Deep Extubations in Pediatric Cath Lab

[HalO'Thane]

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For those of you taking care of pediatric patients in the cath lab, how many of you extubate your patients deep? If you work at a hospital with a dedicated congenital heart service you know that these can be some of the sickest patients in the hospital: all of the co-morbidities of a congenital heart patient and now more aggressive interventions without CPB to fall back on. Normally these are the patients that should be extubated wide awake. However, there are many risk factors for groin bleeding post-op in these patients: large femoral sheaths, anti-coagulated, cyanotic, and if a fontan then high venous pressures. To me it seems like you have to weigh the pros and cons but the more I take care of these patients the more I am leaning toward awake extubations in all but the healthiest patients and just letting the nurses deal with holding pressure longer if the kid is bucking on the ET Tube. When perclose is used the hemostasis is great and I don't worry about groin bleeding but unfortunately the patient needs to be over 20 kg to use it. Just wanted to get some insight from other people on this thread.

 

[btbam]

I was in the cath lab today so this is a relevant thread! I'm an anesthetist, but our protocol is to pull them all deep...The sickest ones just go back to the CICU intubated. The only real exception I can think of is severe pHTN kids where if they don't start breathing at a lower etco2 we just wake them up while keeping the etco2 low via the vent.

At least for us, bucking/coughing patients gets us lots of dirty looks and as you said the bleeding is not insignificant when you consider the size of some of these sheaths and the patients are often heparinized.

 

[CaliforniaBound]

In residency we did a lot too and it depended on the kid and their heart lesion. For a lot of the diagnostic right and left cath post transplant we just lma'd them. The sicker ones or ones with interventions got tubed. We pulled the LMAs deep but the tubes not so much, attending preference where I came from. But there was a lot of bucking, thrashing, and angry glares.....

 

[risnwb]

Most of our peds caths get tubed , and we usually pull deep. Benefit > risk.

 

[Lurch]

A bucking coughing pulmonary hypertensive seems much worse to me than allowing the EtCO2 to drift up within a modest range. We typically avoid instrumenting the airway in the pulm hypertensives but if we need to, we pull deep. A pulmonary hypertensive crisis in cath lab is not pretty.

 

[HalO'Thane]

Awake extubation does not always have to mean coughing and bucking. If you titrate in enough narcotics you can greatly minimize your risk of a pulmonary hypertensive crisis. For me a deep extubation usually requires a > 1 MAC of volatile agent. I have found that a lot of these PHTN kids cannot tolerate this because their PHTN is actually secondary to a crappy heart and pulmonary venous congestion to begin with (unlike the adults who have often brought it on from years of smoking and COPD/Emphysema). I do agree that a pulmonary hypertensive crisis is an ugly situation, especially if you are not in the Cardiac Operating room where you can crash on to bypass or ECMO.

 

[btbam]

Usually for the straightforward caths/annual biopsy type stuff we will do LMAs as well and pull those deep.

 

[deleted9493]

Since there is good evidence that coughing and more significant desaturation occurs with awake extubation, I generally prefer to extubate these kiddos while they're still deep and groin pressure is being held. I like this because it generally allows me to see them through stage II myself without the cardiopulmonary consequences of having a stimulating tube in the trachea. I readily place an airway (LMA or OA) if I'm not immediately 100% happy with the ventilation through the natural airway.

That being said, if the airway was challenging or the child has aspiration risks, that's not happening. In that situation, some options I'll consider: post-med. (dex/clonidine, midazolam), lidocaine down the trachea, and nitrous oxide to smooth the transition. These are the kids that I've also generally given some slowly titrated long-acting opioid to, as well. (Think apneic threshold in the lower 40's with .5 MAC...pretty low dose).

 

[michigangirl]

Awake extubation does not always have to mean coughing and bucking. If you titrate in enough narcotics you can greatly minimize your risk of a pulmonary hypertensive crisis. For me a deep extubation usually requires a > 1 MAC of volatile agent. I have found that a lot of these PHTN kids cannot tolerate this because their PHTN is actually secondary to a crappy heart and pulmonary venous congestion to begin with (unlike the adults who have often brought it on from years of smoking and COPD/Emphysema). I do agree that a pulmonary hypertensive crisis is an ugly situation, especially if you are not in the Cardiac Operating room where you can crash on to bypass or ECMO.

👍👍👍 On the money. The only kids I consider extubating deep in the cath lab are the older kids post-transplant who are otherwise doing very well and are coming in for their routine followup biopsies--even then they have to be a perfect candidate because our recovery room is on a different floor than the cath lab and I'm not interested in laryngospasm during transport. Otherwise, everyone else is awake. Titration of narcotic to a reasonable respiratory rate is the key once you get them spontaneously breathing. As Halo'thane said, coughing and bucking is NOT a necessary component of wake up-- it's all about how the plane is landed. If you do it right, they go through stage 2 without event and open their eyes spontaneously and you pull it. I always have the cath lab staff actively hold pressure during the extubation and shortly after, they're not allowed to run off as soon as the 15 minutes or whatever they normally do is up. Who cares about their dirty looks? Have them hold pressure and do what's right to prevent hypoxia and hypercarbia in a very high risk population. These kids do very scary things-- might as well have all your resources, including a safely intact airway,on your side.

 

[HalO'Thane]

Great points by everyone. This is why I love this site.