Extubating Prone

[Noyac]

This should be a good discussion as I'm sure many will say one thing as others will say the opposite.

Let's say you are doing a prone case, maybe a spine. The pt is breathing at the end. It was an easy airway. The closure may have taken a bit longer than expected and the pt starts to give you signs of wakefulness. Do you extubate just before the flip, hold them down until the flip or give a little something to settle them down?
If you give them something, what is it?

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[GaseousClay]

i guess you could extubate prone but that doesn't make it a good idea. "Sh**, you can drive a car with your feet if you want to, that don't make it a good f**king idea! " - chris rock.
j/k but why not just give a few cc's of propofol by the time they flip over patient will be ready to go.

 

[Doctor4Life1769]

I had extubated prone once or twice but it was after the surgeon had finished closure and the patient was starting to move and had met extubation criteria anyway but the stretcher wasn't quite yet in the OR, so I pulled the tube and talked the patient down while they did their wrap up and was able to get the patient rolled over in a safe manner on his own power when everything was completed.

While closing? I'd titrate in 20-30mg propofol. The patient will wake up again by the time the surgeon, tech, nurses take their sweet time wrapping things up. I'm sure one could extubate prone while closing, but what's the point?

 

[deleted162650]

Not a fan of the prone extubation. Risk/reward ratio just not there for me. I'm sure it'll go fine most of the time but it's just too damn easy to push 30mg of prop and extubate supine where you actually have some access for that 1 in 1000 chance something goes awry. Plus what happens when they can't find the gurney (you know the one everyone swears was right outside a second ago like it's supposed to be for prone cases but has magically vanished) and now you're babysitting a quasi awake prone pt w/ no airway and possibly some unknown degree of facial/airway edema.

I typically like to keep spine cases fairly relaxed throughout closure (low twitch count but reversible) so that way I can lighten em up with impunity without having to worry about them coming up outta the grave (we had an M&M like that in residency - not my case).

 

[Planktonmd]

It can be done safely in the right patient. You need to know what you are doing though and be personally present in the room (no CRNAs involved)

 

[deleted126335]

Can it be done? Sure.
Should it be done? Rare to never.


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[Notorious T.E.E.]

Sounds like a bad idea that probably will work out fine most of the time, but still is a bad idea. I can't imagine it is very defensible in court either.

 

[btbam]

"Well you see your Honor.."

 

[Noyac]

Sounds like a bad idea that probably will work out fine most of the time, but still is a bad idea. I can't imagine it is very defensible in court either.

Please explain your reasoning.

 

[Notorious T.E.E.]

*Edited*

This should be a good discussion as I'm sure many will say one thing as others will say the opposite.

Let's say you are doing a prone case, maybe a spine. The pt is breathing at the end. It was an easy airway. The closure may have taken a bit longer than expected and the pt starts to give you signs of wakefulness. Do you extubate just before the flip, hold them down until the flip or give a little something to settle them down?
If you give them something, what is it?

Actually, now that I reread your original post, you were asking about extubating just before the flip. In that case, with drapes off and bed in the room, it probably doesn't matter which you do from a safety standpoint. The ability to mask ventilate or reintubate is immediately available, although if I had a little propofol left I would probably still give that and extubate supine.

 

[narcusprince]

Don't do it. It can be done. It goes against one of my own personal rules of extubation that if **** hits the fan can I get the tube back in in a quick concise fashion. If not put them in a position which allows reintubation and extubate.

 

[Noyac]

Don't do it. It can be done. It goes against one of my own personal rules of extubation that if **** hits the fan can I get the tube back in in a quick concise fashion. If not put them in a position which allows reintubation and extubation.

I don't see why you wouldn't be able to get the tube back in quickly. But on another point I can't remember the last time I had to reintubate a pt I just extubated. I don't pull the tube until they are ready. And I'm not saying that you do. Just that when I pull it I know it's time.

I'll talk more about this later.

 

[narcusprince]

I don't see why you wouldn't be able to get the tube back in quickly. But on another point I can't remember the last time I had to reintubate a pt I just extubated. I don't pull the tube until they are ready. And I'm not saying that you do. Just that when I pull it I know it's time.

I'll talk more about this later.

In my 4 plus years of practice I have only had to reintubate one patient. I pull when I know it's time but if I have to put it back in I want to be in the best position possible. In my practice I work solo and these tips keep me out of trouble.

 

[Mman]

It can be done safely in the right patient. You need to know what you are doing though and be personally present in the room (no CRNAs involved)

There is nothing about having a CRNA involved that prevents you from being physically present in the room.

 

[deleted162650]

But then you would have to spend more time in close company with CRNA's.

 

[dhb]

I like to extubate while the patient is being turned over.

 

[Planktonmd]

There is nothing about having a CRNA involved that prevents you from being physically present in the room.

You will be accused of micromanagement!

 

[Noyac]

I like to extubate while the patient is being turned over.

That's the idea. Pull the tube and roll. What's the issue?

 

[pgg]

I don't see any problem at all with extubating immediately before the flip. You're going to be supine in a moment anyway. Sometimes the difference between a smooth extubation and a 22 yo angry male thrashing around like a maniac is 15 seconds less plastic in the trachea.

I'm not sure there's much to be gained, not even style points, with extubating so early that they're still closing - i.e. early enough that if you DID need to intervene, it would result in rushing or interfering with the end of the procedure.

I not infrequently do prone cases under GA with no airway device at all (ERCPs, butt pus, etc). You have to choose the patient and choose the surgeon. I'm not sure that situation is really that different than extubating the right patient, under the right circumstances, while still prone.

 

[Mman]

You will be accused of micromanagement!

not by my employee

 

[deleted162650]

That's the idea. Pull the tube and roll. What's the issue?

Ya, if your gonna pull and flip that's cool. That's not the way way you originally set us up though.

 

[Planktonmd]

not by my employee

Well... not everyone is a big shot capitalist with a fantastic $1000,000 a year job like you!

 

[Noyac]

Ya, if your gonna pull and flip that's cool. That's not the way way you originally set us up though.

I thought I did set it up that way.
" Do you extubate just before the flip, hold them down until the flip....." is the statement I used.

 

[GravelRider]

Prone positioning may improve respiratory mechanics compared to supine, and all the drool and secretions ends up on the floor instead of the airway. The concern is having quick access to the airway, so obviously you need to be selective in the patients you choose to do this on.

I've done it if the patient is ready and I have no airway concerns. The problem is the OR staff thinks you are being incredibly cavalier and cruel to the patient if you do it.

 

[Noyac]

Prone positioning may improve respiratory mechanics compared to supine, and all the drool and secretions ends up on the floor instead of the airway. The concern is having quick access to the airway, so obviously you need to be selective in the patients you choose to do this on.

I've done it if the patient is ready and I have no airway concerns. The problem is the OR staff thinks you are being incredibly cavalier and cruel to the patient if you do it.

This post is pretty insightful for a resident ( if that what you are still).
My only questions is why OR staff feel this way? Why cruel to the pt?

 

[drmwvr]

Can count on one hand the number of times I've done it in 20 years. Was never the plan, but was never a risk. In fact, leaving the tube where it was was riskier, as I recall. If the turn is forthcoming, why would you put someone back to sleep that is ready for extubation and whom you'd extubate if supine?

Not a big deal in the right hands.

 

[GravelRider]

This post is pretty insightful for a resident ( if that what you are still).
My only questions is why OR staff feel this way? Why cruel to the pt?

Recent grad.

The OR staff often has a misunderstanding with what we do and why we do things. You may not vocalize why you made the decision to extubate a patient in the prone position. All the OR nurse sees is that the tube is out and the patient is awake and thinks "oh my gosh, I would not want to wake up with my face down like that," or they have not seen anyone else do it that way so they think you are some sort of cowboy.

 

[narcusprince]

You may extubate 50 people prone but the one patient you extubate prone that you have a complication your going to have to explain to the partners your cavalier practice. Is it really worth saving 30-60 seconds?

 

[drmwvr]

You may extubate 50 people prone but the one patient you extubate prone that you have a complication your going to have to explain to the partners your cavalier practice. Is it really worth saving 30-60 seconds?

Yep...I don't think we're talking about the dozing patient that only needs the stimulation of being rolled supine to open his eyes. It's the patient that, despite a good plan and anesthetic, attempts a pushup as the skin glue is drying (or whatever) and the drapes are still up. Avoiding losing an iv, a shoulder injury or worse is absolutely worth saving whatever time there is to save. Maybe we're not thinking of the same patients tho.....

 

[GravelRider]

You may extubate 50 people prone but the one patient you extubate prone that you have a complication your going to have to explain to the partners your cavalier practice. Is it really worth saving 30-60 seconds?

What complication? I would also argue that you should be prepared to manage loss of airway in every single prone case, so why not get comfortable doing so with awake patients who have easy airways.

I personally don't think it's a cavalier practice in the right situation. However, if you have an awake patient with an easy airway who is ready for extubation, but they are dilly-dallying getting the bed in the room, are you really going to re-sedate the patient? How about just let them buck and cough on the tube?

 

[Ronin786]

Haven't done this for long, but I can only recall one case that woke up while we were waiting to get a proper ICU bed in the OR. Guy was too comfy on sufentanil that he just chilled prone with the tube in his mouth for a good 5 minutes.

I probably could have extubated without any issue, but he was so high that he didn't care. I can see taking it out though if they weren't as happy.

 

[sevoflurane]

I think the real question is this: How much time will it take the team to flip the patient supine if you need immediate access to the airway? seconds, 30 seconds... one minute? This is a one way road once you extubate prone.

"Wait... wait... the dermabond is still drying and we have some 4x4's we still need to place". Clearly if in the prone position, extubation will follow these tasks- this is what NOY is implying. So we are talking about seconds btw/ flip and a extubation.

I routinely extubate DLTs in the lateral position and I'll do lma's for THA's in lateral. That being said:

I honestly don't pull the ETT prone mainly because I don't see great benefits to this technique plus I really don't like to do yoga extubation/suctioning.
I don't want to rely on the team to flip them supine quickly in case of a rare AW issue- ie. NPPE immediately after extubation (i've seen it, i don't like it and the treatment needs to be quick). I also like to see the patient when they are supine if and when they go into laryngospasm post extubation.

For Crani's, many of the patients will be in pins. I like to keep an intact AW while I share the head with the surgeon after a flip. Once everyone is out of the way and the pins are removed, I tend to extubate. They are SV and are ready by then anyway.

A brief burst of prop before a flip as my MAC works it's way down to nothing is my preferred method for extubating patients as they go from prone to supine.

Just my way of doing this task.

 

[Pooh & Annie]

Hate to flip n have the iv come out n God forbid an airway issue

 

[Doctor4Life1769]

Hate to flip n have the iv come out n God forbid an airway issue

Ugh, the IV...

 

[Yangkower]

I routinely extubate during closure and almost always extubated my shoulders in beach chair position. I haven't extubated prone but may try it in an easy airway.

 

[Noyac]

I routinely extubate during closure and almost always extubated my shoulders in beach chair position. I haven't extubated prone but may try it in an easy airway.

That's the spirit!!!
But really, I'm not telling you guys/gals that this is the way to do it. Or that if you don't extubated prone then you are some sort of inferior entity. Not at all. Everyone has their own way of doing things. I was merely asking the question.

For those that think it might not be a bad idea but haven't done it yet here's my Rey's on doing it the first few times. Be sure it's the right pt, meaning a favorable airway. Have everything in place, the bed is ready, the monitors (if you keep them on) are accounted for and the IV SECURED. Everyone is in position to flip and waiting on your count. Now just drop the cuff and pull the tube, then count 1-2-3 flip. The pt will more than likely open their eyes and you are ready to roll out of the room.

 

[nimbus]

I routinely extubate during closure and almost always extubated my shoulders in beach chair position. I haven't extubated prone but may try it in an easy airway.

I haven't intubated a shoulder in years. Block+LMA. Beach chair is very favorable for LMA.

 

[Neogenesis]

I prefer tube for shoulders because of all the crap that gets piled on top of the pt. feel it's more secure than LMA and I hate fussing with an LMA that keeps giving me fits. That being said, I prefer extubating in the beach chair position.

On a side note, how many have done prone LMAs?

 

[Noyac]

I haven't intubated a shoulder in years. Block+LMA. Beach chair is very favorable for LMA.

I agree, stop intubation get your beachchair shouLders. You will wonder why you didn't do this earlier.

 

[Noyac]

I prefer tube for shoulders because of all the crap that gets piled on top of the pt. feel it's more secure than LMA and I hate fussing with an LMA that keeps giving me fits. That being said, I prefer extubating in the beach chair position.

On a side note, how many have done prone LMAs?

There's nothing wrong with tube in these cases. It's just so much smoother with an LMA.

 

[deleted162650]

I prefer tube for shoulders because of all the crap that gets piled on top of the pt. feel it's more secure than LMA and I hate fussing with an LMA that keeps giving me fits. That being said, I prefer extubating in the beach chair position.

On a side note, how many have done prone LMAs?

Totally agree that ISB/LMA is the way to go for shoulders.

I have done prone LMA's a couple times for short cases on skinny healthy people i.e. quick butt puss where the surgeon wanted prone jackknife. Worked great the couple times I did it but I plan to limit it to those types of cases and pts.

 

[ArMed]

I actually prefer to INTUBATE prone and extubate supine. Anyone can extubate prone...bfd. Once, I used nothing but the Jackson mirror and an iphone light to guide me.