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dkbmcclellan1
01-25-2009, 10:27 AM
:hmmmm2: It appears that there's varying opinions/definitions on what actually qualifies as a deep extubation. Would like to know what everyone's take/recipe is on this and how/if varies when you do peds cases.

HogFan
01-25-2009, 11:30 AM
extubating in phase III of anesthesia. No coughing, breath holding, diverging eyes. Its just humane in the proper candidate.

Teillard
01-25-2009, 11:48 AM
:flybye:
No coughing, breath holding, diverging eyes.

Agree with the above. Spont. vent, obviously. I give the tube a little wiggle to be sure. Transport in trendellenburg, laterally recumbent with opa in. Sch and ASO4 in your pocket with a breathing bag/mask for the trip. Pulse ox in RR and tell the nurses to leave the kid alone until he emerges. It really helps to have the ekg cables/ leads and pulse ox probe on from the or because it minimizes touching the patient.

nojrevorg
01-25-2009, 01:27 PM
If its a kid i make sure i have a Mapleson circuit so i can give PPV breaths if I have too. The Ambu Bags are not adequate for that. Depending on the case I occasionaly give a little smidge of Glyco as well to aid with secretions

gasaholic
01-25-2009, 02:29 PM
adults: (ETT)

was taught to have MINIMUM of 1MAC of vapor on board. Preferrably 1.5-2 MAC for a "true" deep extubation. as long as regular spont. resps and nice smooth etc02 waveform, I will use a soft suction catheter to suction the oropharynx, then give a nice jaw thrust. if no response from either..... out comes the ETT. Nasal or Oral airway (I prefer nasal - better tolerated IMO - and the only way it was done in my first couple clinical sites......however, my current clinical site frowns on that so I use hard oral airways). then a facemask with 10L o2 and off to PACU.

Kids: (ETT) and (LMA) agree with above. unless procedure or issue warrents an awake extubation.

adults: (LMA) - been told that you don't need a MAC of vapor. Blow the agent off until about 0.5 or 0.4 then pull LMA. Nasal airway (or Oral depending on the culture of your facility), move to stretcher, facemask/02 - off to PACU. haven't had any issues with having removing LMA like this. however, most of the time I just let them wake up with LMA since it seems to be better tolerated. I worked with a CRNA in the beginning of my instruction that used to leave LMA's in until the patient pulled them out themselves. LOL. as patient wakes up, in their fog they realize something is in their mouth, they reach up and pull it out.

ethernaut
01-25-2009, 03:39 PM
adults: (ETT)

was taught to have MINIMUM of 1MAC of vapor on board. Preferrably 1.5-2 MAC for a "true" deep extubation. as long as regular spont. resps and nice smooth etc02 waveform, I will use a soft suction catheter to suction the oropharynx, then give a nice jaw thrust. if no response from either..... out comes the ETT. Nasal or Oral airway (I prefer nasal - better tolerated IMO - and the only way it was done in my first couple clinical sites......however, my current clinical site frowns on that so I use hard oral airways). then a facemask with 10L o2 and off to PACU.

Kids: (ETT) and (LMA) agree with above. unless procedure or issue warrents an awake extubation.

adults: (LMA) - been told that you don't need a MAC of vapor. Blow the agent off until about 0.5 or 0.4 then pull LMA. Nasal airway (or Oral depending on the culture of your facility), move to stretcher, facemask/02 - off to PACU. haven't had any issues with having removing LMA like this. however, most of the time I just let them wake up with LMA since it seems to be better tolerated. I worked with a CRNA in the beginning of my instruction that used to leave LMA's in until the patient pulled them out themselves. LOL. as patient wakes up, in their fog they realize something is in their mouth, they reach up and pull it out.
i have pulled lma at slightly less than a mac in a kid and have experienced laryngospasm. they seem to need a good mac and a half-ish for deep with lma or ett.
for adults, i tend to linger at one mac when pulling deep, whether lma or ett.

Teillard
01-25-2009, 04:07 PM
adults: (ETT)

was taught to have MINIMUM of 1MAC of vapor on board. Preferrably 1.5-2 MAC for a "true" deep extubation. as long as regular spont. resps and nice smooth etc02 waveform, I will use a soft suction catheter to suction the oropharynx, then give a nice jaw thrust. if no response from either..... out comes the ETT. Nasal or Oral airway (I prefer nasal - better tolerated IMO - and the only way it was done in my first couple clinical sites......however, my current clinical site frowns on that so I use hard oral airways). then a facemask with 10L o2 and off to PACU.

Kids: (ETT) and (LMA) agree with above. unless procedure or issue warrents an awake extubation.

adults: (LMA) - been told that you don't need a MAC of vapor. Blow the agent off until about 0.5 or 0.4 then pull LMA. Nasal airway (or Oral depending on the culture of your facility), move to stretcher, facemask/02 - off to PACU. haven't had any issues with having removing LMA like this. however, most of the time I just let them wake up with LMA since it seems to be better tolerated. I worked with a CRNA in the beginning of my instruction that used to leave LMA's in until the patient pulled them out themselves. LOL. as patient wakes up, in their fog they realize something is in their mouth, they reach up and pull it out.


You can't extubate deeply going by a fixed MAC rule. It's how anesthetized someone is at whatever et% agent you're running. Don't know why taking an LMA out deep offers any advantage to taking it out awake. Kind of defeats one of the purposes of using the LMA in the first place.

skipaway
01-25-2009, 05:53 PM
You can't extubate deeply going by a fixed MAC rule. It's how anesthetized someone is at whatever et% agent you're running. Don't know why taking an LMA out deep offers any advantage to taking it out awake. Kind of defeats one of the purposes of using the LMA in the first place.
I so agree with you on the deep extubation of a pt. with an LMA. You have an airway that is secure and non-stimulating. Why take it out, and have to manage an unsecure airway when you don't have to?

ethernaut
01-25-2009, 06:06 PM
I so agree with you on the deep extubation of a pt. with an LMA. You have an airway that is secure and non-stimulating. Why take it out, and have to manage an unsecure airway when you don't have to?
how is putting an OPA and O2 mask on considered managing an unsecure airway? at most, a little chin lift on the way to PACU. to me, no concern.

edited to add: i've had few anesthesia providers point out to me that OPAs are not needed nearly as much as we presume. it's sort of funny the differences between what you learn and what you experience. this is why i appreciate anesthesia.

armygas
01-25-2009, 07:14 PM
http://armygasresources.googlepages.com/deepvsawake.png

armygas
01-25-2009, 07:17 PM
"To achieve a successful deep extubation the end-tidal sevoflurane concentration needs to be >3%. For this purpose sevoflurane is better than isoflurane, which is better than desflurane. Halothane is probably the best of all, but hardly available in the UK."

(Same book as above).

notnecessarilyanesthesia
01-25-2009, 08:18 PM
this is on adults... it matters not with the lma. leave it in if you like. it shouldn't be a stimulating airway if the cuff is not excessively over inflated. however, i can [generally] look at a patient and tell you with high accuracy if they are going to emerge by biting on the lma. i generally pull them deep, but lighter on the agent (as opposed to an et-tube, where i prefer a mac at the very least) in the absence of non-alarming airway features and easy mask before inserting. in the presense of alarming airway features and/or a difficult mask, i leave it in. if you do this (wake them up) on a male between 16-50 with a certain look and history, they may bite down on the lma. a bite block helps this. otherwise, they could theoretically go into neg pressure pulm edema if unable to pull out. if this happens and you can't pull the lma out, try advancing it, which gags them, and makes them open their mouth to pull out... just a pearl for a suck situation, if you ever find yourself in one. in the case of increase complications when deep, that's strictly from lack of vigilance afterward... in my opinion.

ethernaut
01-25-2009, 08:25 PM
this is on adults... it matters not with the lma. leave it in if you like. it shouldn't be a stimulating airway if the cuff is not excessively over inflated. however, i can [generally] look at a patient and tell you with high accuracy if they are going to emerge by biting on the lma. i generally pull them deep, but lighter on the agent (as opposed to an et-tube, where i prefer a mac at the very least) in the absence of non-alarming airway features and easy mask before inserting. in the presense of alarming airway features and/or a difficult mask, i leave it in. if you do this (wake them up) on a male between 16-50 with a certain look and history, they may bite down on the lma. a bite block helps this. otherwise, they could theoretically go into neg pressure pulm edema if unable to pull out. if this happens and you can't pull the lma out, try advancing it, which gags them, and makes them open their mouth to pull out... just a pearl for a suck situation, if you ever find yourself in one.
you know, your 'push it further' idea makes great sense. it was on the same line as my thinking that even though people bite down on tubes, it seems the natural progressive reaction is to relax jaw and open up to breathe. unfortunately, the time it takes for enough anesthetic to wear off without someone breathing to create something like NPPE is more likely quicker than anticipated.

deepz
01-25-2009, 08:32 PM
Back about 1978 or so, I think I extubated someone still deep. Long time ago.

Not since.

armygas
01-25-2009, 08:52 PM
Back about 1978 or so, I think I extubated someone still deep. Long time ago.

Not since.

I have to say I have never done it and never will, just me.....

Teillard
01-26-2009, 01:23 PM
I hate extubating deeply, and rarely do it on adults at all. Crappy excuse, but when I do, it is to make a nervous neurosurgeon go away. There is absolutely no arguing with those guys and I guess I'm getting the punishment from the sins of previous buckmasters at the head of the table. The only time I do it frequently is when I have 16 t & a's to do by 1500 on young kids. Far less spasms and thrashing if they just breath themselves awake in RR.

Teillard
01-26-2009, 01:35 PM
how is putting an OPA and O2 mask on considered managing an unsecure airway? at most, a little chin lift on the way to PACU. to me, no concern.



It is a small point, but all you end up doing is replacing one supra-glottic airway for another. Leaving it in just eliminates a step. BTW an unsecured airway is usecured whether the pt. needs a chin lift or an ETT.

skipaway
01-26-2009, 01:43 PM
how is putting an OPA and O2 mask on considered managing an unsecure airway? at most, a little chin lift on the way to PACU. to me, no concern.

.
Why tie your hands up when you don't need to?


From Teillard: It is a small point, but all you end up doing is replacing one supra-glottic airway for another. Leaving it in just eliminates a step. BTW an unsecured airway is usecured whether the pt. needs a chin lift or an ETT.

Totally agree, you do have an unsecured airway with these maneuvers, so as I said before, I feel more comfortable leaving a secure a/w in my patients, especially one that's tolerable.

ethernaut
01-26-2009, 02:48 PM
It is a small point, but all you end up doing is replacing one supra-glottic airway for another. Leaving it in just eliminates a step. BTW an unsecured airway is usecured whether the pt. needs a chin lift or an ETT.
true. unfortunately at my facility, the pacu nurses would freak if we rolled in with LMA still inserted. they get angry when we ask for t-piece. level one pacu by no means!

ethernaut
01-26-2009, 02:52 PM
Totally agree, you do have an unsecured airway with these maneuvers, so as I said before, I feel more comfortable leaving a secure a/w in my patients, especially one that's tolerable.
true, LMA is more secure than OPA, but not more-so than ETT. as you know, LMA is not a replacement for ETT. so, 'secure' here becomes gray IMO.

skipaway
01-26-2009, 03:28 PM
true, LMA is more secure than OPA, but not more-so than ETT. as you know, LMA is not a replacement for ETT. so, 'secure' here becomes gray IMO.
Absolutely, an ETT is "more" secure". I'm just saying leaving an LMA in until the end of the procedure and until the patient is able to breathe on their own without chin lift or OA is by far easier on the provider. Just my opinion, I know there's more than one way to do an anesthetic. I just like to make mine easier on me.

MmacFN
01-26-2009, 04:49 PM
I pull LMAs out with 1 Mac all the time.

I put in an OPA if they need it for the walk to the PACU and put the nasal cannula into the back of the OPA.

If you suction well it is really a non-issue. It looks better but more importantly, you are not trying to yank out an LMA on a stage 2 pt trying to bite it in half.

I did a couple of deep extubations last week. They just make me real nervous but it certainly seems like a smoother wake up.

notnecessarilyanesthesia
01-26-2009, 05:43 PM
I did a couple of deep extubations last week. They just make me real nervous but it certainly seems like a smoother wake up.
that a boy.

RAYMAN
01-26-2009, 06:56 PM
I try to extubate deep everyone that is a candidate. The timing doesn't always work out to where I can. Today for example, had a lady for ventral hernia that was a great candidate...only got 3ml of fentanyl but she would not breath until the gas was off....

HogFan
01-26-2009, 07:18 PM
I know I have not been doing anesth. long, but I was taught to do all deep extubations on all proper candidates. I agree that it always seem to be a great wake up. I extubate pt. while skin sutures are being done and pt. wakes up calmly between bandages being placed and bed being wheeled into room. When done this way the pt. will not rely on OPA on trip to and in PACU.

I will say that with the amount of non-candidates at current site I have been working on finding ways to do smoother wake ups with pt. still intubated. I have found that narcotics seem to be the key and turning gas of earlier. I never use des. so the timing of turning off iso/sevo has been my biggest obstacle so far.

Teillard
01-26-2009, 08:05 PM
I think the irony with deep extubation is that it is a holdover from the The old days of methoxyflurane, ether, and narcotic /nitrous. If the ether droppers that trained me had the poorly soluble agents we have today, we wouldn't be talking about this here. The reality is that it is an archaic technique that has found favor in some circumstances. But we sure don't extubate deep today for the same reasons they did 40 years ago.

HogFan
01-26-2009, 08:14 PM
What about preventing bronchospasm in reactive airways, coughing causing strains on abdominal sutures, etc... I know I am just starting out and will surely get burned sooner or later, but why is deep extubation archaic. I honestly don't understand why a smooth emergence is considered bad.

notnecessarilyanesthesia
01-26-2009, 08:37 PM
I think the irony with deep extubation is that it is a holdover from the The old days of methoxyflurane, ether, and narcotic /nitrous. If the ether droppers that trained me had the poorly soluble agents we have today, we wouldn't be talking about this here. The reality is that it is an archaic technique that has found favor in some circumstances. But we sure don't extubate deep today for the same reasons they did 40 years ago.
it's all what you get used to. deep extubation takes much more vigilance than an awake extubation, for sure; not to mention the ability of the crna to manage the airway and notice an obstruction at any given moment. i readily admit that i like to get 'style points' with a smooth emergence on the proper candidate (which is about four out of every five patients). shoot me for that if you want. it doesn't make it unsafe or wrong, just different. but rest assured that there is a reason that scrub techs, circulators, and pacu nurses avoid certain anesthesia providers when having procedures done in their own operating room. keep in mind that we're talking about proper candidates, so there is really nothing cavalier about it as long as vigilance is maintained.

Teillard
01-26-2009, 08:38 PM
What about preventing bronchospasm in reactive airways, coughing causing strains on abdominal sutures, etc... I know I am just starting out and will surely get burned sooner or later, but why is deep extubation archaic. I honestly don't understand why a smooth emergence is considered bad.



Where did you get the idea that I think a smooth emergence is bad? The point of what I wrote was that if they actually waited until the patient opened their eyes to extubate them on those old, soluble agents they'd have done 2 hernias by three o'clock. "Archaic" isn't a bad word, and it isn't the same as "obsolete". It is an old technique that has found some applications today. A deep extubation doesn't guarantee a smooth emergence either, any more than an awake one guarantees straining suture lines. Getting good at awake extubations is more important that getting good at deep ones because there are those patients in whom a deep extubation is contraindicated.

HogFan
01-26-2009, 08:46 PM
Where did you get the idea that I think a smooth emergence is bad? The point of what I wrote was that if they actually waited until the patient opened their eyes to extubate them on those old, soluble agents they'd have done 2 hernias by three o'clock. "Archaic" isn't a bad word, and it isn't the same as "obsolete". It is an old technique that has found some applications today. A deep extubation doesn't guarantee a smooth emergence either, any more than an awake one guarantees straining suture lines. Getting good at awake extubations is more important that getting good at deep ones because there are those patients in whom a deep extubation is contraindicated.

My bad for the misunderstanding. Like I said earlier, I am really working on my awake extubations, so they become smoother and less stimulating. Still a work in progress.

jwk
01-26-2009, 10:22 PM
The way I look at it, extubating deep and then waking up with a mask is no different than doing a straight mask anesthetic from beginning to end (surely some still do that, right?). If you are happy with your mask airway on induction, it shouldn't be any problem on emergence. And I'm not that worried if they're not breathing yet when they're extubated - they'll start soon enough. Clearly some won't be good candidates, and some won't be as deep as I thought they were (they'll react from the yankauer suction), so I'll just extubate them awake instead.

Kids really aren't any different. In fact, for tonsillectomies, since our surgeons usually have them nice and dry, we often have the surgeon extubate when he takes out the mouth gag, then turn off the gas and go.

gasaholic
01-27-2009, 10:23 AM
And I'm not that worried if they're not breathing yet when they're extubated - they'll start soon enough.

really?

so you just give them a breath every so often while letting them build up their C02?

jwk
01-27-2009, 11:54 AM
really?

so you just give them a breath every so often while letting them build up their C02?

Sure - as long as their SaO2 is OK.

notnecessarilyanesthesia
01-27-2009, 03:11 PM
Sure - as long as their SaO2 is OK.
i agree with jwk on this. it's better to have them breathing first, of course. but if a good candidate, shouldn't matter whether breathing or not.

stanman1968
01-27-2009, 03:11 PM
I extubate about everyone deep, if LMA they can keep it just drop a mask on it by the time I hit recovery 20 feet from OR eyes are open patients are just ducky, only the obese and OSA get awake extubations, I need to get the fuk outta the room.

Teillard
01-27-2009, 06:27 PM
The way I look at it, extubating deep and then waking up with a mask is no different than doing a straight mask anesthetic from beginning to end (surely some still do that, right?). If you are happy with your mask airway on induction, it shouldn't be any problem on emergence.

Doing a mask anesthetic doesn't involve direct laryngoscopy, tube placement, tube removal or the irritation the tube causes on the glottis just sitting in place. Big difference.

jwk
01-27-2009, 06:39 PM
Doing a mask anesthetic doesn't involve direct laryngoscopy, tube placement, tube removal or the irritation the tube causes on the glottis just sitting in place. Big difference.

Most of my intubations/extubations are pretty atraumatic. And I don't think of it as an "old technique that has found some applications today". It wasn't suddenly re-discovered.

There are good indications for extubating deep as well as extubating awake. You ought to be comfortable with both, just like you should be comfortable with all the different routine and not-so-routine airway toys we have available.

Skeebum
01-27-2009, 08:42 PM
I'm not a fan of the deep extubation. I've found that with a appropriately narcotized patient, I can get them breathing, have them breath down the gas, AND have a smooth extubation/lma removal without them bucking/coughing/sputtering.

Do none of my patiets buck......no, it happens from time to time. But I'm also willing to bet that there are patients who are extubated deep who have de-sats thanks to a poor airway.

Perhaps it is six of one, a half dozen of the other? But my goal is to have a sponatneously breathing, comfortable, awake patient when I pull the tube.

notnecessarilyanesthesia
01-27-2009, 08:47 PM
i agree with jwk on this. it's better to have them breathing first, of course. but if a good candidate, shouldn't matter whether breathing or not.
sorry. but i think i need to clarify this. it is much eaiser to mask assist ventilate an already spontaneously breathing (or effort) patient, especially one that might not have the greatest of airway features for masking to begin with (edentulous, somewhat thick neck, facial hair, etc.). however, for those that fall into the category of easy airway, it matters not if the effort to breath is yet present.

one general rule i use is simple. i always give at least one breath (without an oral airway) to the patient, whether inserting an lma or intubating (aside from true rsi's, which are rare). i've found that there are very few people that i cannot see a litte chest rise on when doing this (for me, it is easiest to look just below xyphoid process to see if the abdomen rises or not... forget the stupid etco2 machine when giving this breath; look at the patient). 99% of the patients that i see chest rise on, i usually have no problem pulling them deep. however, some are easy to mask but still have thick necks or other alarming features... they have a "look" about them that i won't play with them (from past experiences). also, some that were easy to mask and with non-alarming features will surprise you at their inability to maintain their own airway (even with an oral airway in), despite very little agent still on. even with the airway in, they may require being awake in order to not obstruct. many people jaw thrust these patients, which is a good technique. i usually hold them regularly and time my bag assistance with their spontaneous efforts, essentially bagging past the obstruction. most of these people, despite non-alarming features, snore really bad at night. i'm probably one of them.

one thing this does when you do this is (over time) it absolutely makes you more vigilant and appeciative of an anesthetized airway than you might have been before. over time, it makes you better at airway management. you have to watch the patient at all times if you are generally bringing them into the pacu spontaneously breathing with oral airways. i learned in a place that generally made the patient do a calculus problem before extubating them. i started working (after graduation) at a place that had, not necessarily a better, but generally a smoother way of going about this.

so to each his/her own.

Teillard
01-28-2009, 04:59 PM
I'm not a fan of the deep extubation. I've found that with a appropriately narcotized patient, I can get them breathing, have them breath down the gas, AND have a smooth extubation/lma removal without them bucking/coughing/sputtering.

Do none of my patiets buck......no, it happens from time to time. But I'm also willing to bet that there are patients who are extubated deep who have de-sats thanks to a poor airway.

Perhaps it is six of one, a half dozen of the other? But my goal is to have a sponatneously breathing, comfortable, awake patient when I pull the tube.


Amen, Bro. I am absolutely not an anti-deepist. Some of my best friends are deepists. And jwk, all I was pointing out was that they didn't do deep extubations in the 60's for the same reasons we do them today. The reasons have evolved as risk is better understood.

yoga
01-29-2009, 09:29 PM
Amen, Bro. I am absolutely not an anti-deepist. Some of my best friends are deepists. And jwk, all I was pointing out was that they didn't do deep extubations in the 60's for the same reasons we do them today. The reasons have evolved as risk is better understood.

Anesthesia in the 60's was totally different than it is today. I know, I was there...started school in 1960.

!960--
-all agents except cyclopropane were long acting
-no one was an out-patient, they all stayed in the hospital
-muscle relaxants were either long lasting (curare, pancuronium) or a sux drip.
-TIVA was not a technique done here (Liverpool technique done in England, but not big in US)
-Lots of regional anesthesia, but rarely combined general and regional
-NO MONITORS or VENTILATORS. We learned how to watch the patient and to squeeze the bag for hours.

So, most of our extubations were deep, because the agents were long lasting.

I do deep extubations all of the time today, because I do plastic surgery and no way do I want the patient bucking on the tube and starting to bleed or pop the sutures on a tummy tuck.

In real estate, it is location, location, location; in anesthesia, it is technique, technique, technique.

Just some thoughts from the older generation.

Jan

jwk
01-29-2009, 09:52 PM
Some of my best friends are deepists.

OMG - I'm a deepist! I guess as long as I'm not a klepper I'll be OK. ;)

rocketgirl
10-04-2009, 05:29 PM
I see the "I've been taught" response repeatedly however where can I find the definition of "deep extubation" I just looked in 2010 Miller, M&M, and the 2009 Barash. What's a good reference for deep extubation? Thank you

RAYMAN
10-04-2009, 05:56 PM
I remember seeing it in miller or barash...says at least 2 x mac

MmacFN
10-04-2009, 06:32 PM
Here is an article on it.

LINK (http://www.anesthesia-analgesia.org/cgi/reprint/80/1/149.pdf)


I see the "I've been taught" response repeatedly however where can I find the definition of "deep extubation" I just looked in 2010 Miller, M&M, and the 2009 Barash. What's a good reference for deep extubation? Thank you

dontquit
10-05-2009, 08:18 AM
Deep extubation in the right patient population is the key. Reactive airways, smokers, thyroid surgery, hernia surgery, the list goes on and on. I perform deep extubation at least a couple times a week. Patients wake up very smooth. Love it!

:nurse:

rocketgirl
10-05-2009, 04:13 PM
Thanks for the link

gaspass3
05-08-2011, 04:13 PM
I think the irony with deep extubation is that it is a holdover from the The old days of methoxyflurane, ether, and narcotic /nitrous. If the ether droppers that trained me had the poorly soluble agents we have today, we wouldn't be talking about this here. The reality is that it is an archaic technique that has found favor in some circumstances. But we sure don't extubate deep today for the same reasons they did 40 years ago.

Exactly!!!! Well said..

armygas
05-08-2011, 04:24 PM
What about preventing bronchospasm in reactive airways, coughing causing strains on abdominal sutures, etc... I know I am just starting out and will surely get burned sooner or later, but why is deep extubation archaic. I honestly don't understand why a smooth emergence is considered bad.

I have smooth awake extubations 99% of the time..... there should be enough narc on board that the patient could sit up with the tube in if they wanted to and still be comfortable.

jagger67
05-08-2011, 04:35 PM
Ditto, armygas. I most of the time have enough narcotic on board so that there is almost never any coughing. When the patient reaches up with their hand toward their head, it is not to pull the tube but to scratch their nose.....from the narcotics. Most of the time, a surgeon can do a pretty extensive neuro check while the tube is still in. They can open their mouth, stick out their tongue, grip bilaterally, move their legs....pretty much anything they could do without the tube being in....except speak, of course. I enjoy the challenge of being able to duplicate this time after time.

snaggletooth
05-08-2011, 05:24 PM
Ditto, armygas. I most of the time have enough narcotic on board so that there is almost never any coughing. When the patient reaches up with their hand toward their head, it is not to pull the tube but to scratch their nose.....from the narcotics. Most of the time, a surgeon can do a pretty extensive neuro check while the tube is still in. They can open their mouth, stick out their tongue, grip bilaterally, move their legs....pretty much anything they could do without the tube being in....except speak, of course. I enjoy the challenge of being able to duplicate this time after time.

If I was seeing this in my training, I'd be all for awake extubations. But honestly, it's far more the exception

gaspass3
05-08-2011, 05:29 PM
Just give them enough narcs to be comfortable, and sleep through stage II. Then just leave them alone and let them breath, either with the vent or spont, it does not really matter which one. Don't suction, turn their head, say their name, jiggle the tube, or bother them. Just respect stage II and the fact that breathing gets the gas off. Once the ET MAC hits 0.1, say their name, their eyes will pop open, and you can then suction and extubate. Suction once, and once only, right after you decide they are ready to extubate. Good luck and let all of us know how it is going.

gaspass3
05-08-2011, 05:31 PM
jagger 67 and armygas really do know what is going on and are speaking the truth about the end of the case. Anesthesia can be very, very beautiful an elegant when done correctly. Really very little decision making left for the you if you follow just a few simple rules. 99.5% of patients follow this pattern.

rat718
05-08-2011, 05:46 PM
Well I was struggling with some patients coughing, bucking, and fighting with me all the time. With 20 min average time for cases in my facility and patients needing to be discharged ASAP, narcotics is not an option for me. Most of the patients that had problems were asthma, URI, or smokers. They would start coughing, that would lead to some kind of spasm:( @ times I would have the LMA stuck in the mouth when they bite on them. I cannot push it in since I have already pulled it out and the cuff part is the one that is stuck in their mouth !!! I always have a soft block in so I am not worried about neg pressure. I had tried Lidocaine and everything else which was not working. I have started doing deep extubations and like it. I still have to work on my timing when to turn the gas off. However I am getting there:)

snaggletooth
05-08-2011, 05:53 PM
Just give them enough narcs to be comfortable, and sleep through stage II. Then just leave them alone and let them breath, either with the vent or spont, it does not really matter which one. Don't suction, turn their head, say their name, jiggle the tube, or bother them. Just respect stage II and the fact that breathing gets the gas off. Once the ET MAC hits 0.1, say their name, their eyes will pop open, and you can then suction and extubate. Suction once, and once only, right after you decide they are ready to extubate. Good luck and let all of us know how it is going.

If i have them breathing with enough time left in the case, it is fairly easy to titrate narcotics. Otherwise i seem so err on the side of not enough (in part because i don't want to get chewed out for having a narcotized pt and slow emergence).

As for suctioning, my preceptors like it deep and often; really they seem to be using it to wake the patient. Do you suction right down at the glottis with the yankauer?

When the patient needs tracheal suctioning, i like to leave the catheter in place and on suction as i extubate. Not sure if that really does what i'm thinking though

notnecessarilyanesthesia
05-08-2011, 08:47 PM
Just give them enough narcs to be comfortable, and sleep through stage II. Then just leave them alone and let them breath, either with the vent or spont, it does not really matter which one. Don't suction, turn their head, say their name, jiggle the tube, or bother them. Just respect stage II and the fact that breathing gets the gas off. Once the ET MAC hits 0.1, say their name, their eyes will pop open, and you can then suction and extubate. Suction once, and once only, right after you decide they are ready to extubate. Good luck and let all of us know how it is going.

just so you know, while you're doing all of this the rest of us are in pacu giving report... or rolling back with our next patient.

ps... you suction them "after" they meet awake extubation criteria?

RAYMAN
05-08-2011, 08:55 PM
just so you know, while you're doing all of this the rest of us are in pacu giving report... or rolling back with our next patient.

ps... you suction them "after" they meet awake extubation criteria?

LMAO

gaspass3
05-08-2011, 08:56 PM
Yep. After. You suction once and once only (with ETT. Do not routinely suction LMA's at all, as the literature suggests). Sticking a suction tip down their throat does not help them wake up. They are asleep because they have gas on board. Gas comes of only one way, and that is by breathing. Making them cough and gag and sputter with suctioning in the middle of Stage II is illogical at best and dangerous at worst. And you might have to do it again. Why?!?!?! Just do it after you have decided to extubate. A quick sweep is more than enough. They are already awake with reflexes intact. Extubate and you are done. A few simple precautions is all it takes to wake your patient up smoothly, safely, and predictably.

MmacFN
05-08-2011, 11:05 PM
You are killing me. There you are again saying something as if its a fact.

1) I can do awake extubations the same way, i just dont bother.

2) Deep extubations are ALSO the "CORRECT" way of extubating.


jagger 67 and armygas really do know what is going on and are speaking the truth about the end of the case. Anesthesia can be very, very beautiful an elegant when done correctly. Really very little decision making left for the you if you follow just a few simple rules. 99.5% of patients follow this pattern.

MmacFN
05-08-2011, 11:11 PM
Exactly and the patients are doing just fine with an absolutely safe and acceptable technique. On top of that the PACU RNs are happy and the surgeons are requesting me. Crazy I know.


just so you know, while you're doing all of this the rest of us are in pacu giving report... or rolling back with our next patient.

ps... you suction them "after" they meet awake extubation criteria?

ethernaut
05-09-2011, 06:36 AM
this, as with any deep extubation, is entirely dependent on the qualified and experienced PACU staff you're dropping these types of patients off to. not every hospital across the country is "equipped" with the appropriate staff for this type of anesthetic to be done. i hope people don't lose that point in this/these discussion(s).

deepz
05-09-2011, 06:53 AM
.......Sticking a suction tip down their throat does not help them wake up. ........

So all the folks who call the Yankauer 'the wakeup stick' are wrong? Beg to differ.

notnecessarilyanesthesia
05-09-2011, 08:46 AM
this, as with any deep extubation, is entirely dependent on the qualified and experienced PACU staff you're dropping these types of patients off. not every hospital across the country is "equipped" with the appropriate staff for this type of anesthetic to be done. i hope people don't lose that point in these discussion(s).
i don't understand what you are saying. narcotic for adequate resp rate, suction supra-glottic, oral airway, and extubate deep as drapes come down. manage the airway (assist vent, etc) with high flows as the circulator and tech apply dressing, move the tables, and eventually fetch the stretcher. you are waiting on them. rarely are they waiting on you. by now most patients require no intervention on the part of the anesthetist, as they are oxygenating and ventilating just fine with oral airway and supplemental o2 via "nasal" cannula (via the ridges of oral airway). move the patient over to stretcher (if on des, probably awake by now)(remember the foley). (if sevo) re-assess airway that they are moving air after moving to stretcher (usually no airway intervention required). go to pacu. patient usually emerges peacefully as pacu staff applying monitors. if not, say their name before leaving pacu and ask them to open mouth. if still not awake (rare), big deal. they will emerge within a couple of minutes. wait if you like and do it yourself.

i don't know what kind of pacu nurses work up in the northeast, but many of you bash them that they are not capable of pulling out an oral airway or even slightly managing an airway with a chin lift. if that kind of nurse worked down here, they'd get fired.

and yes... stage 2 is to be respected; however, stage 2 is less of a pita in a calm, already extubated environment.

there is an "airway expert" where i attended school. he has numerous difficult airway articles published in many journals. well, this airway expert would put every single patient through the most rigorous extubation gauntlet you've ever seen to justify pulling a tube. he was with me once with a slighly mentally handicapped patient who had an lma. he's at my side emerging the patient (breathing) and the patient open his eyes to command. airway expert staff says "wait... he's not ready". then follows the "can you squeeze my hand's?", "what's 5 - 2 = ?", etc. two minutes after the patient has opened his eyes he's agitated and begins phonating through the lma. airway expert staff says "wait... he's still in stage 2". two minutes later he's agitated, phonating, and trying to sit-up in bed. by this point i'm begging airway expert staff to allow me to pull the lma. he snaps at me that "if we have to re-intubate it will be 'my ass'". patient is still phonating and as i pull the lma he looks up at me and in his best "something about mary franks&beans" voice he says "thank you!!!!!"

my point is that many people go overboard with this. down the street from where i work crna's aren't allowed to extubate without the anesthesiologist in the room telling them they can do so. there are circulators who work at both hospitals that speak of how ridiculous it appears to see them emerge patients like they do and the very next day work 1/2 mile down the street and see patients emerge from anesthesia completely differently. obviously not knowing everything about what we do, they can still identify the difference in techniques and the lack of need in putting most patients through it.

MmacFN
05-09-2011, 09:40 AM
Hey

Well im lucky to have great PACu staff at one hosptial and unlucky to have crappy PACU staff at another. However, I extubate deep at both. When I first went to the new hospital i simply told them exactly how i did things after i came out of the room with a pt and that he would wake up fine on his own within minutes of arrival. I got funny looks because the previous "group" of all MDAs would never do that whereas just about everyone in my grp does. Now, 6 months since we took the contract, they cant get over how smooth the pts arrive to the PACU and how easy they are to manage for the first 2 minutes while putting monitors on. They lay there, sleeping, while monitors are places and temp taken without a sound. Just as Im done with report they are waking up and spitting out the OPA if i put one in (all on their own).

What special skills do they need in PACU for deep extubations that they wouldnt need for awake ones? I cannot think of any...


this, as with any deep extubation, is entirely dependent on the qualified and experienced PACU staff you're dropping these types of patients off. not every hospital across the country is "equipped" with the appropriate staff for this type of anesthetic to be done. i hope people don't lose that point in these discussion(s).

ethernaut
05-09-2011, 10:24 AM
Hey

Well im lucky to have great PACu staff at one hosptial and unlucky to have crappy PACU staff at another. However, I extubate deep at both. When I first went to the new hospital i simply told them exactly how i did things after i came out of the room with a pt and that he would wake up fine on his own within minutes of arrival. I got funny looks because the previous "group" of all MDAs would never do that whereas just about everyone in my grp does. Now, 6 months since we took the contract, they cant get over how smooth the pts arrive to the PACU and how easy they are to manage for the first 2 minutes while putting monitors on. They lay there, sleeping, while monitors are places and temp taken without a sound. Just as Im done with report they are waking up and spitting out the OPA if i put one in (all on their own).

What special skills do they need in PACU for deep extubations that they wouldnt need for awake ones? I cannot think of any...
i would say you'd be surprised to see how easy it is to mess up a chin lift, but i'm sure you wouldn't. as basic a skill it is, some have a hard time doing it properly. and that goes for jaw thrust too. my PACU is level I, for whatever that means, since some scare me with the way they manage patients. but i digress. we can't even roll in the PACU with an LMA in the patient, unless we are to stay there until it comes out. but... it's ok to dump and run when an oral airway is in place. make sense? not to me, but it does to the PACU. go figure.

MmacFN
05-09-2011, 11:18 AM
Oh my...

Well maybe I just have not seen it that bad...


i would say you'd be surprised to see how easy it is to mess up a chin lift, but i'm sure you wouldn't. as basic a skill it is, some have a hard time doing it properly. and that goes for jaw thrust too. my PACU is level I, for whatever that means, since some scare me with the way they manage patients. but i digress. we can't even roll in the PACU with an LMA in the patient, unless we are to stay there until it comes out. but... it's ok to dump and run when an oral airway is in place. make sense? not to me, but it does to the PACU. go figure.

jagger67
05-09-2011, 11:44 AM
Have experienced the same thing in our local PACU's, ethernaut. Bringing in a patient with an endotracheal tube seems less objectionable than bringing in a patient with an LMA. It is mystifying. PACU nurses have NO idea how good they have it now. I was a PACU nurse for 4 years, quite a few years ago, in an 1100 bed hospital. Then, it was pretty standard for about 1/3 of the patients to come in intubated, many requiring ventilation. The VAST majority of the other 2/3rds came in with oral/nasal airways. With the exception of two STELLAR anesthesiologists, no one ever brought in an awake patient. There were no pumps for drips. There were no well accepted patient ratios....like 3:1 or whatever. No pulse ox. No EKG. It is very difficult for me to endure the objections from a snippy PACU nurse on the rare occasion that I bring in a patient with an LMA.

MmacFN
05-09-2011, 05:32 PM
Ive never brought a pt in with an LMA but I wonder how that would go...

I dont think it would take much to convince one set of the PACU RNs that an OPA and an LMA are not much different, however the other hospital.... never happen...

I agree this is an interesting idea. Maybe tomorrow ill bring one in with an LMA and see how it goes :P


Have experienced the same thing in our local PACU's, ethernaut. Bringing in a patient with an endotracheal tube seems less objectionable than bringing in a patient with an LMA. It is mystifying. PACU nurses have NO idea how good they have it now. I was a PACU nurse for 4 years, quite a few years ago, in an 1100 bed hospital. Then, it was pretty standard for about 1/3 of the patients to come in intubated, many requiring ventilation. The VAST majority of the other 2/3rds came in with oral/nasal airways. With the exception of two STELLAR anesthesiologists, no one ever brought in an awake patient. There were no pumps for drips. There were no well accepted patient ratios....like 3:1 or whatever. No pulse ox. No EKG. It is very difficult for me to endure the objections from a snippy PACU nurse on the rare occasion that I bring in a patient with an LMA.

ethernaut
05-09-2011, 06:17 PM
... an OPA and an LMA are not much different,

i respectfully disagree. one is a ventilator/ambu capable airway, the other isn't.

MmacFN
05-09-2011, 06:25 PM
Uh huh.

I meant in terms of how PACU will use/see it.

BTW, when the pt clamps down and bends the LMA in half it does not ventilate well at all, but the OPA will still work just fine ;)

Couldn't resist. :P


i respectfully disagree. one is a ventilator/ambu capable airway, the other isn't.

gaspass3
05-09-2011, 06:38 PM
Just use an LMA Supreme. Strongest jaws in the world cannot occlude one of those bad boys!!


Uh huh.

I meant in terms of how PACU will use/see it.

BTW, when the pt clamps down and bends the LMA in half it does not ventilate well at all, but the OPA will still work just fine ;)

Couldn't resist. :P

ethernaut
05-09-2011, 06:42 PM
Uh huh.

I meant in terms of how PACU will use/see it.

BTW, when the pt clamps down and bends the LMA in half it does not ventilate well at all, but the OPA will still work just fine ;)

Couldn't resist. :P
i use supremes, so there ;)

RAYMAN
05-09-2011, 07:00 PM
i respectfully disagree. one is a ventilator/ambu capable airway, the other isn't.

If you put a mask over the opa u can ventilate just fine :)

MmacFN
05-09-2011, 07:02 PM
too true!! Love those things!

I put em on the vent all the time, and even paralyzed ;)


Just use an LMA Supreme. Strongest jaws in the world cannot occlude one of those bad boys!!

MmacFN
05-09-2011, 07:02 PM
D'oh you win!


i use supremes, so there ;)

ethernaut
05-09-2011, 08:34 PM
If you put a mask over the opa u can ventilate just fine :)
sure, you could ventilate. but... much more work. besides, in all honesty, which would you rather have in when faced with a situation? an opa? c'mon.

RAYMAN
05-09-2011, 08:36 PM
sure, you could ventilate. but... much more work. besides, in all honesty, which would you rather have in when faced with a situation? an opa? c'mon.

Guess it's a good thing I see if I can squeeze in a couple breaths before I place the lma....

MmacFN
05-09-2011, 08:57 PM
hehe

If there is a concern about ventilation Ether, LMA wont be where im headed so from my perspective OPA = LMA when we are talking about RSI.


Guess it's a good thing I see if I can squeeze in a couple breaths before I place the lma....

yoga
05-09-2011, 10:26 PM
I can't help but chucking as I read this thread.

All of us have learned the science of anesthesia, but in my opinion, knowing when and how to extubate comes under the category of the "art of anesthesia". Like everything else, have a reason why you are extubating deep, awake, light or in the laryngospasm depth. Then learn to have some finesse when doing it. No cutting the pilot tube, no yanking out the tube, be gentle, be prepared to ventilate the patient, be prepared to have a certain number of children who will have an extubation spasm and edentulous people who will need airway support.

Anyone who is dogmatic about their technique and never deviates from it, has simply not done enough anesthesia.

Jan (who sometimes extubates deep, sometimes awake, sometimes with an agent still on board, and sometimes by accident)

jayvee79
03-16-2014, 06:50 PM
I've always extubated awake but then lately I have been extubating deep on a few good candidates ie thin petite young healthy females, just to get experience .. Most of them were smooth but I did have 2 pts one with an lma and one with an et , that had laryngiospasmed during transfer to the stretcher , I easily broke it and that was that .. Although most my deep extubation were smooth , the scenario above alarmed me of the fact that what if it happened in pacu or during the transfer . I don't know if it's my technique or just the risk I have to accept when extubating deep .. That was kind of a turn off to deep extubation IMO

PackFan12
03-16-2014, 07:40 PM
Out of curiosity, how many patients total did you deep extubate in your sample? I ask because the site I'm at now deep extubates damn near everyone and I haven't seen this scenario or heard of it happening with adults anyways. I recognize I'm just a student but I just found your experience surprising compared to my limited experience.


I've always extubated awake but then lately I have been extubating deep on a few good candidates ie thin petite young healthy females, just to get experience .. Most of them were smooth but I did have 2 pts one with an lma and one with an et , that had laryngiospasmed during transfer to the stretcher , I easily broke it and that was that .. Although most my deep extubation were smooth , the scenario above alarmed me of the fact that what if it happened in pacu or during the transfer . I don't know if it's my technique or just the risk I have to accept when extubating deep .. That was kind of a turn off to deep extubation IMO

J-Dubya
03-17-2014, 04:45 PM
I've always extubated awake but then lately I have been extubating deep on a few good candidates ie thin petite young healthy females, just to get experience .. Most of them were smooth but I did have 2 pts one with an lma and one with an et , that had laryngiospasmed during transfer to the stretcher , I easily broke it and that was that .. Although most my deep extubation were smooth , the scenario above alarmed me of the fact that what if it happened in pacu or during the transfer . I don't know if it's my technique or just the risk I have to accept when extubating deep .. That was kind of a turn off to deep extubation IMO

You have an oral airway in, correct?

bayoufrogg
03-17-2014, 07:18 PM
I've always extubated awake but then lately I have been extubating deep on a few good candidates ie thin petite young healthy females, just to get experience .. Most of them were smooth but I did have 2 pts one with an lma and one with an et , that had laryngiospasmed during transfer to the stretcher , I easily broke it and that was that .. Although most my deep extubation were smooth , the scenario above alarmed me of the fact that what if it happened in pacu or during the transfer . I don't know if it's my technique or just the risk I have to accept when extubating deep .. That was kind of a turn off to deep extubation

I've done many extubations this way and have only experienced a true spasm 1 time on an asthmatic 3 year old that had a cold for the last two weeks. Are you suctioning adequately? Do you have an oral airway in place?

Google laryngospasm notch for a good article on an alternative method of breaking spasms when they occur.

You can always bring anectine and a syringe with you on transport to ease your reservations.

bayoufrogg
03-17-2014, 07:27 PM
I trained at a facility where most patients, barring any obvious contraindications, were extubated deep. I now work at a facility with very fast turnovers.


A few conclusions I've come to:


Deep extubations(adequate VE, stag 3, OPA) are usually very smooth
Awake extubations "can" be very smooth given the right amount narcotic
You can have a patient extubated as the drapes come down with either method, it's all about timing/finesse (art of anesthesia as Jan said).
The best plan for emergence is the one you have formulated for the specific patient
Providers who lack vigilance and/or good masking skills should not be performing deep extubations......period.


I try to combine patient safety with what is most comfortable for the patient and myself.

ethernaut
03-17-2014, 07:32 PM
I don't see how an oral airway in place will prevent a laryngospasm, especially in lieu of adequate depth of anesthesia and appropriate suctioning. Help prevent negative pressure breathing, sure. Please refresh my memory, Jdub and/or jayvee. Thanks-

gaspass3
03-17-2014, 07:48 PM
I don't see how an oral airway in place will prevent a laryngospasm, especially in lieu of adequate depth of anesthesia and appropriate suctioning. Help prevent negative pressure breathing, sure. Please refresh my memory, Jdub and/or jayvee. Thanks-

I would like to add, I don't see how a patient who is "deep" can laryngospasm. I think the vast majority if spasms are provider error, usually caused by lack of depth for the current activity. A patient does not just spasm spontaneously for no reason. Just does not happen.

Sent from my SAMSUNG-SGH-I747 using Tapatalk

J-Dubya
03-17-2014, 08:31 PM
I don't see how an oral airway in place will prevent a laryngospasm, especially in lieu of adequate depth of anesthesia and appropriate suctioning. Help prevent negative pressure breathing, sure. Please refresh my memory, Jdub and/or jayvee. Thanks-

It would not prevent spasm, however, IME, lots of people start calling spasm when a patient simply obstructs or they have trouble masking.

Personally, I put an OA is every patient that I extubate deep, I always thought this was standard practice, but I have seen people not do it.

ethernaut
03-17-2014, 09:34 PM
It would not prevent spasm, however, IME, lots of people start calling spasm when a patient simply obstructs or they have trouble masking.

Personally, I put an OA is every patient that I extubate deep, I always thought this was standard practice, but I have seen people not do it.

To your first paragraph, I can't argue. But I will say it's misinterpretation, and to what Gaspasser alluded to..provider management/skills/etc.

To your second paragraph.. I see how they breathe without one first, and make the judgement thereafter. Just me though.

J-Dubya
03-18-2014, 06:55 AM
To your second paragraph.. I see how they breathe without one first, and make the judgement thereafter. Just me though.

I think that's fine for experienced practitioners, but for someone struggling, it's probably best just to put an oral airway, as it's makes less much less likely to misdiagnose obstruction as spasm.

I've seen people with poor masking skills struggle to mask and then when they finally start moving air (due to adjusting their hands, getting a better seal etc), they declare "I broke the spasm!"