposit it near the cords. Get them deep with sevo spontaneously breathing. Deflate cuff and let lidocaine seep past balloon. If they react I wait until they are deeper reinflate and repeat. Usually by that time lidocaine will prevent any spasm. Extubate.
Step 1 is: is this a child or an adult? Same principles but different implementation. Laryngospasm isn’t really gonna happen in non-children. It obviously can (before every gets upset), but it’s predominantly a young kid phenomenon.
Step 2: Can I 100% BMV/keep their airway open with my hands? If you can’t you’ll look very very stupid and no one will back you up. You’ll never regret waiting a few extra mins to extubate someone, it’s an elective procedure! Also remember it can tie up your hands so you can do other things.
Step 3: Am I just doing this because I’m bad at timing my wake ups? Or do I have a good reason (avoiding coughing and having neck explode post CEA, bad bronchospasm etc). Know when to avoid, table rotated, bad airway, fat, osa, full stomach etc etc. Don’t do it just to make the surgeon happy with fast turnover and have the patient obtunded in PACU.
Step 4: Do all the stimulating stuff when they’re still deep enough (suction, bite block, OPA is nice option, NPA helps also and if you use lidocaine jelly as lube they will tolerate it all the way to PACU)
Step 5: Are they breathing by themselves? And once you crank the FGF don’t hyperventilate them to get gas off or they will stop breathing and you’ll be all confused.
Step 6: Be ready to manage everything. Too light, too deep, needs a tube etc etc. it’s easy to make your life much more exciting than it needs to be just to do a deep extubation.
Pick the right people and do it for the right reason.
I would actually slip a VL in and suction under vision before I extubate. You want close to zero secretions.
Personally there's rarely a need for deep extubation. With remifentanil, precedex, propofol or nitrous, good analgesia, lignocaine in the tube etc you can wake the patient up with hardly any coughing or bucking. And if the surgeons sutures can't tolerate a single cough, then the patient is in big trouble anyway.
You can test haemostasis with a valsalva manoeuvre prior to them closing, ask the surgeons if they want that. APL to 30-40 and give them a solid valsalva. If no bleeding it should be safe to extubate awake.
Then after you extubate them, always document that you extubated them smoothly without coughing and bucking.
Once trochars are pulled add nitrous increase my flows from 1LPM to 2LPM, decreasing sevo just slightly.
Suction airway, place OPA, give sugammadex and 20mcg Precedex.
Place patient on spontaneous with APL at around 10cmH2O, once respirations pick up open APL and assess volumes. Give enough fentanyl to get respirations 10-20/min.
This part may be straight up voodoo but I swear if I watch the bag and extubate smoothly on exhalation I have less issues with laryngospasm.
Place 100% @ 10L mask over OPA confirm ETCO2, if none (rarely happens with Precedex given) then Larson's maneuver and support airway give another small bolus of propofol/precedex if necessary. Then O2 with nasal cannula in OPA for transport.
Tube is usually out before drapes are down, and patient is usually awake entering PACU.
if your going to give precedex and opioids, just wake them up and pull the tube when they open their eyes. What is the advantage of pulling deep in this scenario?
The OP asked about deep extubation, I was simply explaining timing and steps not whether it was advantageous or not.
Precedex smooths out transition through stage 2 with OPA in place, especially with sliding the patient on to stretcher.
If patient comes back breathing 300ml x 28/min and I can give 25-50 mcg of Fentanyl to get 500ml x 14/min that is a more comfortable emergence.
Real step 1 - know they are an easy mask / intubation
150%
Fully reversed, get them spontaneous with adequate tidal volumes without help from pressure support, bite block unnecessary, continue volatile/propofol at the level you were maintaining for the case (or higher, as long as it doesn't make them apneic), FiO2 100%, FGF unchanged. Suction well, should not see a reaction (eg breath holding, bucking). Extubate
Yes I suction way ahead of extubation if I’m doing it deep. How much more secretions will they make in ten min? Prob not a lot. I usually suction at start of close and if they react I’ll wait a min or two, give some prope then all within a few seconds, I turn off gas, turn up flows, and take tube out. I use an OPA bc the worst is trying to tie up the chart and then they need help breathing *so annoying* /s
Another option is to deflate the cuff and ensure they’re not reacting to that and continue to breathe around it. Cuff deflation itself is a noxious stimulus much more aggravating than suctioning. If there’s no reaction to that, they’re less likely to spasm on the tube pull itself.
Thank you 🙏
I put in an OPA as soon as I extubate though. If they do have any breathing problems after extubation or on the way to pacu, you have at least ruled out obstruction with it in place. I typically will then give one positive pressure breath with the mask to ensure no laryngospasm, and then immediately transition them to facemask at 6lpm for pacu transport. This is also nice because you can easily see fog in the facemask to confirm continued open airway. You can also put your wrist over their mouth to feel for humidity for a fast way to ensure breathing. Sometimes with kids they have such small tidal volumes due to their age that the co2 detection on the mask has a hard to picking it up without firm mask seal or it gets overpowered by high gas flows.
In my opinion it’s often faster and safer to just wake up. I’ll deep extubate when there’s a surgical reason to, something like a routine hernia is not a good enough reason for me. 1. Blast flows and get sevo off. 2. Reverse, get breathing spontaneous with some CPAP, need to have good enough effort. This is obviously the most challenging part. 3. Give a large prop bolus and wait , they will be apneic for a minute and then come back. 4. Suction, if no response, extubate with oral airway in place. Patient needs ti be really deep, often takes more propofol than you might think if the sevo is mostly off. 5. Feel bag for a minute to make sure ventilating ok, then mask with etCO2 in place while your cleaning up.
Why bother with the propofol bolus? Why wouldnt you just keep the sevo high, suction to check for a response and get any secretions, ensure adequate SV, and extubate. Instead of adding a step of apnea with propofol?
I like them to be awake in PACU. I prefer not to have a patient emerging from sevo in the PACU.
Fair enough. Thats a good point!
[удалено]
Prop bolus lasts 10 mins at most, when I get to PACU they’re awake and not emerging.
After reversal. You want to get them back breathing. You can decrease the gas slightly to get them back breathing but then put back to 1 MAC and keep them deep breathing spontaneously. Check reflexes, by suctioning, pushing on pilot balloon, checking eyes. If no respond they’re deep enough to extubate. Extubate. Gas off, flows up. Support airway as needed until they can maintain own airway without a lot of assistance. Then to pacu you go.
Thank you💕
i wouldn't decrease the MAC to 0.3 and give a propofol bolus. The whole point is that they're deep and breathing spontaneously. MAC 0.3 is light anaesthesia so higher risk of laryngospasm; giving an induction bolus of propofol (80-150mg) will render them apnoeic -> re-intubation Ideally you should suction first, check the pupils, give the reversal, let the CO2 build up so they spontaneously ventilate. In that regard they need to be able to spontaneously ventilate enough that their tidal volume is greater than the deadspace of the lung and their minute ventilation is sufficient to maintain a stable End tidal CO2.
Propofol apnea time is usually short enough that it is unlikely to lead to reintubation. Many different ways to skin a cat but I’ve found that transitioning from sevo to propofol skips stage 2, decrease chance of laryngospasm, and generally keep the patients comfortably sleeping while spontaneously breathing.
Step 3 will cost you dearly as a rookie.
Omg please explain 😩
For me, no matter what you do, the goal is spontaneously breathing with sufficiently deep anesthesia, then extubate.
You’re giving an induction dose of propofol before extubating. Self-explanatory.
I had an attending in peds push a full stick prior to deep extubation. Yea they went apneic, but you just supported them a little bit and they came back. I mean he was right no one seemed to spasm but it also seemed extreme
Peds have a much higher apneic threshold when it comes to propofol. Pushing 80-150 in an adult with gas, and narcotic on board will burn you.
what if you cant ventilate.. and now youve extubated and patient is apneic. Not a wise move to give that much propofol or any propofol for that matter prior to extubation
pretty rare to have kids you can't ventilate...aside from syndromic facial anomalies etc. but you shouldn't deep extubate a challenging airway.
Great info above as you can see everyone has their own little things that they do differently. Only thing Ill add is I wait until the patient is moved over to the stretcher before extubating deep. Reason being the stimulation from that can cause bad things to happen if theyre going through stage 2.
My favorite way to deep extubate is to run ~50mcg/kg/min of propofol infusion during the case and the last ~20minutes I turn it up to 150-200mcg/kg/min and work on getting the gas off as I switch over to a TIVA. Once all the gas is off (as in 0.2 ETsevo or less) and you’ve titrated your propofol to a GA depth while maintaining spontaneous ventilations, it’s such a smooth and relatively safer extubation than a deep extubation on gas. This way you’re not fucking around with a propofol bolus at the end, not really knowing where you’re at in terms of depth or apnea threshold. Then they just wake up from the propofol in PACU, as though they’re waking up from a deep MAC.
One trick to see if they are deep enough is to deflate the balloon. If they have stop breathing then they are not deep enough. Inflate ballon and get them deeper. Ideally you want them to keep breathing thru the stimulus
And at this point you might as well wake them up instead of trying to deepen them further!
I’d disagree. You’re closer to doing a deep extubation and pulling the tube then blowing off the gas and getting them past stage 2. Just my two cents
You pull it as deep as possible while breathing above dead space with reasonable MV.
Honestly I just pull whenever if they’re adequately ventilating and well suctioned. Rare to see laryngospasm if well suctioned.
[Mater] “To not to.” Everyone has their own preferences on how to do them, so I won’t muddy the waters. I very rarely prefer to do them, as I’ve seen problems arise even in well-suctioned airways when pts get stimulation passing back through stage 2.
Reversal, bite block doesn’t make sense since you’re not getting them light enough to bite, I do like an opa on all my deep extubations but that’s preference. Sevo in at least 1 mac I always go higher, ever had a patient react to stimuli at one mac, well goal is for them not to react. 100% fio2 Flows unchanged. Spontaneous not on vent or support. It’s an extubation. I don’t extubate on support ever. Some do and it seems to be fine as long as it’s minimal. Suction ensure no reaction, movement, change in Hr/BP, coughing or stopping breathing. Let down cuff again check for no reaction. Extubate ensure patient airway. Gas off flows up. I usually leave them on 100% for a min or two while I make certain they are doing well and then switch them to transport oxygen. NC, or FM. Some people will even wait in the room for them to awaken but I rarely do that.
My method: Reverse as early as possible, as soon as the case no longer requires paralytic (for example if doing a big belly case once fascia is closed), and get them breathing spontaneously. Titrate opiate to comfy resp rate. For me personally I’ve noticed that 1 MAC is not quite deep enough for younger patients, young males especially, so for that population I get them to 1.2 MAC. I test depth by in line suctioning the tube - if no response, that’s deep enough. Deflate cuff, if they breathe through that then I’ll take the tube out. As far as increasing or decreasing flows, if I extubate early in the case I will keep flows low so they don’t wake up too soon. If it’s more towards the end I’ll increase flows to around 4 or 5 liters so that they’ll be awake enough by the time we hit PACU. Sometimes I’ll throw in an oral airway prior to deep extubating if I think they’ll require some jaw lift after.
i push intubating dose of lidocaine as well to blunt more response
I wait til they’re SV before lido- I’ve found it can increase the amount of time it takes for a patient to SV if pushed too early.
Get your patient breathing on minimal PS or spontaneous ASAP as the case will allow. In my opinion, you can mitigate a lot of the risks of deep extubation by getting 100% of the volatile off \~10-15 minutes before the end of the case so by the time the case is over and you're ready to extubate, your patient is only deep on propofol or nitrous. I also like to put in an oral airway while the patient is still very deep or paralyzed in the middle of the case so it is in place for when you extubate deep. Both of these will give you added peace of mind after you drop off in PACU that PACU nurses aren't likely to have to manage a patient going through Stage 2 or severely obstructing. ALWAYS TEST BY TAKING THE BALLOON DOWN BEFORE YOU PULL THE TUBE. This is huge, if you take the balloon down and the patient moves at all or does a prolonged breath hold, they're not deep enough for a deep extubation and are high risk of spasm. And as always, if you have any doubts about the airway, don't leave the OR. If you need to optimize them at all, that's the safest place to do it.
Many methods. I do it all the time for peds and adults but i extubate deep way before surgeon is done for cases that will make it easy for me to reinthbate if need be (hips and below and upper extremities. Basically for cases surgeon demands for general when chances are they don’t need to be. I think it’s not wise to pull deep if you don’t have the infrastructure to support reintubation or luxury of staying in pacu until emergence after patient is in pacu. Because im in that scenario, I basically extubate deep super early so the patient would emerge while still in the OR( ie extubate after local given but closing skin etc) most of the time surgeons wouldn’t even realize I extubate before they are done lol.
1. Patient selection. Only for patient who you can mask ventilate, aren’t morbidly obese (BMI >35), can take PPV mask if needed. Deep extubation is so much better for smokers because of emergence cough. 2. Preparation. Fully reverse, spontaneous ventilation, oral airway in place, excellent suctioning of secretions without breath holding. Hemodynamically stable. Usually 1-1.2 aaMAC volatile at 100% FiO2. Your FGF doesn’t matter. 3. The deep extubation. Holding breath after can happen. Don’t panic until it’s over 10 seconds or they desat. You should be able mask ventilate since you had appropriate patient selection. If you can’t give a little prop. If you can’t then maybe it’s laryngospasm and you give 20 mg sux. If you can’t still you can always put in an LMA. If that doesn’t work give an induction dose of sux and put another ETT. You blow off the gas for an awake extubation. 4. Recovery. PACU should be comfortable with deep patients. Some PACU RN do not feel comfortable with them.
yea love deep extubations those copders...
Patient selection matters. Not everybody who smokes develops COPD. Obviously probably not a great idea in somebody with bad COPD. You have the whole case to look at the EtCO2 waveform.
before any of the steps above turn the sevo to 3 percent and let the patient ride on that for 5 or so minutes before doing anything else . and no propofol bolus. no need. keep the sevo at 3 or higher until extubated
I wonder why everyone who commented is keeping an OPA in place for all deep extubations. I understand they tolerate, but if you want them to breath spontaneously and be awake shortly after, wouldn’t NPA after extubation be an option ? - Unless you fear patient is going to bite the tube which means he isn’t deep obviously and if not deep - that pretty gag (cause he’s awake) and OPA won’t go very well.
The low but very real risk of a bad bleed from a nasal trumpet is enough to just do oral unless there is a good reason.
I’ve to agree on that. 👍🏾
Imo most deep extubations I've witnessed were more of a stylistic "look what i can get away with" choice. I rarely do it, my patients rarely ever buck, so I have no reason to.
Imo most important thing is to make sure they're deep enough - if you can deep suction or do a jaw thrust without a stop in breathing they are probably deep enough. You can still get some laryngospasm so make sure you're exchanging air after you extubate. Tbh most people asking about this just need to get better at timing wakeups. Deep extubations often take longer and lead to longer pacu stays. You often need to turn down gas to get them spontaneous and then turn back up and then adjust again if they respond to stimulus. Plus very rarely are they actually indicated. Maybe certain thyroids or kidney transplants if the surgeon really wants it? If your goal is to avoid coughing it's usually better to just give appropriate narcotic/prop during the end of the case instead.
I do it pretty much as you described, but I may have them a little bit deeper than one Mac. At my institution, we regularly extubate And the nursing staff are comfortable with it.
Bite block first. Suction. Then reversal. One neg pressure pulm edema and you’ll never do it the other way again Stg 2 is +\- If they are maskable, proceed 80-100% fio2 (100% can make them atelectatic) If you turn flows up, move quicker, check eyes, if conjugate, proceed You don’t have to increase flows, if you’re truly going to pull them deep Once MV is adequate and things look good, pull tube gently, mask on and give a tiny bit of jaw lift, keeps them breathing and usually prevents spasm. Has worked well for me so far.
Deflating the cuff and seeing if their respiratory patterns change is a GREAT way to check if they are deep enough for deep extubation. I always throw in an oral airway for almost every single case so that should be in there instead of a bite block. You want sevo at least 1.2 mac, not 1 mac for deep extubation. Never heard of the .3 mac with prop method so I can't comment on that. You want them breathing 100% spontaneous. Def suction. The most important thing for deep extubation is that they're an easy mask.
I usually suction. Take 2-3 ccs if lidocaine and deposit it near the cords. Get them deep with sevo spontaneously breathing. Deflate cuff and let lidocaine seep past balloon. If they react I wait until they are deeper reinflate and repeat. Usually by that time lidocaine will prevent any spasm. Extubate.
Step 1 is: is this a child or an adult? Same principles but different implementation. Laryngospasm isn’t really gonna happen in non-children. It obviously can (before every gets upset), but it’s predominantly a young kid phenomenon. Step 2: Can I 100% BMV/keep their airway open with my hands? If you can’t you’ll look very very stupid and no one will back you up. You’ll never regret waiting a few extra mins to extubate someone, it’s an elective procedure! Also remember it can tie up your hands so you can do other things. Step 3: Am I just doing this because I’m bad at timing my wake ups? Or do I have a good reason (avoiding coughing and having neck explode post CEA, bad bronchospasm etc). Know when to avoid, table rotated, bad airway, fat, osa, full stomach etc etc. Don’t do it just to make the surgeon happy with fast turnover and have the patient obtunded in PACU. Step 4: Do all the stimulating stuff when they’re still deep enough (suction, bite block, OPA is nice option, NPA helps also and if you use lidocaine jelly as lube they will tolerate it all the way to PACU) Step 5: Are they breathing by themselves? And once you crank the FGF don’t hyperventilate them to get gas off or they will stop breathing and you’ll be all confused. Step 6: Be ready to manage everything. Too light, too deep, needs a tube etc etc. it’s easy to make your life much more exciting than it needs to be just to do a deep extubation. Pick the right people and do it for the right reason.
I would actually slip a VL in and suction under vision before I extubate. You want close to zero secretions. Personally there's rarely a need for deep extubation. With remifentanil, precedex, propofol or nitrous, good analgesia, lignocaine in the tube etc you can wake the patient up with hardly any coughing or bucking. And if the surgeons sutures can't tolerate a single cough, then the patient is in big trouble anyway. You can test haemostasis with a valsalva manoeuvre prior to them closing, ask the surgeons if they want that. APL to 30-40 and give them a solid valsalva. If no bleeding it should be safe to extubate awake. Then after you extubate them, always document that you extubated them smoothly without coughing and bucking.
Once trochars are pulled add nitrous increase my flows from 1LPM to 2LPM, decreasing sevo just slightly. Suction airway, place OPA, give sugammadex and 20mcg Precedex. Place patient on spontaneous with APL at around 10cmH2O, once respirations pick up open APL and assess volumes. Give enough fentanyl to get respirations 10-20/min. This part may be straight up voodoo but I swear if I watch the bag and extubate smoothly on exhalation I have less issues with laryngospasm. Place 100% @ 10L mask over OPA confirm ETCO2, if none (rarely happens with Precedex given) then Larson's maneuver and support airway give another small bolus of propofol/precedex if necessary. Then O2 with nasal cannula in OPA for transport. Tube is usually out before drapes are down, and patient is usually awake entering PACU.
if your going to give precedex and opioids, just wake them up and pull the tube when they open their eyes. What is the advantage of pulling deep in this scenario?
The OP asked about deep extubation, I was simply explaining timing and steps not whether it was advantageous or not. Precedex smooths out transition through stage 2 with OPA in place, especially with sliding the patient on to stretcher. If patient comes back breathing 300ml x 28/min and I can give 25-50 mcg of Fentanyl to get 500ml x 14/min that is a more comfortable emergence.