When do you pull the tube?

[dchz]

Please vote before seeing the comments so we can get the best data possible. Please also keep the first 20 posts free of comments that would influence people too much. Thanks!

Given the situation:

43 M
Dx: Osteoarthritis
Surgery: Knee replacement

PMH
HTN, HLD,
Diabetes with A1C of 7.2 on meds well controlled for the last 3 years he's been diagnosed,
BMI 30, Height: 5'11" Weight: 215
NPO for 12 hours
MP 2 airway with slightly thick neck but maskable with oral airway.

Pt asked you to do GA with ETT because he had trouble with staying still with a spinal and sedation for his other knee.
Easy intubation. You have not suctioned the stomach given such an uneventful case.

Surgeon is gives you heads up they will finish in 20 mins, the pt is spontaneously breathing, taking tidal volumes of 350 while supine. you have titrated in narcotics and the patient is breathing 13 times per minute, Et Sevo is at 1.8%. Pt sating 100% on 50% FIO2 at 2 liters of flow.


When do you pull the tube?

--------------------

We had some very spirited discussion in the other thread about extubation timing. So let's see the data from the masses.

Discussions are very welcome, the spirit of this thread is to expand our horizons. However, if we could refrain from posting comments that would influence the votes for a while, that would give us really good data!

If the mods can disable comments but leave the poll up for a few days, that would be the most scientific, not sure if that's possible.

---

Members don't see this ad.

 

[DocVapor]

Edited response away as to not exert undue influence.

 

[dchz]

Sorry I don't know the system well. I think we should disable the comments for a while until enough data is collected?

Also you did not vote for what you're advocating. Please participate in the poll as well as the discussion.

Or at least refrain from posts that can influence the votes? I've asked @docvaper to do the same.

I do look forward to the discussion once we have some good data.

 

[IlDestriero]

.

 

[Guillemot]

Sorry I don't know the system well. I think we should disable the comments for a while until enough data is collected?

Also you did not vote for what you're advocating. Please participate in the poll as well as the discussion.

Or at least refrain from posts that can influence the votes? I've asked @docvaper to do the same.

I do look forward to the discussion once we have some good data.

Sorry, I didnt read your post completely

 

[drmwvr]

I don't like any of the choices.

 

[nimbus]

NPO for 12 hours

MP 2 airway with slightly thick neck but maskable with oral airway.

Then I would just mask him. Just kidding, that’s ridiculous. But an LMA is reasonable. Nowadays with a glidescope and sugammadex I just tube but I did these cases with LMA for many years.

 

[GassYous]

I can't vote because my option is not there

Also would lma the guy
igel 5 and go

 

[dchz]

Then I would just mask him. Just kidding, that’s ridiculous. But an LMA is reasonable. Nowadays with a glidescope and sugammadex I just tube but I did these cases with LMA for many years.

I can't vote because my option is not there

Also would lma the guy
igel 5 and go

Good points. I'm not gonna reply for a bit just to get more data. Please vote as if you took over this case from someone else.

 

[DesiredMemberName?]

This poll was obviously created by someone with a bias towards deep extubation.

 

[BlueRug]

It depends....is there a case to follow?

 

[cchoukal]

Voted awake. Question deep vs awake in this patient I think either is appropriate here. Spinal and an LMA with 0.8MAC SEVO (gasp) would be what I did for this guy. It’s what I do for most of these and a popular option in my group. Personally don’t see much difference than a spinal and cranking a propofol drip to general anesthetic levels to keep someone still.

Do you then bill for the spinal separately for pot-op pain?

 

[DocMcCoy]

Do you then bill for the spinal separately for pot-op pain?

They’ve been kicked back for trying to bill out as a separate procedure. Have seen people put morphine in and bill it for post op pain. Don’t recommend that and I’m not playing that game. I’m salaried now so it doesn’t matter as much. I do it because it is smooth and no narcs needed.

 

[MirrorTodd]

My answer isn't up there either. Personally, I would avoid having 1.8% sevo on when the surgeon is closing the skin.

 

[dchz]

My answer isn't up there either. Personally, I would avoid having 1.8% sevo on when the surgeon is closing the skin.

Fair enough, timing is wrong in the case.

Please vote based on your own timing of removing volatiles. E.g. if you only have 1% end tidal when your surgeon is on skin, please vote the choice as if you had 1% end tidal when the surgeon is on skin.

 

[dchz]

Voted. Question deep vs awake in this patient I think either is appropriate here. Spinal and an LMA with 0.8MAC SEVO (gasp) would be what I did for this guy. It’s what I do for most of these and a popular option in my group. Personally don’t see much difference than a spinal and cranking a propofol drip to general anesthetic levels to keep someone still.

Right, I think you missed some of the point of this poll. The question is designed so it's marginal situation either way and trying to get the data on people's preference.

Would you mind removing how you voted? The whole idea is to let people vote without seeing how others voted. See all the people have covered up their answers before you.

 

[Arch Guillotti]

If the mods can disable comments but leave the poll up for a few days, that would be the most scientific, not sure if that's possible.

Not possible.

 

[zizzer]

I didn't vote because the situation doesn't really affect my practice. If I found myself in that situation I would extubate deep with an oral airway. However, I typically find it faster to control ventilation to hyperventilate off volatile rather than wait around for them to breath spontaneously if I don't need a strict smooth extubation.

 

[Morzh]

If the surgeons are closing skin then by this point I would already have the Sevo <0.5% (and dropping with gas off, flow up). I'd keep the patient spontaneous but deeply comfortable with PRN propofol and opiates. When dressings are on I suction, +/- insert oral airway, deflate cuff, give a little more propofol if there was any reaction to those maneuvers, and then pull the ETT and mask ventilate for a few breaths with a little CPAP to ward off the laryngospasm spirits.

I like deep extubations in most patients... but deep is a state of mind, not a sevoflurane % on the monitor. For kids I will deep extubate with Sevo at 2.5-3%, but in adults I prefer the above approach.

 

[sevo00]

Don’t like any of those options. At this point I would have sevo at 0.2 max already and don’t care if thr patient is lifting his head. I’ll just confirm he’s opening his eyes to command and then I’ll pull the tube

 

[nimbus]

I usually don’t rely on ET Sevo. Is the case finished? Is the patient breathing? Then I pull the tube.


Occasionally for patients who received no opioids (because they’ve been blocked or had a nonpainful procedure) I’ll reduce minute ventilation while they’re still paralyzed, reduce ET sevo to <1%, suction, extubate, then reverse with sugammadex. Most of the time they breathe right away. If not, I’ll assist for a minute or 2 until they do.


There are many ways to do this and it’s fun to play around.

 

[dchz]

If the surgeons are closing skin then by this point I would already have the Sevo <0.5% (and dropping with gas off, flow up). I'd keep the patient spontaneous but deeply comfortable with PRN propofol and opiates. When dressings are on I suction, +/- insert oral airway, deflate cuff, give a little more propofol if there was any reaction to those maneuvers, and then pull the ETT and mask ventilate for a few breaths with a little CPAP to ward off the laryngospasm spirits.

I like deep extubations in most patients... but deep is a state of mind, not a sevoflurane % on the monitor. For kids I will deep extubate with Sevo at 2.5-3%, but in adults I prefer the above approach.

Don’t like any of those options. At this point I would have sevo at 0.2 max already and don’t care if thr patient is lifting his head. I’ll just confirm he’s opening his eyes to command and then I’ll pull the tube

Fair enough, timing is wrong in the case.

Please vote based on your own timing of removing volatiles. E.g. if you only have 1% end tidal when your surgeon is on skin, please vote the choice as if you had 1% end tidal when the surgeon is on skin.

A lot of people brought this up. I have changed the scenario. Now you have a 20 min heads up.

 

[woopedazz]

Don’t like any of those options. At this point I would have sevo at 0.2 max already and don’t care if thr patient is lifting his head. I’ll just confirm he’s opening his eyes to command and then I’ll pull the tube

Yeah, I'm more in this camp. I turn the sevo off 10+ minutes prior to extubation on low flows. I aim to get the patient to have an ETsevo that more accurately represents effect site conc. I aim for 0.3MAC by the time the skin is closing. Which should end up at 0.2ish when dressing is going on. At that point flows go high for transfer to the bed and they wake up during the slide stimulation and tube comes out. If I'm a bit off I've got rapidly distributing propofol at my disposal.

In my hospitals recovery can't handle large numbers of patients in Stage 1. Nor do I have the ability to go check on them endlessly to chart whatever the nurses want. Nor are they good at airways. The easiest and safest method is to do what i do above. It's also the method that allows me to leave on time with only one (awake) patient to hand over to the floor.

 

[nimbus]

@dchz

Your survey clearly illustrates that all the options work.

 

[epidural man]

I can't vote because my option is not there

Also would lma the guy
igel 5 and go

How has the I-gel not survived as the only supraglotic airway on the planet? I love those things. They make me hate every other brand.

 

[drmwvr]

Don't care what the ET agent is...any purposeful movement whether a sustained grimace, any localizing of noxious stimuli (which includes head turning to the side the tube is secured) or a hand to the face...whatever...extubate...mechanically ventilated or SV...

 

[deleted875186]

Don't care what the ET agent is...any purposeful movement whether a sustained grimace, any localizing of noxious stimuli (which includes head turning to the side the tube is secured) or a hand to the face...whatever...extubate...mechanically ventilated or SV...

These are not purposeful movements. Let’s be honest, patient is still not completely awake but removing the tube early will not result in laryngospasm the vast majority of the time.

 

[drmwvr]

These are not purposeful movements.

Yes they are. They're not chess moves, but they require a level of consciousness that also allows the airway to be protected without obstruction.

 

[deleted875186]

Yes they are. They're not chess moves, but they require a level of consciousness that also allows the airway to be protected without obstruction.

I would disagree. Some airway reflexes have returned, but the movements are not purposeful. The patient will be able to protect their airway, but are not fully emerged, hence t he discussion about laryngospasming above.

 

[IMGASMD]

How has the I-gel not survived as the only supraglotic airway on the planet? I love those things. They make me hate every other brand.

Just like everything else in the world… $$

Probably.

 

[dchz]

How has the I-gel not survived as the only supraglotic airway on the planet? I love those things. They make me hate every other brand.

Just like everything else in the world… $$

Probably.

Too phallic. It's getting cancelled because of toxic masculinity.

 

[BobLoblaw78]

How has the I-gel not survived as the only supraglotic airway on the planet? I love those things. They make me hate every other brand.

I keep hearing how great they are and want to get them, but get sidetracked. I might have to take the time to actually bring some in and use them.

 

[epidural man]

I keep hearing how great they are and want to get them, but get sidetracked. I might have to take the time to actually bring some in and use them.

They take a little while to get used to - because they are a gel, they don't "seal" right away, so that is annoying when you first start using them. But I suspect, you will love them after using them a few times.

 

[narcusprince]

I am a fan of the Igel LMA. My answer have the discussion with your attending when to extubate. Go with what’s comfortable for them. Awake/Deep depends on so many more factors then listed.
Btw does Igel make condoms?

 

[BobLoblaw78]

I am a fan of the Igel LMA. My answer have the discussion with your attending when to extubate. Go with what’s comfortable for them. Awake/Deep depends on so many more factors then listed.
Btw does Igel make condoms?

I thought you were a roughrider?

 

[AnesRunner]

There is only one answer: right before you reach to take down the drapes. Better facilitated with an LMA. Not deep because I have no interest in supporting the airway as we roll to the PACU. Sevo would have been long gone beforehand.

 

[BobLoblaw78]

I am a fan of the Igel LMA. My answer have the discussion with your attending when to extubate. Go with what’s comfortable for them. Awake/Deep depends on so many more factors then listed.
Btw does Igel make condoms?

Gives a whole new meaning to "when do you pull the tube?"

(can't believe I missed that one the first time around. you guys deserve better. i will try harder)

 

[dchz]

So it's been a few days and we had over 140 responses so far. Thank you for those that participated. I think it's good time to start discussing the options.

Thank you @DocVapor , @Guillemot ,@IlDestriero , @DocMcCoy , and @narcotics999 for editing your responses to not influence the poll.

No poll is perfect, so I'd be the first one to say this poll was probably biased for deep intubation, because I'm a big proponent of it. I tried to collaborate with another poster who is pro choice 1 but we couldn't get a collaboration going.

Let's begin the discussion with the following questions:

- those that chose the deep extubation with Et 1.8%, what changes in the scenario would make you go to the Et 0.1% option? BMI of 45?

- similarly, those that chose Et 0.1% option, what changes in the scenario would make you comfortable to choose the Et 1.8% option?

 

[GassYous]

I thought you were a roughrider?

He likes how it feels on the inside

 

[vector2]

:

- those that chose the deep extubation with Et 1.8%, what changes in the scenario would make you go to the Et 0.1% option? BMI of 45?

-

Severe N/V preop. Uncontrolled DM/gastroparesis. Any other baseline GI tract issues. Difficult intubation. Unexpected hemodynamic instability or fluid shifts during the case.

I would also think twice with known OSA on CPAP but that's not an absolute contraindication imo

 

[BlueRug]

I think the real answer depends largely on the culture of your shop. If PACU nurses aren’t used to deep patients, you’re going to have a bad time

 

[Southpaw]

I believe there is very little good that is almost always outweighed by the bad with textbook deep extubation. I don't do it. Some of the CRNAs I work with do. There is an art to anesthesia and almost always its not difficult to wake a patient up smoothly without deep extubation. Our patients are getting bigger, more OSA, sicker. In my opinion just not worth it.

 

[dchz]

I believe there is very little good that is almost always outweighed by the bad with textbook deep extubation. I don't do it. Some of the CRNAs I work with do. There is an art to anesthesia and almost always its not difficult to wake a patient up smoothly without deep extubation. Our patients are getting bigger, more OSA, sicker. In my opinion just not worth it.

How often do you do the textbook deep extubation?

What risks and what benefits do you foresee?

How often do you see the mentioned complications in the CRNAs that do them?

 

[deleted875186]

In the average patient I just don’t see an advantage to deep extubation, only risk. Fine in low risk patients, but as stated above I don’t do it in obese, OSA, edentukojs and potentially difficult to mask, any hemodynamics concern, etc. I would also never do it unless I induced and did the airway, or someone I really trusted told me it was easy mask and tube. “More comfortable for the patient” is not a reason to deep extubate someone. We all agree it does not save a meaningful amount of time.

 

[MirrorTodd]

Coincidentally, colleague had a middle aged male for a robotic ventral hernia repair with a large mesh. Waking the pt up, he coughed/bucked, bronchospasm, hard to bag, desat, needed like 30mcg of epi to break it. Pt was overweight but not morbidly obese, without significant OSA or other breathing problems. Surgeon needed to re-explore once he settled out, so case ended taking an extra hour or hour and a half. Bet they could've deep extubated this guy and avoided all that (hindsight 20/20 of course).

 

[Mehd School]

I think it depends on your patient and your pacu. Most of my patients suck and most of my pacu nurses are young and nervous. They aren't comfortable taking care of a patient under general anesthesia and honestly they probably shouldn't be. One thing I learned early on is pulling the tube deep doesn't save as much time I would have thought.

 

[deleted875186]

Coincidentally, colleague had a middle aged male for a robotic ventral hernia repair with a large mesh. Waking the pt up, he coughed/bucked, bronchospasm, hard to bag, desat, needed like 30mcg of epi to break it. Pt was overweight but not morbidly obese, without significant OSA or other breathing problems. Surgeon needed to re-explore once he settled out, so case ended taking an extra hour or hour and a half. Bet they could've deep extubated this guy and avoided all that (hindsight 20/20 of course).

Or, perhaps he would have bronchospasmed or laryngospasmed waking up but without a secure ETT with an even worse outcome ….

Also, I don’t beleive healthy people without any breathing problems or even a remote history of asthma bronchospasm to the point of needing epi.

 

[vector2]

Or, perhaps he would have bronchospasmed or laryngospasmed waking up but without a secure ETT with an even worse outcome ….

IMO, 99 times out of 100 the stimulus to bronchospasm on emergence is the ETT. I've had quite a few pts who I would've preferred to extubate awake but who started spasming/uncontrollably coughing as soon as the anesthetic was coming off despite adequate opioid. There was a 370 lb lady once in cysto who I threw the kitchen sink at to treat her spasm (sevo, prop, albuterol, mag, ketamine, glyco, epi etc). Tried to wake up her 3 times, but every time as she was getting light her lungs would turn into rocks. Eventually just had to pull her deep, nasal trumpet with lido jelly on it in place, and mask assist her until she was awake....which took like 15 minutes because her PCO2 was like 85.

 

[DrOwnage]

I would say I deep extubate around 40% of my patients. If you do it prior to the procedure ending when they are bandaging/splinting/dressing, oral airway with high facemask flows, patient is usually awake sooner than some of my partners who extubate "awake" and narcotize their patients. I give 1mg/kg of lido with deep extubation and rarely have a true spasm, mostly just obstruction that goes away with some gentle CPAP.

 

[nimbus]

I bet folks who supervise residents and CRNAs are more likely to extubate wide awake than those who do their own cases.