Deep extubations

[MTGas2B]

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So I'm doing some time at the VA-Spa this month. Ortho amputations for vascular patients. The surgeon is in the middle of closing, my attending walks in and says to me, "Pull the LMA."

"What, now?"

"Yes, you need to learn how to extubate deep, we don't need to sit around yelling at the patient to wake up so you can pull it later. You know how we can tell our turnover is fast enough, when the surgeon doesn't have time for lunch."

LMA out, mask on. Sevo still on.

"So, back the U, they would slap your hands for this, they would say, now your hands aren't free. Watch this."

Grabs mask straps, cinches mask down.

"Now what if they're obstructing, you need to hold some chin lift?"

Grabs IV pole and tape, pole centered at the head of bed, loop of tape, chin to pole

"See hands free. Try this while your here."

Last case of the day, just about done closing, I pull the LMA, mask on. Late attending comes, "Oh, you were working with attending X today, whatever." And leaves. Worked well, its nice when they can transfer off the bed at the end of the case.

 

[OldManDave]

Just goes to show that there are many ways to skin the cat. I made, and still make, a point to try out the idiosyncratic methods of different staff people - esp when we inherit a new staff member who trained at somewhere other than Dartmouth, BI or MGH - to try out "new" stuff. I actively solicit them to show me the way they learned it even though I only have approx 7 mos left to train.

If I like the tech, I find a way to polish & integrate it into my own practice. If I don't like it - hey, I tried. Most of the time, there are elements that I like & others I don't; so I cherry-pick & use the good stuff.

You never stop learning...or more accurately, you never SHOULD stop trying to learn.

 

[VentdependenT]

The LMA is just a fancy airway device. So you can pull the thing deep if you'd like or when they open their eyes or mouth. Just don't pull it in stage 2 or the chance for laryngospasm is higher.

If you can mask him with an oral or nasal airway then just deepen and reinsert if there is end of the case is nowhere in the near future.

I titrate my volitaile off slowly, keep em where I need em with propofol bumps, and titrate small amounts of fentanyl to RR. Works well ALMOST every time. Some folks cords just want to laryngospasm so bad.

I will give 0.2 of glyco to people who are really "drooly" in hopes that globs of the stuff don't hit the cords. I also will not deflate the LMA in hopes of pushing out the saliva out when I remove it at the end o the case.

Treatment:
Big ol jawthrust. Dig your 3rd digits into that area of the mandible just anterior to the ear. The "laryngospasm spot." It works. Then attach the mask strap to half o the mask and give sustained positive pressure (popoff tight as she goes).

If all else fails hit em with some sux.

 

[ReefTiger]

My 2 cents:

I used to just leave the LMA in and roll them to the PACU with it. One of my attendings told me when they wake up they will either pull it out themselves or you can pull it.

Another attending told me he pulls all LMAs deep because he's actually had folks spasm on him when they wake. So, then I started yanking them deep.

I just make sure they are pulling good volumes and have an adequate rate. Then I pull it without making any adjustments, ie: volatile at one MAC or so. I usually titrate small doses of fent to keep their rate around 12-16. Once the surgeons are wrapping/dressing the wound, off with the volatile. I've never had any problems. I never suction them until they are awake. I do place a bite block (gauze with tape) after pulling the LMA though.

 

[VolatileAgent]

I used to just leave the LMA in and roll them to the PACU with it. One of my attendings told me when they wake up they will either pull it out themselves or you can pull it.

i agree. the best LMA GA is the one where the patient pulls the thing out him/herself. they won't remember doing it anyway. and, if they can pull it out, you know they can protect their airway.

 

[TIVA]

It's better to be lucky than smart.

The LMA is nothing more than an elegant oral airway. Why pull it out when its working? Why pull it out when they're deep and then have to worry about their airway collapsing (hypotonic pharyngeal musculature) and you doing all that jaw thrust, chin taping razzle dazzle?

Most patients don't remember the LMA or ETT coming out, even though they might have been fully "awake" before you pulled it.

And if your patient goes into laryngospasm, what are you gonna do? Sometimes they go into laryngospasm just during the transfer from table to bed. And, you can't give positive pressure through an LMA. You either have to deepen them, which defeats the purpose of a "speedy wake-up" which is why you were trying to get it out in the first place. Or you have to do hard jaw thrust, which while usually effective, sometimes isn't ... and it just looks like a rookie's mistake to everyone else in the OR (you trying to pull the LMA when the patient's not ready and biting down on it).

If your getting away with pulling the LMA deep consistently, it's cuz your lucky, not smart. And as I said before, it's better to be lucky than smart.

Having said that, I'll usually pull the LMA deep in children. But in the adults, I rarely pull it deep.

 

[MTGas2B]

I've really grown to like pulling the LMA with a mac of agent on. They wake up much smoother. I'm at the VA right now, and since most of our patients are not really a model of health, one of our attendings like to recommend what he calls CAD prophylaxis, keep HR less then 80, maintain perfusion pressures. Pulling them deep just makes it that much easier.

A few months ago I had an attending make me do an entire case with a mask (it was a short case). So, spontaneous ventilation, sevo, and holding the mask on by hand. With a few exceptions, any case you do with an LMA you can do with a mask, your arm would just get tired.

 

[s204367]

Many would argue strongly against pulling the LMA out anytime other than deep. Rather than let the patient go through stage two with a possible airway irritant in, and laryngospasm....there is nothing through the cords with an LMA...That little point thing on the tip of the LMA...certainly it could be placed on or near the cords, especially in a kid. At CHONY(children's hospital of ny-columbia university) let a kid wake up with an LMA in and you lose your fingers....

I suction, pullem deep, then maybe use an oral airway if needed. It is a very smooth wake up.

 

[fval28]

any case I put an LMA in is a case I would mask if not for wanting to keep my hands free-- therefore I pull all my LMA's inflated and deep. Much smoother wake up and (anecdotally) a lower incidence of PONV. I'm a firm believer that a lot of patients with a history of PONV are ones who were required to do a tap dance and recite the pledge of allegiance before they had their airway device removed- all the while gagging and coughing- so I do a lot of deep extubations too.

I like to see the surprised look on my patients' faces when I tell them in PACU that their surgery is all done- most look wide eyed at me and say "No way!" right before they take a little nap😴 . 30 min later they've eaten, iv pulled, gotten dressed and are waiting for their ride. 👍 👍

 

[johankriek]

It's better to be lucky than smart.

The LMA is nothing more than an elegant oral airway. Why pull it out when its working? Why pull it out when they're deep and then have to worry about their airway collapsing (hypotonic pharyngeal musculature) and you doing all that jaw thrust, chin taping razzle dazzle?

Most patients don't remember the LMA or ETT coming out, even though they might have been fully "awake" before you pulled it.

And if your patient goes into laryngospasm, what are you gonna do? Sometimes they go into laryngospasm just during the transfer from table to bed. And, you can't give positive pressure through an LMA. You either have to deepen them, which defeats the purpose of a "speedy wake-up" which is why you were trying to get it out in the first place. Or you have to do hard jaw thrust, which while usually effective, sometimes isn't ... and it just looks like a rookie's mistake to everyone else in the OR (you trying to pull the LMA when the patient's not ready and biting down on it).

If your getting away with pulling the LMA deep consistently, it's cuz your lucky, not smart. And as I said before, it's better to be lucky than smart.

Having said that, I'll usually pull the LMA deep in children. But in the adults, I rarely pull it deep.

I only pull my LMAs out deep.. waking patients up with an airway in and its not a controlled device. to me is asking for trouble..

Pull it out deep... ( means deep) not semi deep).. soon as you pull it put oral airway in .. always..(will solve all the collapse airway problems) place mask on patient.. chin lift and they will open their eyes when theyre ready..

If you get laryngospasm which occurs ocasionally.. you ive pos pressure and anectine if needed..


If they bite on the oral airway.. so what... ?

deep extubations with LMAs is smart medicine

 

[rn29306]

I only pull my LMAs out deep.. waking patients up with an airway in and its not a controlled device. to me is asking for trouble..

Pull it out deep... ( means deep) not semi deep).. soon as you pull it put oral airway in .. always..(will solve all the collapse airway problems) place mask on patient.. chin lift and they will open their eyes when theyre ready..

If you get laryngospasm which occurs ocasionally.. you ive pos pressure and anectine if needed..


If they bite on the oral airway.. so what... ?

deep extubations with LMAs is smart medicine

Same here. Suction, deep extubation, OA in place, SFM and off to PACU. Pts take the OA out in recovery and its a done deal.

There is nothing worse than waking a pt up with a LMA and everyone seeing you fight with a half conscious patient who has a mouthfull of latex.

I prefer smoother wakeups myself....

 

[VolatileAgent]

Same here. Suction, deep extubation, OA in place, SFM and off to PACU. Pts take the OA out in recovery and its a done deal.

There is nothing worse than waking a pt up with a LMA and everyone seeing you fight with a half conscious patient who has a mouthfull of latex.

I prefer smoother wakeups myself....

😕

i've never "fought" with a patient during an LMA wake-up. i let them reach up and pull it out themselves. nothing 'un-smooth' about that. to me, fighting with a patient is standing over them doing positive-pressure ventilations against stridorous cords... which i've seen happen with "early" LMA extractions.

 

[s204367]

was I in your or??? .........when are you coming up ....RS4 is broken in and waiting for you to see what a German V8 can do at 8250rpm..none of that jap 9000 rpm stuff..................

 

[rn29306]

😕

i've never "fought" with a patient during an LMA wake-up. i let them reach up and pull it out themselves. nothing 'un-smooth' about that. to me, fighting with a patient is standing over them doing positive-pressure ventilations against stridorous cords... which i've seen happen with "early" LMA extractions.

So I guess you are so slick you've never had a patient bite an LMA with it half in and half out of their mouth...as you were in the process of removing it. If he or she clamps down with the cuff still in the mouth, you essentially have to wait for them to cooperate and open their mouth, or help then relax....Not a pretty picture. Since the LMA is essentially a modified mask case, why not take it out deep, OA in, and be done with it?

And I've never had a patient that needed PPV for stridorous cords with deep LMA removal. Not saying it won't happen because it can theoretically, but I've never seen it and will continue to pull LMAs deep.

Each to his own....

 

[bullard]

So after reading this thread and pulling LMAs deep on a couple of toddlers, I tried pulling it deep on a healthy 16 year old. He proceeded to go into laryngospasm. I had my attending paged, tried to break it with PPV. Attending came in, took over, couldn't break it either, and we had to give 20 mg of sux. No reintubation needed, kid did fine. Attending was like, "You didn't do anything wrong. Some people pull LMAs deep. Some don't. I don't for this very reason."

Any more thoughts on this subject? Are there any patients that the "deep" crowd think twice about in terms of pulling the LMA deep?

Signed,
-A concerned CA1

 

[Planktonmd]

So after reading this thread and pulling LMAs deep on a couple of toddlers, I tried pulling it deep on a healthy 16 year old. He proceeded to go into laryngospasm. I had my attending paged, tried to break it with PPV. Attending came in, took over, couldn't break it either, and we had to give 20 mg of sux. No reintubation needed, kid did fine. Attending was like, "You didn't do anything wrong. Some people pull LMAs deep. Some don't. I don't for this very reason."

Any more thoughts on this subject? Are there any patients that the "deep" crowd think twice about in terms of pulling the LMA deep?

Signed,
-A concerned CA1

Deep extubation means pulling the tube out when the patient is fully anesthetized and it might actually require you to increase the concentration of your inhaled agent before you extubate to make sure you are not at stage 2 anesthesia where bad things like laryngospasm could happen.
Did you have a deep anesthetic of at least 1.5 to 2 MAC?
With LMA's you have to also remember to suction the oropharynx very well
after removing the LMA before the patient gets light.
I actually think that deep extubation is the best way to deal with teenage boys who tend to be combative and rough on emergence unless they are morbidly obese or look like a difficult intubation.

 

[seinfeld]

So I guess you are so slick you've never had a patient bite an LMA with it half in and half out of their mouth...as you were in the process of removing it. If he or she clamps down with the cuff still in the mouth, you essentially have to wait for them to cooperate and open their mouth, or help then relax....Not a pretty picture. Since the LMA is essentially a modified mask case, why not take it out deep, OA in, and be done with it?

And I've never had a patient that needed PPV for stridorous cords with deep LMA removal. Not saying it won't happen because it can theoretically, but I've never seen it and will continue to pull LMAs deep.

Each to his own....

I have had this happen too many times as well, pt biting down on bite block, lma no longer seated well, cant remove, cant ventilate, and then you have no ability for an airway without putting the patient down (as they desat), and it doesnt look smooth. My thinking as many have already mentioned. An lma is just a mask case but i get to keep my hands free.

When i first started doing them deep i did get larygospasm occationally, more often in kids, but as others have mentioned every time it was because the patient was not at MAC 1.5 or greater.

As far as being lucky versus good, i think we all get used to the way we practice and also how to deal with the common "side effects" of the way we practice. In the end this whole thing is a style issue.

 

[stone123]

I agree with Plankton regarding the suggestion of suctioning the oropharynx very well after the removal of the LMA, then put in the OA. In addition, I give some glyco pre-op with most of my LMA cases to prevent the juicy airway problem. After you've worked in an outpatient surgery center where fast turnovers are essential, you'll pull them all deep or you'll be talked about by the nurses and surgeons as the slow emergence guy in room 2. Plus its a smooth wake-up with an extremely rare laryngospasm when done right.

 

[VentdependenT]

I agree with Plankton regarding the suggestion of suctioning the oropharynx very well after the removal of the LMA, then put in the OA. In addition, I give some glyco pre-op with most of my LMA cases to prevent the juicy airway problem. After you've worked in an outpatient surgery center where fast turnovers are essential, you'll pull them all deep or you'll be talked about by the nurses and surgeons as the slow emergence guy in room 2. Plus its a smooth wake-up with an extremely rare laryngospasm when done right.

I always pull surgicenter tubes deep. My fav is yakin the tube with the patient sill in the beach chair position.

Its a luxury that I often cannot afford in the main OR's where ASA III's and obese patients abound.

 

[jwk]

Doesn't anyone ever do cases with a 😱 mask 😱 anymore?

 

[VentdependenT]

Doesn't anyone ever do cases with a 😱 mask 😱 anymore?

On occasion.

Unfortunately even a simple D&C on a Rush patient downtown can take 45 minutes. Not to mention they are 300 lbs.

 

[bullard]

Deep extubation means pulling the tube out when the patient is fully anesthetized and it might actually require you to increase the concentration of your inhaled agent before you extubate to make sure you are not at stage 2 anesthesia where bad things like laryngospasm could happen.
Did you have a deep anesthetic of at least 1.5 to 2 MAC?
With LMA's you have to also remember to suction the oropharynx very well
after removing the LMA before the patient gets light.
I actually think that deep extubation is the best way to deal with teenage boys who tend to be combative and rough on emergence unless they are morbidly obese or look like a difficult intubation.

Ah. I was not even at 1.5 MAC. I pulled fully inflated thinking I didn't have to suction after that. And I didn't give glyco beforehand. Thanks for the tips all!

 

[Lonestar]

damned if you and damned if you don't. Question is where do you want to fight the laryngospasm (OR or PACU). Neither way is wrong, but i have learned to just pull them deep knowing that there is a small chance of laryngospam in the pacu.

 

[huktonfonix]

I will only pull the LMA deep if I have worked at a place for a while and know and trust the PACU staff to recognize laryngospasm quickly. If the PACU is not used to seeing deep extubations/LMA removals then I'm not going to do it.