Extubation and bucking

[codeb1ue]

As I am nearing the end of my CA-1 year, this is an issue I am still confused on. At my home institution (large academic center), I have been taught to never pull tube until patient is awake (opens eyes), taking good TV, and following commands (squeezing followed by letting hand go). Only other option is pulling deep.

I recently rotated at an affiliate hospital (a private practice type setting), and I have run into numerous attendings there that pull the tube as soon as the patient starts bucking. This initially freaked me out as it went against all that I have been taught and have grown accustomed to. They say the only reason patient is bucking is because he hates the tube in the throat and is coughing, therefore you need to pull it right away. So far it has worked like a charm. Pull tube, patient immediately calms down, all is well.

I am now confused about what exactly is the difference between second staging and patient simply coughing on tube... or is there a difference at all. Please help. Thanks.

---

Members don't see this ad.

 

[EdPierce]

you ideally want to pull it even before they start bucking, learning when to pull the tube is an art. its easy to have them just wake up completely and fight the tube and then pull it, but its unpleasant for the patient, delays turn over time, and causes temporary combativeness. you want a nice smooth extubation seamless transitioned over to a NRB mask while the patient is still asleep to the untrained eye, but may respond to commands or stimulus, is breathing spontaneously plus minus an oral or nasal airway. so when do you pull it?

get them breathing well spontaneously on minimal or no pressure support. do this well prior to the end of the case, they can be pretty deep on gas, narcotic titrated to RR of 12. make sure all relaxant is reversed. the more likely they are to obstruct (fat or diff aw), the more awake you want them.

as the case ends, when you increase flows and shut off the gas, once you are down to 0.3 MAC ET of gas or less you can think about pulling the tube as long as they are breathing spontaneously, not likely to obstruct/able to mask.

what i often do is either let them breath spontaneously with the gas off until they respond to me lightly speaking their name, then pull. or if not breathing and otherwise healthy i will let the vent breath it off for them until they either wake up (respond to name) or react to the vent breathing for them, then pull at that point

 

[jetproppilot]

As I am nearing the end of my CA-1 year, this is an issue I am still confused on. At my home institution (large academic center), I have been taught to never pull tube until patient is awake (opens eyes), taking good TV, and following commands (squeezing followed by letting hand go). Only other option is pulling deep.

I recently rotated at an affiliate hospital (a private practice type setting), and I have run into numerous attendings there that pull the tube as soon as the patient starts bucking. This initially freaked me out as it went against all that I have been taught and have grown accustomed to. They say the only reason patient is bucking is because he hates the tube in the throat and is coughing, therefore you need to pull it right away. So far it has worked like a charm. Pull tube, patient immediately calms down, all is well.

I am now confused about what exactly is the difference between second staging and patient simply coughing on tube... or is there a difference at all. Please help. Thanks.

ACADEMIC DOGMA.

You're welcome.

 

[jetproppilot]

As I am nearing the end of my CA-1 year, this is an issue I am still confused on. At my home institution (large academic center), I have been taught to never pull tube until patient is awake (opens eyes), taking good TV, and following commands (squeezing followed by letting hand go). Only other option is pulling deep.

I recently rotated at an affiliate hospital (a private practice type setting, and I have run into numerous attendings there that pull the tube as soon as the patient starts bucking. This initially freaked me out as it went against all that I have been taught and have grown accustomed to. They say the only reason patient is bucking is because he hates the tube in the throat and is coughing, therefore you need to pull it right away. So far it has worked like a charm. Pull tube, patient immediately calms down, all is well.

I am now confused about what exactly is the difference between second staging and patient simply coughing on tube... or is there a difference at all. Please help. Thanks.

Ummmmm,

Some of what we're taught as residents

IS NOT TRUE.

Got about

1287 hours?

I'll fill you in on the rest.

 

[BLADEMDA]

you ideally want to pull it even before they start bucking, learning when to pull the tube is an art. its easy to have them just wake up completely and fight the tube and then pull it, but its unpleasant for the patient, delays turn over time, and causes temporary combativeness. you want a nice smooth extubation seamless transitioned over to a NRB mask while the patient is still asleep to the untrained eye, but may respond to commands or stimulus, is breathing spontaneously plus minus an oral or nasal airway. so when do you pull it?

get them breathing well spontaneously on minimal or no pressure support. do this well prior to the end of the case, they can be pretty deep on gas, narcotic titrated to RR of 12. make sure all relaxant is reversed. the more likely they are to obstruct (fat or diff aw), the more awake you want them.

as the case ends, when you increase flows and shut off the gas, once you are down to 0.3 MAC ET of gas or less you can think about pulling the tube as long as they are breathing spontaneously, not likely to obstruct/able to mask.

what i often do is either let them breath spontaneously with the gas off until they respond to me lightly speaking their name, then pull. or if not breathing and otherwise healthy i will let the vent breath it off for them until they either wake up (respond to name) or react to the vent breathing for them, then pull at that point

Excellent post. I agree with you but prefer a 0.25 or less ET vapor reading on my screen and not 0.3 MAC. 0.3 MAC may still leave some patients without a gag and would technically be considered a deep extubation. While there is nothing wrong with "deep" extubation I prefer the patient's gag reflex to be intact and 0.25 ET Vapor reading or less almost guarantees that is the case.
I am concerned with negative pressure pulmonary edema with a CA1/CA2 or CRNA extubating a patient who isn't quite ready yet. But, this complication occurs in young, healthy males most often so fortunately the only thing a "green" trainee really needs to worry about is laryngospasm and/or the ability to ventilate if the patient obstructs.

One last thing is consider turning off the gas and turning on Nitrous Oxide for the last 10 minutes of the case. The Nitrous will allow for a super speedy wake up and your ET vapor reading will be less than 0.25. I absolutely agree about the spontaneous respirations with the breather bag assist (if needed) while titrating in the narcotics slowly. It also doesn't hurt to have 50 mg of Propofol ready if you guess wrong about the wake up time because the medical student or intern is closing the wound.

There is so much variability from patient to patient because of age, co morbidities, etc that any hard and fast rule won't apply to everyone .
For example, 0.3 MAC may be quite a lot to an 80 year old ASA 4 awakening from a 2 hour anesthetic compared to 0.3 MAC on a drinker age 35 (who would be awake at 0.5 MAC most likely).

Be careful about all those hard and fast textbook rules which imply 50% of patients will be "awake" at 0.3 MAC as this may not be the case. In fact, Eger has noted that many patients do not have sufficient laryngeal reflexes at 0.3 MAC so be attentive when pulling the tube out.

 

[somedumbDO]

I "deep" extubate 95% adults and 80% kids... Academic dogma

 

[Mman]

As I am nearing the end of my CA-1 year, this is an issue I am still confused on. At my home institution (large academic center), I have been taught to never pull tube until patient is awake (opens eyes), taking good TV, and following commands (squeezing followed by letting hand go). Only other option is pulling deep.

I recently rotated at an affiliate hospital (a private practice type setting), and I have run into numerous attendings there that pull the tube as soon as the patient starts bucking. This initially freaked me out as it went against all that I have been taught and have grown accustomed to. They say the only reason patient is bucking is because he hates the tube in the throat and is coughing, therefore you need to pull it right away. So far it has worked like a charm. Pull tube, patient immediately calms down, all is well.

I am now confused about what exactly is the difference between second staging and patient simply coughing on tube... or is there a difference at all. Please help. Thanks.

The answer is always "it depends" and you learn with experience. It's possible that your "private practice" type dudes are pulling a few tubes too soon but are dutifully applying quick positive pressure immediately afterwards to fight any potential laryngospasm and doing so in low risk patients without full stomachs. It's a different story with a 400 lb fatty that was very difficult to ventilate and not so easy to intubate. They are going buck on the tube and it probably won't look pretty, but they will at least be safe.

The healthier your patients are, the more different ways you can do things safely. But you learn it in time.

 

[45408]

I "deep" extubate 95% adults and 80% kids... Academic dogma

Definitely appreciated after a hernia repair. I had a hernia repair split open when the patient was bucking violently before the CRNA was ready to pull the tube. Had to put the pt back down to repair it again. The patients have no pain after we've just numbed it all up, and no cognitive control to not cough violently, so it's asking for excessive strain on an abdominal closure, especially a hernia repair. We only have a few anesthesiologists who wake the patients up deep, but it seems so much smoother.

 

[NOTJOHN]

As I am nearing the end of my CA-1 year, this is an issue I am still confused on. At my home institution (large academic center), I have been taught to never pull tube until patient is awake (opens eyes), taking good TV, and following commands (squeezing followed by letting hand go). Only other option is pulling deep.

I recently rotated at an affiliate hospital (a private practice type setting), and I have run into numerous attendings there that pull the tube as soon as the patient starts bucking. This initially freaked me out as it went against all that I have been taught and have grown accustomed to. They say the only reason patient is bucking is because he hates the tube in the throat and is coughing, therefore you need to pull it right away. So far it has worked like a charm. Pull tube, patient immediately calms down, all is well.

I am now confused about what exactly is the difference between second staging and patient simply coughing on tube... or is there a difference at all. Please help. Thanks.

Let me explain something to you. I would NOT and I repeat NOT go by what the private practice guys say. Extubating someone when they start bucking is the most dangerous thing ive heard of. If you want a short career go ahead and start doing that. YOu will run into problems GUARANTEED. YOu extubate someone when they are ready ( meaning awake) or deep.if you like.. not in the middle.. and if they are awake when they bucking fine.. but if not.. keep the tube in until they are ready. THere are PITFALLS everywhere.. Everywhere in the practice of anesthesia. The only way you will make sense of it all and not lose your career is to pay attention to basic principles. And if you dont know the basics you will be a dangerous dude because every problem you will face in anesthesia will be solved by going back to the basics.

The private practice guys are smoother,but they still adhere to basic principles of extubation.

 

[nap$ter]

Definitely appreciated after a hernia repair. I had a hernia repair split open when the patient was bucking violently before the CRNA was ready to pull the tube. Had to put the pt back down to repair it again. The patients have no pain after we've just numbed it all up, and no cognitive control to not cough violently, so it's asking for excessive strain on an abdominal closure, especially a hernia repair. We only have a few anesthesiologists who wake the patients up deep, but it seems so much smoother.

why are your hernia patients getting intubated instead of an LMA?

 

[lane]

Definitely appreciated after a hernia repair. I had a hernia repair split open when the patient was bucking violently before the CRNA was ready to pull the tube. Had to put the pt back down to repair it again. The patients have no pain after we've just numbed it all up, and no cognitive control to not cough violently, so it's asking for excessive strain on an abdominal closure, especially a hernia repair. We only have a few anesthesiologists who wake the patients up deep, but it seems so much smoother.

Sounds like a prolene deficiency, doctor

 

[NOTJOHN]

you ideally want to pull it even before they start bucking, learning when to pull the tube is an art. its easy to have them just wake up completely and fight the tube and then pull it, but its unpleasant for the patient, delays turn over time, and causes temporary combativeness. you want a nice smooth extubation seamless transitioned over to a NRB mask while the patient is still asleep to the untrained eye, but may respond to commands or stimulus, is breathing spontaneously plus minus an oral or nasal airway. so when do you pull it?

get them breathing well spontaneously on minimal or no pressure support. do this well prior to the end of the case, they can be pretty deep on gas, narcotic titrated to RR of 12. make sure all relaxant is reversed. the more likely they are to obstruct (fat or diff aw), the more awake you want them.

as the case ends, when you increase flows and shut off the gas, once you are down to 0.3 MAC ET of gas or less you can think about pulling the tube as long as they are breathing spontaneously, not likely to obstruct/able to mask.

what i often do is either let them breath spontaneously with the gas off until they respond to me lightly speaking their name, then pull. or if not breathing and otherwise healthy i will let the vent breath it off for them until they either wake up (respond to name) or react to the vent breathing for them, then pull at that point

This thread is Scary..... With a capital S.... Some of the hairiest and scariest airways that i have extubated ALONE at 2am have been successful because of adherence to basic principles.... I tell residents (when i see them) I dont care if they are ca3s.. If they look like they know what they are doing.. they are doing something wrong..

 

[45408]

Sounds like a prolene deficiency, doctor

Negative, Ghostrider, the pattern was full.

 

[jetproppilot]

.

 

[codeb1ue]

. If they look like they know what they are doing.. they are doing something wrong..

I don't get that statement. And can you elaborate on what you do? Do you let the patient buck through second stage then only pull when following commands and able to lift head off table etc?

 

[Lurch]

What do you guys think of the "no stage 2 for propofol philosophy" wherein you pull the tube in advance of patient following commands (spont breathing with no ET gas but having received a propofol bolus)? Proponents will say no risk of laryngospasm but you must be ready to handle obstruction.

 

[jetproppilot]

What do you guys think of the "no stage 2 for propofol philosophy" wherein you pull the tube in advance of patient following commands (spont breathing with no ET gas but having received a propofol bolus)? Proponents will say no risk of laryngospasm but you must be ready to handle obstruction.

THERE IT IS.

Of course laryngospasm is a risk!!!

It doesn't happen often. It doesn't happen every once in a while. It happens

RARELY.

The Poster said it very well:

"Proponents will say no risk of laryngospasm but you must be ready to handle obstruction."

OBSTRUCTION? Thats our gig man. We are AIRWAY SPECIALISTS. WE CAN HANDLE OBSTRUCTION while simultaneously thinking about what we want for dinner

BUCKING PATIENTS NEED THEIR ENDOTRACHEAL TUBE REMOVED ASAP.

999 out of 1000 patients you extubate in this manner will

APPRECIATE YOU REMOVING THE TUBE.

For the .1% of patients that have a laryngospasm after removing the tube,

NO BIG DEAL MAN.

MINOR ISSUE for well trained anesthesiologists:

1) Turn your APL knob all the way to the right and your flows up all the way

2) LEFT PINKY under the mandible pushing towards the ceiling

3) RIGHT HAND on the bag, keeping positive pressure

4) THIS USUALLY WORKS to break laryngospasm. I.E. major jaw lift + positive pressure

5) IF NOT,

NO BIG DEAL.

6) GIVE A SMALL DOSE OF IV SUX (40mg) AND KEEP DOING WHAT YOU'RE DOING

7) Laryngospasm will break.

8) Bag the patient until the minute sux dose wears off

9) Move to PACU

Message?

Don't base how you practice on something that can happen every once in a while, especially when you know how to handle it when it does.

JESUS CHRIST.

OUR CURRENT DAY RESIDENTS ARE NOT BEING TAUGHT

CORRECTLY.

 

[Colba55o]

There are a few other tricks that havent been mentioned...but great thread so far.

1mg/kg IV lidocaine 15-20 minutes before case ends
Low dose propofol infusions again, started 30 mins before case ends, I love these for thyroids, ENT cases where violent bucking can be detrimental.
Also good narcotization with longer acting agents like dilaudid or morphine. I have found that solely using fentanyl for a narcotic may blunt sympathetic response, slow RR but it doesnt make for smooth wakeups.


Philosophically, it makes sense, if the ET is wreaking havoc, pull it. But wouldnt it make MORE sense and be SAFER to pharmacologically make the ET tolerable so you can wait until it's actually safe to pull it out? I have found in my limited experience that if done well, I can wake even a young male up and have him follow commands, not buck, give me a thumbs up sign, and calmly have him nod his head when I ask "Do you want me to take that tube out?"

 

[dhb]

6) GIVE A SMALL DOSE OF IV SUX (40mg) AND KEEP DOING WHAT YOU'RE DOING

The ED95 for sux is something like 0.4mg/kg so 40mg is actually a solid, dose i think you can acheive your goal with 20mg or less

 

[pgg]

The ED95 for sux is something like 0.4mg/kg so 40mg is actually a solid, dose i think you can acheive your goal with 20mg or less

Agree 20 mg should be enough. 40 is fine too, the take home message is that you absolutely do not need an intubating dose of succ to break laryngospasm.

Also, in a patient who got neostigmine for NMBD reversal, succ may last substantially longer. That's not a reason not to give it if you need it, but you have to be aware that it might not wear off in a minute or two.


Another thing that is an option for cases in which bucking or coughing is really undesirable, but you don't want to extubate deep, is to use an LTA.

 

[sevoflurane]

THERE IT IS.

Of course laryngospasm is a risk!!!

It doesn't happen often. It doesn't happen every once in a while. It happens

RARELY.

The Poster said it very well:

"Proponents will say no risk of laryngospasm but you must be ready to handle obstruction."

OBSTRUCTION? Thats our gig man. We are AIRWAY SPECIALISTS. WE CAN HANDLE OBSTRUCTION while simultaneously thinking about what we want for dinner

BUCKING PATIENTS NEED THEIR ENDOTRACHEAL TUBE REMOVED ASAP.

999 out of 1000 patients you extubate in this manner will

APPRECIATE YOU REMOVING THE TUBE.

For the .1% of patients that have a laryngospasm after removing the tube,

NO BIG DEAL MAN.

MINOR ISSUE for well trained anesthesiologists:

1) Turn your APL knob all the way to the right and your flows up all the way

2) LEFT PINKY under the mandible pushing towards the ceiling

3) RIGHT HAND on the bag, keeping positive pressure

4) THIS USUALLY WORKS to break laryngospasm. I.E. major jaw lift + positive pressure

5) IF NOT,

NO BIG DEAL.

6) GIVE A SMALL DOSE OF IV SUX (40mg) AND KEEP DOING WHAT YOU'RE DOING

7) Laryngospasm will break.

8) Bag the patient until the minute sux dose wears off

9) Move to PACU

Message?

Don't base how you practice on something that can happen every once in a while, especially when you know how to handle it when it does.

JESUS CHRIST.

OUR CURRENT DAY RESIDENTS ARE NOT BEING TAUGHT

CORRECTLY.

Nice post Jet. A lot of truth there... especially the what's for dinner part.

Bucking...? What's that? 99.9% of my tubes come out deep.

My only contraindication to this is a full stomach.

 

[Oggg]

Sux 10mg will work too, but if you just gave neostogmine, you could have weak hypoventilation for 30min. I much prefer a slug of propofol for L spasm

 

[divinemsm]

If the patient is bucking -you've done something wrong-period.
1. Not paying attention to what's going on.
2. Not paying attention to what's going on.
3. Not paying attention to what's going on.

Whether your preference is deep extubation or with purposeful commands-meeting criteria-bucking should not be the case.

Taking a tube out of a bucking patient ? No.
Distort their cns with a few cc s of lido, and allow them to establish a reasonable breathing pattern and calm. Titrate a touch of narc if need be. Elevate the head of the bed or put em in reverse trendenlenberg for the bariatric patients who just got their band/sleeve/bypass.
Or for the bariatric patient who has yet to have bariatric surgery but is in your OR for a chole/ ex lap etc..;-)

Oral airways are your friend.

Don't mistake bucking for being ready to extubate-Strong patients do not mean awake if " awake " extubation is your thing.

I have seen more than one m and m in my short career when the patient was prematurely Extubated because of pulling at tube-but were hypercapnic and crazed and STRONG. Things spiral out of control quickly.

My two cents.

 

[Lurch]

Nice post Jet. A lot of truth there... especially the what's for dinner part.

Bucking...? What's that? 99.9% of my tubes come out deep.

My only contraindication to this is a full stomach.

I don't think laryngospasm is anything to roll your eyes at. Knowing how to handle it and wanting to avoid it are 2 different things entirely. In my practice, I do what I can to reduce its occurrence b/c of its associated morbidity. Negative pressure pulmonary edema only takes one breath i.e. before you can reach for your sux. Propofol and lidocaine are used at my institution as previously described in this thread to reduce this risk since they theoretically have no stage 2. I was curious about everyone else's utilization of these agents and whether you believe they can accomplish what it is being asserted they can.

 

[Lurch]

I don't think laryngospasm is anything to roll your eyes at. Knowing how to handle it and wanting to avoid it are 2 different things entirely. In my practice, I do what I can to reduce its occurrence b/c of its associated morbidity. Negative pressure pulmonary edema only takes one breath i.e. before you can reach for your sux. Propofol and lidocaine are used at my institution as previously described in this thread to reduce this risk since they theoretically have no stage 2. I was curious about everyone else's utilization of these agents and whether you believe they can accomplish what it is being asserted they can.

Was trying to quote jet's post btw

 

[EdPierce]

re: waking up comfortable with a tube..

is this your goal? would you want to wake up with a tube in your mouth in the or? if you have to do this, you have to do this. but why on a young healthy patient with an easy airway? i think a quality anesthesiologist would want to avoid any memory/idea of the tube, not just have them tolerate it comfortably (which is asking a lot and most do not in reality). the goal is to have the first memory be the PACU 15 minutes into your stay, with a buzz on.

 

[sevoflurane]

I don't think laryngospasm is anything to roll your eyes at. Knowing how to handle it and wanting to avoid it are 2 different things entirely. In my practice, I do what I can to reduce its occurrence b/c of its associated morbidity. Negative pressure pulmonary edema only takes one breath i.e. before you can reach for your sux. Propofol and lidocaine are used at my institution as previously described in this thread to reduce this risk since they theoretically have no stage 2. I was curious about everyone else's utilization of these agents and whether you believe they can accomplish what it is being asserted they can.

Left over propofol from my 20cc induction dose is great to use at the end of a case. Def. a part of my deep extubation. Laryngospasm happens. I've seen NPPE a couple of times in my life (my own patients). In fact, this past year I saw it with an LMA. Copious frothy sputum. I knew it right away when I saw it.
At my old academic institution a collegue had a post-op tonsil kid spasm in PACU and get NPPE. The child got severely hypoxemic and quickly progressed to asystole and suffered an anoxic brain injury. The hospital settled out of court. I am very aware of this complication.

Not for one second did I say that laryngospasm is something you roll your eyes at. What is being said here on this thread and what I support is this: If you know what you are doing, you can handle it with ease. If you F'up laryngospasm you are CA-2 material and need some more practice. As for lidocaine. I'm not sure how effective it is, but it doesn't hurt. Propofol and some gas on board is way more effective.

 

[saratoga733]

laryngojet to cords, lidocaine ointment around ett cuff for most of my sinus, thyroid, and hernia procedures that require tube (large ventral hernia etc). granted not very helpful if procedure >> 2 hrs.

get pt breathing spontaneously early for emergence. titrate narc of choice in at this time. i like keep these patients on high O2 (add measure of safety).

+/- squirt of iv lido or propofol while suctioning airway bone DRY with suction catheter.

this routine has served me well and pleases even the most neurotic surgeons. with this said, don't let your guard down when you extubate deep/ deep(ish). when i hand off to pacu nurse, i insist they keep close eye on pt until more awake.

btw, obviously all this goes out the window for diffic a/w or morbid obese, diff to ventilate folks.

 

[Ipassgas]

Lidocaine is effective. You can also put some 2 or 4% in the cuff of you're really concerned. That works too.

 

[soorg]

Does placing lidocaine (I'm assuming you're using the 2% jelly) on the cuff really work? Does the lidocaine affect the integrity of the cuff in any way?

 

[heathermed]

quick question please.

what is the correct time frame relative to extubation for giving lidocaine?
I've heard a min before anticipated extubation and now 15-20.

thank you for the clarification.

There are a few other tricks that havent been mentioned...but great thread so far.

1mg/kg IV lidocaine 15-20 minutes before case ends
Low dose propofol infusions again, started 30 mins before case ends, I love these for thyroids, ENT cases where violent bucking can be detrimental.
Also good narcotization with longer acting agents like dilaudid or morphine. I have found that solely using fentanyl for a narcotic may blunt sympathetic response, slow RR but it doesnt make for smooth wakeups.
"

 

[Colba55o]

quick question please.

what is the correct time frame relative to extubation for giving lidocaine?
I've heard a min before anticipated extubation and now 15-20.

thank you for the clarification.

IV lidocaine should be given a minute before intubation to blunt sympathetic response. To blunt the coughing reflex during emergence, it should be given at least 20-30 minutes ahead before the end of the case. And even then, it doesn't ALWAYS work.

FWIW I love these threads because they show how many different ways there are to achieve the same goal. At my large academic center, its like pulling teeth to get an attending to let us extubate a patient deep. Who doesn't have some GERD which may/may not be well controlled?

 

[W222]

IV lidocaine should be given a minute before intubation to blunt sympathetic response. To blunt the coughing reflex during emergence, it should be given at least 20-30 minutes ahead before the end of the case. And even then, it doesn't ALWAYS work.

FWIW I love these threads because they show how many different ways there are to achieve the same goal. At my large academic center, its like pulling teeth to get an attending to let us extubate a patient deep. Who doesn't have some GERD which may/may not be well controlled?

Where are you getting the 20-30 min thing? Any actual evidence? 30 min is an awful long time to expect a 70-100mg bolus to work wonders. I know in laryngospasm it works quickly, like seconds.

 

[dhb]

IV lidocaine should be given a minute before intubation to blunt sympathetic response. To blunt the coughing reflex during emergence, it should be given at least 20-30 minutes ahead before the end of the case. And even then, it NEVER work.

Fixed it for you

 

[deleted162650]

For those of you working in MD only PP groups that routinely extubate deep, who is immediately available for things like L-spasm, etc. that occur in PACU, or do you guys hang out until pt is awake after giving report?

 

[nimbus]

For those of you working in MD only PP groups that routinely extubate deep, who is immediately available for things like L-spasm, etc. that occur in PACU, or do you guys hang out until pt is awake after giving report?

Just doesn't happen. With sevo they are usually awake by the time you give report, even if you extubate deep. If they are deep and breathing smoothly, they don't later develop laryngospasm.

 

[Mman]

Just doesn't happen. With sevo they are usually awake by the time you give report, even if you extubate deep. If they are deep and breathing smoothly, they don't later develop laryngospasm.

How long does it take you to get to PACU? If you pull the tube deep (with a MAC of gas on board), they aren't going to be awake at any point in the next 10-15 minutes.

And yes, laryngospasm can happen to people breathing smoothly. Secretions can develop in the back of their throat between the time they get extubated and the time they are awake.

 

[dhb]

Obstruction is much more frequent than laryngospasm

 

[nimbus]

How long does it take you to get to PACU? If you pull the tube deep (with a MAC of gas on board), they aren't going to be awake at any point in the next 10-15 minutes.

And yes, laryngospasm can happen to people breathing smoothly. Secretions can develop in the back of their throat between the time they get extubated and the time they are awake.

I should have been more careful in my response.

Surgery end time to anes end time is usually 10 min for me. And you are correct, I rarely do true "deep" extubation with full MAC vapor. I usually extubate asleep at 0.2-0.3% sevo.

I have had a few cases of laryngospasm immediately at extubation but once a good airway is established, it has never progressed to laryngospasm in my hands. When secretions collect, they cough not spasm. And that is after 15000 cases all personally performed. I suppose it could happen but it must be exceedingly rare.

 

[Arch Guillotti]

I have had a few cases of laryngospasm immediately at extubation but once a good airway is established, it has never progressed to laryngospasm in my hands.

Uh, what?

 

[Mman]

Surgery end time to anes end time is usually 10 min for me. And you are correct, I rarely do true "deep" extubation with full MAC vapor. I usually extubate asleep at 0.2-0.3% sevo.

intriguing

 

[24858]

Why is everyone waiting Til 0.2? I pull every lma deep usually 2.0. If I pull a tube deep I would do it at 2 as well

 

[Sublimazing]

Why is everyone waiting Til 0.2? I pull every lma deep usually 2.0. If I pull a tube deep I would do it at 2 as well

If you pull that deep though your patient is blowing off a lot of gas w no support and potentially smaller Tv without the lma helping airway...just seems slower with a higher chance of obstruction

What's the advantage of pulling an Lma at 1mac as opposed to 0.5-0.2mac?

 

[GoldnLead]

ACADEMIC DOGMA.

You're welcome.

Jet,
I've been reading this forum and your posts for a while now, since I was in residency, and for the most part, you're spot on about what it takes to succeed, especially in the PP setting. However, I think you're sometimes too quick to poo-poo academics.

Many of my partners extubate early as soon as the patients cough. Like you said, 99% of the time you get lucky but 1% of the time the patient gets hosed because of a cavalier maneuver and I've seen 2 instances of NPPE requiring NIPPV in the 4 years I've been with my group. Doesn't look good for the physician, especially if one is working at a "boutique" type-practice.

 

[24858]

If you pull that deep though your patient is blowing off a lot of gas w no support and potentially smaller Tv without the lma helping airway...just seems slower with a higher chance of obstruction

What's the advantage of pulling an Lma at 1mac as opposed to 0.5-0.2mac?

The difference is there is less dead space ventilation once the lma or tube is pulled and patients awaken a lot faster. I haven't had any issues using this technique and most ventilate very well on their own a few need an oral airway, but to me pulling at stage two sets the patient up for lartngospasm

 

[24858]

To me I do many deep macs without an lma, so to me it's the same once I pull the lma, the patient is a deep Mac. To me it makes sense maybe I'm missing something

 

[dhb]

Why is everyone waiting Til 0.2? I pull every lma deep usually 2.0.

If you have an oral airway you might as well use it

 

[IveGotTwins]

One of my staff will t-piece all LMAs until the patient pulls it themselves. His argument is that if you pull it and then the patient obstructs you can either place an OA or wish you had just left the LMA in. He is extremely cost conscious using the minimal amount of equipment, drugs, supplies etc. in order to safely perform the anesthetic. His favorite topic re: cost-savings is remifentanil closely followed by BIS. I supposed saving the cost of an OA each time he uses an LMA must be significant to him. Usually by the time we're hitting PACU the patient pulls it. Seems to work well.

 

[codeb1ue]

I appreciate all the responses in this thread. It has definitely given me much to think about.

On an unrelated but similar topic (didn't want to start a whole new thread just on this), what are people's thoughts on giving positive pressure with bag while pulling tube. Is this actually helpful or just more theoretical and perpetuated. This is something I hear mixed things about as well even amongst just academic attendings.

 

[dhb]

Never done it can't see the benefit