extubating deep

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

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

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.

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...

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 ...

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

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.

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

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