Deep Extubation

[VentdependenT]

What do you all think about this?

I've done it twice so far with an attending. First time was because the pt was highly anxious about waking up and remembering being extubated (which happened to her once in the past) and the second was for a plastics case and was the surgeons request. Neither case was abdominal or thoracic in nature.

No nondepolarizers given since start o' case and all twitches with sustained tetany back. First pt was extubated with sevo around .4 end tidal. We just flipped the vent off, extubated, and mask ventilated till she woke up. Second one she was spontanously breathing with sevo around .3 end tidal.

Both extubations were smooooth.

I can contrast the comfortable wake ups with the ones where i've titrated some narcs at the end for respiratory rate control. They wake up nicely but there are obvious inherent dangers with that approach.

So....what do yall think?

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[militarymd]

I do it all the time, but I keep them deeper ....Sevo end tidal about 3 to 4 %.

Works well for fast turnover rooms where you really want to get out of the room ASAP after the surgeon is done.

Obviously there are contraindications.

ETT out, oral airway in, make sure airway is patent, straight to the PACU before the patient wakes up.

 

[jetproppilot]

What do you all think about this?

I've done it twice so far with an attending. First time was because the pt was highly anxious about waking up and remembering being extubated (which happened to her once in the past) and the second was for a plastics case and was the surgeons request. Neither case was abdominal or thoracic in nature.

No nondepolarizers given since start o' case and all twitches with sustained tetany back. First pt was extubated with sevo around .4 end tidal. We just flipped the vent off, extubated, and mask ventilated till she woke up. Second one she was spontanously breathing with sevo around .3 end tidal.

Both extubations were smooooth.

I can contrast the comfortable wake ups with the ones where i've titrated some narcs at the end for respiratory rate control. They wake up nicely but there are obvious inherent dangers with that approach.

So....what do yall think?

Best way to go for the majority of cases. Not all, but most.

Gett'em breathing ASAP near the end, suction the oropharynx before you lighten the anesthetic (so you dont have to do it later when the anesthesia is lighter....less bucking risk).

Yank it on the second to the last "click-click of the staple gun, or thereabouts when no stapler is used.



You can emerge a patient safely without having them do push-ups before you pull the tube (old joke from residency about one of our attendings).

 

[davvid2700]

What do you all think about this?

I've done it twice so far with an attending. First time was because the pt was highly anxious about waking up and remembering being extubated (which happened to her once in the past) and the second was for a plastics case and was the surgeons request. Neither case was abdominal or thoracic in nature.

No nondepolarizers given since start o' case and all twitches with sustained tetany back. First pt was extubated with sevo around .4 end tidal. We just flipped the vent off, extubated, and mask ventilated till she woke up. Second one she was spontanously breathing with sevo around .3 end tidal.

Both extubations were smooooth.

I can contrast the comfortable wake ups with the ones where i've titrated some narcs at the end for respiratory rate control. They wake up nicely but there are obvious inherent dangers with that approach.

So....what do yall think?

deep extubation is riskier than standard wake up .. thats why its not done too often. but patient should be spontaneously breathing on at least 1 mac of agent if not more.. .4 of sevo is not enough.. why? because the lighter you are the higher risk of laryngospasm.. and thats exactly what you dont want.. that and aspiration.. The surgeons must be told that deep extubation takes longer.. also suction generously while the tube is in prior to extubation

 

[jetproppilot]

deep extubation is riskier than standard wake up .. thats why its not done too often. but patient should be spontaneously breathing on at least 1 mac of agent if not more.. .4 of sevo is not enough.. why? because the lighter you are the higher risk of laryngospasm.. and thats exactly what you dont want.. that and aspiration.. The surgeons must be told that deep extubation takes longer.. also suction generously while the tube is in prior to extubation

I humbly disagree with you.

Its done very, very often. Safely.

And from an efficiency standpoint there is no comparison.

 

[VentdependenT]

I was told it was very common in private practice. Same with LMA's.

With LMA's I wait till they just open their eyes. Have the home made bite block in place as well.

 

[militarymd]

deep extubation is riskier than standard wake up ..

I must humbly disagree. The majority of my wake ups go the deep route.

 

[davvid2700]

I humbly disagree with you.

Its done very, very often. Safely.

And from an efficiency standpoint there is no comparison.

I didnt say its not done safely, i was saying awake intubations are safer..

 

[Noyac]

I also do it often but I think your sevo conc. is a little too low. Try keeping them at 0.7 mac (not ET 0.7) or greater. I am usually pretty close to MAC and always above ET sevo 1.0. Or you can do what Mil says, ET sevo 3-4. Personally, I hardly ever have it that high except with kids. It is safer in my opinion if the pt. is spontaneously breathing also. With the low sevo levels you described I would be concerned that the pt. would laryngospasm. It is a great skill to use on asthmatics and smokers, not to mention the cases that you really don't want them bucking on.

 

[davvid2700]

awake extubations. rather

 

[davvid2700]

I must humbly disagree. The majority of my wake ups go the deep route.

why would you deep extubate a majority of your patients? if you mean in the purest definition... You can achieve a smooth wake up even with awake extubations..

 

[Noyac]

Wow 3 posts while I was typing mine.
As far as LMA's, I always pull them deep. But they can also cough and buck if they are too light. If you pull them deep they get cleaned a put back in your drawer b/4 the next case and the tech doesn't have to go to PACu to find them. Its all about efficiency in the private world.

 

[VentdependenT]

I also do it often but I think your sevo conc. is a little too low. Try keeping them at 0.7 mac (not ET 0.7) or greater. I am usually pretty close to MAC and always above ET sevo 1.0. Or you can do what Mil says, ET sevo 3-4. Personally, I hardly ever have it that high except with kids. It is safer in my opinion if the pt. is spontaneously breathing also. With the low sevo levels you described I would be concerned that the pt. would laryngospasm. It is a great skill to use on asthmatics and smokers, not to mention the cases that you really don't want them bucking on.

Word

I did have nitrous going as well (half mac) with the sevo...so I guess I was around .7 MAC.

Thanks guys. I'll ask some attendings to let me give it a shot.

 

[Noyac]

why would you deep extubate a majority of your patients? if you mean in the purest definition... You can achieve a smooth wake up even with awake extubations..

even with a deep extubation my patients are usually aroused enough by moving them to the stretcher to wake them up. Maybe we are too rough!

 

[VentdependenT]

Wow 3 posts while I was typing mine.
As far as LMA's, I always pull them deep. But they can also cough and buck if they are too light. If you pull them deep they get cleaned a put back in your drawer b/4 the next case and the tech doesn't have to go to PACu to find them. Its all about efficiency in the private world.

If you don't mind me asking how much agent is on board when you remove the LMA. Perhaps I'm waiting a little too long. I have nitrous running at 66% with end tidal sevo at .3 when I pull them. Like I said I usually wait till the pt can open their eyes.


My fear is aspiration if too deep and laryngospasm if too light. Correct me if need be oh wise ones.

 

[Noyac]

Word

I did have nitrous going as well (half mac) with the sevo...so I guess I was around .7 MAC.

Thanks guys. I'll ask some attendings to let me give it a shot.

Crap I can't keep up.
I like to have them on 100% O2 with deep extub. You know the risk of extubating on N2O is that it will disipate O2 ( or something like that, Jet? Mil?). The O2 will also allow you more time if you extub too early and they spasm.

 

[Noyac]

If you don't mind me asking how much agent is on board when you remove the LMA. Perhaps I'm waiting a little too long. I have nitrous running at 66% with end tidal sevo at .3 when I pull them. Like I said I usually wait till the pt can open their eyes.


My fear is aspiration if too deep and laryngospasm if too light. Correct me if need be oh wise ones.

I don't rightly know. I think I have about the same (0,7 MAc or more) I do suction and another trick I like is to not deflate the LMA when I pull it. This brings all the secretions up with the LMA and away from the cords. I don't know if this is routine now or not but it sure wasn't when I trained.

 

[jetproppilot]

If you don't mind me asking how much agent is on board when you remove the LMA. Perhaps I'm waiting a little too long. I have nitrous running at 66% with end tidal sevo at .3 when I pull them. Like I said I usually wait till the pt can open their eyes.


My fear is aspiration if too deep and laryngospasm if too light. Correct me if need be oh wise ones.

If you're using an LMA, Venty, your risk of aspiration is very very low, since you chose an LMA in the first place. Dont let that deter you from pulling it B4 eyes open.

 

[militarymd]

why would you deep extubate a majority of your patients? if you mean in the purest definition... You can achieve a smooth wake up even with awake extubations..

I, we, do a lot of LMA cases, where it is easier just to leave the agent on, take the LMA out, OA in, straight to PACU.

When the cases are <1 hour, I find this is more efficient.

As for N2O....I think the term Noyac is looking for is "diffusion hypoxia"....very real phenonmenon...especially in anyone who is fat or has lung disease.

 

[VentdependenT]

I think I need to simplify my steps then.

I know when you flip the nitrous off all that stuff comes rushing back out and can displace the oxygen in the alveoli for a short time. So I do have 100% 02 running for some time before removing the LMA. Anypoops I'm going to try things a little differently as suggested.

Ahh clinical goodies.

 

[militarymd]

Risk of aspiration is over-rated.

The coughing, bucking, gagging patient is much more likely to aspirate than the nicely anesthetized spontaneously breathing patient.

My 2 cents.

 

[jetproppilot]

I like to have them on 100% O2 with deep extub. You know the risk of extubating on N2O is that it will disipate O2 ( or something like that, Jet? Mil?). The O2 will also allow you more time if you extub too early and they spasm.

I think N2O diffusion hypoxia is more an academic described entity than a clinical worry, Noy.

That being said, I agree with you that the higher the FiO2 at the end of the case, the longer you have before desaturation if something goes awry.

 

[Noyac]

"Diffusion Hypoxia"
Yeah that's it

 

[militarymd]

I think N2O diffusion hypoxia is more an academic described entity than a clinical worry, Noy.

That being said, I agree with you that the higher the FiO2 at the end of the case, the longer you have before desaturation if something goes awry.

Ooops, we disagreed!!! I posted a few posts back that it was very real!!!! The worlds are going to collide and explode!!!! We're all going to die!!!

 

[VentdependenT]

Speaking of dying. Did y'all see what happened to Cheif Resident? Its called BANNED.

 

[jetproppilot]

Ooops, we disagreed!!! I posted a few posts back that it was very real!!!! The worlds are going to collide and explode!!!! We're all going to die!!!

OK MIL,

I watched The Ultimate Fighter all day yesterday.

I'm ready to settle this UFC style.

Word of advice to all toughguys out there: Whatever you do, know matter how big/bad you are,

don't get in a fight with Matt Hughes.

 

[Noyac]

Speaking of dying. Did y'all see what happened to Cheif Resident? Its called BANNED.

Very Nice!

I couldn't take one more post from that loser.

 

[jetproppilot]

Speaking of dying. Did y'all see what happened to Cheif Resident? Its called BANNED.

Thanks, Venty.

 

[lvspro]

OK MIL,

I watched The Ultimate Fighter all day yesterday.

I'm ready to settle this UFC style.

Word of advice to all toughguys out there: Whatever you do, know matter how big/bad you are,

don't get in a fight with Matt Hughes.

I've never seen a 170-180 pound guy just take people apart like hughes. BTW, trigg got what deserved x2. I like triggs stand-up, but when they start rollin', as hughes usually does, it's just a matter of time before hughes has a vantage point where he can tear your (insert appendage) off.

 

[adleyinga]

I've never seen a 170-180 pound guy just take people apart like hughes. BTW, trigg got what deserved x2. I like triggs stand-up, but when they start rollin', as hughes usually does, it's just a matter of time before hughes has a vantage point where he can tear your (insert appendage) off.

back to topic of deep extubation
i extubate all LMAs deep- at end of case pull the sucker out when turn off gas- use nasal tumpet if needed

If planning deep extubation i also get them deep- in 100% O2 I let them breath 8% sevo for one minute or until 2,0 MAC and then pull. May need nasal trumpet.
Data suggests that the vast majority of aspiration is on at risk pt- full stomach, bowel obstruction etc. Oddly enough half aspirate at end of cse when tube is pulled out even when awake.

 

[jetproppilot]

back to topic of deep extubation
i extubate all LMAs deep- at end of case pull the sucker out when turn off gas- use nasal tumpet if needed

If planning deep extubation i also get them deep- in 100% O2 I let them breath 8% sevo for one minute or until 2,0 MAC and then pull. May need nasal trumpet.
Data suggests that the vast majority of aspiration is on at risk pt- full stomach, bowel obstruction etc. Oddly enough half aspirate at end of cse when tube is pulled out even when awake.

Yet another affirmation of what Mil previously said, which I agree with, that the whole aspiration thing is overblown, and the steps that clinicians take to "prevent it" is a big waste of time and money.

Of course there are times to worry about it. Just not as much as alotta people worry about it, with no return in terms of safety, for all their effort.

 

[jetproppilot]

I've never seen a 170-180 pound guy just take people apart like hughes. BTW, trigg got what deserved x2. I like triggs stand-up, but when they start rollin', as hughes usually does, it's just a matter of time before hughes has a vantage point where he can tear your (insert appendage) off.

Rear naked choke, baby. Dude's like an anaconda.

 

[Laurel123]

So it sounds like a lot of you in private practice take the LMA out 'deep'. Do you crank up the sevo and then take it out? I have found that sometimes when I take it out around .4 or .5 MAC, they will get a little agitated when the LMA comes out and bite down on it.

Have any of you run into the case when you extubated a patient before they were awake, but spontaneously breathing, and then go apneic because the 'stimulus' was removed?

Just wondering

 

[sean wilson]

is possible to add such threads to the tutorial series? Seems prett useful and worth making obvious to others down the road.

 

[Gimlet]

is possible to add such threads to the tutorial series? Seems prett useful and worth making obvious to others down the road.

Sounds like a job for Venty!

I have found that sometimes when I take it out around .4 or .5 MAC, they will get a little agitated when the LMA comes out and bite down on it.

Would this be where the "bite block" I've heard mentioned would come in?

 

[jwk]

Back in the old days...pre LMA...

It was not unusual to do multi-hour cases with a mask. Breathing spontaneously, OAW, mask strap, and off we go.

You start and end your case with a mask, right? Take the tube/LMA out deep and early - the "art" of anesthesia. Amaze your friends and neighbors.

 

[VentdependenT]

Back in the old days...pre LMA...

It was not unusual to do multi-hour cases with a mask. Breathing spontaneously, OAW, mask strap, and off we go.

You start and end your case with a mask, right? Take the tube/LMA out deep and early - the "art" of anesthesia. Amaze your friends and neighbors.

Ok ok..so If I get em deep and its near the end of the case do I need to have them spontanously breathing even though my TOF and Tetanus are indicitave of less than 75% receptors blocked. OR should I just slap in oral airway, bag them slowly, let the CO2 build for a while, and await spontaneous respiration.

I'll add this to the "pearls" section.

 

[jetproppilot]

Ok ok..so If I get em deep and its near the end of the case do I need to have them spontanously breathing even though my TOF and Tetanus are indicitave of less than 75% receptors blocked. OR should I just slap in oral airway, bag them slowly, let the CO2 build for a while, and await spontaneous respiration.

I'll add this to the "pearls" section.

You wanna leave in whatever youve got in (ETT or LMA) and gett'em breathing with that in place. No need to increase your workload. If youve got a tube in, you can place an oral airway while the pt is still deep..remember any oral manipulation you do after the volatile agent is lightened (suctioning, oral airway) may lead to pt movement. Some people leave an oral airway in for the entire case when the pt is intubated. I dont. Have seen some pissed off uvulas from doing that.
Theres another PEARL thread somewhere, Venty, that has alotta description on how to get a patient breathing and extubating. I just dont know where it is. If somebody runs across it, maybe they can post in in here.

 

[davvid2700]

you know i never knew why people put in an oral airway after intubation.. Patients dont bite down on the endotracheal tube on emergence.. thats not the reflex.. its to gag.. and open their mouths. they wont bite down.. with an lma they will bite down on emergence. thats why I always remove deep and then put an oral airway in and then mask and wait for them to wake up. Have your anectine handy for the laryngospasm that you are anticipating..

 

[jwk]

you know i never knew why people put in an oral airway after intubation.. Patients dont bite down on the endotracheal tube on emergence.. thats not the reflex.. its to gag.. and open their mouths. they wont bite down.. with an lma they will bite down on emergence. thats why I always remove deep and then put an oral airway in and then mask and wait for them to wake up. Have your anectine handy for the laryngospasm that you are anticipating..

Hmmm, I have plenty of patients bite down on endotracheal tubes on emergence (when I haven't extubated them deep).

And although I used to use oral airways on just about everyone, my current clientele has much more expensive dental work than my old gig.

And to Vent's earlier question - I have on occasion extubated folks prior to or as I was reversing their NMB's. Usually for surgeons who close very quickly.

 

[jetproppilot]

. Patients dont bite down on the endotracheal tube on emergence...

Sorry Dude, no humbly disagreeing.

Youre flat out wrong.

I've seen negative pressure pulmonary edema from a dude bighting the tube on emergence (albeit a rarity). And people do periodically bite the tube on emergence...usually broken by strong fingers pushing the mandible towards the ceiling.

 

[jetproppilot]

Sorry Dude, no humbly disagreeing.

Youre flat out wrong.

I've seen negative pressure pulmonary edema from a dude bighting the tube on emergence (albeit a rarity). And people do periodically bite the tube on emergence...usually broken by strong fingers pushing the mandible towards the ceiling.

biting. sorry about the typo.

 

[VolatileAgent]

Patients dont bite down on the endotracheal tube on emergence.. thats not the reflex.. its to gag.. and open their mouths. they wont bite down.. with an lma they will bite down on emergence.

it's called 'stage 2'. look it up. they gag when they are back to stage 1 and essentially awake - ie, ready for the tube to be pulled anyway. they will bite down on a lma if you overstimulate them during stage 2, a rookie mistake. they rarely bite - period - (at least when i'm giving the gas) with an lma. that's because i leave them alone until it's ready to be pulled.

basically you are just flat out wrong, as jet put it. sorry.

 

[davvid2700]

Ok im wrong

Ill look up what stage 2 is!

 

[davvid2700]

If people bite down on tubes why dont i remember anyone biting down in 3 years of residency 700 plus cases per year..

 

[militarymd]

If people bite down on tubes why dont i remember anyone biting down in 3 years of residency 700 plus cases per year..

I have to say that I have some patients who bite down, and I have seen NPPE with tube biting....

Anyways, perhaps there is some way that you do your cases that does not result in biting.....

Everyone's technique is a little different...perhaps you got something there....It happens to me every once in a while, and it is very annoying.

 

[adleyinga]

it's called 'stage 2'. look it up. they gag when they are back to stage 1 and essentially awake - ie, ready for the tube to be pulled anyway. they will bite down on a lma if you overstimulate them during stage 2, a rookie mistake. they rarely bite - period - (at least when i'm giving the gas) with an lma. that's because i leave them alone until it's ready to be pulled.

basically you are just flat out wrong, as jet put it. sorry.

I am little lost on where things are so i will put in my 4 cents- 2 cents plus 20 years

If let the pt wake up with ETT in I have had them bite down on the ETT and have also seen neg. press. pulm. edema. I have also seen it when extubated and they have laryngospasm takeone breath and develop it. It no big deal unless you were planning on sending home.

Rarely- bite- OK - but it does happen- seen it 2-3 times in 20 years- that is rare but memorable

Having seen this- leaving LMA in until awake scares me for this exact reason- if they bite it then can aspirate. So take them out deep with them breathing spontaneously. I rarely if ever control ventilation with LMA.

If it makes you feel superior- Irene Osborne- one of the poeple who introduce LMA to states- made her career on it in fact- also waits until they are awake. So maybe you are correct but I feel that if I could maks them before placing the LMA- which I do at least once- then I can mask a end also. So i pull it early. I actually try to get it out before end of surgery and then surgeon occasionally stimulate them while in phase 2.

I guess many ways to skin a cat

 

[adleyinga]

it's called 'stage 2'. look it up. they gag when they are back to stage 1 and essentially awake - ie, ready for the tube to be pulled anyway. they will bite down on a lma if you overstimulate them during stage 2, a rookie mistake. they rarely bite - period - (at least when i'm giving the gas) with an lma. that's because i leave them alone until it's ready to be pulled.

basically you are just flat out wrong, as jet put it. sorry.

basically you are just flat out wrong, as jet put it. sorry.[/QUOTE]


I am little lost on where things are so i will put in my 4 cents- 2 cents plus 20 years

If let the pt wake up with ETT in I have had them bite down on the ETT and have also seen neg. press. pulm. edema. I have also seen it when extubated and they have laryngospasm takeone breath and develop it. It no big deal unless you were planning on sending home.

Rarely- bite- OK - but it does happen- seen it 2-3 times in 20 years- that is rare but memorable

Having seen this- leaving LMA in until awake scares me for this exact reason- if they bite it then can aspirate. So take them out deep with them breathing spontaneously. I rarely if ever control ventilation with LMA.

If it makes you feel superior- Irene Osborne- one of the poeple who introduce LMA to states- made her career on it in fact- also waits until they are awake. So maybe you are correct but I feel that if I could maks them before placing the LMA- which I do at least once- then I can mask a end also. So i pull it early. I actually try to get it out before end of surgery and then surgeon occasionally stimulate them while in phase 2.

I guess many ways to skin a cat

I avoid oral airways because of tongue necrosis after prolonged used. Use a bite block instead. Cheap- just use rolled up gauze.

 

[jetproppilot]

you know i never knew why people put in an oral airway after intubation.. Patients dont bite down on the endotracheal tube on emergence.. thats not the reflex.. its to gag.. and open their mouths. they wont bite down.. with an lma they will bite down on emergence. thats why I always remove deep and then put an oral airway in and then mask and wait for them to wake up. Have your anectine handy for the laryngospasm that you are anticipating..

Alright, Bro, Mil pointed something out to me in his post.

Which made me realize my response to you was pretentious.

I'm sorry.

Maybe you're doing something that I'm not that eliminates any tube biting....

I'm sure my anesthetics are similar to all the dudes here...and I admit the tube-biting-thing is very uncommon...but once a month or so...maybe once every cuppla months...some dude bites on his tube to the point where the bag stops moving.

38 year old otherwise healthy but very drunk gangsta dude who got in a knife fight with the wrong OG. Severed left radial artery needing surgical intervention. Poor dentition.

Surgeon does his thing. Oropharyngeal airway placed 15 minutes before end of case (ETT still in)

On emergence, dude bites down so hard he bends his front teeth forward ON the oropharyngeal airway to the point that the bag stopped moving since he had bitten enough on the ETT.

I like the deep extubation thing and use it frequently, but this dude was an emergency with a true full stomach...and on every dude like this I put an orogastric tube down during the case to suction the stomach out...I got about 400mL out..which is alot for a non-bowel case...so really didnt wanna pull the tube when he couldnt protect his airway.

Just one of those things. Dont know how I couldve prevented him from biting down so hard in light of being worried about an unprotected airway with stomach contents, even though suctioned...and believe me, I'm VERY liberal on the full stomach/aspiration worry...but this was one of those FEW cases where I was truly concerned.

Again, David, sorry for the pretentious response.

I'm always willing to listen to stuff to make my anesthetics better, and maybe you know something I dont know.

 

[VolatileAgent]

If it makes you feel superior- Irene Osborne- one of the poeple who introduce LMA to states- made her career on it in fact- also waits until they are awake. So maybe you are correct but I feel that if I could maks them before placing the LMA- which I do at least once- then I can mask a end also. So i pull it early. I actually try to get it out before end of surgery and then surgeon occasionally stimulate them while in phase 2.

I guess many ways to skin a cat

had an attending once tell me that the best 'extubation' with an lma is the patient taking it out him/herself. i leave the audience to their own judgement whether or not that's a good idea.

I avoid oral airways because of tongue necrosis after prolonged used. Use a bite block instead. Cheap- just use rolled up gauze.

rolled up gauze is definitely king. little transpore tape around it for good measure. never hurts to leave that tucked-up next to the tube, of course (again) you want to line it up with the molars so you don't look like a rookie.