Mil/JPP: How would you extubate deep?

ecCA1 said:

I've had some asthmatics that some would argue would benefit from deep extubation. What is your approach to this? A related question: how do you do the lido/propfol/fentanyl "smooth" extubation on someone you don't want to buck at the conclusion of the case (s/p abdominoplasty etc.)?

Thanks!

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They probably don't......

unless they were a difficult airway/intubation or might be hard to mask for some reason(mustache, no teeth, big honker), i would usually extubate abdominoplasties deep - why risk bucking.

so say you can smoothly extubate people 95% of the time with your own concoction of fentanyl/prop/lido. what are you going to tell the person that ruins his abdominoplasty by bucking that 5% of the time?

ecCA1 said:

I've had some asthmatics that some would argue would benefit from deep extubation. What is your approach to this? A related question: how do you do the lido/propfol/fentanyl "smooth" extubation on someone you don't want to buck at the conclusion of the case (s/p abdominoplasty etc.)?

Thanks!

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You're making more work for yourself than you have to, dude/dudette.

No literature that I'm aware of/no personal experiences swaying me to feel the need to deep-extubate asthmatics.

And the recipe you mention for prophylactic-bucking-prevention is advocated by some....but IMHO not needed.

Get'em breathing well before extubation will be one of your best tools to an easy extubation.

Turn your volatile agent off as the surgeon starts the last few minutes of his work. Turn the O2 up to max to optimize volatile-agent-exit.

When the last few skin staples are imminent, deflate the ETT cuff and whip out the tube.

Put the mask on and pull up on the mandible with birdie-fingers behind the mandibular ridges, pulling up, and thumbs on the mask, pushing down. APL open.

99% of the time pt will continue breathing. Occasionally you'll have to change hand positions (left hand forming seal of mask on face, right hand squeezing bag) so you can give some positive pressure to the airway.

practice

and even deep extubations lead to coughing....just not at the time you pull the tube.....

militarymd said:

practice

and even deep extubations lead to coughing....just not at the time you pull the tube.....

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I agree...practice practice practice.. analyze practice some more



and it may lead to coughing but not as much.....

think about how you pull lmas deep.. it has to be at 1.5 mac at least to pull deep otherwise your asking for trouble for yourself.. take a suction catheter and go down to the airway.. If there is response to stimulus.. youre too light.. better go deeper..

stephend7799 said:

I agree...practice practice practice.. analyze practice some more



and it may lead to coughing but not as much.....

think about how you pull lmas deep.. it has to be at 1.5 mac at least to pull deep otherwise your asking for trouble for yourself.. take a suction catheter and go down to the airway.. If there is response to stimulus.. youre too light.. better go deeper..

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Sorry,

disagree.

I routinely pull them while the patient is on the verge of waking up, ventilating well, with just a smidge of gas on board.

And the UK (the brits) routinely just leave them in with the patient breathing and transport them to the PACU, then pull it there.

These are the kind of posts that scare people into believing one has to perform something one-exact-way...

when in fact we practice a..

"theres-twenty-ways-to-do-most-things" business.

jetproppilot said:

Sorry,

disagree.

I routinely pull them while the patient is on the verge of waking up, ventilating well, with just a smidge of gas on board.

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disagree.

deep extubation means what it says.. "DEEP"

anything else is awake.. meaning.. awake.. sure we all take the tube out early all the time.. but its still awake.. NO GAS ONBOARD.. anything else is stage 2 and you are risking excitation.. dude you know that.. thats why my attendings for 3 ficking years pounded that in my head...

stephend7799 said:

disagree.

deep extubation means what it says.. "DEEP"

anything else is awake.. meaning.. awake.. sure we all take the tube out early all the time.. but its still awake.. NO GAS ONBOARD.. anything else is stage 2 and you are risking excitation.. dude you know that.. thats why my attendings for 3 ficking years pounded that in my head...

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They pounded in your head a totally overblown risk. Which is commensurate with academic medicine.

Dude, with all due respect, I dont make this s hit up.

Since I'm still just a working class dude, I live this stuff every day I go to work.

And come the end of June, it'll be ten years in the biz.

Not bragging. BELIEVE me, nothing to brag about.

Once I become a stay-at-home-dad I'll start bragging.

Just pointing out that there are what I consider anesthesia myths.

I certainly wouldnt profess on a situation I wasnt familiar with.

Believe me.

I've pulled a zillion LMAs in my ten year career.

And it can be done without deleterious sequelae.

Patient breathing good tidal volumes?

Sevo at end-tidal .2%?

No problem.

Rip it out.

On just about every patient, I do an aggressive jaw lift, at least initially. Birdie fingers buried behind the mandibular ridges, pushing-to-the-ceiling.

Thumbs on top of the mask, pushing to-the-floor.

With APL open, looking at the bag for movement.

Works, dude. And sometimes its not even needed. Upon removing the LMA, if the pt starts breathing, just place mask on face, APL open, call for stretcher.

You are conveying a fear that does not need to be conveyed.

No matter what extubation criteria you abide by (with ETT and LMA), you are still gonna see a (rare) laryngospasm.

No big deal.

Apply a big-time seal with the mask, pull up on the mandible with your left hand, apply positive pressure with your right hand on the bag.

Most of the time this is all it takes.

If it doesnt work (RARE), give 20-40 mg sux. Enough to address the problem without stranding you in the OR for 20 minutes.

Dont be fooled, folks, by posters that tell you THIS IS THE WAY IT HAS TO BE DONE.

In anesthesia, and probably every other specialty,

yes, there are a few scenerios that require adherence to a certain protocol.

This isn't one of them.l

jetproppilot said:

No matter what extubation criteria you abide by (with ETT and LMA), you are still gonna see a (rare) laryngospasm.

No big deal.

Apply a big-time seal with the mask, pull up on the mandible with your left hand, apply positive pressure with your right hand on the bag.

Most of the time this is all it takes.

If it doesnt work (RARE), give 20-40 mg sux. Enough to address the problem without stranding you in the OR for 20 minutes.

Dont be fooled, folks, by posters that tell you THIS IS THE WAY IT HAS TO BE DONE.

In anesthesia, and probably every other specialty,

yes, there are a few scenerios that require adherence to a certain protocol.

This isn't one of them.l

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Laryngospasm, if you see it do as Jet says and also if yu put a fair amount of pressure on the pressure point behind the angle of the mandile just below the earlobe, you can break it without sux. Just try it yoursel. Push fairly hard on the spot and see how it feels. It works.

I do the same as Jet described. I pull the ETT and the LMA (still inflated) with very little gas onboard. No problems to date but i have had to apply a little pressure on that point from time to time.

Noyac said:

Laryngospasm, if you see it do as Jet says and also if yu put a fair amount of pressure on the pressure point behind the angle of the mandile just below the earlobe, you can break it without sux. Just try it yourself. Push fairly hard on the spot and see how it feels. It works.

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M&M talk about this in the airway chapter. Haven't had the opportunity to try it out. Glad to know it works.

Noyac said:

Laryngospasm, if you see it do as Jet says and also if yu put a fair amount of pressure on the pressure point behind the angle of the mandile just below the earlobe, you can break it without sux. Just try it yoursel. Push fairly hard on the spot and see how it feels. It works..

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The truth spoken by a franchise playa.

Noyac said:

Laryngospasm, if you see it do as Jet says and also if yu put a fair amount of pressure on the pressure point behind the angle of the mandile just below the earlobe, you can break it without sux. Just try it yoursel. Push fairly hard on the spot and see how it feels. It works.

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It's true kids! I was supervising an SRNA when this happened JUST THE OTHER DAY. He was ready to intubate, I was ready to ventilate. 45 seconds later, the patient was in the PACU.

Peace out.