Deep in those Cheeks(Deep Extubation)

[narcusprince]

So this comes up every year. I have become a MASTER of the deep extubation. 0 episodes of lyrngospasm 0 episodes of aspiration, I have never had to reintubate my deep extubations. I have also sped up the time my patients are leaving the OR awake and alert and oriented. So here is a little trick I select pristine patients for the extubation ASA 1-2's not obese, no history of GERD, certainly not difficult airways. So I get them spontaneous on 50mcg/kg/min of Propofol and a half MAC of Desflurane. Suction them place them on 100% FIO2 ET O2 somewhere in the 90% range, Pull the tube then gentley suction place OPA while making sure its appropriatly size as not to touch the cords or push any secretions back into the airway and cause laryngospasm. Place the mask on patient oxygenate. And roughly 99% of the time when the OR team is ready to leave the OR patient is alert oriented and ready to go. Be cautions patient selection and type of case play a big role in trying the deep extubation.

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[OB1🤙]

I mean, good job and all, but sounds like you're also a master of wasting propofol.

Same thing can be accomplished with just gas.

Deep extubation isn't some lost ninja art. Pt breathes. Keep them deep. Extubate. Ensure airway patency. Pt wakes up. Time it right so that the drapes come down and the patient is already opening their eyes. Yay.

Nothing fancy about it. Just requires a little extra vigilance to make sure they don't obstruct.

Definitely no need for a propofol drip. If a cc or 2 helps you sleep better at night, fine, but a gtt for all deep extubations is kinda overkill. Sure, it works, but it works just as well without it.

Also, I extubate plenty of ASA 3 and 4s deep. Why draw a distinction?

 

[Idiopathic]

wait, so you start propofol to extubate your patients?

 

[narcusprince]

I use propofol for two reasons. First we do not have many antiemetics such as Droperidol and Phenergan only zofran propofol and anzamet. So my primary reason is for ponv prophylaxis. Works great for patients with risk factors. Hawaillian whats faster to blow off a Mac of des or half a mac of des and half a mac of propofol? I have tested it its 50% decreased time of emergence then straight gas because your using two different systems of elimination the exhalational and hepatic metabolism.

 

[pgg]

First we do not have many antiemetics such as Droperidol and Phenergan

Wait, the slaveship got rid of droperidol? Phenergan too? Those rat bastards.

 

[dhb]

Deep extubation should not mean 1MAC or more

I guess it should be called asleep extubation or non-awake extubation.
As long as the patient is in SV and not in stage 2 you can extubate for me 99% of the time it's EtSev at 0.3-0.5

 

[OB1🤙]

I use propofol for two reasons. First we do not have many antiemetics such as Droperidol and Phenergan only zofran propofol and anzamet. So my primary reason is for ponv prophylaxis. Works great for patients with risk factors. Hawaillian whats faster to blow off a Mac of des or half a mac of des and half a mac of propofol? I have tested it its 50% decreased time of emergence then straight gas because your using two different systems of elimination the exhalational and hepatic metabolism.

A half MAC of des is gone quicker than a half MAC-equivalent of propofol, IMO, and behaves more predictably.

Dude, des comes off fast. Like, really fast. You don't need to monkey around with sedative drips to make a des emergence happen faster.

And I seriously hope you aren't suggesting that the clinical effect of propofol is mediated by hepatic metabolism.

 

[Idiopathic]

Deep extubation should not mean 1MAC or more

I guess it should be called asleep extubation or non-awake extubation.
As long as the patient is in SV and not in stage 2 you can extubate for me 99% of the time it's EtSev at 0.3-0.5

For me, deep extubation means something different. I want a patient to be breathing and not at risk of coughing or laryngospasm, which does mean high concentration of volatile agent, but I only call it deep extubation when I want those effects (i.e. post thyroid, etc).

Otherwise, when Im doing it the way you describe, I just call it extubation.

 

[periopdoc]

Agree it isn't absolutely necessary, but propofol emergence is smoooooth. Great for little tykes and teenage boys. I rarely use it though. Even with Des I get very smooth wakeups with 99.9% of patients.

If I have someone who I feel is high risk of bucking on the tube at the end I will extubated deep and drop in an LMA for the wakeup. Works like a charm. Patient selection allowing of course.

-pod

 

[HollATme]

I simply stop Sevo while the surgeon is closing. Turn flows up from 2L to 4-5L. As they're about to steristrip I turn the flows all the way up. No nitrous unless they're taking too long. I titrate fentanyl based on RR, EtCO2, TV, other hemodynamic factors. By the time they're done, drapes ready to come down, I call out the pt's name and they usually open their eyes, I pull the tube and slap a FM on them.

No coughing or bucking. No issues with obstruction or "laryngospasm"

I like to pull LMAs deep, though, since they're spontaneously breathing - and I'll just pull it before turning off agent and place an oral airway.

I don't usually do propofol unless I have 20-30mg leftover from induction, then I'll just slug it in there towards the end of the case.

I don't use Des much, the few times I did with an attending, it wasn't all that smooth of a wake-up. Chances are it's lack of experience on my part.

 

[dhb]

For me, deep extubation means something different. I want a patient to be breathing and not at risk of coughing or laryngospasm, which does mean high concentration of volatile agent, but I only call it deep extubation when I want those effects (i.e. post thyroid, etc).

Otherwise, when Im doing it the way you describe, I just call it extubation.

Extubating at deeper levels of anesthesia will decrease the incidence of immediate coughing but will just delay the point where secretion will accumulate hit the larynx causing the patient to cough. You just won't see it if it happens in the pacu.

 

[narcusprince]

I am stating your using two different pathways to eliminate your anesthetics. You metabolise propofol via hepatic peroxidase and you eliminate inhalational agents via exhalation and high flows of fresh gas. My primary use is antiemetic purposes secondary use aids my deep extubations.

 

[Sublimazing]

I am stating your using two different pathways to eliminate your anesthetics. You metabolise propofol via hepatic peroxidase and you eliminate inhalational agents via exhalation and high flows of fresh gas. My primary use is antiemetic purposes secondary use aids my deep extubations.

I think he was referring to the fact that hepatic propofol metabolism isn't clinically relevant to the situation you're describing...redibs is

 

[narcusprince]

Redistribution after bolus dosing yes but 3-4 hr infusions likely not. At least the way I understand it.

 

[pgg]

Redistribution after bolus dosing yes but 3-4 hr infusions likely not. At least the way I understand it.

Are you running the infusion the entire case then? Or just at the end for the wakeup?

 

[narcusprince]

Yes I only do the combined gas and propofol deep extubation is when I run a propofol infusion for antiemetic purposes. So yes I run it the entire case.

 

[HollATme]

Is PONV that significant in your patients?

Isn't there always a propofol shortage? I don't see the point in running propofol infusions the entire case for these healthy patients not requiring intraop neuro monitoring.

If there's a PONV history, give scop patch and other antiemetics (zofran, decadron, can also give reglan intraop if concerned over gastroparesis/ileus).

I just dont see the point especially since one can safely and quickly extubate without an infusion anyways.

 

[narcusprince]

Yes it is many female gyn plastics procedures. I use decadron, propofol, ondansetron we do not have scop patches.

 

[ssmallz]

Is there any good evidence that a mixed propofol/VA anesthetic causes less PONV than a straight VA anesthetic?

 

[nap$ter]

Is there any good evidence that a mixed propofol/VA anesthetic causes less PONV than a straight VA anesthetic?

this paper by hammas is the best evidence i'm aware of...:

"Superior prolonged antiemetic prophylaxis with a four-drug multimodal regimen - comparison with propofol or placebo."
Acta Anaesthesiol Scand. 2002 Mar;46(3):232-7.

 

[periopdoc]

I like to pull LMAs deep, though, since they're spontaneously breathing - and I'll just pull it before turning off agent and place an oral airway.

This I really don't get. Why the hell replace one well tolerated oral airway with a different, usually less well tolerated, oral airway?


- pod

 

[W222]

This I really don't get. Why the hell replace one well tolerated oral airway with a different, usually less well tolerated, oral airway?


- pod

Does anyone here leave the LMA in and transport to the Pacu to let the person spit it out there? I have seen this done but haven't done it myself.

 

[OB1🤙]

This I really don't get. Why the hell replace one well tolerated oral airway with a different, usually less well tolerated, oral airway?

Kinda mystifying to me too. IMO supraglottic airway=supraglottic airway.

I'm all for pulling an ETT deep, but pulling an LMA deep (supraglottic airway) and replacing it with an oral airway (supraglottic airway) is just spinning in circles.

 

[OB1🤙]

Yes I only do the combined gas and propofol deep extubation is when I run a propofol infusion for antiemetic purposes. So yes I run it the entire case.

So what you're really saying is that you have decided that for healthy patients going for high PONV risk surgeries, you run a propofol drip as part of a prophylaxis regimen. And that incidentally, you extubate only this specific cohort of patients deep. Got it.

Your OP sounded like your wake-up strategy for all candidates for deep extubation involved starting a propofol drip at the end of the case.

 

[Arch Guillotti]

This I really don't get. Why the hell replace one well tolerated oral airway with a different, usually less well tolerated, oral airway?

I think it makes perfect sense, much more than pulling an et tube and replacing it with an LMA that some have described.

 

[dhb]

Does anyone here leave the LMA in and transport to the Pacu to let the person spit it out there? I have seen this done but haven't done it myself.

Usually not necessary but yes i do it as well as others in my group. Replacing an LMA for an oral airway makes no sense to me.

 

[MTGas2B]

Wait, the slaveship got rid of droperidol? Phenergan too? Those rat bastards.

Still have both at the Starship

 

[ssmallz]

this paper by hammas is the best evidence i'm aware of...:

"Superior prolonged antiemetic prophylaxis with a four-drug multimodal regimen - comparison with propofol or placebo."
Acta Anaesthesiol Scand. 2002 Mar;46(3):232-7.

But that's kind of the point. The evidence is scarce at best and I'm not sure running a background infusion will do anything. The study stated that PONV increased significantly after termination of propofol. Even though proprofol is an antiemetic while infusing, do these effects last for a significant amount of time when the infusion is turned off? I'm not so sure it does so it seems like we're just wasting an expensive drug w/out much benefit

 

[periopdoc]

I think it makes perfect sense, much more than pulling an et tube and replacing it with an LMA that some have described.

Just two questions for you.

Do you ever place an oral airway after a deep extubation?

What is(are) the difference(s) between an oral airway and a LMA?

- pod

 

[GoldnLead]

Does anyone here leave the LMA in and transport to the Pacu to let the person spit it out there? I have seen this done but haven't done it myself.

Depends on the strength/quality of PACU nursing. Was routinely done at the county hospital where I trained. If I tried it now, I'd get written up.

 

[narcusprince]

Yes. Also have you ever terminated refractory ponv with 1-2 ccs of propofol? I think either the propofol terminates the reflex ark of ponv or its effictive blood concentration has little to do with redistribution and more the plasma elimination of propofol and do the metabolites of propofol suppress ponv?

 

[24858]

Extubating at deeper levels of anesthesia will decrease the incidence of immediate coughing but will just delay the point where secretion will accumulate hit the larynx causing the patient to cough. You just won't see it if it happens in the pacu.

i do plenty of deep propofol mac cases with no airway at all, just the patient spontaneously breathing. If I pull an LMA at 1 MAC and the patient is spontaneously breathing, whats the difference between that and a spontaneously breathing patient under deep propofol sedation? I do alot of deep extubations with tubes and lmas and then the patient is identical to my patient that is under a deep sedation minus an airway.
I agree with bruin about this topic, it isnt some mysterious ancient chinese secret, logic usually dictates and all of these hard and fast rules are ludicrous. If someone uses an opa vs an lma or lma vs an ett great, but in my own practice it is very rare that i need an opa after a deep extubation, but if after repositioning the head or a little chin lift for 30 seconds til the patient begins rebreathing again, which works greater than 90% of the time then I go to an opa. Same as my deep sedation cases, very rarely do i need an opa, but when i do i use it.

 

[Arch Guillotti]

Just two questions for you.

Do you ever place an oral airway after a deep extubation?

What is(are) the difference(s) between an oral airway and a LMA?

- pod

No, but the nurses I direct sometimes do.

Size, cost and acceptance by the PACU staff.

 

[Pooh & Annie]

I think it makes perfect sense, much more than pulling an et tube and replacing it with an LMA that some have described.

Agreed. That seems really wasteful.

The only patients I put oral airways in are the ones who are obstructing, and even then I can usually just adjust the pillow so their neck is extended.

Yes LMAs aren't nearly as stimulating as a tube, but pt's will gag and bite. I suction when I'm pulling it (way under 1MAC) and have never had a problem.

Someone mentioned that then they'll cough in recovery from accumulated secretions. I don't know if I've ever seen that.

If they're breathing, an easy airway (or LMAS case), and their stomach's empty, I think pulling the tube can be appropriate and helpful.

 

[24858]

I was confused by the tag line of this post, Deep in those Cheeks(Deep Extubation), so I looked in the urban dictionary, still confused by the meaning of the start of this post

1. cheeks deep
Reference to eating *****. Like "balls deep" is to ****ing.
Guy1: I heard he got balls deep in her last night.

Guy2: No. he's a *****. he only got cheeks deep and then she left.

First, there was balls deep. Then, came hips deep. Now we have (drum roll) cheeks deep!