How to time your extubation in non supine patients

[Sleeplessbordernights]

i think im decent enough timing my extubation in supine patients, however im having trouble doing this in prone or lat patients as in VATS, nephrectomys and such. Most of my attendings don’t want to start Reversing nmb or opioids Until the pt is supine again, but at that point the surgery is over and we end up holding the room until we are ready to extubate. Any tips and tricks?

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[Mman]

i think im decent enough timing my extubation in supine patients, however im having trouble doing this in prone or lat patients as in VATS, nephrectomys and such. Most of my attendings don’t want to start Reversing nmb or opioids Until the pt is supine again, but at that point the surgery is over and we end up holding the room until we are ready to extubate. Any tips and tricks?

if you are giving Narcan, you are probably doing it wrong

If the patient is prone and relaxed with NMB, depends on how you are reversing. Neostigmine takes a while to work so would need to give that before flipping. If using suggamadex it works so damn fast you can just wait til after supine to push it. But you need to be lightening the patient prior to that. Don't need a full MAC of gas to be amnestic, especially with narcotic on board.

For a random case that is narcotized adequately and relaxed, get your gas down to 0.4 MAC before you flip and push the suggamadex as soon as you flip and crank up the flows and get the gas off. Patient should meet extubation criteria fairly quickly.

 

[woopedazz]

If on gas --> lighten them as usual, then give them a tiny squirt of propofol with some neostigmine 1 minute pre-flip.

 

[coffeebythelake]

Hypoventilate the patient and Let the Etco2 climb to the high 40s to low 50s.

 

[patriot6]

Sometimes I have the patient breathing spontaneously prior to flipping. Sometimes they're on VC/PC. Sometimes, they're on PS. Sometimes I lighten the gas a lot and keep them down with bumps of propofol. Sometimes I keep them deep and extubate deep. Sometimes the end tidal is 60. Sometimes its 30. Sometimes I push neostigmine 10 minutes out. Sometimes I push it right before we flip. In all scenarios, that tube is coming out really quickly after turning supine. It's hard to nail down one method of waking up a prone case. Repitition, repitition, repitition. I will say that sugammadex has been a game changer in so many ways. I think it's helpful to keep the big guys down with NMBs while lightening the gas (maybe coming in on some nitrous/0.2 sevo) with a good opioid base. Once I see the stretcher in the room, it's flows up and sugammadex immediately before the flip.

 

[Morzh]

I personally tend to reverse and get them breathing comfortably on their own while still prone. Not fully emerging, but very comfortable as the gas is coming off as I am generous with opioids and adjuncts like low dose ketamine, precedex, and end-of-case bits of propofol. I'll then give a final bolus of propofol a minute before flipping like someone else mentioned. I've done it enough that I'm comfortable with my timings and it goes very smoothly.

But I do all my own cases solo. It's challenging for attendings who are supervising to trust trainees to be smooth and timely with their emergence plans... sometimes they'll overshoot and sometimes they'll undershoot. A prone patient bucking and flailing is dangerous. So the safest thing to do, especially when you have multiple rooms to cover with a variety of trainees coming and going each year, is to just keep them on controlled ventilation and paralyzed until the patient is supine... knowing that you're compromising a bit on efficiency.

 

[coffeebythelake]

i think im decent enough timing my extubation in supine patients, however im having trouble doing this in prone or lat patients as in VATS, nephrectomys and such. Most of my attendings don’t want to start Reversing nmb or opioids Until the pt is supine again, but at that point the surgery is over and we end up holding the room until we are ready to extubate. Any tips and tricks?

Just don't do what one of my fellows did, pulling out the endotracheal tube mid flip because patient was breathing spontaneously. His only criteria for extubation is that thr patient was breathing spontaneously.

 

[nimbus]

Just don't do what one of my fellows did, pulling out the endotracheal tube mid flip because patient was breathing spontaneously. His only criteria for extubation is that thr patient was breathing spontaneously.

That’s perfect timing!

 

[MirrorTodd]

Just don't do what one of my fellows did, pulling out the endotracheal tube mid flip because patient was breathing spontaneously. His only criteria for extubation is that thr patient was breathing spontaneously.

But did he die?

 

[MirrorTodd]

i think im decent enough timing my extubation in supine patients, however im having trouble doing this in prone or lat patients as in VATS, nephrectomys and such. Most of my attendings don’t want to start Reversing nmb or opioids Until the pt is supine again, but at that point the surgery is over and we end up holding the room until we are ready to extubate. Any tips and tricks?

I'm all about that low flow anesthesia.

 

[GassYous]

Just don't do what one of my fellows did, pulling out the endotracheal tube mid flip because patient was breathing spontaneously. His only criteria for extubation is that thr patient was breathing spontaneously.

Tbh don't see anything wrong with that

I've extubated in lateral and prone with no problems. Don't like it as much as supine

 

[dchz]

Everytime we have an extubation timing thread, it amazes me how many people out there don't deep extubate their pts.

I'm adult CT anes, I extubate >99% of my pts deep. I do it for VATS, CABGs, pulm embolectomies, robotic CABGs. If I am concerned about aspiration, I suction the stomach, I do it whether I deep extubate or not. I used to be shy about sharing it. But I firmly believe that's how I'd want someone to extubate me.

Edit: I have realized that >99% shouldn't be the norm, I have selection bias in my data because i don't do trauma/ob/bowel cases in my current practice.

So to answer how you should time your extubations while none supine, you do it the same way you do it supine. Assuming you've optimized the way you extubate supine.

A prone patient bucking and flailing is dangerous. So the safest thing to do, especially when you have multiple rooms to cover with a variety of trainees coming and going each year, is to just keep them on controlled ventilation and paralyzed until the patient is supine... knowing that you're compromising a bit on efficiency.

This is the biggest barrier to people doing it widely. You needed good attendings that let you do it during residency. Several of my co-residents deep extubate as much as we could during residency.

To be fair, a bucking and flailing pt is also dangerous supine. One should minimize that however they feel most comfortable.

Just don't do what one of my fellows did, pulling out the endotracheal tube mid flip because patient was breathing spontaneously. His only criteria for extubation is that thr patient was breathing spontaneously.

The difference between advanced and dangerous is a fine line. I would argue extubating criteria should also include steps to minimize aspiration. But for > 99% of cases I would argue deep extubation is just as safe as the stand way most people extubate.

My exception for deep extubating are those pts that have had surgeries or changes that could affect their airway protection post extubation, eg. ENT surgeries that may cause blood to drip down to the airway, neurosurgery that may affect how a pt could protect their airway after they are awake, pts that you cannot suction the stomach, etc.

 

[coffeebythelake]

Tbh don't see anything wrong with that

I've extubated in lateral and prone with no problems. Don't like it as much as supine

I don't know what you gain by extubating patients in positions that would make laryngospasm or other complications difficult to manage. Just to save a few minutes? Not worth it.

And @dchz deep extubation in 99% of your patients lmao, I'm going to call you out, hyperbole is supposed to be a little more subtle. Or maybe your patient population doesn't consist of 30% obese with aspiration risk factors.

While there may be select situations where you decide to implement this, it is a risk benefit analysis. There are definite risks. What is the benefit?

Ask yourself why you are the outlier when it comes to doing these maneuvers. It's not because you are a genius while everyone else is dumb.

 

[GravelRider]

Grow a set and extubate prone. I don’t do it as a routine, but I will. Breathing dynamics are usually better in prone position and you’re less likely to get laryngospasm because all that drool is going in the direction of gravity. If the patient is breathing spontaneously and meets extubation criteria then it seems low risk to me. I usually try to time extubation to mid flip, but sometimes the patient is ready and the bed isn’t quite in position yet for flip.

Edit: You’re a trainee, so don’t extubate prone without your attending, but maybe talk to your attendings to try it in certain situations. Nothing better than a controlled setting like residency training to try out certain scenarios like prone extubation. In fact, it was in residency where I had a few attendings make me extubate prone so I could feel comfortable in a variety of situations.

 

[anbuitachi]

pull the tube, mask ventilate the patient. reverse. problem solved

 

[coffeebythelake]

Everytime we have an extubation timing thread, it amazes me how many people out there don't deep extubate their pts.

I'm adult CT anes, I extubate >99% of my pts deep. I do it for VATS, CABGs, pulm embolectomies, robotic CABGs. If I am concerned about aspiration, I suction the stomach, I do it whether I deep extubate or not. I used to be shy about sharing it. But I firmly believe that's how I'd want someone to extubate me.

So to answer how you should time your extubations while none supine, you do it the same way you do it supine. Assuming you've optimized the way you extubate supine.



This is the biggest barrier to people doing it widely. You needed good attendings that let you do it during residency. Several of my co-residents deep extubate as much as we could during residency.

To be fair, a bucking and flailing pt is also dangerous supine. One should minimize that however they feel most comfortable.



The difference between advanced and dangerous is a fine line. I would argue extubating criteria should also include steps to minimize aspiration. But for > 99% of cases I would argue deep extubation is just as safe as the stand way most people extubate.

My exception for deep extubating are those pts that have had surgeries or changes that could affect their airway protection post extubation, eg. ENT surgeries that may cause blood to drip down to the airway, neurosurgery that may affect how a pt could protect their airway after they are awake, pts that you cannot suction the stomach, etc.

All this just to save a few minutes? Not worth the risk. Even you said this could be dangerous. I don't need to try to walk this fine line every time i give a patient a general anesthetic. That's a lot of risk where a single failure could negate any time you potentially save. And if deep extubation is the only way you can prevent your patient from flailing about on emergence then that's a problem.

 

[GassYous]

It's not to save time. Sometimes the patient is ready to extubate a little earlier than others. I've had people ready to extubate at 0.3 or 0.5 mac. Usually I like to wait longer for the gas to go down but I've found that if they are breathing with adequate tidal volumes, it's okay. I was taught not to pull the tube until all the gas was off in residency and I've found that to be much too conservative. It only takes a few seconds to turn a patient supine so it's not like you're burning frc to any significant difference.

 

[staple]

Just do what we all do..... flip the anesthesia light switch to off and press the green wake up button on the front of the machine that says “o2+”... then transport the patient to pacu intubated

 

[2Fast2Des]

Just don't do what one of my fellows did, pulling out the endotracheal tube mid flip because patient was breathing spontaneously. His only criteria for extubation is that thr patient was breathing spontaneously.

That's exactly the criteria in real life... I don't have time to talk to them or do calculus... That being said if it's a high risk case or where I need them to be coherent enough to maintain airway then I make sure that they have some ability to respond.

Side note question - do you guys put supplemental oxygen before you roll out the door? I usually don't unless I feel the pt needs it.

 

[coffeebythelake]

That's exactly the criteria in real life... I don't have time to talk to them or do calculus... That being said if it's a high risk case or where I need them to be coherent enough to maintain airway then I make sure that they have some ability to respond.

Side note question - do you guys put supplemental oxygen before you roll out the door? I usually don't unless I feel the pt needs it.

Breathing spontaneously tells you little about their depth of anesthesia. I don't need them to do math, but I do want them to do something to show me that they are in the process of regaining consciousness. Not laying there like a log breathing spontaneously. And you can bet if my fellow or resident is bringing a nonresponsive patient to pacu they will get chewed out. Our pacu nurses are not prepared to deal with stuff like this.

 

[dchz]

And @dchz deep extubation in 99% of your patients lmao, I'm going to call you out, hyperbole is supposed to be a little more subtle. Or maybe your patient population doesn't consist of 30% obese with aspiration risk factors.

Good, you can call me out. Let's have a constructive and serious discussion about deep extubation. Both pros and cons.

First, I would like to ask you how often you deep extubate and how many times you have done it. I am not aiming at an ad hominem attack. But merely pointing out that your view/experience of deep extubation might not be complete. You might have completely dismissed it before you examined the risk and benefits.

Second, some common ground. We both agree there are risk and benefits to every situation:

While there may be select situations where you decide to implement this, it is a risk benefit analysis. There are definite risks. What is the benefit?

Pros:
-Less stimulus during stage 2
-Patient comfort
-No need to wait for volatiles to diffuse out.

Cons:
-Aspiration risk if stomach not empty
-Reintubation if laryngospasms happen
-Attendings will scream at you (see cheeky comment below)

I think we can agree on the above. correct me if i'm wrong.

I contend the aspiration risk is reduced to 0 if you suction the stomach. Now you only have to worry about laryngospasm and reintubation. If you take away the stimulus during stage 2 laryngospasms are extremely rare in adults.

So now the pros and cons look like this:

Pro:
-less stimulus during stage 2
-patient comfort
-no need to wait for volatiles to diffuse out

Cons:
-reintubating if emergence does not go smoothly (with zero aspiration risk and near zero laryngospasm risks)

Examining this objectively, it's a very easy choice of risk and benefits. I would want to deep extubate if the above holds true.

Breathing spontaneously tells you little about their depth of anesthesia. I don't need them to do math, but I do want them to do something to show me that they are in the process of regaining consciousness. Not laying there like a log breathing spontaneously.

I understand you want them to do this. However, physiology does not dictate this is only way to do it safely and effectively.

As long as the patient is ventilating, the gas will diffuse off. Regardless if they have a tube between their vocal cords. Laying like a log breathing is very comfortable. Much more comfortable than pressing against vocal cords.

hyperbole is supposed to be a little more subtle.

It's not a hyperbole. I can remember exactly 1 patient I did not deep extubate this year - a patient that has an unrepairable esophageal-pleural fistula 2/2 GIST tumor. A situation where the positive pressure from the gagging actually lessens pneumo chances.

All this just to save a few minutes? Not worth the risk. Even you said this could be dangerous. I don't need to try to walk this fine line every time i give a patient a general anesthetic. That's a lot of risk where a single failure could negate any time you potentially save. And if deep extubation is the only way you can prevent your patient from flailing about on emergence then that's a problem.

No, my objective is not to save time. It's actually quite offensive to dismiss anyone that deep extubates as someone that only cares about their time and not making the best decision for the patient. If you look at the things I do to ensure the patient isn't obstructing and suctioning stomach, it's actually more cumbersome at times than the way you extubate.

I don't know what you gain by extubating patients in positions that would make laryngospasm or other complications difficult to manage. Just to save a few minutes? Not worth it.

Again, it's quite cocky of you just to assume i'm doing it to save time.

Or maybe your patient population doesn't consist of 30% obese with aspiration risk factors.

I live in Texas, where you're not obese until your BMI hits 35. I minimized the aspiration risk factors.

Ask yourself why you are the outlier when it comes to doing these maneuvers. It's not because you are a genius while everyone else is dumb.

The mere fact that you think i'm an outlier shows your lack of perspective. Plenty of anesthesiologists do this nearly 100% of the time. I may be the first one to point it out to you.

Breathing spontaneously tells you little about their depth of anesthesia. I don't need them to do math, but I do want them to do something to show me that they are in the process of regaining consciousness. Not laying there like a log breathing spontaneously. And you can bet if my fellow or resident is bringing a nonresponsive patient to pacu they will get chewed out.

Sorry if i'm not feeling your full political clout, but just because you're chewing someone out doesn't mean you're a good teacher. It merely means you're abusing your powers and can't control your emotions.

 

[Arch Guillotti]

I contend the aspiration risk is reduced to 0 if you suction the stomach.

No way to know if you got everything out.

 

[Gator7]

Lateral - pull it deep while lateral. Then turn them onto stretcher.

Prone - lighten so flip to stretcher wakes them then pull immediately.

If bed takes too long then pull prone.

 

[dchz]

No way to know if you got everything out.

Fair point, I should have known SDN wouldn't let me off this easily .

If the patient is appropriately NPO, there shouldn't be much in there in the first place.
I also make sure the patient is upright the oropharynx is suctioned out. With the lessened stimulus, the patient rarely coughs or fights before going through stage 2. After going stage 2, the patient is able to protect the airway like any awake patient.

the corrected pros and cons should be:

Pro:
-less stimulus during stage 2
-patient comfort
-no need to wait for volatiles to diffuse out

Cons:
-Aspiration risk if the patient's stomach is not empty enough after suctioning, given the patient is not bucking or gagging during the period between stage 2 and awake. (this is not 0, but very small chance i would contend it's near 0).
-reintubating if emergence does not go smoothly

 

[nimbus]

I’m not even sure what deep extubation means but if the case is done and they are breathing with decent tidal volumes, I pull the tube. I don’t need any other signs of life. A couple of my partners wait til the patients open their eyes or whatever but most don’t. If I were supervising residents or CRNAs I might do things differently but I do all my own cases. Also if they are truly a full stomach just had a burrito before crashing the motorcycle trauma, I will wait til they’re more awake.

 

[dchz]

I’m not even sure what deep extubation means but if the case is done and they are breathing with decent tidal volumes, I pull the tube. I don’t need any other signs of life. A couple of my partners wait til the patients open their eyes or whatever but most don’t. If I were supervising residents or CRNAs I might do things differently but I do all my own cases. Also if they are truly a full stomach just had a burrito before crashing the motorcycle trauma, I will wait til they’re more awake.

The purest definition for the academics contend that the pt is so deep in the anesthetic plane that they will not react to any stimulus. Often confirmed by the fact that they do not move when the endotracheal balloon is manipulated.

But my definition is more closely to yours in practice. I pull the tube at et sevo of about 2.

 

[2Fast2Des]

NPO status doesn't guarantee anything. I've had patient aspirate after being NPO for 3 days. Sometimes even the routine laparoscopic case where you throw down the OGT and you get back a couple of hundred cc of gastric juices. That being said, I don't think it's reasonable to and I'm not going to stick an OGT for every case if it's not indicated

 

[Toothpickwars]

I switch from gas to a prop gtt at ~60 for the last half hour, turn up flows to get gas <0.1 mac, give a 20-30mg prop bolus, stop gtt, flip. By the time I’ve suctioned they’re ready to extubate.

Reversal doesn’t matter as much as technique, early if neostigmine, right before flip if suggamadex.

 

[coffeebythelake]

Good, you can call me out. Let's have a constructive and serious discussion about deep extubation. Both pros and cons.

First, I would like to ask you how often you deep extubate and how many times you have done it. I am not aiming at an ad hominem attack. But merely pointing out that your view/experience of deep extubation might not be complete. You might have completely dismissed it before you examined the risk and benefits.

I deep extubate patients when there is a clear benefit to doing so. Patients with no identifiable aspiration risk factors and reasonably easy to mask ventilate. And where there is a good reason. I don't do it more often because my mental calculus is that it is an unnecessary extra risk to do routinely.

Pros:
-Less stimulus during stage 2
-Patient comfort
-No need to wait for volatiles to diffuse out.

Cons:
-Aspiration risk if stomach not empty
-Reintubation if laryngospasms happen
-Attendings will scream at you (see cheeky comment below)

I think we can agree on the above. correct me if i'm wrong

As I've said already, plenty of ways to limit stimulation from the endotracheal tube on emergence without having to do a deep extubation. 99% of my patients who I want to minimize bucking or coughing will emerge smoothly with an endotracheal tube. And without any of the potential cons you've listed.

People get good at things they do frequently. Maybe you are better than me for these deep extubations. Maybe I'm better than you for ensuring my patients emerge smoothly with an ett in their airway.

Examining this objectively, it's a very easy choice of risk and benefits. I would want to deep extubate if the above holds

I question thr assumptions you made to come to such conclusion. Since you deep extubate nearly 100% patients by your "objective" examination nobody is at risk for aspiration or other complications.

As long as the patient is ventilating, the gas will diffuse off. Regardless if they have a tube between their vocal cords. Laying like a log breathing is very comfortable. Much more comfortable than pressing against vocal cords.

If they are laying there like a log they are comfortable with the ett in.

The mere fact that you think i'm an outlier shows your lack of perspective. Plenty of anesthesiologists do this nearly 100% of the time. I may be the first one to point it out to you.

My test for what is an outlier is what a reasonable anesthesiologist would do. I deep extubate in select circumstances. You deep extubate as a matter of routine. So.. let's say you are sued when your patient aspirates or had a severe larynospasm episode because you decide to deep extubate. Or hypoventilates, obstructs, and desats because you have difficulty with mask ventilation. How will you respond when your judgement is questioned. Will you say this is just how you do things?

Since you brought this up, perhaps we should take a poll for how many anesthesiologists deep extubate nearly 100% of the time. Maybe you are right. But I suspect you aren't.

Sorry if i'm not feeling your full political clout, but just because you're chewing someone out doesn't mean you're a good teacher. It merely means you're abusing your powers and can't control your emotions.

Hahahha ok throttle down, buddy. If your resident did not discuss this plan beforehand and did this without your knowledge I think that deserves this sort of action. Deep extubation is not a standard way of doing things no matter how you try to argue that it is.

 

[abolt18]

Fair point, I should have known SDN wouldn't let me off this easily .

If the patient is appropriately NPO, there shouldn't be much in there in the first place.
I also make sure the patient is upright the oropharynx is suctioned out. With the lessened stimulus, the patient rarely coughs or fights before going through stage 2. After going stage 2, the patient is able to protect the airway like any awake patient.

the corrected pros and cons should be:

Pro:
-less stimulus during stage 2
-patient comfort
-no need to wait for volatiles to diffuse out

Cons:
-Aspiration risk if the patient's stomach is not empty enough after suctioning, given the patient is not bucking or gagging during the period between stage 2 and awake. (this is not 0, but very small chance i would contend it's near 0).
-reintubating if emergence does not go smoothly

Took over a case from a crna as a resident. He tells me this whole story about how the guy was nauseated and puking (just stomach acid) in pre-op. He then tells me that "i placed an OG and got some stuff out (acid) and gave him an EXTRA 4mg of ondansetron, so i was going to deep extubate him."

I manipulated the OG to try to get more out, probably got 200 in total. Woke him up all the way to extubate. About 30 seconds after extubation, he proceeded to vomit ~500mL of stomach juices. Threw up 2-3 more times on the way to pacu.

I have lost all faith in the ability to truly empty the stomach when dropping an OG.

 

[Arch Guillotti]

I contend the aspiration risk is reduced to 0 if you suction the stomach.

At the risk of being redundant, this contention is unequivocally false. It's zero until you have an event and a bad outcome.

 

[dchz]

Took over a case from a crna as a resident. He tells me this whole story about how the guy was nauseated and puking (just stomach acid) in pre-op. He then tells me that "i placed an OG and got some stuff out (acid) and gave him an EXTRA 4mg of ondansetron, so i was going to deep extubate him."

I manipulated the OG to try to get more out, probably got 200 in total. Woke him up all the way to extubate. About 30 seconds after extubation, he proceeded to vomit ~500mL of stomach juices. Threw up 2-3 more times on the way to pacu.

I have lost all faith in the ability to truly empty the stomach when dropping an OG.

I think I'm seeing where the disconnect lies. I have some selection bias in my patient population.

In my practice, everyone is appropriately NPO. I'm a heavy cardiac practice and no trauma/OB/bowel surgery. I have not had a patient that was puking in pre op this year. Nor have I done an lap case for a bowel issue this year. I would not deep extubate a person that has an active bowel problem.

At the risk of being redundant, this contention is unequivocally false. It's zero until you have an event and a bad outcome.

So does this mean you're never extubating deep?

I deep extubate patients when there is a clear benefit to doing so. Patients with no identifiable aspiration risk factors and reasonably easy to mask ventilate. And where there is a good reason. I don't do it more often because my mental calculus is that it is an unnecessary extra risk to do routinely.

I question thr assumptions you made to come to such conclusion. Since you deep extubate nearly 100% patients by your "objective" examination nobody is at risk for aspiration or other complications.

I think I just discovered the disconnect. see above for my patient population. I rarely see any aspiration risk factors in my patients. I now recognize the selection bias in my views.

We do differ in respect to laryngospasm risk. My patient population has a median age of 70. I discount (very deeply discount) any laryngospasm risk in this patient population.

Breathing spontaneously tells you little about their depth of anesthesia. I don't need them to do math, but I do want them to do something to show me that they are in the process of regaining consciousness. Not laying there like a log breathing spontaneously. And you can bet if my fellow or resident is bringing a nonresponsive patient to pacu they will get chewed out. Our pacu nurses are not prepared to deal with stuff like this.

Hahahha ok throttle down, buddy. If your resident did not discuss this plan beforehand and did this without your knowledge I think that deserves this sort of action. Deep extubation is not a standard way of doing things no matter how you try to argue that it is.

You mentioned nothing about your resident extubating deep without talking to you. I agree that is a big deal and they shouldn't do that. All your said was if they bring a non-responsive pt to the pacu then you will chew them out. You can see my confusion.

Since you brought this up, perhaps we should take a poll for how many anesthesiologists deep extubate nearly 100% of the time. Maybe you are right. But I suspect you aren't.

I think a poll is a great idea. I don't want to be right. I can be corrected, i don't mind being wrong. I am interested in what everyone does. Should we start a new thread or just make a poll here??

 

[PainDrain]

Just curious but what are the advantages of extubating prone? Do you keep the patient proned during transport and in the PACU? Is it that difficult to plan your anesthetic to extubate immediately after flip?

 

[vector2]

I think I'm seeing where the disconnect lies. I have some selection bias in my patient population.

In my practice, everyone is appropriately NPO. I'm a heavy cardiac practice and no trauma/OB/bowel surgery. I have not had a patient that was puking in pre op this year. Nor have I done an lap case for a bowel issue this year. I would not deep extubate a person that has an active bowel problem.



So does this mean you're never extubating deep?



I think I just discovered the disconnect. see above for my patient population. I rarely see any aspiration risk factors in my patients. I now recognize the selection bias in my views.

We do differ in respect to laryngospasm risk. My patient population has a median age of 70. I discount (very deeply discount) any laryngospasm risk in this patient population.




You mentioned nothing about your resident extubating deep without talking to you. I agree that is a big deal and they shouldn't do that. All your said was if they bring a non-responsive pt to the pacu then you will chew them out. You can see my confusion.



I think a poll is a great idea. I don't want to be right. I can be corrected, i don't mind being wrong. I am interested in what everyone does. Should we start a new thread or just make a poll here??

Fwiw, ortho, plastics, neuro, vascular, thoracic, EP, IR, gyn....I extubate deep (~1 mac of volatile with no reflexes to stimulation) pretty much every time with senior residents if the surgery doesn't have a GI tract related component and the airway was easy. With more junior residents more often than not we wake the pt up pretty much all the way so they know how to do it smoothly.

Also +1 on the fact that deep extubation isn't really necessarily faster. With residents we're still rolling out of the room before the pt is fully awake, but I usually wait til the pt has blown off enough gas and has transitioned through stage 2 as to ensure they don't laryngospasm in the hallway on the way to pacu.

 

[deleted875186]

This thread is insane.


Deep extubating is undoubtedly more unsafe. I default to awake extubation unless zero risk factors, and even then, the only real advantage is it looks a bit smoother. The patient is not going to remember anything whether you deep extubate or do it more awake, so the patient comfort arguement is ridiculous. Only time I find it safer to deep extubste is a young muscular hulk dude I think is going to have agitated emergence delirium.

 

[deleted875186]

And to the OP, practice improves your timing. Just get the gas off as fast as possible. Give some prop if they get light. Suga helps keep them light and reverse at the last minute avoiding breath holding and bucking.

 

[nimbus]

I trained at a time when some of the attendings wouldn’t let us use ETTs or LMAs for certain cases to develop our mask ventilation and mask airway skills. So we’d mask a lineup of cystos or knee scopes through the whole case, sometimes inserting an oral airway.

 

[MirrorTodd]

I trained at a time when some of the attendings wouldn’t let us use ETTs or LMAs for certain cases to develop our mask ventilation and mask airway skills. So we’d mask a lineup of cystos or knee scopes through the whole case, sometimes inserting an oral airway.

Had a few attendings who had me do that and while I probably got something out of it, my god it sucked balls.

 

[coffeebythelake]

I trained at a time when some of the attendings wouldn’t let us use ETTs or LMAs for certain cases to develop our mask ventilation and mask airway skills. So we’d mask a lineup of cystos or knee scopes through the whole case, sometimes inserting an oral airway.

do it once or twice for some short cases to develop skills in mask ventilation. anything more than that is unnecessary

 

[vector2]

Deep extubating is undoubtedly more unsafe.

Source? And if so to what degree?

Hypothetically, 7 aspirations per say 100,000 vs 3 aspirations per 100,000 is "more unsafe" ...but the statistical difference is trivial.

I don't know the data, in 4 yrs of practice including with trainees, I have not noticed a difference in outcome with awake vs deep pulls, especially when the pt is in slight reverse T and the stomach is suctioned as @dchz says.

 

[ChiDO]

Just do what we all do..... flip the anesthesia light switch to off and press the green wake up button on the front of the machine that says “o2+”... then transport the patient to pacu intubated

 

[dhb]

I extubate light asleep (0.4-0.6 et sevo) 100% of the time with 0% aspiration. I never suction the stomach unless there is a surgical request.

Disclaimer since people like to get their panties in a bunch: i'm not recommending this, i don't care what you do, the tube is going to be coming out eventually but that's just how i roll.

 

[coffeebythelake]

I extubate light asleep (0.4-0.6 et sevo) 100% of the time with 0% aspiration. I never suction the stomach unless there is a surgical request.

Disclaimer since people like to get their panties in a bunch: i'm not recommending this, i don't care what you do the tube is going to be coming out eventually but that's just how i roll.

But why..
What do you possibly gain by doing this

 

[patriot6]

But why..
What do you possibly gain by doing this

Two minutes

 

[deleted875186]

Source? And if so to what degree?

Hypothetically, 7 aspirations per say 100,000 vs 3 aspirations per 100,000 is "more unsafe" ...but the statistical difference is trivial.

I don't know the data, in 4 yrs of practice including with trainees, I have not noticed a difference in outcome with awake vs deep pulls, especially when the pt is in slight reverse T and the stomach is suctioned as @dchz says.

This is crazy, any degree of aspiration is potentially harmful. Deep extubation only makes the anesthesiooogist look smoother, patient won’t care what you do as they won’t remember any of this.

Maybe if there is agitated delirium or Yoj want to avoid bucking or hypertension then deep is beneficial, otherwise you cannot argue with the fact that waiting until airway reflexes, swallowing, coughing etc to return before removing ETT is safer, even if I can’t tell a difference because aspiration is so rare.

 

[coffeebythelake]

@dhb So you are knowingly pulling the tube when patient might be in stage 2? When breath holding, vomiting,, coughing, laryngospasm etc could happen?That's even worse... you can't possibly think that is good care, even if u don't have any complications (yet)

 

[deleted875186]

Just because we are anesthesiologists and can handle airway issues, we can mask, we can identify and break laryngospasm, we have mostly fasted and NPO patients, doesn’t mean that deep extubation is just as safe as awake, just means we can get away with deep extubation without any bad events happening the vast majority of the time.

 

[dhb]

@dhb So you are knowingly pulling the tube when patient might be in stage 2? When breath holding, vomiting,, coughing, laryngospasm etc could happen?That's even worse... you can't possibly think that is good care, even if u don't have any complications (yet)

No before stage 2.
I'm not really trying to gain anything, tube has to come out so sv, good reversal and the tube comes out. When do you don't gain much is when you pull the tube with 1mac then you prolong the time of your unprotected airway + you have to place an oral airway etc..

 

[vector2]

This is crazy, any degree of aspiration is potentially harmful. Deep extubation only makes the anesthesiooogist look smoother, patient won’t care what you do as they won’t remember any of this.

Maybe if there is agitated delirium or Yoj want to avoid bucking or hypertension then deep is beneficial, otherwise you cannot argue with the fact that waiting until airway reflexes, swallowing, coughing etc to return before removing ETT is safer, even if I can’t tell a difference because aspiration is so rare.

Just because we are anesthesiologists and can handle airway issues, we can mask, we can identify and break laryngospasm, we have mostly fasted and NPO patients, doesn’t mean that deep extubation is just as safe as awake, just means we can get away with deep extubation without any bad events happening the vast majority of the time.

I mean I'm just throwing out hypothetical numbers- do you actually know the rate of complications between deep vs awake? Has it been studied? Obviously just because something seems intuitively true doesn't mean it actually is.

And I'm not trying to slippery slope you but there are plenty of things we do which are safe but not necessarily as maximally safe as they theoretically could be. So I think the burden is on you to demonstrate the difference in outcome between deep and awake, especially because we know there are a lot of people pulling "awake" when there is still just a wee bit too much volatile on board, which imo is more dangerous than a true deep extubation.

 

[dhb]

But why..

The question should be why not?