Extubation?

FYI- there have been previous posts on this with lots of good answers.

But to answer your questions- yes.

I know that in some places hearts are coming back extubated. OUr hearts come directly back to the unit and if everything looks good, we start the weaning process about three hours after arrival...we typically extubate in 4-6 hours though. The "RN" criteria that has to be met includes:

Stable on "low" amounts of vasoactives and no IABP, map

CT out put

Able to hold head off pillow for five seconds.

Off fentanyl for 30 minutes prior to wean trial.

OFf propofol for 15 minutes prior to wean trial.

May initiate weaning when on 40% Fio2

And there are one or two others that I can't seem to remember right now...usually I look at the SVO2 as well....

There are also some respiratory criteria. OUr hearts come back on simv 10, psv 12, peep 5. We wean down to simv of 5, ps 5, then to cpap....resp. rate has to be between 6-30, mv 6-12....have patient do a vital capacity...run a set of abgs and if all look good we can extubate. It is pretty rare that we have to reintubate but it occassionally happens...

FYI- there have been previous posts on this with lots of good answers.

But to answer your questions- yes.

I know that in some places hearts are coming back extubated. OUr hearts come directly back to the unit and if everything looks good, we start the weaning process about three hours after arrival...we typically extubated in 4-6 hours though. The "RN" criteria that has to be met includes:

Stable on "low" amounts of vasoactives and no IABP, map

CT out put

Able to hold head off pillow for five seconds.

Off fentanyl for 30 minutes prior to wean trial.

OFf propofol for 15 minutes prior to wean trial.

May initiate weaning when on 40% Fio2

And there are one or two others that I can't seem to remember right now...usually I look at the SVO2 as well....

There are also some respiratory criteria. OUr hearts come back on simv 10, psv 12, peep 5. We wearn down to simv of 5, ps 5, then to cpap....resp. rate has to be between 6-30, mv 6-12....have patient do a vital capacity...run a set of abgs and if all look good we can extubate. It is pretty rare that we have to reintubate but it occassionally happens...

Good Answer Zambezi!

Thanks for great answers!

It helps alot, but what about the procedure it self? What I mean is - how do you extubate your patients? I have seen some physicians/clinicians give patients 100% oxygen before extubation, other do not unplug the respirator and extubated while the respirator is still working (cpap, 5 peep). And some put the suction catheter down in the tube and extubate on their way up again.

So my question is this: How do you do it, do you follow some protocol or does everybody have their own style, so to speak?

Thanks again from Iceland,

Thorsteinn Jonson

Thanks for great answers!

It helps alot, but what about the procedure it self? What I mean is - how do you extubate your patients? I have seen some physicians/clinicians give patients 100% oxygen before extubation, other do not unplug the respirator and extubated while the respirator is still working (cpap, 5 peep). And some put the suction catheter down in the tube and extubate on their way up again.

So my question is this: How do you do it, do you follow some protocol or does everybody have their own style, so to speak?

Thanks again from Iceland,

Thorsteinn Jonson

We usually have the RT and primary RN at the bedside. OUr patient's remain on 30-40% FIO2. Some of our RTs leave the patient on cpap while they run the abgs and some put the patient back on an simv of 5/psv 5 to let the patient rest until the abg's are done and we are ready to extubate.

The procedure is explained to the patient. We typically suction out the tube once or twice, clean the oropharynx with a yankauer to clear any secretions. We have a nasal cannula and yankauer hooked to suction at the bedside. The RT removes the tape (we still use tape to hold our tubes). I splint the person's chest, the RT deflates the pilot balloon, we encourage the patient to do a big cough and the RT guides the tube out. We suction the orophaynx with the yankauer, I give the patient some mouthwas to swish and suck out with the yankauer, restraints are removed and RT places the NC, typically at 3L to start. The vent is then turned off and (hopfully) taken out of the room. I give the patient a few minutes, make them say hi, breathing tx if necessary, practice coughing and IS. Because all of the pain meds have been off, if we can't use toradol, most patients are fairly painful. I usually give two percocets down the NG before I pull it out (I pull it out when we dc the ETT if patient has bowel sounds) and stick with IV or IM MS until pain is under adequate control and can switch to PO pain meds.

I don't know if there is an actual written protocol for the steps of extubation, I am sure their must be somewhere. As I said earlier, we have a written "weaning" protocol to help us determine when the patient is ready. Our RTs do things pretty consistently, but each one does do things a little differently, with their own style.

After three years in ICU (on nights) I just realized that I have never been around for a "planned" extubation. Thanks everyone for your input because I just learned a thing or three.

Linnda