For the past 2 years I've been training with a anesthesia group that does very little deep extubation. Once in blue moon I have come across an MDA or a CRNA that liked to deep extubate and would allow me to do so. Despite the fact that I can count the number of times this happened on 2 hands, I remain interested in deep extubation.

Initially, as a student struggling to work as staff (and having what seemed like at least one really slow wake per day), I viewed deep extubation as a possible way to ease the turnover pressure I felt, i.e. no worries about titrating the agent down and guessing when unpredictable, unfamiliar surgeons would be done, I could just pull the tube and leave the room.

Now that I am a little better with VAs, I don't really see deep extubation as a way to speed turnover, as I think someone who knows the agent can time wakeups pretty well. However, I still see deep extubation as an attractive way of having really smooth wakeups. Cough, bucking, fighting not only can cause surgical problems, but I don't like the idea of my patients having massive stress responses during emergence.

However, one problem I face is that my PACU RNs (I go to a number of sites) are generally not trained or comfortable to deal with patients that have been deep extubation (i.e. they will touch/stimulate a patient going through state 2, they will complain that such a sleepy patient will never be ready for discharge, etc, etc).

So, I've been playing around with ways to get the best of both worlds. How risky/innapropriate/dumb would you find the following technique:

-pt is an easy airway, non-full stomach
-pt is spont breathing well

-I titrate down my gas as I would for a "standard" awake extubation
- I aggressively suction the back of the oropharnxy
-Right when the patient starts to enter stage 2, as judged by PIA levels, vitals etc, I give a 30-40mg of propofol, place an oral airway, suction one last time and pull the tube, then give some gentle CPAP

My thoughts: IME that dose of prop will break most laryngospasms and should get the patient deep enough to prevent laryngospam as the tube comes out. This dose is also not going to hang around forever. Ideally, the prop wears off right around the time the patient is in stage 1 - looking nice upon arrival in the PACU

Disadvantage: prop may make patient apnic, which is generally a no-no with deep extubations. Plus, if I mess up and the patient is not deep enough from the prop, then I just pulled a tube at the exact wrong time (stage 2) and I know will probably have to manage a larysospasm. Of course, part of management will probably be giving some more prop.

Any comments on the ramblings of an SRNA?