Extubate??

[Laurel123]

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Just wanted to share a case:

75 year old non-English speaking, hard of hearing dude has a subdural hematoma and is scheduled for a crani. Pre-op, he doesn't really move one side, he is somnolent, but he does respond to commands if you yell at him and shake him. Breathing is fine, the gas looks perfect. Vital signs stable.

Smooth induction, easy toothless airway - surgery is done in about half hour and everything goes smoothly.

At the end of the case, he is breathing at 15, TV 500-600, paralysis reversed, moving the same side he was moving before, equal reactive pupils, + gag, withdraws from pain, but isn't 'waking-up'. No response to sound, no eye-opening.

Extubate?

 

[jetproppilot]

Just wanted to share a case:

75 year old non-English speaking, hard of hearing dude has a subdural hematoma and is scheduled for a crani. Pre-op, he doesn't really move one side, he is somnolent, but he does respond to commands if you yell at him and shake him. Breathing is fine, the gas looks perfect. Vital signs stable.

Smooth induction, easy toothless airway - surgery is done in about half hour and everything goes smoothly.

At the end of the case, he is breathing at 15, TV 500-600, paralysis reversed, moving the same side he was moving before, equal reactive pupils, + gag, withdraws from pain, but isn't 'waking-up'. No response to sound, no eye-opening.

Extubate?

Absolutely. If he was a full stomach before the case I wouldve placed an OG tube during the case to suck out the stomach so I could extubate him anyway.

Problems?

You can always reintubate but usually isnt required.

 

[Laurel123]

Absolutely. If he was a full stomach before the case I wouldve placed an OG tube during the case to suck out the stomach so I could extubate him anyway.

Problems?

You can always reintubate but usually isnt required.

Yeah, I extubated.

I ended up reintubating in the PACU about 45 minutes later, but I still think it was the right thing to give him a trial of extubation.

 

[militarymd]

I would have extubated also,...

what was the cause of the re-intubation?

 

[Laurel123]

I would have extubated also,...

what was the cause of the re-intubation?

Hard to say for sure, but basically about every 5 minutes he seemed to go into laryngospasm which was broken by some jaw lift, but his mental status never improved and he had one particularly bad laryngospasm type episode that required bagging and very brief desating, so instead of staring at him - I just put the tube back in. Stat CT showed nothing new.

 

[jetproppilot]

Hard to say for sure, but basically about every 5 minutes he seemed to go into laryngospasm which was broken by some jaw lift, but his mental status never improved and he had one particularly bad laryngospasm type episode that required bagging and very brief desating, so instead of staring at him - I just put the tube back in. Stat CT showed nothing new.

did you have an oral airway in him in the pacu? was he maybe just obstructing instead of spasming?

 

[militarymd]

Hard to say for sure, but basically about every 5 minutes he seemed to go into laryngospasm which was broken by some jaw lift, but his mental status never improved and he had one particularly bad laryngospasm type episode that required bagging and very brief desating, so instead of staring at him - I just put the tube back in. Stat CT showed nothing new.

Not an uncommon problem in old people having GA....especially with an underlying neurologic problem.

 

[Noyac]

Definitely would have extubated.

 

[Laurel123]

did you have an oral airway in him in the pacu? was he maybe just obstructing instead of spasming?

Yes, oral airway in. My first thought was obstruction, since that is more common. But he had a high pitched inspiratory stridor and appeared to be 'choking'

 

[jetproppilot]

Yes, oral airway in. My first thought was obstruction, since that is more common. But he had a high pitched inspiratory stridor and appeared to be 'choking'

gotcha.

 

[Breezee]

Do you guys feel that it is okay to pull the tube if the patient is spontaneously breathing with good tidal volumes, even though the patient is not really following commands? Also, what do you guys consider to be "good" tidal volumes? Or a better way to ask that is what is a solid minimum number to say below this number is not adequate for tidal volume?

 

[VentdependenT]

Just wanted to share a case:

75 year old non-English speaking, hard of hearing dude has a subdural hematoma and is scheduled for a crani. Pre-op, he doesn't really move one side, he is somnolent, but he does respond to commands if you yell at him and shake him. Breathing is fine, the gas looks perfect. Vital signs stable.

Smooth induction, easy toothless airway - surgery is done in about half hour and everything goes smoothly.

At the end of the case, he is breathing at 15, TV 500-600, paralysis reversed, moving the same side he was moving before, equal reactive pupils, + gag, withdraws from pain, but isn't 'waking-up'. No response to sound, no eye-opening.

Extubate?

whats this guy baseline. like before he was symptomatic from the bleed.

sounds like a pretty good SDH if patient was getting paralysis.


I would leave the tube in and send him up on cpap/ps and let his geriatric brains get over the anesthesia and the neurologic insult.

 

[Gasworks]

leave the tube in.. s/p crani all the pts here will either go to the unit or spend 24 hours in pacu.. plenty of time to extubate them. If they are ready at the end of the case they wont be any less ready 2 hours later. When they are ready to rip the tube out then its time. Nonresponive to verbal stimuli means poor mental status in my book.. unless you drowned the guy in iso until the last minute or gave him a load of pentathol towards the end (ah those wacky neurosurgeons and their empiric remedies) he's got no good reason to be that unresponsive.