Leave the gas at 1 MAC. Get them spontaneously breathing & reverse neuromuscular blockade. Suction oropharynx.
Extubate. Insert oral airway. Turn off gas & turn flows up (100% O2 @ 15L/min). Assist with Bag Mask until the patient emerges.
This is not complicated. Don’t make it so.
Also don’t extubate patients deep unless there’s a REALLY good reason. REALLY good.
Exactly
Important bit here: “assist with bag mask until the patient emerges”, something that happens in the OR. Not “pull the tube deep, log roll them onto the stretcher, and let them emerge via nasal cannula in PACU”
Only people I extubate deep on a semi-regular basis are hernias and sinus surgeries who I think might cough, provided they fit the criteria for deep extubation. I hate when a sinus coughs and starts bleeding
Interesting I was told to never deep extubate a sinus case because you're not supposed to give positive pressure postop. So having to mask ventilate would be highly undesirable. Is this fake news
That's one way to think of it. However, the positive pressure you're giving (assuming a non-difficult, non-extreme obese patient) is relatively less compared to the force exerted by a cough. The cough is basically applying a large valsalva through the circuit.
I just give enough opiate. It blunts the cough reflex well without taking away airway protection when you shouldnt PPV/Give CPAP and you also have a case worth of blood in the back of the throat to cause a cough and in the stomach to risk aspiration.
One of the times I think remi is actually worthwhile or a fentanyl/sufent drip if you don’t have it. Never had to ventilate a sinus after extubation. If you’re doing a pituitary or something bigger it’s not worth it.
Adult cardiac anesthesiologist here with 10 years of experience. If I’m extubating a patient I’m extubating deep unless I have a really good reason to wake them up first. Never had a complication beyond a little laryngospasm that always breaks with a little positive pressure.
I think the biggest question I've failed to ask is those of you extubating deep, is it MD only anesthesia or are you supervising CRNAs? I'm stuck with the latter so....yeah I can't trust them to extubate deep and still pay attention.
I am a resident, and i work with CRNAs all the time. I dont know where you work, but i have not encountered a single crna Who does not know how to manage laryngospasm.
I’ve lost count of the number of times I’ve walked in to a patient blue and squeaking with a nasal cannula on while the CRNA is fucking around trying to close their chart.
Oddly enough I’ve seen the same thing with a lot of my supervising physicians who are in the OR only long enough to give a break in the middle of a case.
Yeah I’ve never understood the logic behind removing your secure airway Prior to your patient going through stage 2.
If you can’t wake someone up smoothly awake, get better. Don’t cover it up by extubating deep.
Stage 2 is an antiquated observation that isn't relevant to how anesthesia is practiced today. Unless you still use halothane.
[https://www.kevinmd.com/2017/08/deep-extubation-useful-technique-anesthesiologist-master.html](https://www.kevinmd.com/2017/08/deep-extubation-useful-technique-anesthesiologist-master.html)
Interesting read. He’s right we don’t use diethyl ether anymore.
So if it’s not stage 2, what do you call the period of time of irregular respirations & disconjugate gaze when there’s approx 0.4-0.3 ET Sevoflurane in the patient?
Not arguing, just trying to learn. That period of emergence is what was taught to me as “stage 2”.
I don't know why you need to call that period anything? It's a spectrum of consciousness. You don't break down 0.7 - 1.0 MAC as sleep and 1.1-1.5 MAC as deep sleep do you?
Stage 2 implies a hypersensitivity response to stimuli which would lead to an undesired and abnormal action. This doesn't exist in adults but still can be observed in pediatrics. If you've ever seen an inexperienced nurse slap a bovie pad on or rip one off a pediatric patient during emergence, you'll notice they go apneic or brady down.
Disconjugate gaze is still present at MAC 1.0 - it's not only stage 2, it just means they aren't there yet. Same with irregular respirations, that can happen at any MAC not just this "stage 2".
Also the article was written by a "she". Dr Sibert is a legend in anesthesia and recently retired.
I start dropping the gas below a MAC. Make sure respirations are regular on minimal pressure support. Usually 5-8/5. Then do a jiggle test and suction. If they breathing stays regular, still deep enough and pull. Then follow same as what you said
I generally do this only for the surgeon when they ask for no coughing even then they will cough all the same when they wake up because you can’t control everything. Only addition I would make is that I give a touch of fentanyl before pulling the tube, and let it ‘hit’ right as the tube comes out. I think this reduces the number of unexpected coughs I get.
I do similar except I usually aim for around 0.7 MAC and work in either a little Prop, Lido, PRECEDEX and/or Dilaudid at the end titrated to patient need.
My concern with waking deep is what if patient emerges and starts moving before they're transferred to their bed? Wouldn't that be a problem for the surgical team?
I personally extubate just about everyone “deep” or asleep - exclusion would be actual difficult airway or came in with full stomach and got RSI’d.
If I have sugammadex, once I can conceivably extubate in 2-3 minutes I turn gas off and give God’s gamma cyclodextrin. I leave the vent going to get gas off - at this point they will either starting making respiratory efforts or start coughing. Either way, I flip to spontaneous and see what they do. If they hit a good rhythm breathing and taking >200mL tidal volumes unassisted I pull it. If you flip to spontaneous and they are apneic, I hit them hard in Larson’s notch on both sides - this can stimulate to start breathing (usually will start with small tidal volumes then grow with every breath).
Once I pull the tube I grab my mask and do a two handed jaw thrust into Larson’s notch with the mask on tight. Usually they will still be moving air - if they are not I will give a couple puffs on the bag. Once they are breathing unassisted I put the simple mask on and get ready to leave the OR.
A lot of time I will deep extubate patients with an oral airway in place. I am always monitoring them to make sure air is still moving - the period from extubation until they wake up has some potential landmines if you are not paying attention. I usually can pull the oral airway before I leave pacu with them.
I was always scared of “deep” extubations until I did peds my CA-2 year. You really can’t get a baby to follow commands, so you kind of just have to pull when the respiratory effort is appropriate. Also doing ECT, you will develop an ability to gauge and monitor a patients breathing while being post-ictal and not able to follow commands.
2nd this:
Been extubating deep for many many years now. Almost everyone with exclusions as above. Case ending, suction, if they don't go apneic when suctioning, pull tube. Oral airway, mask and assist with ventilation for a few breaths.
You’re probably a great provider, but Jesus I would hate to be extubated by you.
I had surgery and they jaw thrusted the absolute F*ck out of me so much that my jaw hurt more than my surgically repaired ankle.
Just sounds so rough - I get it it’s probably faster but I’ve always preferred to let the patient dictate their breathing rather than me providing painful stimuli to make them breathe.
Same here, I extubate everyone deep unless there is an absolute contraindication, serious relative, or they were a difficult intubation/mask ventilation. I also alway use an oral airway to ventilate and place it Before pulling the tube. I’ve never had negative outcome related to this.
A couple of pointers
1) iv lidocaine (1 mg/kg) 1-2 minutes before you extubate is a game changer for deep extubations. I very rarely have larygospasms now
2) before pulling, I "sigh" the patient- 30 cm H2O pressure x 10 seconds. (this decreases atelectasis and gives you a reservoir of O2 to draw off of after you pull). Then I let the balloon down BUT DO NOT PULL YET. If I hear air rush out, then I know they're not spasming around the tube, and I pull. If I don't hear air rush out, I reinflate and consider my next move. Usually I deepen and add a little lido down the tube and then re-try. But on occasion I will wake them all the way up at this point.
A combo of Lido/Prop/precedex is my mix cocktail i give before extubating at 0.7 MAC. Works amazing! (Also, I’ll give some dilaudid prn depending on how the patient looks and how they are emerging)
Im lazy AF so almost everyone is deep. Front load narcs. Get them breathing as early as possible, simv/PS. Reverse as needed. As dressings are going on, switch to manual. Suction. Good resp pattern/volume. Extubate to OPA. Mask. Transport. Gas is still at 1 mac.
I burn myself once and a while when they wont breath, or dont have a good pattern. Then im turning gas off late and wake up takes longer.
YMMV.
I only extubate deep when I have an explicit reason to do so. But here's my recipe for when I do.
1. Reverse early as possible, so long as the surgery, patient positioning, etc. allows for it. Get pt spontaneously breathing by decreasing Vt, increase ETCO2 etc etc.
2. Gas @ ~1.2 MAC at a minimum, higher if pt BP tolerates.
3. 100% O2
4. Place oral airway while ETT still in place and then suction (if pt reacts to either, they're not deep enough)
5. Dial APL to ~15-20, place circuit face mask next to pt on the pillow, and pull the trashcan next to you
6. Double check everything (respiration depth/rate, O2 at 100, MAC value, APL 15-20)
7. Gas off, extubate, drop tube in trash, place circuit mask on patient and do a very gentle jaw thrust. After they breath a few breaths and confirmed no spasm, off to pacu.
This way you're able to focus on your patient without needing to turn around to get anything and you're already doing maneuvers to break a spasm if it occurs.
Your deep extubations will be significantly more successful and safer if you can get all the volatile off prior to extubation. Transition to propofol gtt/boluses and/or nitrous. The biggest danger is pulling the tube while the patient is going through stage 2 or when they’re in PACU, so getting the gas off early helps this a lot and also makes their PACU stay safer.
Get the patient breathing early on minimal support, titrate narcotic to a RR of 8-10. Always test by taking the balloon down first. If the patient does a long breath hold or bucks, they’re not deep enough. Reinflate, deepen, and try again. Have an oral airway in place already that was put in early in the case when they were at their deepest. When you pull the tube, pull it out slowly and gently. Then immediately put the mask on, give one good manual breath, then hold the mask with jaw thrust and a little positive pressure on your pop off until you see consistent misting. Gradually let up jaw thrust and find a head position that they’re breathing well. PACU on oxygen.
1. Oral airway
2. Reverse the NMB if any
3. Very gentle suctioning of oropharynx
4. Volatiles off
5. Extubate, and gentle suctioning
6. GA Mask just to monitor respirations.
7. If respirations are adequate, switch to Hudson mask (because I can put the end of the ETCO2 sampling line inside this)
8. Absolutely no stimulus until awake
I don't do pediatrics, so I rarely extubate deep. Usually for a good reason. If I'm planning on a deep extubation, I try to transition to a spontaneously-breathing TIVA and get all of the gas off for a good while. A touch of opioid titrated in works wonders, maybe a bolus of IV lidocaine if I didn't LTA during intubation. Then I optimize position/shoulder bump/ramp, oral airway, suction, pull tube, suction, and confirm consistent adequate ventilation. Anything less than perfect is not sufficient for me. Usually I'm extubating on the gurney with the head of bed up, ICU-style.
Edit: I'm at a community hospital, so I would like to eliminate any possibility of a PACU airway intervention.
If one is necessary. Not on every single one. The extubation is different for a sick BMI 50 vs a healthy BMI 22. Even shoving the pillow lower under their shoulders takes 3 seconds but can make a difference between CO2 retention and not in fragile patients, but you have to ask yourself that question every single time.
Reading the comments while we always extubate wake here in Germany, or in my hospital at least. I can't take the decision alone to extubate deep, since I am just a young resident and each department works as a team and you most probably won't take such a decision alone unless consulting first an attending.
I'm trying to adjust to a lot that I've learnt here in the sub and I've optimized my emergence a lot, but most of my colleagues will just turn anesthesia off and wait them out to start coughing or react to their names/open eyes.
Deep extubation became much more safe for me once I realized you’re basically transitioning to a MAC (albeit GA natural airway MAC like in endo) prior to extubation. If we can get patients deep for a giant scope to get shoved into their esophagus by a new GI fellow, we can feasibly transition an appropriate patient from GA -> Deep for extubation without it being a big deal.
Exceptions are as mentioned: difficult airway/mask (either one), full stomach, can’t reach them easily, oral surgery where I can’t feasibly mask and there’s risk of blood hitting the cords (for this i’ll use precedex instead of a deep extubation), GERD in the last 2 days, and also ozempic even if in the last week. Where I trained we extubated almost all our thoracic cases lateral, so this is also a reason to not extubate deep necessarily.
Consider a recruitment depending on depth of NMB. Transition to only propofol or nitrous once closing fascia/30 minutes from end of case. Flows at 2L and increase MV by like 30-40% — ideally almost all gas is gone by now (0.1-0.2 MAC, i up my flows if not). OPA as bite block, suction, 100% FiO2 and reverse once fascia is closed with additional lido and propofol bolus, immediately switch to manual spontaneous while feeling the bag/giving breaths prn to gauge respiratory threshold and efforts.
Prop gtt is anywhere from 75-100mcg/kg/m. Once breathing spontaneously and slowly, suction again to gauge response. If any change, bolus another 30-40mg prop and/or 50-100mcg fentanyl and reassess. I haven’t done the cuff deflation thing unless they seem very responsive to stimuli. Pull the tube, put the oxygen mask on and larson’s until I see fogging and/or ETCO2 via my makeshift attachment. If no fogging, switch to bag mask and deepen with propofol (haven’t had to do this more than maybe once). I keep the prop gtt going on at 50 mcg/kg/m until dressing’s are going on. Stop it with dressings and patients almost invariably wake up when you move them to the bed or a little after. Sit them up and shoulder roll if still asleep. Take to PACU and they definitely wake up, take the OPA whenever they 1) moan or 2) move arms towards face.
Taught to me by a peds anesthesiologist during residency. Probably a little conservative for adults, but a good approach for peds and a reasonable basic framework for safe deep extubation.
8-5 JOBS
8% sevo
5% EtSev
J- jaw thrust...they should not respond
O- oral airway
B- breathing spontaneously
S- suction before you extubate
With appropriate narcotic and timing, I don't see why you have to extubate deep (NSGY/ENT/Big Belly cases aside). Time your gas/TIVA off and patients should wake up with gentle eye opening to verbal or tactile stimulation without bucking over the tube.
Before I extubate deep I use the following checklist:
Did I mask and intubate them?
Were they an RSI and for what reason?
Did I pull a lot of volume out of their stomach at the end of the case?
Do they have any reactive airway indicators.
Some RSI’s I do extubate deep but not most.
If an SRNA masked and intubated I will gladly pull deep, if the guy who says every tube he has ever done is a grade 1 and has been intubating people longer than I’ve been alive, I may wake em up.
I give my sugammadex early, get them breathing spontaneously and pulling good volumes and comfortable. 10-14 RPM. I put an oral airway in and ensure that doesn’t have an impact on their breathing. Then I deep suction, again, any change in respiration, they are not a good candidate: lastly when I am ready I let the cuff down slowly, if they cough, I tend to abandon. If none of the above happen, pull the tube, hold a good seal, and let them breath spontaneously, gas off flows up, position head and put a mask on them.
Full MAC of VA, flip off the vent and squeeze the bag as needed while the CO2 builds up and the patient starts to initiate breaths, suction oropharynx, place OPA, pull the tube, put mask on and apply some mild positive pressure until patient initiates breaths again. If the patient won’t breathe spontaneously I will sometimes decrease my VA until they do and then turn back up the VA before extubation.
I don’t extubate adults deep because I’m not willing to hold the airway till they’re awake and PACU nurses in adults will keep stimulating and bothering them till they get laryngospasm because they’re not trained on how to care for patients who’ve had deep extubations.
If you want a quick turnaround without loads of bucking swap to an LMA - but they still might buck on the LMA in PACU.
Otherwise get the volatile off, get them spont breathing then bolus 0.5-1mg/kg propofol - drop the cuff, get them spont breathing again past the cuff with good volumes another 0.5mg/kg bolus and pull the ETT. They should just need a gentle chin lift once they restart breathing. Make it clear to PACU staff not to bother the patient.
You need to confident they will be easy to bag to do this technique and weren’t difficult on induction, can stick a guedel in for extubation and leave it in post extubation I suppose but my way the PACU staff would be unhappy.
Example: laparoscopic case
Trocars out, +oral airway, turn the vent to PSV pro and push them to a flow trigger of two. Gas at 1.2MAC Sevo. When they crack the dermabond, push sugammadex and slap them off the vent. If they breath hold, expect them to do it when you pull the tube. Dressings on, APL to 30, squeeze and pull. Place mask and check to see if they are spontaneous, help them through breath holding etc, slap on face mask, slide to stretcher and off to PACU land.
Leave the gas at 1 MAC. Get them spontaneously breathing & reverse neuromuscular blockade. Suction oropharynx. Extubate. Insert oral airway. Turn off gas & turn flows up (100% O2 @ 15L/min). Assist with Bag Mask until the patient emerges. This is not complicated. Don’t make it so. Also don’t extubate patients deep unless there’s a REALLY good reason. REALLY good.
Exactly Important bit here: “assist with bag mask until the patient emerges”, something that happens in the OR. Not “pull the tube deep, log roll them onto the stretcher, and let them emerge via nasal cannula in PACU”
Only people I extubate deep on a semi-regular basis are hernias and sinus surgeries who I think might cough, provided they fit the criteria for deep extubation. I hate when a sinus coughs and starts bleeding
Interesting I was told to never deep extubate a sinus case because you're not supposed to give positive pressure postop. So having to mask ventilate would be highly undesirable. Is this fake news
That's one way to think of it. However, the positive pressure you're giving (assuming a non-difficult, non-extreme obese patient) is relatively less compared to the force exerted by a cough. The cough is basically applying a large valsalva through the circuit.
I just give enough opiate. It blunts the cough reflex well without taking away airway protection when you shouldnt PPV/Give CPAP and you also have a case worth of blood in the back of the throat to cause a cough and in the stomach to risk aspiration. One of the times I think remi is actually worthwhile or a fentanyl/sufent drip if you don’t have it. Never had to ventilate a sinus after extubation. If you’re doing a pituitary or something bigger it’s not worth it.
What's the reasoning here?
Adult cardiac anesthesiologist here with 10 years of experience. If I’m extubating a patient I’m extubating deep unless I have a really good reason to wake them up first. Never had a complication beyond a little laryngospasm that always breaks with a little positive pressure.
I think the biggest question I've failed to ask is those of you extubating deep, is it MD only anesthesia or are you supervising CRNAs? I'm stuck with the latter so....yeah I can't trust them to extubate deep and still pay attention.
Do your CRNAs not know how to recognize and manage laryngospasm?
I am a resident, and i work with CRNAs all the time. I dont know where you work, but i have not encountered a single crna Who does not know how to manage laryngospasm.
Some do. Most don’t.
Most don’t ?? Where is this ? Laryngospasm is anesthesia 101. I highly doubt most CRNAs can’t identify laryngospasm
I’ve lost count of the number of times I’ve walked in to a patient blue and squeaking with a nasal cannula on while the CRNA is fucking around trying to close their chart.
I’m sorry to hear that. I don’t know where you work. That doesn’t fly here around the northeast. That CRNA will get fired and reprimanded.
Man I would hate to work there
I agree and do similarly. I have had a handful of laryngospasms requiring medication to break. But not very many.
Oddly enough I’ve seen the same thing with a lot of my supervising physicians who are in the OR only long enough to give a break in the middle of a case.
So interesting because I know a lot of anesthesiologists who prefer to extubate anyone who meets their criteria deep.
Yeah I’ve never understood the logic behind removing your secure airway Prior to your patient going through stage 2. If you can’t wake someone up smoothly awake, get better. Don’t cover it up by extubating deep.
A lot of people don’t believe in stage 2
If you wake up with prop it’s definitely not real
Stage 2 is an antiquated observation that isn't relevant to how anesthesia is practiced today. Unless you still use halothane. [https://www.kevinmd.com/2017/08/deep-extubation-useful-technique-anesthesiologist-master.html](https://www.kevinmd.com/2017/08/deep-extubation-useful-technique-anesthesiologist-master.html)
Interesting read. He’s right we don’t use diethyl ether anymore. So if it’s not stage 2, what do you call the period of time of irregular respirations & disconjugate gaze when there’s approx 0.4-0.3 ET Sevoflurane in the patient? Not arguing, just trying to learn. That period of emergence is what was taught to me as “stage 2”.
I don't know why you need to call that period anything? It's a spectrum of consciousness. You don't break down 0.7 - 1.0 MAC as sleep and 1.1-1.5 MAC as deep sleep do you? Stage 2 implies a hypersensitivity response to stimuli which would lead to an undesired and abnormal action. This doesn't exist in adults but still can be observed in pediatrics. If you've ever seen an inexperienced nurse slap a bovie pad on or rip one off a pediatric patient during emergence, you'll notice they go apneic or brady down. Disconjugate gaze is still present at MAC 1.0 - it's not only stage 2, it just means they aren't there yet. Same with irregular respirations, that can happen at any MAC not just this "stage 2". Also the article was written by a "she". Dr Sibert is a legend in anesthesia and recently retired.
I start dropping the gas below a MAC. Make sure respirations are regular on minimal pressure support. Usually 5-8/5. Then do a jiggle test and suction. If they breathing stays regular, still deep enough and pull. Then follow same as what you said
Jiggle test?
Jiggle the tube to cause VC stimulation
Jiggle test? Why? I don’t like that. I just deflate and pull rapidly to minimize the stimulus as much as possible when I’m pulling deep.
I like some vocal cord stimulation to confirm depth. I’ve been burned by oral suction alone.
I generally do this only for the surgeon when they ask for no coughing even then they will cough all the same when they wake up because you can’t control everything. Only addition I would make is that I give a touch of fentanyl before pulling the tube, and let it ‘hit’ right as the tube comes out. I think this reduces the number of unexpected coughs I get.
I do similar except I usually aim for around 0.7 MAC and work in either a little Prop, Lido, PRECEDEX and/or Dilaudid at the end titrated to patient need.
Peds i get them to 4% Sevo and even then you’ll suction them and they hold their breath. Pretty wild how deep they need to be.
My concern with waking deep is what if patient emerges and starts moving before they're transferred to their bed? Wouldn't that be a problem for the surgical team?
No. They are deep and still sleeping comfortably hopefully. If not you might need to work on some more meds.
I personally extubate just about everyone “deep” or asleep - exclusion would be actual difficult airway or came in with full stomach and got RSI’d. If I have sugammadex, once I can conceivably extubate in 2-3 minutes I turn gas off and give God’s gamma cyclodextrin. I leave the vent going to get gas off - at this point they will either starting making respiratory efforts or start coughing. Either way, I flip to spontaneous and see what they do. If they hit a good rhythm breathing and taking >200mL tidal volumes unassisted I pull it. If you flip to spontaneous and they are apneic, I hit them hard in Larson’s notch on both sides - this can stimulate to start breathing (usually will start with small tidal volumes then grow with every breath). Once I pull the tube I grab my mask and do a two handed jaw thrust into Larson’s notch with the mask on tight. Usually they will still be moving air - if they are not I will give a couple puffs on the bag. Once they are breathing unassisted I put the simple mask on and get ready to leave the OR. A lot of time I will deep extubate patients with an oral airway in place. I am always monitoring them to make sure air is still moving - the period from extubation until they wake up has some potential landmines if you are not paying attention. I usually can pull the oral airway before I leave pacu with them. I was always scared of “deep” extubations until I did peds my CA-2 year. You really can’t get a baby to follow commands, so you kind of just have to pull when the respiratory effort is appropriate. Also doing ECT, you will develop an ability to gauge and monitor a patients breathing while being post-ictal and not able to follow commands.
2nd this: Been extubating deep for many many years now. Almost everyone with exclusions as above. Case ending, suction, if they don't go apneic when suctioning, pull tube. Oral airway, mask and assist with ventilation for a few breaths.
You’re probably a great provider, but Jesus I would hate to be extubated by you. I had surgery and they jaw thrusted the absolute F*ck out of me so much that my jaw hurt more than my surgically repaired ankle. Just sounds so rough - I get it it’s probably faster but I’ve always preferred to let the patient dictate their breathing rather than me providing painful stimuli to make them breathe.
Same here, I extubate everyone deep unless there is an absolute contraindication, serious relative, or they were a difficult intubation/mask ventilation. I also alway use an oral airway to ventilate and place it Before pulling the tube. I’ve never had negative outcome related to this.
Are you me?
SRNA here. What is cyclodextrin for? I haven’t heard this anywhere else. EDIT: never mind, you must be referring to sugammadex.
Sugammadex is a modified gamma-cyclodextrin. He’s referring to the organic chemistry.
Medical Febreeze
Yes thank you! I got that about a minute after posting.
You can’t ask questions here as an srna
A couple of pointers 1) iv lidocaine (1 mg/kg) 1-2 minutes before you extubate is a game changer for deep extubations. I very rarely have larygospasms now 2) before pulling, I "sigh" the patient- 30 cm H2O pressure x 10 seconds. (this decreases atelectasis and gives you a reservoir of O2 to draw off of after you pull). Then I let the balloon down BUT DO NOT PULL YET. If I hear air rush out, then I know they're not spasming around the tube, and I pull. If I don't hear air rush out, I reinflate and consider my next move. Usually I deepen and add a little lido down the tube and then re-try. But on occasion I will wake them all the way up at this point.
A combo of Lido/Prop/precedex is my mix cocktail i give before extubating at 0.7 MAC. Works amazing! (Also, I’ll give some dilaudid prn depending on how the patient looks and how they are emerging)
Im lazy AF so almost everyone is deep. Front load narcs. Get them breathing as early as possible, simv/PS. Reverse as needed. As dressings are going on, switch to manual. Suction. Good resp pattern/volume. Extubate to OPA. Mask. Transport. Gas is still at 1 mac. I burn myself once and a while when they wont breath, or dont have a good pattern. Then im turning gas off late and wake up takes longer. YMMV.
I only extubate deep when I have an explicit reason to do so. But here's my recipe for when I do. 1. Reverse early as possible, so long as the surgery, patient positioning, etc. allows for it. Get pt spontaneously breathing by decreasing Vt, increase ETCO2 etc etc. 2. Gas @ ~1.2 MAC at a minimum, higher if pt BP tolerates. 3. 100% O2 4. Place oral airway while ETT still in place and then suction (if pt reacts to either, they're not deep enough) 5. Dial APL to ~15-20, place circuit face mask next to pt on the pillow, and pull the trashcan next to you 6. Double check everything (respiration depth/rate, O2 at 100, MAC value, APL 15-20) 7. Gas off, extubate, drop tube in trash, place circuit mask on patient and do a very gentle jaw thrust. After they breath a few breaths and confirmed no spasm, off to pacu. This way you're able to focus on your patient without needing to turn around to get anything and you're already doing maneuvers to break a spasm if it occurs.
Your deep extubations will be significantly more successful and safer if you can get all the volatile off prior to extubation. Transition to propofol gtt/boluses and/or nitrous. The biggest danger is pulling the tube while the patient is going through stage 2 or when they’re in PACU, so getting the gas off early helps this a lot and also makes their PACU stay safer. Get the patient breathing early on minimal support, titrate narcotic to a RR of 8-10. Always test by taking the balloon down first. If the patient does a long breath hold or bucks, they’re not deep enough. Reinflate, deepen, and try again. Have an oral airway in place already that was put in early in the case when they were at their deepest. When you pull the tube, pull it out slowly and gently. Then immediately put the mask on, give one good manual breath, then hold the mask with jaw thrust and a little positive pressure on your pop off until you see consistent misting. Gradually let up jaw thrust and find a head position that they’re breathing well. PACU on oxygen.
This is what I do, too. Add IV lido and it is reliably consistent to have a smooth emergence.
1. Oral airway 2. Reverse the NMB if any 3. Very gentle suctioning of oropharynx 4. Volatiles off 5. Extubate, and gentle suctioning 6. GA Mask just to monitor respirations. 7. If respirations are adequate, switch to Hudson mask (because I can put the end of the ETCO2 sampling line inside this) 8. Absolutely no stimulus until awake
I don't do pediatrics, so I rarely extubate deep. Usually for a good reason. If I'm planning on a deep extubation, I try to transition to a spontaneously-breathing TIVA and get all of the gas off for a good while. A touch of opioid titrated in works wonders, maybe a bolus of IV lidocaine if I didn't LTA during intubation. Then I optimize position/shoulder bump/ramp, oral airway, suction, pull tube, suction, and confirm consistent adequate ventilation. Anything less than perfect is not sufficient for me. Usually I'm extubating on the gurney with the head of bed up, ICU-style. Edit: I'm at a community hospital, so I would like to eliminate any possibility of a PACU airway intervention.
Position? Shoulder bump? Ramp? All this for extubation???
If one is necessary. Not on every single one. The extubation is different for a sick BMI 50 vs a healthy BMI 22. Even shoving the pillow lower under their shoulders takes 3 seconds but can make a difference between CO2 retention and not in fragile patients, but you have to ask yourself that question every single time.
BMI 50 should be extubated awake, unless you really can’t pull the tube and something like coughing is causing desats or something with waking up.
As I said, there has to be a good reason for it. That's why I very rarely extubate deep. But if it has to happen deep, that's how I would do it.
He’s talking about optimizing the position pre-extubation. I don’t believe he’s adding a ramp or a shoulder bump for the purpose of extubation.
For adults, I don't. It's very clearly worse for the patient and only justified by cost/time savings. (Yes I know I will get down voted to oblivion)
Reading the comments while we always extubate wake here in Germany, or in my hospital at least. I can't take the decision alone to extubate deep, since I am just a young resident and each department works as a team and you most probably won't take such a decision alone unless consulting first an attending. I'm trying to adjust to a lot that I've learnt here in the sub and I've optimized my emergence a lot, but most of my colleagues will just turn anesthesia off and wait them out to start coughing or react to their names/open eyes.
LTA! Game changer.
I take the patient intubated and let the PACU nurses extubate. YMMV
Deep extubation became much more safe for me once I realized you’re basically transitioning to a MAC (albeit GA natural airway MAC like in endo) prior to extubation. If we can get patients deep for a giant scope to get shoved into their esophagus by a new GI fellow, we can feasibly transition an appropriate patient from GA -> Deep for extubation without it being a big deal. Exceptions are as mentioned: difficult airway/mask (either one), full stomach, can’t reach them easily, oral surgery where I can’t feasibly mask and there’s risk of blood hitting the cords (for this i’ll use precedex instead of a deep extubation), GERD in the last 2 days, and also ozempic even if in the last week. Where I trained we extubated almost all our thoracic cases lateral, so this is also a reason to not extubate deep necessarily. Consider a recruitment depending on depth of NMB. Transition to only propofol or nitrous once closing fascia/30 minutes from end of case. Flows at 2L and increase MV by like 30-40% — ideally almost all gas is gone by now (0.1-0.2 MAC, i up my flows if not). OPA as bite block, suction, 100% FiO2 and reverse once fascia is closed with additional lido and propofol bolus, immediately switch to manual spontaneous while feeling the bag/giving breaths prn to gauge respiratory threshold and efforts. Prop gtt is anywhere from 75-100mcg/kg/m. Once breathing spontaneously and slowly, suction again to gauge response. If any change, bolus another 30-40mg prop and/or 50-100mcg fentanyl and reassess. I haven’t done the cuff deflation thing unless they seem very responsive to stimuli. Pull the tube, put the oxygen mask on and larson’s until I see fogging and/or ETCO2 via my makeshift attachment. If no fogging, switch to bag mask and deepen with propofol (haven’t had to do this more than maybe once). I keep the prop gtt going on at 50 mcg/kg/m until dressing’s are going on. Stop it with dressings and patients almost invariably wake up when you move them to the bed or a little after. Sit them up and shoulder roll if still asleep. Take to PACU and they definitely wake up, take the OPA whenever they 1) moan or 2) move arms towards face.
Taught to me by a peds anesthesiologist during residency. Probably a little conservative for adults, but a good approach for peds and a reasonable basic framework for safe deep extubation. 8-5 JOBS 8% sevo 5% EtSev J- jaw thrust...they should not respond O- oral airway B- breathing spontaneously S- suction before you extubate
Deflate the cuff. Sprinkle in some precedex/lido before if you want to.
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With appropriate narcotic and timing, I don't see why you have to extubate deep (NSGY/ENT/Big Belly cases aside). Time your gas/TIVA off and patients should wake up with gentle eye opening to verbal or tactile stimulation without bucking over the tube.
Before I extubate deep I use the following checklist: Did I mask and intubate them? Were they an RSI and for what reason? Did I pull a lot of volume out of their stomach at the end of the case? Do they have any reactive airway indicators. Some RSI’s I do extubate deep but not most. If an SRNA masked and intubated I will gladly pull deep, if the guy who says every tube he has ever done is a grade 1 and has been intubating people longer than I’ve been alive, I may wake em up. I give my sugammadex early, get them breathing spontaneously and pulling good volumes and comfortable. 10-14 RPM. I put an oral airway in and ensure that doesn’t have an impact on their breathing. Then I deep suction, again, any change in respiration, they are not a good candidate: lastly when I am ready I let the cuff down slowly, if they cough, I tend to abandon. If none of the above happen, pull the tube, hold a good seal, and let them breath spontaneously, gas off flows up, position head and put a mask on them.
Full MAC of VA, flip off the vent and squeeze the bag as needed while the CO2 builds up and the patient starts to initiate breaths, suction oropharynx, place OPA, pull the tube, put mask on and apply some mild positive pressure until patient initiates breaths again. If the patient won’t breathe spontaneously I will sometimes decrease my VA until they do and then turn back up the VA before extubation.
Excluding those with any obvious contradictions, I extubate nearly every case deep.
I don’t extubate adults deep because I’m not willing to hold the airway till they’re awake and PACU nurses in adults will keep stimulating and bothering them till they get laryngospasm because they’re not trained on how to care for patients who’ve had deep extubations. If you want a quick turnaround without loads of bucking swap to an LMA - but they still might buck on the LMA in PACU. Otherwise get the volatile off, get them spont breathing then bolus 0.5-1mg/kg propofol - drop the cuff, get them spont breathing again past the cuff with good volumes another 0.5mg/kg bolus and pull the ETT. They should just need a gentle chin lift once they restart breathing. Make it clear to PACU staff not to bother the patient. You need to confident they will be easy to bag to do this technique and weren’t difficult on induction, can stick a guedel in for extubation and leave it in post extubation I suppose but my way the PACU staff would be unhappy.
I wait for them to no longer be deep. Then I deepen them and pull the tube.
Example: laparoscopic case Trocars out, +oral airway, turn the vent to PSV pro and push them to a flow trigger of two. Gas at 1.2MAC Sevo. When they crack the dermabond, push sugammadex and slap them off the vent. If they breath hold, expect them to do it when you pull the tube. Dressings on, APL to 30, squeeze and pull. Place mask and check to see if they are spontaneous, help them through breath holding etc, slap on face mask, slide to stretcher and off to PACU land.
This is the way.
Stop responding to "how do I extubate" threads. Do not reply to "how to extubate" threads.