Deep Extubation With Propofol

[interleukin2]

So, If I have a patient which was an easy mask and easy intubation and I would like to extubate deep but want to avoid blowing off excess gas at the end ( say I did the case with iso or sevo) would giving a bolus of propofol of say 0.5-1 mg/kg and then extubating avoid the risk of stage 2 induced laryngospasm? The advantage I see here is having minimal gas ( thus reducing your exposure to volatile agent) and minimizing the time one needs to mask ventilate while decreasing the risk of laryngospasm one sees when patients are extubated during stage 2. I think this could be useful to prevent/minimize coughing and bucking. Anyone tried this? Does it make your wakeup smoother, or is it not worth the risk of laryngospasm? Would the smooth iso wake ups negate the need for such an approach, and thus it is worth doing cases with just iso where one is concerned for the potential for severe coughing and bucking, ie smokers? Appreciate the input!

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[BobBarker]

I assume you are planning on masking for a few minutes when the 100mg of prop makes the patient apneic. I would consider switching from a tube to an LMA and let the patient pull the LMA on he way to the PACU.

 

[Arch Guillotti]

I assume you are planning on masking for a few minutes when the 100mg of prop makes the patient apneic. I would consider switching from a tube to an LMA and let the patient pull the LMA on he way to the PACU.

Switching from a tube to an LMA sounds kind of silly.

I do think that giving small propofol bumps at the end of a case smooths things out though.

 

[IlDestriero]

Get the patient spontaneously ventilating at the end of the case on 1/2- 1 Mac of sevo, move to gurney, suction, tube/lma out, Oral or nasal airway in, put them lateral, blow some O2 at them, the end.
They wake up fine in the pacu. I do it every day.
Don't try to get fancy.

 

[Matty44]

Do your patients not react to suctioning when you do this? I'd be surprised if they didn't with just 1/2 a MAC of sevo on board. And if they DO react, does that not indicate to you that they aren't deep enough for the tube to be taken out? Or at the very least, they are at higher risk for spasm than someone who doesn't react to suctioning...Not criticizing here, just curious of your thought process.

 

[Mman]

Do your patients not react to suctioning when you do this? I'd be surprised if they didn't with just 1/2 a MAC of sevo on board. And if they DO react, does that not indicate to you that they aren't deep enough for the tube to be taken out? Or at the very least, they are at higher risk for spasm than someone who doesn't react to suctioning...Not criticizing here, just curious of your thought process.

he said between 0.5 and 1 MAC. And if you have plenty of narcotics in their system, 0.5 MAC could be plenty (notice I said could not should).

 

[dhb]

Get the patient spontaneously ventilating, tube out
Don't try to get fancy.

This is what i do.

 

[jwk]

To the OP - you're essentially putting your patient back to sleep to extubate them. That will certainly not speed up your emergence.

 

[Bertelman]

To the OP - you're essentially putting your patient back to sleep to extubate them. That will certainly not speed up your emergence.

He's looking to speed up time to extubation, not emergence.

 

[RxBoy]

I wouldn't do it. You're not covering your bases in between washing the gas out and bolusing propofol phase. The patient can get light, start bucking, moving during surgery, ect. If I were to do it, I would work in an infusion as I wash the gas out. But this is my strategy for smooth awake extubation (+working in opiates and 4% lido down tube). Plus bolusing is dangerous on hemodynamics causing wide swings.

 

[IlDestriero]

Do your patients not react to suctioning when you do this? I'd be surprised if they didn't with just 1/2 a MAC of sevo on board. And if they DO react, does that not indicate to you that they aren't deep enough for the tube to be taken out? Or at the very least, they are at higher risk for spasm than someone who doesn't react to suctioning...Not criticizing here, just curious of your thought process.

he said between 0.5 and 1 MAC. And if you have plenty of narcotics in their system, 0.5 MAC could be plenty (notice I said could not should).

Correct, you don't need to be >/= 1 Mac to not respond to suctioning and extubation. If they respond to suctioning, just put the sevo up for a couple minutes and then extubate.
Suction your patient tomorrow as your lightening your anesthetic at 0.6 Mac of Iso or sevo. Provided they have opiates on board, I'd be surprised if they even swallow.

 

[IlDestriero]

If you don't care about recovery time, extubate them on 1.3 Mac on your way out the door. That won't fly at the ASC though.

 

[urge]

So, If I have a patient which was an easy mask and easy intubation and I would like to extubate deep but want to avoid blowing off excess gas at the end ( say I did the case with iso or sevo) would giving a bolus of propofol of say 0.5-1 mg/kg and then extubating avoid the risk of stage 2 induced laryngospasm? The advantage I see here is having minimal gas ( thus reducing your exposure to volatile agent) and minimizing the time one needs to mask ventilate while decreasing the risk of laryngospasm one sees when patients are extubated during stage 2. I think this could be useful to prevent/minimize coughing and bucking. Anyone tried this? Does it make your wakeup smoother, or is it not worth the risk of laryngospasm? Would the smooth iso wake ups negate the need for such an approach, and thus it is worth doing cases with just iso where one is concerned for the potential for severe coughing and bucking, ie smokers? Appreciate the input!

That should work. However, you will have a lot of explaining to do if you ever lose an airway.

I don't think it is worth it.

 

[periopdoc]

Geez, this is a great way to do a deep extubation. Let's review basic pharmacokinetics of propofol vs sevo at the end of the case. Offset of propofol is determined by... redistribution. Offset of sevo after breathing it for a while is determined by... Bueller.... Bueller... Bueller....

Difference in duration of offset (emergence) of these two drugs is an order of magnitude.

100 mg is probably a little too much, but if you want to extubate deep and wake em up fast, lighten them up at the end of the case. Drop 25-50mg of propofol and extubate.

Redistribution is a lot faster than waiting for the patient to breath off a deep level of sevo.

Of course this is assuming the patient is a good candidate for deep extubation in the first place and it isn't as sweet as timing the sevo for a perfect wakeup as the drapes go down, but it is a perfectly acceptable and safe way to go.

Worried about losing the airway... well that is a concern with ANY deep extubation. No more or less with this technique. Let me ask you, you misjudged the depth needed for a deep sevo extubation and the patient goes into laryngospasm... What do you do next... oh yeah PROPOFOL (or maybe sux). Hmm why not just start with propofol. Which one is better at blunting airway reflexes at a low dose?

- pod

 

[nap$ter]

Geez, this is a great way to do a deep extubation. Let's review basic pharmacokinetics of propofol vs sevo at the end of the case. Offset of propofol is determined by... redistribution. Offset of sevo after breathing it for a while is determined by... Bueller.... Bueller... Bueller....

Difference in duration of offset (emergence) of these two drugs is an order of magnitude.

100 mg is probably a little too much, but if you want to extubate deep and wake em up fast, lighten them up at the end of the case. Drop 25-50mg of propofol and extubate.

Redistribution is a lot faster than waiting for the patient to breath off a deep level of sevo.

Of course this is assuming the patient is a good candidate for deep extubation in the first place and it isn't as sweet as timing the sevo for a perfect wakeup as the drapes go down, but it is a perfectly acceptable and safe way to go.

Worried about losing the airway... well that is a concern with ANY deep extubation. No more or less with this technique. Let me ask you, you misjudged the depth needed for a deep sevo extubation and the patient goes into laryngospasm... What do you do next... oh yeah PROPOFOL (or maybe sux). Hmm why not just start with propofol. Which one is better at blunting airway reflexes at a low dose?

- pod

sounds great but isn't great in my experience. tried this a few times late in residency - getting the dose right is tricky as the "mac" deep extubation dose is highly variable at the end of a case. the pharmacokinetics are as pod describes but the pharmacodynamics are all screwy with the polypharmacy present at the end of a case. the therapeutic window between apnea for long minutes and depth sufficient to pull the tube without bucking/coughing seems to be pretty narrow. do you do this often pod?

better IMHO as has been mentioned - keeping flows low, turning volatile off EARLY and giving lil bumps of propofol for predictable and fast awake extubation. if you need a deep extubation keep it simple and go with volatile or whatever anesthetic you've been running.

 

[vman]

Correct, you don't need to be >/= 1 Mac to not respond to suctioning and extubation. If they respond to suctioning, just put the sevo up for a couple minutes and then extubate.
Suction your patient tomorrow as your lightening your anesthetic at 0.6 Mac of Iso or sevo. Provided they have opiates on board, I'd be surprised if they even swallow.

Agree with above- a small bump of narcotics towards the end would do the trick. no need to flood the patient with sevo by going up several MAC. the presence of narcotics will smooth out any delirium from rapid emergence and prevent laryngospasm as the enter a slighter plane.

 

[periopdoc]

Many ways to skin a cat. Is a deep extubation one where (as we were classically trained) the patient has 2-3 MAC of gas on board or one where the patient is just deep enough that they don't cough with manipulation of the trachea? (We argued that one into the ground a while back). What vman is describing is the latter and this is how I typically do a "deep extubation" in my practice. Although I rarely do any type of deep extubation anymore except for on pedi tonsils where I do a classical 2 mac of gas deep extubation.

I used to do the propofol bolus, and with a little trial and error became pretty good at it not as predictable as my current recipe, but no less predictable than getting them deep on gas then waiting for them to ventilate it off slowly after extubation and dealing with the not infrequent partial airway obstruction, drop in a Guedel and hold the airway open scenario. It can be done, but that much propofol is way too much. That is an induction dose for many folks.

Went through a phase of extubate to LMA (a technique which I still use in certain cases as it frees up the hands and reduces the stimulation of the ETT). I think it is a great technique if you get to the end of the case and haven't set the patient up for a smooth wakeup.

The more you do this though, the better you get at timing the wakeup so that the patient opens his eyes to command, and lets you pull the tube with nothing more than a slight cough if that. Sometimes I will have the patient pull it out and hand it to me right before the move to the stretcher, but only if everyone in the OR is looking at us.

Never underestimate the power of a good show.

- pod

 

[fakin' the funk]

So, If I have a patient which was an easy mask and easy intubation and I would like to extubate deep but want to avoid blowing off excess gas at the end ( say I did the case with iso or sevo) would giving a bolus of propofol of say 0.5-1 mg/kg and then extubating avoid the risk of stage 2 induced laryngospasm?

That's a TON of propofol at the END of a case. I agree that if you're going to use it, use smaller doses.

I personally get them breathing spontaneously on iso or sevo somewhere around 1 MAC, usually with at least 1mcg/kg fentanyl on board, and just take the ETT cuff down and see what happens. Usually they don't cough. If they do, well then I've bought myself several minutes of deepening them with gas before trying again.

Alternatively, you can just deep-extubate everyone (regardless of airway irrritability) to 20-30cm H2O positive pressure by mask and jaw thrust like crazy

 

[periopdoc]

If their airway is irritable it is not a deep extubation by any definition/ criteria.

- pod

 

[fakin' the funk]

If their airway is irritable it is not a deep extubation by any definition/ criteria.

I view deep extubation as, does this person meet all extubation criteria EXCEPT
a) arousal (awake), OR
b) airway reflexes intact (cough/gag)

The deep extubation I described may not be a pretty one but by MY definition, it's "deep."

 

[Bertelman]

I view deep extubation as, does this person meet all extubation criteria EXCEPT
a) arousal (awake), OR
b) airway reflexes intact (cough/gag)

The deep extubation I described may not be a pretty one but by MY definition, it's "deep."

Then you are kidding yourself and misleading others.

Call it a...
"shallow extubation"
"early extubation"
"Stage II extubation"

..or whatever else you want, but don't call it deep, 'cause that's not at all what it is.

I am purposefully avoiding arguing whether what you are doing is right; at the least, you should be honest about what you are doing.

 

[Arch Guillotti]

That's a TON of propofol at the END of a case. I agree that if you're going to use it, use smaller doses.

I personally get them breathing spontaneously on iso or sevo somewhere around 1 MAC, usually with at least 1mcg/kg fentanyl on board, and just take the ETT cuff down and see what happens. Usually they don't cough. If they do, well then I've bought myself several minutes of deepening them with gas before trying again.

Alternatively, you can just deep-extubate everyone (regardless of airway irrritability) to 20-30cm H2O positive pressure by mask and jaw thrust like crazy

If you have a 70 kg person and give them 35 mg I don't consider it a ton.

 

[Arch Guillotti]

If their airway is irritable it is not a deep extubation by any definition/ criteria.

- pod

Agree. If they are still asleep and don't respond to deflating the cuff and/or extubation then I consider it "deep". If the airway is irritable I fail to see how it is a deep extubation. To me, they may be "deep" but if they respond it isn't a "deep extubation".

 

[Matty44]

Agree. If they are still asleep and don't respond to deflating the cuff and/or extubation then I consider it "deep". If the airway is irritable I fail to see how it is a deep extubation. To me, they may be "deep" but if they respond it isn't a "deep extubation".

Exactly. If they are responding to suctioning, or messing with the cuff, or whatever, then they aren't truly "deep" and are therefore at a higher risk of laryngospasm when you pull the tube.