Deep extubation in apneic patient

[bkell101]

Hey guys...what are your thoughts on this?

Crani for tumor removal, healthy 40's, no lung or carsiac issues, thin, easy mask and intubation, uneventful 4 hr case, 100 mcg fent on induction, reversed, prone with head pinned, dez + remi maint

Attending's preference: flip and deep extubate in apneic pt, mask pt till wake up.

Everything goes fine.

Books say deep extubation one of the major criteria breathing spontaneously with adequate oxygenation and ventilation with minimal support.

Some of the residents and I were talking about this...what are your thoughts and opinions? Anybody deep extubating apneic patients on remi?

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[caligas]

Balsy but not totally insane

 

[pgg]

Nothing dangerous about masking an apneic patient. We do it all the time after induction. Plan B when you can't mask is the same, too - stick something in the airway.

 

[GaseousClay]

I prefer patient awake before extubating cranis

 

[fakin' the funk]

For me this is all downside with minimal upside. What's the upside? Less coughing? You (or your attending) can't get a crani pt awake and extubated without coughing?

A) Extubating a crani deep, IMO, is ill-advised. Arousal is the first sign that there hasn't been major surgical misadventure and you're not going to CT scanner and then ICU intubated. If you had to reintubate, that would not only be stupid, but you would probably be QA-flagged or somesuch.
B) Extubating an apneic patient deep isn't necessarily wrong, but there's no advantage to it versus extubating deep w/ spontaneous ventilation.

 

[narcusprince]

NO! BAD ANESTHESIA!

 

[dhb]

NO! BAD ANESTHESIA!

Typical reaction

 

[deleted171991]

Hey guys...what are your thoughts on this?

Crani for tumor removal, healthy 40's, no lung or carsiac issues, thin, easy mask and intubation, uneventful 4 hr case, 100 mcg fent on induction, reversed, prone with head pinned, dez + remi maint

Attending's preference: flip and deep extubate in apneic pt, mask pt till wake up.

Everything goes fine.

Books say deep extubation one of the major criteria breathing spontaneously with adequate oxygenation and ventilation with minimal support.

Some of the residents and I were talking about this...what are your thoughts and opinions? Anybody deep extubating apneic patients on remi?

Very risky. I wouldn't call it ballsy; I would call it much worse. You don't know when/if that patient will wake up.

The more you mask ventilate, the higher the chance for regurg and aspiration. We rarely see that on induction, because we only do it for a minute or two.

A much more elegant plan is to wake up the patient intubated in a controlled fashion. That's what remi is there for; beautiful drug.

Or if the attending wants deep ET extubation, stick in an LMA. The patient will not buck, you can wake him up on the vent, and you don't risk putting air in the stomach.

 

[scudrunner]

Remi wake ups are beautiful. No point in extubating deep. The only trick is make sure remi is the only thing keeping the patient asleep- that means getting whatever other anesthetic off before turning off the remi. If they buck, you didn't get the other stuff off in time.

 

[deleted171991]

Remi wake ups are beautiful. No point in extubating deep. The only trick is make sure remi is the only thing keeping the patient asleep- that means getting whatever other anesthetic off before turning off the remi. If they buck, you didn't get the other stuff off in time.

Bingo!

 

[loveumms]

Wouldn't be my preference. I love deep exhibitions but not cranis.

I always do TIVA for cranis and found this smoothes wake up. I like to keep just a little precedex in too. Shut off propofol early and use dex and rent to wake up.

If they buck it's because not enough narcotics have been given.

 

[PainDrain]

Remi wake ups are beautiful. No point in extubating deep. The only trick is make sure remi is the only thing keeping the patient asleep- that means getting whatever other anesthetic off before turning off the remi. If they buck, you didn't get the other stuff off in time.

Our cocktail for cranis during residency was remi and precedex with a small amount of volatile agent or propofol if doing full TIVA. About ten minutes before expected wake up you shut off the gas and then about a minute before you shut off the remi and dex. The wakeups were amazing, patients simply opened their eyes and voila.

I wouldn't extubate deep in apnea because (a) you are having to mask a patient who just had brain surgery and you are trying to avoid increases in ICP, coughing and bucking make for increases. (B) Like others have said what if they aren't breathing, is that your fault or surgical error? What if you have to reintubate? That will increase ICP.

 

[Jay K]

For me this is all downside with minimal upside. What's the upside? Less coughing? You (or your attending) can't get a crani pt awake and extubated without coughing?

A) Extubating a crani deep, IMO, is ill-advised. Arousal is the first sign that there hasn't been major surgical misadventure and you're not going to CT scanner and then ICU intubated. If you had to reintubate, that would not only be stupid, but you would probably be QA-flagged or somesuch.
B) Extubating an apneic patient deep isn't necessarily wrong, but there's no advantage to it versus extubating deep w/ spontaneous ventilation.

Agree

 

[criticalelement]

Remi wake ups are beautiful. No point in extubating deep. The only trick is make sure remi is the only thing keeping the patient asleep- that means getting whatever other anesthetic off before turning off the remi. If they buck, you didn't get the other stuff off in time.

what is your technique for remi wakeups?

 

[Twiggidy]

I don't see the point AT ALL. What's wrong with at the very least getting the patient breathing and extubating deep? Is you attending in that much a hurry? I mean, it was a 4hr crani....again, what's the rush? Unless you have a second one scheduled, but still, get the patient breathing at least.

 

[pgg]

I wouldn't choose to do it this way - like fakin the funk says, no real upside - but I don't really see the problem, if it's done competently.

(I am assuming that after this weird deep extubation, they are remaining in the OR for emergence and the return of SV.)


Aspiration risk? Really? I put an OG in and out of everyone I extubate deep, which isn't often. Surely one wouldn't choose the OP's attending's technique if masking wasn't easy. If you pick your patients with even a shred of caution there's no appreciable risk of gastric insufflation, regurgitation, and aspiration.

Delayed emergence? That's a rare occurrence, and if it does happen, just put the tube back in, or use an LMA. Reintubations get flagged for review if they occur in the PACU / floor / ICU. No sane person would submit an in-OR "airway adjustment" for review because of a neurologic misadventure, and if someone insane did sic the peer review process on it, it'd be easy to defend. Optional airway maneuvers are a problem if they introduce risk; this one doesn't.

If you think the odds of delayed emergence are high (e.g. trauma) then don't pick this technique.


Much ado about nothing.

 

[Spinach Dip]

Maybe I'm missing something, but I don't understand why you would EVER remove an ET tube before a patient has recovered their ability to respire without intervention.

 

[Urzuz]

Your attending is teaching you terrible technique and reasoning. Just because you CAN do something and it has worked in the past doesn't mean you SHOULD do it. I can kind of see what his reasoning is, but there are a number of different ways to prevent a patient from bucking...and taking the tube out before the patient has started breathing is probably the worst of all of them in terms of risk/benefit. As people have mentioned before, you have no idea if the patient even WILL start breathing again (which may be a good exercise for you -- what is your differential for a patient who doesn't start breathing or doesn't wake up after anesthesia?) Disregard everything that attending has taught you and unlearn any habits he has tried to impress upon you, because I can only imagine they are equally as dangerous.

And as a side note, since you're a resident it is probably worth mentioning -- if you say something like this on your oral boards I wouldn't be surprised if you automatically failed.

 

[pgg]

Maybe I'm missing something, but I don't understand why you would EVER remove an ET tube before a patient has recovered their ability to respire without intervention.

The idea in this case is that
1) the only reason the patient isn't breathing is the remifentanil infusion, which will be very predictably gone very soon
2) the wakeup will be very smooth

There are about 9 ways to accomplish a smooth emergence. This method might be #9 on my list, but that doesn't make it stupid or unsafe.


One of the primary anesthetic goals after a neurosurgical procedure is a patient that is promptly awake and cooperative for a neurologic exam. Presumably this guy shut off the remi, extubated the patient deep, masked for a few minutes, the remi did its dose-independent ester magical disappearance, SV and consciousness ensued, and an exam was done. It was probably a quiet, smooth event. Except for all this flea-like angst over it.

And as a side note, since you're a resident it is probably worth mentioning -- if you say something like this on your oral boards I wouldn't be surprised if you automatically failed.

While true, that doesn't really speak to the safety of the technique. Presenting any unconventional plan is a bad idea for the oral boards. You want to give a simple, satisfactory answer to each question, then STFU so the examiner can move on, not spend time defending your unconventional plan.

More time answering, less time explaining = passing.

 

[OB1🤙]

I agree with pgg on this. It isn't the way I would do it, but I don't think it's inherently unsafe in a fasted patient who is predicted to be an easy mask.

 

[Scotty_G]

Let's be honest if you are using dex and remi you won't need to extubate deep because you should have a smooth wakeup lol. Bkel you can always leave remi on and lower the infusion rate until they start breathing.

 

[Urzuz]

While true, that doesn't really speak to the safety of the technique. Presenting any unconventional plan is a bad idea for the oral boards. You want to give a simple, satisfactory answer to each question, then STFU so the examiner can move on, not spend time defending your unconventional plan.

I agree with you that it is unconventional, but the reason why it is unconventional is because it is not the safest route to take (which at the end of the day is what the oral board examiners are looking for -- are you safe and can you justify your actions).

Safety is anesthesia is completely skewed. Anesthesia is extraordinarily safe -- so safe that incompetent nurses can do it and not off patients left and right. Regardless of how sick a patient is or how invasive a surgery is the rate of complications will be low. However, when discussing and debating safety, it is all relative. The absolute incidence of complications associated with taking an ETT out before a patient has started breathing may be low, but relative to the other routes it will be higher. Do I have a study to back that claim up? No, but you don't need an RCT to prove the sky is blue. To leave a patient with an unprotected airway while they have zero airway reflexes, before they've started breathing, not even knowing if they will EVER wake up since a chunk of their brain was just excised, is infinitely times more unsafe than letting a patient breathe spontaneously and taking other measures to prevent coughing/bucking.

And getting back to OP's post, the fact that he was using remifentanil and desflurane should make having a timely, smooth wakeup that much easier!

 

[lakersbaby]

agree its probably safe but seems like a waste of energy and really makes no sense to me why anyone would ever wake up a crani like that...

 

[teeva]

I'm lazy. Dunno why I'd want to mask a pt til they wake up when a machine can do it for you if you hadn't yet gotten the pt to do it on their own. /s

But seriously, it is unnecessary. When they start closing, turn down propofol and gas. Titrate BP with labetalol, give Zofran, and I like to also give a small dose of Dilaudid. Get the pt breathing. Turn off propofol and gas when they're done closing and keep remi low dose going 0.05. When they take head out of the pins and pt the pt supine, turn remi off. By the time wipe off all the dried blood, wrap bandage, put the headboard back on, and change the pt's gown, the pt will be ready to open his/her eyes and give you a signal to please remove the tube, and then you put a face mask on the pt stand around for a while catching up on charting and waiting for neurosurg to come back and do neuro exam before leaving the OR.

 

[deleted171991]

Extubating a patient while still not breathing is almost like turning off the engines while the plane is still in the air.

Yes, any good attending will probably get away with it, but that's not the point. The point is that he should not be teaching this.

And, btw, suctioning one's stomach does not completely eliminate the risk for aspiration.

 

[Planktonmd]

What's the point???
Doing something that provides no benefit and potential risk is simply stupid!

 

[scudrunner]

what is your technique for remi wakeups?

Whatever else I am using with remi- prop or volatile, turn it off early, go up on remi if needed. Surgical dressing on, remi off, drapes down, transfer or to bed, slide in 50 of fent, pt opens eyes, vent off, pull ett tube after first breath and head to pacu. Time from remi off to wake up is usually about 10-12 min. Adjust timing of things as needed.

 

[pgg]

And, btw, suctioning one's stomach does not completely eliminate the risk for aspiration.

Yeah, and a meteor could strike the hospital and kill us all; no risk is zero.

Would you also argue that PPV with an LMA is an unacceptable risk for aspiration? Or that SV with an unprotected airway prior to emergence is an unacceptable risk?

You're really conjuring aspiration as the deal killing risk here?

What's the point???
Doing something that provides no benefit and potential risk is simply stupid!

Nothing wrong with deep extubation. It has some benefits, mostly overblown IMO, but they exist.

All this angst over a few minutes of mask ventilation while the remi gets metabolized strikes me as bizarre.

 

[bkell101]

For me this is all downside with minimal upside. What's the upside? Less coughing? You (or your attending) can't get a crani pt awake and extubated without coughing?

Agree, but to play devils advocate...most crani wake ups go fine and smooth with remi and short acting volatiles , but can you say that you 100% of the time you wake up patients without coughing on remi?


B) Extubating an apneic patient deep isn't necessarily wrong, but there's no advantage to it versus extubating deep w/ spontaneous ventilation.

Reasoning was to have a fully reversed patient in pins, light gas and use remi to keep patient from moving in pins (sacrificing respiration obviously)...agree that this is impatient as you could flip turn down remi, get patient breathing then extubate deep

 

[bkell101]

Nothing dangerous about masking an apneic patient. We do it all the time after induction. Plan B when you can't mask is the same, too - stick something in the airway.

At first my impression was, well that sounds insane....but this point above is exactly what we as residents were arguing about ....let's say it wasn't a crani and you had all short acting agents, easy mask, easy case, thin...pull tube and mask? Is adequate respiration an absolute for deep extubation? Masking increases aspiration risk even if done properly?

 

[bkell101]

Very risky. I wouldn't call it ballsy; I would call it much worse. You don't know when/if that patient will wake up.

The more you mask ventilate, the higher the chance for regurg and aspiration. We rarely see that on induction, because we only do it for a minute or two.


A much more elegant plan is to wake up the patient intubated in a controlled fashion. That's what remi is there for; beautiful drug.

Totally agree, crani wake ups are for the most part very easy with remi. Hardly ever have a problem.

Or if the attending wants deep ET extubation, stick in an LMA. The patient will not buck, you can wake him up on the vent, and you don't risk putting air in the stomach.

Proper mask ventilation vs lma has higher chance of aspiration in an apneic patient?

 

[bkell101]

Maybe I'm missing something, but I don't understand why you would EVER remove an ET tube before a patient has recovered their ability to respire without intervention.

You aren't missing anything....that is the entire point of this case and exactly why I brought it to this board. I've always been taught deep extubation requires adequate respiration: end of story.

 

[bkell101]

The idea in this case is that
1) the only reason the patient isn't breathing is the remifentanil infusion, which will be very predictably gone very soon
2) the wakeup will be very smooth

I think this is one of the main points. This is a healthy patient that one would predict to have no issues oxygenating and ventilating after an uneventful case and the only only only this keeping him apneic is a very short acting drug.


There are about 9 ways to accomplish a smooth emergence. This method might be #9 on my list, but that doesn't make it stupid or unsafe.




One of the primary anesthetic goals after a neurosurgical procedure is a patient that is promptly awake and cooperative for a neurologic exam. Presumably this guy shut off the remi, extubated the patient deep, masked for a few minutes, the remi did its dose-independent ester magical disappearance, SV and consciousness ensued, and an exam was done. It was probably a quiet, smooth event. Except for all this flea-like angst over it.


Took about 2.5 min from time we flipped and took out tube for the patient to be compliant with neuro exam. Rock solid hemodynamics. Never any obstruction during masking. Minimal pressure to mask.

While true, that doesn't really speak to the safety of the technique. Presenting any unconventional plan is a bad idea for the oral boards. You want to give a simple, satisfactory answer to each question, then STFU so the examiner can move on, not spend time defending your unconventional plan.

I agree, this would be an absolutely insane thing to say for oral boards.

More time answering, less time explaining = passing.

 

[bkell101]

agree its probably safe but seems like a waste of energy and really makes no sense to me why anyone would ever wake up a crani like that...

Agree 100% , on my own Remi and des are so easy to use I can't see a reason to use this technique on my own in the future, it's just interesting that it defies what we are taught about deep extubation.

 

[bkell101]

What's the point???
Doing something that provides no benefit and potential risk is simply stupid!

The point was that sometimes patients still cough and buck on remi. Rarely happens, but it does because we aren't perfect at guessing how much remi somebody needs. So the advantage would be less chance of coughing and bucking and more stable hemodynamics.

Then extubate deep with a patient spontaneously breathing right? But then again why do they have to be spontaneously breathing if u can easily and properly mask them? Aspiration? They can still aspirated when they are spontaneously respiring and extubated deep right?

As a disclaimer this is absolutely not the way I chose to extubate my cranis but I think it's worth playing devils advocate and having the discussion

 

[Planktonmd]

Yeah, and a meteor could strike the hospital and kill us all; no risk is zero.

Would you also argue that PPV with an LMA is an unacceptable risk for aspiration? Or that SV with an unprotected airway prior to emergence is an unacceptable risk?

You're really conjuring aspiration as the deal killing risk here?



Nothing wrong with deep extubation. It has some benefits, mostly overblown IMO, but they exist.

All this angst over a few minutes of mask ventilation while the remi gets metabolized strikes me as bizarre.

Deep extubation is great but extubating an apneic patient before return of spontaneous ventilation is pretty stupid!

 

[Planktonmd]

The point was that sometimes patients still cough and buck on remi. Rarely happens, but it does because we aren't perfect at guessing how much remi somebody needs. So the advantage would be less chance of coughing and bucking and more stable hemodynamics.

Then extubate deep with a patient spontaneously breathing right? But then again why do they have to be spontaneously breathing if u can easily and properly mask them? Aspiration? They can still aspirated when they are spontaneously respiring and extubated deep right?

As a disclaimer this is absolutely not the way I chose to extubate my cranis but I think it's worth playing devils advocate and having the discussion

The advantage of waiting for the return of spontaneous ventilation before deep extubation is to assess the patient's respiratory drive and respiratory effort to avoid situations where you have to mask ventilate for a long time or reintubate.

 

[Arch Guillotti]

NO! BAD ANESTHESIA!

Why?
If something can be safely without bad outcomes, why is it bad? Especially if there are no complaints from the surgeon.

Stupid, for all the reasons already listed but not necessarily bad.

I would be thankful that as a resident I had an opportunity to try different things.

 

[pgg]

Deep extubation is great but extubating an apneic patient before return of spontaneous ventilation is pretty stupid!

Dogma, from you? I am disappoint.

I don't think it matters. So far in this thread, these are the reasons presented as to why it's dangerous: aspiration risk, and delayed emergence risk. Neither of which I buy.


At worst, the technique amounts to making a spectacle out of something that is a routine afterthought to most of us.

So, minus style points for doing it the hard way.

 

[Planktonmd]

If you extubate before the return of spontaneous ventilation you are basically guessing that your dosage of opiate and residual anesthetics will permit the patient to start breathing adequately in a reasonably short time without being in too much pain.
Allowing spontaneous ventilation to happen first takes the guessing out of the equation, you will know that the patient can breath on his own and it will also allow you to give more opiates if the respiratory rate is too high.

 

[pgg]

Some wakeups are more predictable than others. There's not much voodoo involved in guessing when the remi's going to be gone.

 

[Planktonmd]

Some wakeups are more predictable than others. There's not much voodoo involved in guessing when the remi's going to be gone.

Most people give another longer acting opiate at the end of surgery when they are using Remi and having a spontaneously breathing patient allows better titration of the dose.
Although I submit that with a craniotomy you might get away with nothing but Remi since there is no post-op pain usually.

 

[bkell101]

If you extubate before the return of spontaneous ventilation you are basically guessing that your dosage of opiate and residual anesthetics will permit the patient to start breathing adequately in a reasonably short time without being in too much pain.
Allowing spontaneous ventilation to happen first takes the guessing out of the equation, you will know that the patient can breath on his own and it will also allow you to give more opiates if the respiratory rate is too high.

Agree, but this is why I stated 100mcg of fentanyl on induction and that's it. Gas is nill and it's not much guesswork with remi. No real reason a young healthy guy shouldn't vent/oxygenate just fine.Our cranis really don't have much pain. So no need to iterate to resp rate at the end. Maybe some headache that a little fent or dilaudid can fix just before leaving the room or in the nccu.

 

[Twiggidy]

All this angst over a few minutes of mask ventilation while the remi gets metabolized strikes me as bizarre.

On this same very forum people made it seem like it was malpractice because I put a CVP in a patient. So the angst isn't that bizarre to me.

 

[Urzuz]

Dogma, from you? I am disappoint.

I don't think it matters. So far in this thread, these are the reasons presented as to why it's dangerous: aspiration risk, and delayed emergence risk. Neither of which I buy.


At worst, the technique amounts to making a spectacle out of something that is a routine afterthought to most of us.

So, minus style points for doing it the hard way.

Whether or not you buy delayed emergence risk, delayed emergence following intracranial surgery is a real thing. I trained at one of the busiest neurosurgical centers in the country (think multiple cranis a week all through residency), and I can tell you that it happens not infrequently, and though there are some characteristics that can help you predict delayed emergence, you won't know until the end of the surgery.

Read this for more information: http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1948448

Extubating a patient before they start breathing is not dangerous because it delays emergence. Extubating a patient before they have started breathing is dangerous because of the potential for delayed emergence which is something you won't know about until you've been standing around masking the patient for an hour waiting for them to wake up following removal of the endotracheal tube. Patients sometimes need to get stat CT scans following extubation if they have delayed emergence. Or perhaps they have to have their head reopened. Could you put the ETT back in at that point? Sure you could. But not only have you left a patient with no airway reflexes sitting there while you mask them like a dolt, you have also delayed the identification of a potential life threatening complication from the surgery. You will get away with it maybe 9 times out of 10, maybe even 99 times out of a 100. But you should shoot for 100/100, not anything less.

It is like asking this, could you induce someone without preoxygenating them? Sure you could. You are standing right there to mask them after they stop breathing. Why waste time preoxygenating? I think we would all agree that it is good anesthetic practice, because though 99 times out of 100 preoxygenating won't change the outcome, every 1/100 time when you get someone who is difficult to intubate or ventilate, that FRC filled with oxygen is going to buy you precious minutes that you wouldn't have had otherwise.

Perhaps if coughing on the tube once spelled death for the patient I could see why this technique would make sense. Anything outside of that scenario makes this technique completely idiotic.

 

[bkell101]

Whether or not you buy delayed emergence risk, delayed emergence following intracranial surgery is a real thing. I trained at one of the busiest neurosurgical centers in the country (think multiple cranis a week all through residency), and I can tell you that it happens not infrequently, and though there are some characteristics that can help you predict delayed emergence, you won't know until the end of the surgery.

Read this for more information: http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1948448

Extubating a patient before they start breathing is not dangerous because it delays emergence. Extubating a patient before they have started breathing is dangerous because of the potential for delayed emergence which is something you won't know about until you've been standing around masking the patient for an hour waiting for them to wake up following removal of the endotracheal tube. Patients sometimes need to get stat CT scans following extubation if they have delayed emergence. Or perhaps they have to have their head reopened. Could you put the ETT back in at that point? Sure you could. But not only have you left a patient with no airway reflexes sitting there while you mask them like a dolt, you have also delayed the identification of a potential life threatening complication from the surgery. You will get away with it maybe 9 times out of 10, maybe even 99 times out of a 100. But you should shoot for 100/100, not anything less.

It is like asking this, could you induce someone without preoxygenating them? Sure you could. You are standing right there to mask them after they stop breathing. Why waste time preoxygenating? I think we would all agree that it is good anesthetic practice, because though 99 times out of 100 preoxygenating won't change the outcome, every 1/100 time when you get someone who is difficult to intubate or ventilate, that FRC filled with oxygen is going to buy you precious minutes that you wouldn't have had otherwise.

Perhaps if coughing on the tube once spelled death for the patient I could see why this technique would make sense. Anything outside of that scenario makes this technique completely idiotic.

Great response. Risk of delayed emergence after a large tumor removal would make this a very poor technique. Have to take as closer look at this paper.

For which neurosurgical procedure would post op bucking and htn be the most deleterious?

 

[pgg]

Urzuz, your points are well taken.

I would agree that "standing around masking the patient for an hour" would indeed be clown-shoes ******ed; I was assuming the OP's attending would begin a delayed emergence workup shortly after it was clear the remi was gone.

What are you really arguing - that deep extubation itself makes delayed emergence (if it happens) worse because it delays diagnosis? That makes little sense to me. The answer, of course, regardless of one's airway management technique, is that if the patient isn't awake when you expect them to be awake (crani or no crani) you better dust off your differential and start working it up and figuring it out.

As we've both mentioned, in the neurosurgical arena, a primary objective of the anesthetic is a rapid and predictable wakeup to facilitate an exam. There's no reason that can't be done with a deep extubation.


What I'm taking away from your argument, is that given your concern for delayed emergence after any crani, that deep extubation should never be done at all, because the patient might not wake up, and you'd have to reintubate for a CT.

That stance is defensible, even prudent, but it has nothing to do with whether or not the patient is spontaneously breathing when extubated.

 

[bkell101]

Urzuz, your points are well taken.

I would agree that "standing around masking the patient for an hour" would indeed be clown-shoes ******ed; I was assuming the OP's attending would begin a delayed emergence workup shortly after it was clear the remi was gone.

What are you really arguing - that deep extubation itself makes delayed emergence (if it happens) worse because it delays diagnosis? That makes little sense to me. The answer, of course, regardless of one's airway management technique, is that if the patient isn't awake when you expect them to be awake (crani or no crani) you better dust off your differential and start working it up and figuring it out.

As we've both mentioned, in the neurosurgical arena, a primary objective of the anesthetic is a rapid and predictable wakeup to facilitate an exam. There's no reason that can't be done with a deep extubation.


What I'm taking away from your argument, is that given your concern for delayed emergence after any crani, that deep extubation should never be done at all, because the patient might not wake up, and you'd have to reintubate for a CT.

That stance is defensible, even prudent, but it has nothing to do with whether or not the patient is spontaneously breathing when extubated.

I am interpreting it this way too. It's deep vs awake extubation (our case falls into the deep extubation category obviously). BUT if you are willing to deep extubate, why do they have to be spontaneously breathing?

In terms of the primary objective: rapid and predictable wake up......in my small N of 42 cranis throughout residency, I feel that the patient is ready for a neuro exam sooner when I titrate down the gas/remi and pull tube in awake, comfy, breathing patient. One of my co-residents has been deep extubating his crani patients and I would argue that keeping the gas up till the very end just to deep extubate delays the time until the patient is awake and following commands.

 

[pgg]

I agree. I extubate my cranis awake.

Actually, I'm not really a big fan of deep extubations in general, despite my defense of it in this thread.

 

[jl lin]

Maybe I'm missing something, but I don't understand why you would EVER remove an ET tube before a patient has recovered their ability to respire without intervention.

It goes w/o saying that comparatively, I am a nobody here, but honestly, I have rarely seen this, and of course have never seen this in children I've received back from OR. I mean I get the reversal aspect, it's just that things can go wrong, and it seems on the risky side to me--especially with re: neurosurg. PICU gets way more that than CI, but still. But what the hell do I know after recovering critical patients for 20 years. shrug.

Sorry to have responded, but the thread was eye-catching. (Honestly, anesthesia threads are often one of the most educational here at SDN.) I'll shut-up now.