5 DAS Extubation Guidelines 2012

Question 1

Principais causas de problemas relacionados a extubacao (5)

Answer 1

• Reflexos de vias aereas (aumentados, reduzidos, disfuncionais)
• Deplecao de reserva de oxigenio
• Lesao de via aerea
• Comprometimento fisiologico de outros sistemas
• Fatores humanos (equipamentos, monitores, distrações, fadiga…)

Question 2

What is Laryngospasm and how is it often triggered?

Answer 2

• Protective exaggeration of the normal glottic closure reflex
• Stimulation of the Superior Laryngeal Nerve
• Triggered by the presence of blood, secretions or surgical debris, particularly in a light plane of anesthesia. Nasal, buccal, pharyngeal or laryngeal irritation, upper abdominal stimulation or manipulation and smell have all been implicated in the aetiology of laryngospasm.

Question 3

Conforme o algoritmo de extubacao da DAS, o que é feito no “Step 1: plan extubation”.

Answer 3

Determinar se baixo ou elevado risco

→ Are there airway risk factors?

• was the airway normal ⁄ uncomplicated at induction?
• has the airway changed?

→ Are there general risk factors?

Low-risk extubation. This is a routine or uncomplicated extubation. The airway was normal⁄uncomplicated at induction and remains unchanged at the end of surgery, and no general risk factors are present.

‘At-risk’ extubation. This is an extubation ‘at risk’ of potential complications. Airway risk factors are present:

1. Pre-existing airway difficulties. Airway access was difficult at induction (anticipated or unanticipated) and may have worsened intra-operatively. This group includes patients with obesity and OSA, and those at risk of aspiration of gastric contents;
2. Peri-operative airway deterioration. The airway was normal at induction, but may have become difficult to manage, for example, due to distorted anatomy, haemorrhage, haematoma or oedema resulting from surgery, trauma or non-surgical factors;
3. Restricted airway access. Airway access was straight- forward at induction, but is limited at the end of surgery, for example, where the airway is shared, or head ⁄ neck movements restricted (halo fixation, mandibular wiring, surgical implants, cervical spine fixation).

General risk factors may also be present; these may complicate or even preclude extubation, and include impaired respiratory function, cardiovascular instability, neurological ⁄ neuromuscular impairment, hypo ⁄ hyperthermia, and abnormalities of clotting, acid-base balance or electrolyte levels.

Step 1 would stratify both these patients into the ‘at- risk’ extubation group. Step 2 would enable stabilisation of general factors and optimisation of logistical factors e.g. communication with the intensive care unit, assembling equipment, getting help.

Question 4

Conforme o algoritmo de extubacao da DAS, o que é feito no “Step 2: prepare for extubation”.

Answer 4

Avaliação e otimização final dos fatores de via aerea

Checar:

1. Via aerea - edema, sangramento, corpo estranho, distorcao anatomica
2. Laringe - cuff-leak test, espirometria.
3. VA inferior
4. Reverse de BNM
5. Estabilidade cardiaca, temperatura, DHEAB, coagulada
6. Analgesia adequada

Step 1 would stratify both these patients into the ‘at- risk’ extubation group. Step 2 would enable stabilisation of general factors and optimisation of logistical factors e.g. communication with the intensive care unit, assembling equipment, getting help.

Question 5

Consideracoes gerais do passo 3 (“perform extubation”) do algoritmo DAS de Extubacao:

Answer 5

• Pre-oxigenação
• Succao
• Coxim / Guedel
• Evitar estimulo da via aerea
• Supressao da tosse: remifentanyl, lidocaina
• Antagonizar BNM

Sem evidencias robustas:

• posicionmaneto TDL reverso
• Manobras de recrutamento alveolar

Sucction: the soft tissues of the oropharynx are at risk of trauma if suction is not applied under direct vision, ideally using a laryngoscope, particularly if there are concerns about oropharyngeal soiling from secretions, blood or surgical debris. Laryngoscopy should be carried out with the patient in an adequately deep plane of anaesthesia, but may need to be repeated.

Question 6

Vantagens e desvantagens de extubacao acordado e em plano:

Answer 6

Acordado

• mais seguro
• mais reflexo de tosse

Plano

• menos incidencia de tosse e efeitos hemodinamicos do movimento do tubo
• maior incidencia de obstrucao de via aerea
• apenas para paciente sem risco de aspiracao

Question 7

Em que situacoes aplicar o algoritmo de “alto risco” para extubacao?

Answer 7

• Identificados fatores que sugerem que o mpaciente nao vai manter VA apos remoção do TOT
• preocupacao que o manejo da VA nao sera adequado se reintubacao for necessaria

An example of an ‘at-risk’ extubation might involve the patient having emergency surgery to repair a leaking aortic aneurysm for whom general factors such as a full stomach, unstable cardiovascular physiology, acid-base derangement or temperature control can make extuba- tion more challenging.

An example of ‘at-risk’ extubation due to airway factors might involve the patient undergoing head and neck surgery after awake fibreoptic intubation before induction of general anaesthesia, because of previous head and neck radiotherapy.

Question 8

No algoritmo de Extubacao de “alto risco”, o que é feito nos passos 1, 2 e 3?

Answer 8

1. Extratificacao do paciente em Alto Risco
2. Estabilizacao de fatores gerais e otimização de fatores logísticos (equipamento, UTI, ajuda, etc)
3. Decidir se é segura a extubacao ou manter o paciente intubado

Question 9

Sequencia de extubacao para paciente acordado de “baixo risco”

Answer 9

Question 10

Sequencia de extubacao em plano para paciente de “baixo risco”

Answer 10

Question 11

O que é a manobra de Bailey, em que situacoes pode ser benéfica e quando é contraindicada?

Answer 11

• Trocar o TOT com ML para manter uma VA patente e nao estimulada.
• Assegurar profundidade anestesica adequada para evitar laringoespasmo

Possiveis beneficios em:

• useful in cases where there is a risk of disruption of the surgical repair due to the cardiovascular stimulation resulting from the presence of a tracheal tube.
• It may also benefit smokers, asthmatics and other patients with irritable airways.

Contraindicacao:

• It is inappropriate in patients in whom re-intubation would be difficult or if there is a risk of regurgitation.

Question 12

O que sao pacientes em situacao de “alto risco” para extubacao?

Answer 12

• Oxigenacao incerta
• reintubacao possivelmente dificil

Fatores de risco Gerais:

• General risk factors may also be present; these may complicate or even preclude extubation, and include impaired respiratory function, cardiovascular instability, neurological ⁄ neuromuscular impairment, hypo ⁄ hyperthermia, and abnormalities of clotting, acid-base balance or electrolyte levels.

Question 13

Estrategias de extubacao em pacientes de “alto risco”:

Answer 13

• Extubacao acordado
• troca por mascara laringea
• tecnica de Remifentanyl
• Airway exchange catheter
• Traqueostomia eletiva - a ser decidida antes da cirurgia

Alternativa: postergar extubacao. A extubacao é um processo ELETIVO

Question 14

Indicacoes da tecnica de extubacao com Remifentanyl em pacientes de “alto risco” e como é feita?

Answer 14

• Grupos de pacientes em que a tosse, agitação e distúrbios hemodinamicos durante o despertar sao indesejados (neurocirurgias, maxilofacial, plástica, pacientes com doencas cardíacas ou cerebrovasculares importantes)

A remifentanil infusion can be used in two ways: infusion may be continued after intra-operative use; or it can be administered specifically for extubation.

• The success of these approaches lies in removing the hypnotic compo- nent of anaesthesia (inhalational agent or propofol) well in advance of extubation, allowing appropriate titration of remifentanil.*

Question 15

Quais pacientes de alto risco se beneficiariam da extubacao assistida por cateter de via aerea e como é realizado?

Answer 15

• pacientes em que a reintubacao é possivelmente dificil
• inserir o cateter na traqueia antes da extubacao

Question 16

Qual a sequencia de reintubacao em paciente em que foi inserido cateter de troca de VA?

Answer 16

This is a complex procedure. Full monitoring, skilled assistance and essential equipment should be available.

Question 17

Indicacoes de TQT eletiva em pacientes de “alto risco” para extubacao.

Answer 17

• problemas em VA previos
• tipo de cirurgia
• extensão do tumor / lesao
• risco de edema, sangramento, deterioração da VA

Question 18

Conforme o algoritmo de extubacao da DAS, o que é feito no “Step 4: post-extubation care, recovery and follow up”.

Answer 18

1. Oxigenio SN
2. comunicacao e equipe treinada
3. Observacao e sinais de alarme
4. equipamentos e monitores
5. transferencia segura
6. Cuidados respiratorios - estimular inspiracoes profundas, tosse para limpar secrecoes
7. Corticoide em pacientes de alto risco para edema de VA inflamatório
8. Analgesia
9. anti-emese
10. documentacao e manejo futuro

Question 19

Fatores de risco para laringoespasmo:

Answer 19

1. Criancas
2. Tabagistas (ativos ou passivos)
3. infeccao de VA pre-existente
4. agentes anestésicos específicos
5. manipulator de VA, secrecoes, sangue, debris cirurgico ao redor da area da glote

Question 20

Tratamento de laringoespasmo: (9)

Answer 20

Question 21

Principais causas de edema pulmonar pós-obstrutivo (nao-cardiogenico): (2)

Answer 21

• Laringoespasmo
• Paciente que morde TOT ou ML, ocluindo o lumen

The pathophysiology is uncertain and is likely to be multifactorial, but negative pleural pressure is the most important.

Question 22

Diagnosticos diferenciais de Edema Pulmonar Pos-Obstrutivo

Answer 22

• Outras causas de Edema Pulmonar
• Aspiracao de conteudo gastrico

Question 23

Qual o manejo do Edema Pulmonar pos-obstrutivo e como é a prevenido?

Answer 23

• Prevencao com coxim ou Guedes durante o despertar