extubating deep

gaspassah · Mar 24, 2004

only being a student, i have little authority over when to extubate patients whose case i;m in on. however there are certain circumstances that extubating deep would seem appropriate. i know several crna's who state unless there is a contraindication they extubate most everyone deep with proper suctioning etc. i would think an easy airway in a neuro pt would be one to do deep. ie decrease intracranial pressure from coughing gagging etc.

those that tell me they extubate deep usually mention that they dont think it's necessary for the patient to do jumpin jacks before extubation, and that they arrive to rr more comfortable.

just what i've been told.

d

yoga crna · Mar 24, 2004

What are your objectives with extubating? How good is your recovery staff?

You can never go wrong with doing what the patient needs. Full stomachs--extubate awake; patients who were difficult to ventilate or intubate--extubate awake; patients that you do not want to buck on the tube--extubate deep, etc, etc etc. There are no recipe cards in anesthesia. Consider each patient and situation separately and you will do safe anesthesia.

Yoga CRNA

pasgasser · Mar 24, 2004

I extubate many pt's deep. In response to gaspassah, I would not extubate a neuro pt deep. By using IV lidocaine coughing on the ETT is avoidable, however, the volatile anesthetic depth needed to extubate deep would increase CBF also the respiratory depressant effect of the VA will cause an increase in PaCO2 again increasing CBF (ICP). I extubate nearly all children deep who do not have a contraindication, this allows them a smoother emergence and less emotional trauma.

Tenesma · Mar 24, 2004

agreed w/ pasgasser... not a good idea to do deep extub. on neuro patient for many, many reasons... but your concept of avoiding coughing/gagging so as not to increase ICP is a good one in theory... my favorite trick for extubating a neuro pt without coughing or gagging is a small bolus of remifentanil prior to arousal...

CRHSrn · Mar 25, 2004

i, personally, NEVER, EVER, EVER want to know about being intubated. soooo ... that being said, if any of you are, God forbid, to have to intubate me ... please, PLEASE, PLEASE extubate me deep and bag me for 15 minutes or so ... :)

ps. the God forbid is not b/c i don't trust any of you .... i just never wanna be intubated ...

Passin' Gas · Mar 25, 2004

CRHSRN "personally, NEVER, EVER, EVER want to know about being intubated. soooo ... that being said, if any of you are, God forbid, to have to intubate me ... please, PLEASE, PLEASE extubate me deep and bag me for 15 minutes or so ... " italics added

Perhaps you should understand what entails a 'deep extubation' before developing such a strong opionin.

PG

gaspassah · Mar 25, 2004

well so much for my theory. thanks for setting me straight, my first case i ever did was a craniotomy for aneurysm clipping. the crna i was with suggested the deeper ext. although we did give lidocaine iv.., my question now is,

specifically to pasgasser and tenesma or anyone else willing to teach for that matter.

when choosing to ext lighter, what sort of resp rate, tv, and co2 level do you look for (other than your standard extubating criteria for patients other than neuro) .

i am assuming that once the patient is more awake they will not continue to hyperventilate themselves (ie vasoconstriction of cerebral vasc etc). i do understand that the more awake they are the less hypercarbic they would tend to be. also i thought lidocaine has sedative properties also..wouldnt this also depress resp?

so i guess my question is (if i havent gone around the world to ask it is) when is the best time to ext a neuro pt.? (concidering all other parameters as normal as can be)

thanks for any replies.

Tenesma · Mar 25, 2004

best time to extubate a neuro patient... depends on several factors

1) appropriate neuro exam - cause if there are changes you don't want to have to reintubate so they hold still during their post-op CT-scan

2) good feeling that they can protect their airway (a whole new discussion)

i tend to stay away from IV lidocaine - it is unpredictable in how much it is a depressant of mental status.... prefer propofol and remifentanil

CRHSrn · Mar 26, 2004

CRHSRN "personally NEVER, EVER, EVER want to know about being intubated. soooo ... that being said, if any of you are, God forbid, to have to intubate me ... please, PLEASE, PLEASE extubate me deep and [i']bag me for 15 minutes or so ... "[/i] italics added
Perhaps you should understand what entails a 'deep extubation' before developing such a strong opionin.
PG

ok then PASSIN GAS ... enlighten me ... :specs:

Passin' Gas · Mar 26, 2004

ok then PASSIN GAS ... enlighten me ...

Stage One anesthesia: slight sedation, slow regular breathing, some amnesia

Stage two anesthesia: period of excitement; unconsciousness, dysconjugate gaze, reflex activity--laryngospasm**, vomiting reflex**

Stage three anesthesia: Split into four planes--

Plane 1--regular breathing, active ocular muscles

Plane 2--eyes immobile, respiratory patterns change to decreased tidal volumes and increased rate, eyes become immobile

Plane 3--Surgical plane/stage of anesthesia--diaphragmatic breathing due to loss of intercostal muscles (muscle relaxant effect of inhaled anesthetics) further decrease in tidal volume with a less than compensatory increase in respiratory rate; end result is arterial carbon dioxide levels will increase; plus there is a diminished response by the chemoreceptors to increase ventilation in response to an increased arterial carbon dioxide level

Plane 4--Dilated pupils, irregular breathing

Stage four anesthesia: cardiovascular and respiratory collapse; don't go here.

So, in a long-winded answer to your question, a patient needs to be in stage three, plane three with unreactive airways, regular ventilatory rate and rhythm. Taking OUT an ETT should pose NO RESPONSE by the airways...no coughing, sputtering, no dreaded laryngospasm or bronchospasm.

The patient should gradually 'breathe off' the anesthetic through the lighter planes and stages of anesthesia ON THEIR OWN WITHOUT ASSISTANCE i.e. as you referred to "bag me for 15 min or so...".

Now, think of the time frame. And my reference point is my main clinical practice. I practice anesthesia in an anesthesia care team, office-based practice, and do locum tenens. My main practice setting is in a busy, large, private facility. Literally, time from rolling out of the operating room with a patient alllll the waaaay dooowwwnn the hhaaaalll to PACU can take realistically 1 minute to even 2 minutes if I'm in one of the farther reaches of the OR. So, when is the patient going through stage 2 anesthesia upon awakening if I extubate deep in the OR and am traveling from OR to PACU??? Probably in the hallway. Do I have equipment to break a laryngospasm between OR 2 and PACU? Probably not, I don't routinely carry an AMBU BAG and/or Sch to treat this improbable complication if I avoid the situation by extubating the patient awake. Ensuring patient's hemodynamic and ventilatory stability is a KEY requirement BEFORE leaving the OR for PACU or an ICU. Obviously, if I am transporting a critical patient to an intensive care environment these critieria change.

Now, since I've gotten on my soap box, one must consider all of the variables others have presented before....Primarily: the PATIENT and his/her PARTICULAR SITUATION. That will be the primary determinant of what is the SAFEST recourse for extubation whether it be awake or asleep.

Much of what anesthesia providers practice is due to what they are exposed to. The PACU I send my patients to is very busy, quick turnover. I attempt to send patients fairly awake to minimize their workload, speeds up patient discharge in the long-run, surgeons are happily assessing neuro status of back procedures, etc.

PG

PS. I apologize if the prior post was taken as terse. Not the intent. I tire of individuals developing opinions in areas where the lack of knowledge impinges upon true understanding of what a particular situation entails.

I, personally had several misconceptions and misunderstandings cleared up during anesthesia school.

CRHSrn · Mar 27, 2004

wow, thank you for the info. ... however ... it still doesn't change my mind about NEVER, EVER, EVER wanting to know about being intubated ... :chuckle maybe i should just be careful about how long i say to bag me ... or better yet ... i'll just leave that up to you guys ... :wink2:

p.s. sorry for developing an opinion "in areas where the lack of knowledge impinges upon true understanding of what a particular situation entails." because i know you're tired of it ... :rotfl: