How to time your extubation in non supine patients

[Arch Guillotti]

The question should be why not?

EGD for gastric outlet obstruction when the stomach couldn't be emptied all the way.

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[coffeebythelake]

The question should be why not?

Why not do something that could prevent a serious complication. good question. I don't need to pull a tube in a patient who is anesthetized. I don't need to unsecure a secured airway when they might still need it.. I think it's interesting that pulling a tube at 0.4-0.5 MAC gas "before they stage 2" is just fine but for you it's nono to do it a 1.0 MAC. It's pretty cavalier to think there is no risk with what you do simply because you haven't had a serious complication yet.

And yet you argue for some evidence showing your way is inferior. Something that is unlikely to exist as that would require comparing a standard of care with something nonstandard and in almost all cases not superior. So I have concede, I have yet to find a solid, randomized control trial showing that difference between deep extubation vs. 0.4 MAC extubation vs. Usual practice extubation for all patient populations. Maybe you should do one.

 

[nimbus]

How many of you have ever seen a patient vomit and aspirate at emergence? I know it’s possible but I have not seen it in over 20000 cases.

 

[coffeebythelake]

How many of you have ever seen a patient vomit and aspirate at emergence? I know it’s possible but I have not seen it in over 20000 cases.

Yes, projective vomit. No known bowel obstruction. More than one case.

 

[GassYous]

How many of you have ever seen a patient vomit and aspirate at emergence? I know it’s possible but I have not seen it in over 20000 cases.

One time in very early in residency with a crappy attending who was a nervous nellie. Foot case in a bad diabetic with no block and tube with etomidate. No antiemetics given.

I've had a patient vomit on the way to pacu. She was pretty awake and protected her airway. But never on emergence/extubation.

I think pulling the tube before stage 2 is fine n= several thousand. This is the difference between pp and academics. Lots of myths and fear of things that are done routinely in practice. Then again we don't do anything with trainees.

 

[shepardsun]

Seen patients vomit a couple times pretty soon after extubation after an otherwise standard, uneventful emergence. Both young men after non emergent ortho trauma with decent fasting periods (6-8 hrs). Turned them on their side and suctioned, don't think either frankly aspirated but definitely dramatic enough to pucker my sphincter

 

[GassYous]

Seen patients vomit a couple times pretty soon after extubation after an otherwise standard, uneventful emergence. Both young men after non emergent ortho trauma with decent fasting periods (6-8 hrs). Turned them on their side and suctioned, don't think either frankly aspirated but definitely dramatic enough to pucker my sphincter

There's no such thing as a fasted period when it comes to trauma

 

[abolt18]

There's no such thing as a fasted period when it comes to trauma

What if they were ALREADY fasted when the trauma happened? MVC while driving into the hospital for their EGD/colonoscopy. Finished their bowel prep 10 hours ago.

 

[dchz]

How many of you have ever seen a patient vomit and aspirate at emergence? I know it’s possible but I have not seen it in over 20000 cases.

One of the other advantages I want to point out is that when you extubate deep, there is no STIMULUS to cause the vomiting. That's most likely the missing piece of information that the staunch defenders of pulling the tube awake are not considering.

The pt is laying there and whatever in the stomach is not coming up. It's not randomly gonna shoot out of the stomach when they are just sitting there breathing.

At a certain point the pt senses the stimulus at the vocal cords and then the bucking and reaction to the tube also causes intra abdominal pressure to raise. THAT is what causes the stomach content to move.

The reason you haven't seen it in 20k cases is probably because in your 20k cases you pts never had a stimulus to increase their intra-abdominal pressure.

 

[DrZzZz]

How many of you have ever seen a patient vomit and aspirate at emergence? I know it’s possible but I have not seen it in over 20000 cases.

Once in residency. Can't recall what procedure, but it was an elective case, patient vomitted within seconds of the ETT being pulled. Turned to the side and suctioned, no problems afterwards, and she was still able to go home same day.

 

[zizzer]

You shouldn't be routinely reversing opioids. NMB reversal with sugammadex is instant and with neostigmine doesn't take long enough to significantly delay you if you wait to do it right before you flip.

 

[deleted875186]

One of the other advantages I want to point out is that when you extubate deep, there is no STIMULUS to cause the vomiting. That's most likely the missing piece of information that the staunch defenders of pulling the tube awake are not considering.

The pt is laying there and whatever in the stomach is not coming up. It's not randomly gonna shoot out of the stomach when they are just sitting there breathing.

At a certain point the pt senses the stimulus at the vocal cords and then the bucking and reaction to the tube also causes intra abdominal pressure to raise. THAT is what causes the stomach content to move.

The reason you haven't seen it in 20k cases is probably because in your 20k cases you pts never had a stimulus to increase their intra-abdominal pressure.

How about nausea from
Volatiles, opioids, or surgical
Pain or stimulus?

 

[dchz]

How about nausea from
Volatiles, opioids, or surgical
Pain or stimulus?

I pre treat with ondansetron.

I always ask if my pts have any pain or nausea in the pacu before I leave. They rarely (less than 5% of my pts, but again my pts rarely have any bowel issues due to pt population, and also no bucking or valsalva) have any nausea or pain from opioids and volatiles.

I would venture to say the nausea and vomiting has to occur after the pt emerges from GA, which is no different than the period after which you pull the tube the "normal" way. (In a pt population with no active bowel disease and appropriately NPO)