Back to normal

[Noyac]

Same. I’ve done all my sitting shoulders with LMA for the past 15yrs. Never had a problem. They work even better in the sitting position than supine.

Boom. Exactly. And you get more respiratory pattern info from it. I have always believed that an LMA in the beach chair is safer.

---

Members don't see this ad.

 

[Noyac]

The theoretical benefit is the lack of glottic/tracheal instrumentation, aka not poking the beast in someone with reactive airway disease. But as I said earlier you can avoid that by pretreatment with neb, methylpred, touch of opioid. Then achieve nice plane of hemodynamically stable anesthesia masking with volatile, D/L, Ropi LTA (+- lido jelly on cuff etc), then smooth sailing.

Effect of topical ropivacaine on the response to endotracheal tube during emergence from general anesthesia: a prospective randomized double-blind controlled study

The airway reflex such as cough is common accompanied with severe fluctuations of hemodynamics during emergence. This prospective double-blind randomized controlled trial tested the hypothesis that topical ropivacaine may reduce extubation response and ...

www.ncbi.nlm.nih.gov

Yes you can do all of that.
Or you can place an LMA and call it good.

 

[deleted875186]

There is an ENTIRE thread about that subject. Just search the forum.

There are a lot of advantages, main one being the ability to keep the patient lighter (an ETT in the trachea is WAY more stimulating).

Also, for a patient with RV issues or PHTN, avoiding PPV is golden. Again, much easier with LMA, because the patient is lighter, so more likely to breathe.

I would have thought the opposite. I usually need to run patients deeper with an LMA. Typically can paralyze and run patients light with an ETT.

What degree of PPV do you think actually affects RV function, so long as the patient isn’t hypovolemia. I think the bigger concern is hypoxia and hypercarbia, both of which are far more like with an LMA instead of an ETT.

 

[Noyac]

He’s really good with that thing.

Ha ha. Yeah. You would be surprised. I’m like ZORO with that thing.

 

[Noyac]

Advantages of the LMA Supreme

LMA Supreme
The LMA Supreme is designed to make optimal insertion technique easier. Compared to the Unique LMA, the tube on the LMA Supreme is shorter and made of hard plastic. It is preformed into the optimal curve to allow even the inexperienced inserter to slide it into position over the glottic opening. The Supreme has a reinforced tip intended to prevent it from folding over and to allow it to easily slip under the arytenoids.

That’s funny. It’s designed for even the inexperienced user. I much prefer the classic LMA. I am way slicker with the classic. But I have been using it for so long I now know all the issues.

 

[nimbus]

I would have thought the opposite. I usually need to run patients deeper with an LMA. Typically can paralyze and run patients light with an ETT.

What degree of PPV do you think actually affects RV function, so long as the patient isn’t hypovolemia. I think the bigger concern is hypoxia and hypercarbia, both of which are far more like with an LMA instead of an ETT.

You can paralyze and run them light with an LMA too. I often do that with hernias when the surgical field starts looking like a stormy sea.

 

[DirtDocMD]

There is an ENTIRE thread about that subject. Just search the forum.

There are a lot of advantages, main one being the ability to keep the patient lighter (an ETT in the trachea is WAY more stimulating).

Also, for a patient with RV issues or PHTN, avoiding PPV is golden. Again, much easier with LMA, because the patient is lighter, so more likely to breathe.

What does an etCO2 of 65 do for that RV and pulm htn??

Now that we have Sugammadex, I just give ‘em more Rocuronium for “airway stimulation”. I do plenty of intubated cases with only 100ug of fentanyl, and the tube doesn’t seem to wind them up from a pain standpoint.

To each their own, but I’ve seen too many “belly breathers”, elevated CO2’s, agressive surgeons yanking on arms, etc—-to play games with LMA’s in pt’s with BMI’s of 48, in the sitting position. YMMV.....

Y’all have fun with that...

 

[deleted162650]

when the surgical field starts looking like a stormy sea.

A calm sea never made a skillful sailer.

 

[deleted162650]

Ha ha. Yeah. You would be surprised. I’m like ZORO with that thing.

Ya, maybe this version of Zoro.

 

[DocMcCoy]

Good case.

I’m in the ISB camp for this patient as well. could not agree more with laying it all out in the table and managing expectations during the consent process. I want her to think really hard about how much she needs this procedure. ICU stays don’t come cheap and the amenities suck.

My blocks happen in the OR before induction so I’d get to see how she responds from a respiratory standpoint.

I’m not totally opposed to LMAs for shoulders. That being said, I haven’t been doing this for 15 years but I’ve seen a handful of LMA shoulder cases go sideways. I’m really concerned with the BMI of almost 50. It’s rare for me to use an LMA in these patients unless it’s going to be a quick and minimally stimulating case that I have immediate access to the airway and I still don’t feel great about it. I need to man up?

Low and slow induction, no Aline if cuff is working fine and I don’t want to hear surgeon bitching about BPs in the 140s-150s.

paralyzed with controlled ventilation. No opioids.

sugammadex. She extubates when everything looks good and she’s ready to pull the tube herself.

 

[sevoflurane]

I sense some concerns.

Lol... you mean the hypoxic butterball that is being worked up for lung reduction surgery?

Good case and management bruh.

 

[dchz]

But you’re probably not aiming for a deep extubation in a BMI 50 patient anyway.

sugammadex. She extubates when everything looks good and she’s ready to pull the tube herself.

I'd like to focus on this. I would think deep extubation while sitting up would be the best thing for this patient. Anyone else or am I crazy?

I hate making "fat" people reach for the tube and bucking before i pull the tube.... these people slept for decades w/o dying.... why is it a big deal to deep extubate? I know people are trying to appear cautious, but in my mind, a sleepy fat person is a lot safer than a fat person trying to fight for their life.

If you're concerned about the phrenic nerve, you can test that before you pull the tube deep.

What does an etCO2 of 65 do for that RV and pulm htn??

her RV is stressed daily when she falls asleep, so the answer is probably the same thing it does when she falls asleep and obstructs. Also the PVR increase from 45 to 65 isn't that impressive.

 

[vector2]

I’m not totally opposed to LMAs for shoulders. That being said, I haven’t been doing this for 15 years but I’ve seen a handful of LMA shoulder cases go sideways. I’m really concerned with the BMI of almost 50. It’s rare for me to use an LMA in these patients unless it’s going to be a quick and minimally stimulating case that I have immediate access to the airway and I still don’t feel great about it. I need to man up?

There is never the need to do something in anesthesia with which you are uncomfortable or which your gut is telling you may be the riskier option...unless the benefits of doing so are pretty stellar.

When I see a pt who, if I had an LMA in her, made the differential for decreased EtCO2 (in addition to leak) have a non-insignificant chance of also being severe bronchospasm, decreased cardiac output, or fatty's diaphragm can no longer move air against a vapor-relaxed 300 lb chest wall and belly, I don't think anyone will fault you for going ETT.

 

[FiO2@21]

I'd like to focus on this. I would think deep extubation would be the best thing for this patient. Anyone else or am I crazy?

I hate making "fat" people reach for the tube and bucking before i pull the tube.... these people slept for decades w/o dying.... why is it a big deal to deep extubate? I know people are trying to appear cautious, but in my mind, a sleepy fat person is a lot safer than a fat person trying to fight for their life.

When I say deep I mean with 1 MAC of gas on board. I would still work in fentanyl and have her RR 12-14 and pull it as soon as her eyes were open. Don’t need her to be lifting her head, thrashing around, etc.


Sent from my iPhone using Tapatalk

 

[dchz]

When I say deep I mean with 1 MAC of gas on board. I would still work in fentanyl and have her RR 12-14 and pull it as soon as her eyes were open. Don’t need her to be lifting her head, thrashing around, etc.

Yep, we are on the same page, I'd pull this tube when Et Sevo is 2.0%. Why would you think her eyes wouldn't open?

Furthermore, if on the 0.01% chance her eyes don't open, she's still breathing right? reintubate at your leisure for "airway protection"

 

[dchz]

I’m not totally opposed to LMAs for shoulders. That being said, I haven’t been doing this for 15 years but I’ve seen a handful of LMA shoulder cases go sideways. I’m really concerned with the BMI of almost 50. It’s rare for me to use an LMA in these patients unless it’s going to be a quick and minimally stimulating case that I have immediate access to the airway and I still don’t feel great about it. I need to man up?

LOL plz don't try to "prove" yourself because some guy on a forum said so. do what you think is safe.

I'd 100% intubate this person. Not because i'm not confident that LMAs won't work, it's because if on the 1% chance LMA doesn't work, the headache is nothing something i'm willing to deal with. I know for a fact that i'm not experienced enough with sitting LMAs to have the confidence to do this case w/o a tube.

I would argue if i'm the anes physician, tube with deep extubation is safer than LMA.

 

[FiO2@21]

Yep, we are on the same page, I'd pull this tube when Et Sevo is 2.0%. Why would you think her eyes wouldn't open?

If I’m tracking your question right I’m not concerned that she won’t be able to wake up after the tube is pulled. I’d be concerned that her airway reflexes would not be intact like they would be with “physiologic” sleep.

Then again a few months ago I did exactly that and I strapped a mask on and put the pt on PSV Pro to get the gas off fast before I went to PACU. I told myself later that it was a dumb CA-1 move since I was giving a patient without intact reflexes positive pressure.

But now that I’m typing it out it seems dumb because that’s exactly what we do with LMAs. But I guess you have a seal up to 20 cm H2O with an LMA, something you don’t have with a mask. I’ll have to think about that one some more.

 

[dchz]

If I’m tracking your question right I’m not concerned that she won’t be able to wake up after the tube is pulled. I’d be concerned that her airway reflexes would not be intact like they would be with “physiologic” sleep.

Then again a few months ago I did exactly that and I strapped a mask on and put the pt on PSV Pro to get the gas off fast before I went to PACU. I told myself later that it was a dumb CA-1 move since I was giving a patient without intact reflexes positive pressure.

But now that I’m typing it out it seems dumb because that’s exactly what we do with LMAs. But I guess you have a seal up to 20 cm H2O with an LMA, something you don’t have with a mask. I’ll have to think about that one some more.

Welcome to the forum. I discovered this place when I was a CA-1. You should save this thread and look back in two years and see if you think differently. I was lucky enough to have good attendings that opened my mind as a CA-1. Hopefully we do the same for you.

As you are pondering this also think about at what point do the airway reflexes truly go away.

 

[Noyac]

So did the group decide that block with potential for knocking out phrenic nerve is better vs no block and using opiates is better for obese COPDers? I was taught that COPD with home O2 use is kind of a contraindication to interscalene maybe even supraclav block, but like so many things from residency, may not be so black and white...

Pretty much everyone that weighed in believed that the block was worth the risk. Plus as mentioned I was prepared to try Blade’s Block Reversal technique if needed.

 

[Noyac]

I would have intubated this patient likely with a glidescope but if the LMA worked out then that is acceptable. I have SUPREMES available to me and would have used one on this large patient even in a standard supine case.

Comparison of Anterior Suprascapular, Supraclavicular, and Interscalene Nerve Block Approaches for Major Outpatient Arthroscopic Shoulder Surgery: A Randomized, Double-blind, Noninferiority Trial

This study suggests that anterior suprascapular block provides noninferior analgesia compared to interscalene block, and better preserves vital capacity. While supraclavicular block was associated with some vital capacity preservation compared to interscalene block, the analgesia provided by...

anesthesiology.pubs.asahq.org

Has anyone considered the positioning of this case? Morbidly obese having difficulty breathing while flat. Sit her up and she can breath again.

 

[dhb]

Yep, we are on the same page, I'd pull this tube when Et Sevo is 2.0%.

You guys have a strange notion of deep.
My deep is 0.5 0.6% sevo
2% in a whale means you're going to need a cannula and wait 20+ min for wake up.

 

[Noyac]

Good case.

I’m in the ISB camp for this patient as well. could not agree more with laying it all out in the table and managing expectations during the consent process. I want her to think really hard about how much she needs this procedure. ICU stays don’t come cheap and the amenities suck.

My blocks happen in the OR before induction so I’d get to see how she responds from a respiratory standpoint.

I’m not totally opposed to LMAs for shoulders. That being said, I haven’t been doing this for 15 years but I’ve seen a handful of LMA shoulder cases go sideways. I’m really concerned with the BMI of almost 50. It’s rare for me to use an LMA in these patients unless it’s going to be a quick and minimally stimulating case that I have immediate access to the airway and I still don’t feel great about it. I need to man up?

Low and slow induction, no Aline if cuff is working fine and I don’t want to hear surgeon bitching about BPs in the 140s-150s.

paralyzed with controlled ventilation. No opioids.

sugammadex. She extubates when everything looks good and she’s ready to pull the tube herself.

Good post. I have a couple comments. First, know your surgeons. If they are the kind that have good frank discussions with their pts then why do we need to do it all over again in the day of surgery? Just confirm that the pt is well informed and proceed. Don’t waste peoples time (surgeons, etc). I would be pissed if I did all the leg work and dotted i’s crosses t’s and then someone walks in last minute and changes everything Because they don’t want to do the case. I am not saying this is anyones approach here but I have seen it happen many many times. So confirm what they have discussed and confirm her understanding and move on. That’s my approach.
Secondly, the last statement of not extubating until she is ready to pull the tube herself is a common approach by many. It’s far from my approach though for a few reasons. This pt has PHTN and ETT’s when managed poorly do bad things in these pts. Coughing and bucking and anxiety and fighting all make these pts decompensate and then you are stuck with the decision of either pull the tube or resedate them and try again later. I much prefer to pull the tube before they are aware that there is one in place at all. Some cases that as soon as they open their eyes, some cases I pull it deep and when appropriate I usually put in an LMA to avoid it all together. Many people don’t like to pull the ETT deep because of various concerns, loss of airway or reflexes etc. But you should have a damn good idea if the airway is difficult or not from induction and I hope you gave a couple breaths just to confirm that it’s not difficult.
just my $0.02 here.

 

[Noyac]

I would argue if i'm the anes physician, tube with deep extubation is safer than LMA.

important point here. Do what you are best at.

 

[Noyac]

Deep Extubation. I‘m more in the DHB camp here. I extubate deep at 1/2 MAC or less sometimes. I don’t want to be holding a mask on the pt for any longer than I need too. Deep to me means that the pt doesn’t respond to extubation, or to voices. It’s not necessarily a number. Also, I tend to get the gas down as far as possible then I give lido and propofol which I know will be gone in less than 5 min. The gas is variable depending on the pts TV and respiratory mechanics So they can take longer to fully support their breathing sometimes.

 

[MoMoGesiologist]

You guys have a strange notion of deep.
My deep is 0.5 0.6% sevo
2% in a whale means you're going to need a cannula and wait 20+ min for wake up.

How often u getting laryngospasm or breath holding pulling the ETT at that EtAA?

 

[dchz]

You guys have a strange notion of deep.
My deep is 0.5 0.6% sevo
2% in a whale means you're going to need a cannula and wait 20+ min for wake up.

Interesting point. Given all things equal.

What is the time to reach Et Sevo of 0.1% If you start at 2.0% et vs 0.6% et for a 2 hour shoulder case?

Obv it's hard to do a randomized control study for this, but my experience going from 2.0% Et to 0.1% Et is no more than 1.5x the amount of time it goes from 0.6% et to 0.1% et. In my experience we are talking more like a difference of 2-3 mins at the most. plus, I can pull the tube sooner at 2.0% because the pt is deep already anyways. Factoring transport time, I feel like this is a non-factor. But I still have yet to try this in a rapid turnover pace (20mins turnover or less).

Disclaimer: i always suction Ett, Stomach, and Oropharynx meticulously when I pull deep. Obv pt has to be spon breathing 300+ TV.

 

[dchz]

Has anyone considered the positioning of this case? Morbidly obese having difficulty breathing while flat. Sit her up and she can breath again.

I assumed everyone agreed that she should be sitting or reverse T .

Deep Extubation. I‘m more in the DHB camp here. I extubate deep at 1/2 MAC or less sometimes. I don’t want to be holding a mask on the pt for any longer than I need too. Deep to me means that the pt doesn’t respond to extubation, or to voices. It’s not necessarily a number. Also, I tend to get the gas down as far as possible then I give lido and propofol which I know will be gone in less than 5 min. The gas is variable depending on the pts TV and respiratory mechanics So they can take longer to fully support their breathing sometimes.

Lido, no. propofol yes.

This usually isn't a problem for me since for a shoulder case they would have been breathing by themselves for about 10mins on spont before I pulled the tube. Any problem with breathing from that point is pretty much upper airway obstruction, which we should prevent empirically anyways with an oral/naso airway in this pt population.

 

[J Peterman]

Occasionally. We all know how to treat laryngospasm right? Usually an unfriendly jaw thrust at the “laryngospasm notch” does the trick. In this patient population (morbidly obese), I put a lido-lubed NPA in before extubation to maintain airway patency as the incidence of OSA reaches 100%. In someone you’re really concerned about, a Bailey maneuver (slip an LMA, which is a glorified oral airway, in well before removing the ETT) can be a good option as well. People are far more likely to wake up smoothly and pull an LMA out on their own when ready without coughing/desatting/spiking PVR like they would with an ETT.

I extubate pretty much everyone a little “deep”, except like Noy it’s with nearly all of the gas off (0.3 etSevo or less) with the patient waking up on the propofol bolus they received during closure.

 

[vector2]

My deep is 0.5 0.6% sevo

I extubate deep at 1/2 MAC or less sometimes.

“deep”, (0.3 etSevo or less)

What in the world......none of these is even close to the classic definition of a "deep" extubation. In fact, the technique described above is essentially a "hopefully past theoretical stage 2 and almost awake however not following commands quite yet" extubation. I do it all the time but I don't describe it to anyone as deep.

 

[dhb]

How often u getting laryngospasm or breath holding pulling the ETT at that EtAA?

Nothing that isn't solve by a forcefull jaw thrust. I might dare say that >95% of what we see is more upper airway obstruction that a true vocal cord closure.

 

[dhb]

What in the world......none of these is even close to the classic definition of a "deep" extubation. In fact, the technique described above is essentially a "hopefully past theoretical stage 2 and almost awake however not following commands quite yet" extubation. I do it all the time but I don't describe it to anyone as deep.

I say deep as in not awake, i don't see the point of extubating at 1 mac: you're just kicking the can down the road and the road is shorter at 0.3 mac.

Classic is for academics i don't want turnovers that last more than 15min

 

[vector2]

I say deep as in not awake, i don't see the point of extubating at 1 mac: you're just kicking the can down the road and the road is shorter at 0.3 mac.

Classic is for academics i don't want turnovers that last more tha 15min

My anecdotal experience is that bronchospasm/laryngospasm incidence is remarkably higher in pts (especially those like this lady with COPD or reactive airway disease) if I pull the tube while they have airway reflexes/disconjugate gaze/irregular respirations/~0.4-0.5 MAC of vapor on board. For me, the pt has gotta be <0.3 end tidal sevo concentration or >2.

I'm not kicking any can down the road or delaying because I just pull the tube when they're almost done closing fascia instead of waiting til they're on skin. It doesn't take that long for the pt to blow off a MAC of sevo as long as airway patency is maintained with OPA/NPA + a little CPAP using the popoff.

 

[dhb]

as long as airway patency is maintained with OPA/NPA

I try to limit my carbon footprint

 

[vector2]

I try to limit my carbon footprint

I'm still using the anesthesia circuit with a good mask seal post-deep extubation while they're closing....

 

[J Peterman]

That’s why the tube is pulled with regular respirations and always check for conjugate gaze beforehand. With minimal etSevo and with propofol on board. No sputtering or coughing.
Tube is out as the drapes are coming down and the patient is usually awake by the time they need to move to the gurney. I’m not saying this is the only way to do it, just my preference and practice most of the time.

 

[DirtDocMD]

Some of you guys seem to confuse “deep” extubation and “early” extubation. I can do both in old folks, but try “early” on a young/strong male (30 y/o), with no propofol “chaser” added to the mix, and see what happens....

 

[vector2]

That’s why the tube is pulled with regular respirations and always check for conjugate gaze beforehand. With minimal etSevo and with propofol on board. No sputtering or coughing.
Tube is out as the drapes are coming down and the patient is usually awake by the time they need to move to the gurney. I’m not saying this is the only way to do it, just my preference and practice most of the time.

That's what I do as well and what I tell my residents to do once I'm confident they can manage minor airway complications, but that is not a deep extubation. For me, that's just a regular extubation, and that's further contrasted with the "pt wide awake, potentially bucking, definitely protecting airway, can pull tube out by themselves" extubation that I reserve pretty much only for extremely difficult airways. It might seem like I'm being overly pedantic but I'm used to having to be very specific with them when they ask me if we can do a "deep" extubation. "Deep" for me means we are extubating when the patient has NMB reversed, ~1 MAC on board, no cough or gag reflex to stimulation, conjugate gaze, regular spontaneous respirations with adequate Vt.

For people with severe reactive airway disease, a "deep" extubation has this very specific meaning. If you have someone with say such a severe intraop bronchospasm that they required a bit of IV epi to break it, and I say we're doing a deep extubation, I definitely don't mean that I want their airway to get stimulated by the return of reflexes as they make their way down to 0.3 ET sevo and then we pull the tube before they're fully awake.

 

[Hork Bajir]

I’m a big proponent of extubating “deep-ish”. Some would call it stage 2 extubation... every now and again someone will L-spasm, but if you’re paying attention that’s easy to catch and treat. It’s also less common than academic dogma would have you believe (particularly in older folks). In most cases I’ll pull the tube if someone is breathing spontaneously, provided airway wasn’t difficult and aspiration risk isn’t a concern, regardless of what the ET sevo is (often 0.2 or 0.3%).

 

[Hork Bajir]

Exactly what Vector said. I like making senior residents take this approach, but critical to distinguish that it’s different that a classical deep extubation

 

[Urzuz]

Just to throw my 2 cents into the mix, I tube every patient in beach chair, regardless of how favorable their airway anatomy is. During my first couple years in practice I used to try to use LMAs in all sorts of ways (sitting position, very short laparoscopic cases, once even prone (!!!!)), until I began to realize 1) it’s ****ing stressful when the LMA doesn’t seat perfectly or the patient’s ventilation gets compromised midway through the case, and 2) intubating people is something we do all day, every day, and in the vast majority of patients it’s benign and adds minimal/no time onto a case. The potential risk of the LMA unseating and the hassle of having to manage an airway under the drapes in the sitting position just isn’t worth it.

The general rule I live by is that, if I think for even a second that I may want to intubate someone, I do. If I have to convince myself to put an LMA in, I don’t. “I’ve never regretted intubating someone, but I’ve regretted plenty of LMAs I’ve used.”

Block, tube, less than 1/2 MAC of gas, propofol infusion through the case, extubate at end.

 

[6svette]

That’s why the tube is pulled with regular respirations and always check for conjugate gaze beforehand. With minimal etSevo and with propofol on board. No sputtering or coughing.
Tube is out as the drapes are coming down and the patient is usually awake by the time they need to move to the gurney. I’m not saying this is the only way to do it, just my preference and practice most of the time.

Dose and timing of prop bolus?

 

[nimbus]

Some of you guys seem to confuse “deep” extubation and “early” extubation. I can do both in old folks, but try “early” on a young/strong male (30 y/o), with no propofol “chaser” added to the mix, and see what happens....

Do it all the time. I never extubate “awake” (eyes opening and following commands). Rarely give propofol.

 

[BLADEMDA]

If I am concerned about extubating a patient awake for any reason my deep technique is end tidal vapor of 0.3 MAC with about 0.5-.8 mg/kg of propofol IV. I then place an oral Airway or LMA.

 

[Noyac]

My anecdotal experience is that bronchospasm/laryngospasm incidence is remarkably higher in pts (especially those like this lady with COPD or reactive airway disease) if I pull the tube while they have airway reflexes/disconjugate gaze/irregular respirations/~0.4-0.5 MAC of vapor on board. For me, the pt has gotta be <0.3 end tidal sevo concentration or >2.

I'm not kicking any can down the road or delaying because I just pull the tube when they're almost done closing fascia instead of waiting til they're on skin. It doesn't take that long for the pt to blow off a MAC of sevo as long as airway patency is maintained with OPA/NPA + a little CPAP using the popoff.

Strange post imo. The ET gas may not matter if you give propofol at closure therefore, we are talking about two different means of deep extubation. Your hard and fast <0.3 or >2 is too rigid for my speed. But if you want to do this with gas alone then be my guest. Maybe I am not understanding your point here, which I am sure is the case.

 

[Noyac]

That's what I do as well and what I tell my residents to do once I'm confident they can manage minor airway complications, but that is not a deep extubation. For me, that's just a regular extubation, and that's further contrasted with the "pt wide awake, potentially bucking, definitely protecting airway, can pull tube out by themselves" extubation that I reserve pretty much only for extremely difficult airways. It might seem like I'm being overly pedantic but I'm used to having to be very specific with them when they ask me if we can do a "deep" extubation. "Deep" for me means we are extubating when the patient has NMB reversed, ~1 MAC on board, no cough or gag reflex to stimulation, conjugate gaze, regular spontaneous respirations with adequate Vt.

For people with severe reactive airway disease, a "deep" extubation has this very specific meaning. If you have someone with say such a severe intraop bronchospasm that they required a bit of IV epi to break it, and I say we're doing a deep extubation, I definitely don't mean that I want their airway to get stimulated by the return of reflexes as they make their way down to 0.3 ET sevo and then we pull the tube before they're fully awake.

Well all I can say is that you are there to train these residents. Not to protect your insecurities in their abilities. You need to bring them along.
I had an attending that made me mask a pt for any case under 2 hRA when it was appropriate for the case. I veryquickly learnedto manage an airway with the least amo7nt of work on my part As possible so that I could do other things like charting, drawing up drugs etc

 

[vector2]

Strange post imo. The ET gas may not matter if you give propofol at closure therefore, we are talking about two different means of deep extubation. Your hard and fast <0.3 or >2 is too rigid for my speed. But if you want to do this with gas alone then be my guest. Maybe I am not understanding your point here, which I am sure is the case.

I was responding to dhb who said ET “0.5-0.6%” sevo is his definition of deep- he didn’t say anything about bumping some propofol as well which would blunt some of the airway hyperexcitation in pts who are susceptible. However, I shouldn’t have stated hard numbers because that’s not actually my practice and obviously the ET vapor concentration (plus whatever other meds are on board) cause different levels of anesthesia in different pts. Whether the the pt has airway reflexes to stimulation, breath holding, irregular respirations, disconjugate gaze, hypersalivation etc is more important than any number.

“Stage 2” more and more is a bit of a contested phenomenon compared to the days of say straight ether dropping, but I think the concept is useful because even with modern volatile, there is clearly a danger zone (particularly with kiddos) between deeeeep (1+ MAC) and near-awake (0.1 MAC). Someone claimed earlier that the incidence of laryngospasm/bronchospasm with stage 2 extubation has historically been overestimated. That may be so, but given that the lady in the OP is fat as all getout and has clearly documented moderate to severe COPD with minimal response to bronchodilators, I don’t think a complication associated with a cavalier “0.5%” sevo extubation with her is nearly as defensible as yanking the tube at will in a 110lb ASA 1 lap appy who you know you can quickly mask, reintubate, and get O2 to the alveoli without causing massive hemodynamics swings.

 

[FiO2@21]

less than 1/2 MAC of gas, propofol infusion through the case

Why?

 

[vector2]

Well all I can say is that you are there to train these residents. Not to protect your insecurities in their abilities. You need to bring them along.
I had an attending that made me mask a pt for any case under 2 hRA when it was appropriate for the case. I veryquickly learnedto manage an airway with the least amo7nt of work on my part As possible so that I could do other things like charting, drawing up drugs etc

What I’m there for primarily is to train residents how to do anesthesia safely. Also, I’m not exactly sure how the F you think what I said “That [pulling the tube near-awake] is what I do as well and what I tell my residents to do once I’m confident they can manage minor airway complications” has anything to do with insecurities. Insecure would be making them wake every pt up til the point of gagging, bucking, coughing, coming off the table, punching the circulator in the face and then telling them not to pull it until I’ve finished my coffee and can be physically present.

 

[Urzuz]

Why?

With a functioning block, anything more is unnecessary.

You get guaranteed amnesia, reduced risk of PONV (though barring any other information her risk is low), reduced risk of laryngospasm/bronchospasm, expeditious wake up / emergence.

 

[Planktonmd]

I sense some concerns.

People are forgetting that Noyac works in a physician only practice, which means he is not placing an LMA and handing the patient to some nurse "anesthesiologist" keeping his fingers crossed.
There are many things I do differently when I am the one doing the case.