Deep extubation in apneic patient

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bkell101 said:
Proper mask ventilation vs lma has higher chance of aspiration in an apneic patient?
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Yes. Not all patients have good lower esophageal sphincters, and even those who do will not withstand 20 cmH2O (which is sometimes the pressure needed to mask an obese patient).

But to answer @pgg 's question: the aspiration risk is not the main issue in this thin patient. Still, it's something one really never thinks about as a resident. The main issue in this patient is CO2. Many neurosurgeons would freak out from the masking. I understand this is a thin patient blah-blah, but it's still a bad example. So why don't we just mask all patients we deep extubate, instead of waiting for SV, if there are no risks?

Btw, most complications in anesthesia are rare nowadays. That's why we can afford having CRNAs.

P.S. This entire argument makes me smile, because I have misextubated a couple of apneic patients by mistake, at the end of LMA cases. The fact that we can doesn't mean that we should.
 
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I've been scared of neuroanesthesia ever since I was a resident and heard about a young healthy patient at the end of a crani that didn't wake up. Not to say that hasn't happened in a heart either (definitely have seen a "healthy heart" for a valve not wake up).

Anyway, I think the overall message is that just because something cavalier can be done I don't think we should be teaching residents (the potential future of anesthesia) these techniques. Only fuels the fire to let conservative robotic CRNAs do caseses.
 
FFP said:
Yes. Not all patients have good lower esophageal sphincters, and even those who do will not withstand 20 cmH2O (which is sometimes the pressure needed to mask an obese patient).
Click to expand...

OK, but we probably masked this patient after induction without worrying about this concern. Unless you RSI everyone, this argument doesn't hold much water TBH.

I really don't see how proper masking after anesthetic induction, when the patient is apneic and NPO is any different from at the end of the case.

Again, this is not what I do with my patients. I think it's big time academic fancy-play syndrome. But I don't think it's unsafe.
FFP said:
So why don't we just mask all patients we deep extubate, instead of waiting for SV, if there are no risks?
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Because now you're doing work you didn't have to do. You're creating work for yourself that the patient could be doing on their own. I have other things I could be doing other than masking a patient that could be breathing. Doesn't make it unsafe.
 
It doesn't, if it's for 5 minutes. The longer it is, the higher the risk of putting air in the stomach. The reason we don't get regurg on induction is probably that we don't mask for 20 minutes.

Also, the longer the toying around, the higher the risk the CO2 will get out of control. If that patient doesn't wake up, the surgeon will throw you under the bus first, accusing you that it's because of the ICP.

Regardless, it's just not worth the headache for me.
 
FFP said:
It doesn't, if it's for 5 minutes. The longer it is, the higher the risk of putting air in the stomach. The reason we don't get regurg on induction is probably that we don't mask for 20 minutes.

Also, the longer the toying around, the higher the risk the CO2 will get out of control. If that patient doesn't wake up, the surgeon will throw you under the bus first, accusing you that it's because of the ICP.

Regardless, it's just not worth the headache for me.
Click to expand...

I have seen what's in bold...seriously.
 
Twiggidy said:
I've been scared of neuroanesthesia ever since I was a resident and heard about a young healthy patient at the end of a crani that didn't wake up. Not to say that hasn't happened in a heart either (definitely have seen a "healthy heart" for a valve not wake up).
Click to expand...
Sometimes when we cut parts of someone's brain that brain might just not work right immediately after surgery... that's how it is!
 
bkell101 said:
Attending's preference: flip and deep extubate in apneic pt, mask pt till wake up.
Click to expand...

On the flip side, it won't faze you when the surgeon/scrub/PA/RN accidentally extubates the patient at end of case when the drapes come off - it's been known to happen in ENT/Neuro cases where the patient's also incidentally turned 180 from you as well. Granted, you also get to practice while the patient is still deep in this situation vs in a stage conducive to laryngospasm.
 
FFP said:
Yes. Not all patients have good lower esophageal sphincters, and even those who do will not withstand 20 cmH2O (which is sometimes the pressure needed to mask an obese patient).

But to answer @pgg 's question: the aspiration risk is not the main issue in this thin patient. Still, it's something one really never thinks about as a resident. The main issue in this patient is CO2. Many neurosurgeons would freak out from the masking. I understand this is a thin patient blah-blah, but it's still a bad example. So why don't we just mask all patients we deep extubate, instead of waiting for SV, if there are no risks?

Btw, most complications in anesthesia are rare nowadays. That's why we can afford having CRNAs.

P.S. This entire argument makes me smile, because I have misextubated a couple of apneic patients by mistake, at the end of LMA cases. The fact that we can doesn't mean that we should.[/QUOTE

I totally buy the desire to control Co2. I typically control ventilation till the very last min in these cranis while the remi is wearing off. I really don't mess with letting them go apneic on the vent to try to get them breathing on their own.....that being said I feel like deep extubation with masking the patient appropriately would control the co2 better than deep extubation and oral airway. Would you all agree?

Also, can we talk about the difference/importance of controlling the co2 prior to lesion removal vs post craniotomy?
Click to expand...
 
Sorry I messed up the last post......


I totally buy the desire to control Co2. I typically control ventilation till the very last min in these cranis while the remi is wearing off. I really don't mess with letting them go apneic on the vent to try to get them breathing on their own.....that being said I feel like deep extubation with masking the patient appropriately would control the co2 better than deep extubation and oral airway. Would you all agree?

Also, can we talk about the difference/importance of controlling the co2 prior to lesion removal vs post craniotomy?
 
bkell101 said:
I totally buy the desire to control Co2. I typically control ventilation till the very last min in these cranis while the remi is wearing off. I really don't mess with letting them go apneic on the vent to try to get them breathing on their own.....that being said I feel like deep extubation with masking the patient appropriately would control the co2 better than deep extubation and oral airway. Would you all agree?

Also, can we talk about the difference/importance of controlling the co2 prior to lesion removal vs post craniotomy?
Click to expand...

Yes, let's.

It's not important to control CO2 after successful crani for tumor removal. (within grossly normal limits, say, 30-70).
 
fakin' the funk said:
Not a big fan of this technique
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Agreed. Big difference between a pt that can't move in pins because they are chemically paralyzed and a pt you think won't move in pins because they have "plenty of remi" on board. Ever seen pins slip? Not pretty.
 
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