When do you pull the tube?

[GassYous]

Btw why are you guys trying to save time anyway? Take a few minutes and do it right so you can get that extra unit

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[DrOwnage]

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

Yeah totally lol. Supervising is different. Less things to worry about.

 

[IMGASMD]

Btw why are you guys trying to save time anyway? Take a few minutes and do it right so you can get that extra unit

For the sweet sweet starting base units. Then dump it to junior guys.

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

Can’t agree with this enough. One of our hospitals is recruiting heavily, so lots of young graduates…. Most of them don’t stay pass the year mark.

The other hospital, are basically lifers, lots ex-icu nurses, who just don’t wanna take evening/night shifts anymore.

Then there’s the surgery centers. If I even have an oral airway coming out with the patient…. I will not hear the end of it. I’ve received dirty looks when I give 20mg of ketamine.

If I want a quiet day and not receiving any calls from PACU. Everyone pulls their own damn tube wide awake.

 

[BobLoblaw78]

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.

This. I am sure the 99/100 is hyperbole, but these patients happen frequently. You must know that you can intubate them. But they are the ones that you have to "pull the tube to get them extubated." Lol. I don't know how many times I have responded to help call bc they do the above and they get them deep again to fix it. They will do this 3-4x and be back where they started. If you are that worried about airway, then do extubation over exchange catheter with lido and maybe a little prop.

 

[Southpaw]

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?

I never extubate deep, per the textbook. I also never extubate completely awake, with the patient self-extubating, staff holding them down, eyes watering, gagging on the ETT, extremities flailing all over.

The risks of deep extubation are airway concerns and everything that can potentially occur when you drop off a patient, still under GA with some airway in, on a PACU RN. The benefits I guess are you look slick and you don’t have to actually emerge your patient.

I’m called to the PACU often enough to know it’s not worth it. And sure, for those that do your own cases, do whatever you want. If you F it up the PACU RN will absolutely call you or one of your partners back to fix it.

I think patients can safely be extubated deep. I also think those same patients could be extubated awake, or at least mostly awake (past stage 2 or whatever) with a proper emergence plan.

 

[MirrorTodd]

You all know you don't have to wait to deep extubate until after the drapes are down? Nor do you have to deep extubate on gas right? It seems like most people are assuming a deep extubation after the surgeon has stepped away and shredded their gown and the gas is still on 1.4 mac or something.

 

[Southpaw]

You all know you don't have to wait to deep extubate until after the drapes are down? Nor do you have to deep extubate on gas right? It seems like most people are assuming a deep extubation after the surgeon has stepped away and shredded their gown and the gas is still on 1.4 mac or something.

Not sure anyone is assuming that, though you could be right. Certainly in residency that's how deep extubation was taught to me. Drapes down, my attending in, ready to extubate, okay now we get them EVEN DEEPER, pull ETT, oral airway in, moving air okay?, okay great now we're moving and off to PACU.

Honestly a well timed emergence and extubation can occur as the drapes are coming down and it's time to move the patient. It really doesn't require that much effort or that much planning in advance. It also, like most things, becomes very routine after a few times.

 

[MirrorTodd]

Not sure anyone is assuming that, though you could be right. Certainly in residency that's how deep extubation was taught to me. Drapes down, my attending in, ready to extubate, okay now we get them EVEN DEEPER, pull ETT, oral airway in, moving air okay?, okay great now we're moving and off to PACU.

Honestly a well timed emergence and extubation can occur as the drapes are coming down and it's time to move the patient. It really doesn't require that much effort or that much planning in advance. It also, like most things, becomes very routine after a few times.

Agree with you 100% and that is something I am actively working on, as I never really developed that skill in residency being bounced around so many hospitals and working under so many different anesthesiologists. Same thing with deep extubations, they were a rarity in residency. I am not really performing that many, partially due to short pacu staffing, and also because I need to get better at awake extubations myself and finally because the residents I am teaching need to get better at awake extubations.

 

[DocVapor]

Yeah totally lol. Supervising is different. Less things to worry about.

I have a very small handful of CRNAs that I let extubate deep (I'm still there, of course). Most of them the patient needs to be awake.

When I'm doing my own cases I deep extubate 75% of them while surgeon is finishing closing skin and they're plenty awake in PACU. Of course, very rare the surgeon takes longer to close than expected.

 

[GassYous]

I extubate with gas almost off, patient reversed and breathing with good tidal volumes. Don't check to see if they're awake. 80% of the time they open eyes to verbal stimulus by the time they hit pacu. Some of the old ones or long prop infusion patients don't but eventually do.

 

[linkin06]

i definitely make sure i look at this eyes. if they're crossed and disconjugate, no way am i pulling then.

 

[GassYous]

i definitely make sure i look at this eyes. if they're crossed and disconjugate, no way am i pulling then.

Myth, you don't need to look at eyes to pull tube

 

[Gaslamp]

I pull the tube when the pt is spontaneously breathing, the gas is off, and we're ready to move the pt onto the stretcher or already moved the pt on the stretcher. I dont pay attention to etGas.