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hey there. new on here so not sure if this is the right place to post my question...

wondering what the OMFSers thoughts are on the necessity of opening a pt up from mmf for nasal extubation. is it absolutely necessary? what do you think the absolute and relative contraindications to this is? thanks!
 

aphistis

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hey there. new on here so not sure if this is the right place to post my question...

wondering what the OMFSers thoughts are on the necessity of opening a pt up from mmf for nasal extubation. is it absolutely necessary? what do you think the absolute and relative contraindications to this is? thanks!
Full disclosure: I'm not OMFS. I have, however, managed an airway or two.

Any situation like this needs to be carefully evaluated on its own merits before proceeding. In general, though, if a patient is in IMF you'd better be damned sure they're ready to extubate before you pull the tube. That means vigorous central respiratory drive, upper airway patency, normal tidal volumes, and all the rest.

If you're looking to extubate someone after a recent trauma, consider the possibility of airway obstruction 2/2 edema and whether the tube is the only thing propping their trachea open. You can check this easily by deflating the cuff to see whether the tube leaks when you give a breath. No leak? That means you've got no empty space around the tube, and that means nobody's getting extubated today. Alternately, if you have a flexible bronchoscope (like you'd do a fiberoptic intubation with), you can just inspect the area directly. If you lose that kind of boggy, edematous airway, you might not get it back short of a blade in the patient's neck.

If they've been in MMF for a while, on the other hand, you run the risk of losing the airway then trying to perform direct laryngoscopy on a patient whose MMF-induced trismus won't let you open them far enough to visualize the larynx (and that's after you waste the time cutting their wires) to begin with. You could probably handle this situation pretty easily with a fiberoptic scope, but you're not going to be doing very many of those in general, and a crashing lost-airway scenario isn't a great place to find out you're not as skilled with the fiberoptic as you thought. This scenario would likely be a good candidate to rescue with an LMA, but that's only a temporary solution.

In general, if you're sufficiently concerned about the airway that you're already making preparations to reintubate, you and the patient will often both be better off just leaving the tube in a little longer until they've proved to you that they're ready to extubate.
 

InMyCrossHairs

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Everything Bill said, and I would add, if they are still in MMF, and you are the surgeon, do not leave the OR until they are extubated and completely stable. If you want to see someone crap their pants, just watch an anesthesiologist try and cut someoneout out of IMF quickly to access the airway.

Bill, how did you get all your anesthesia training?
 

servitup

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If cutting MMF was necessary for extubation, plastic surgeons would be screwed.
 

aphistis

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Everything Bill said, and I would add, if they are still in MMF, and you are the surgeon, do not leave the OR until they are extubated and completely stable. If you want to see someone crap their pants, just watch an anesthesiologist try and cut someoneout out of IMF quickly to access the airway.

Bill, how did you get all your anesthesia training?
I was sufficiently impressed by my GPR anesthesia rotation that I did a fellowship year immediately afterward. One of the IU med center hospitals has a superb one-year fellowship they quietly offer. My clinical responsibilities were identical to those of the other first-year residents, and since I worked with the same attendings all year instead of rotating between hospitals every month, as the year progressed they trusted me enough to assign me some pretty sweet cases. The experience I gained during that year added so much depth to my understanding of medicine in general, and acute patient management in particular, that I couldn't have even imagined was possible before starting.

To any OMFS interns-to-be who might be reading this, here's the best advice I can give you. Your anesthesia rotation will be one of the most valuable, high-yield portions of your entire residency if you let it. Stay humble, work hard, and read everything you can get your hands on, and have fun.