Principles exam 3 extubation Flashcards
What patients would you do an awake extubation on?
patients at risk of aspiration (full stomach) or for patients whom reintubation would be difficult (difficult intubation, bulky dressings or bandages, jaw wired).
When should patient be extubated ideally to prevent coughing or laryngospasm?
Ideally accomplished while the patient is still adequately anesthetized so as to diminish the likelihood of coughing or laryngospasm.
How much O2 should a patient be on prior to extubating?
Patients always receive 100% O2 prior to extubation
Why should you always suction before extubating?
Oropharynx suctioned thoroughly (so that secretions proximal to the cuff do not drain into the trachea when the cuff is deflated). Helps prevent laryngospasm.
When should you pull the tube during inspiration or expiration?
during inspiration when the vocal cords are open (may apply pressure to the bag as the tube is removed so that the lungs will be inflated and initial gas flow is outward - this maneuver facilitates a cough and expulsion of any aspirated material.
If your patient received a non-depolarizing muscle relaxer what should you always do prior to extubation?
reverse the patient and wait until breathing spontaneously and consistently before extubation
What should you have readily available prior to extubation?
O2, Succinylcholine, suction and equipment for reintubation should be readily available.
How do you know if a patient is in Stage II or not?
Stage II characterized by enlarged pupils, diveregent gaze,tachycardia, breath-holding
What does bucking signal during emergence?
return of the cough reflex and at this point you must make a decision to remove or wait until the patient is more awake. (Assure patient not in Stage II)
-Smokers will cough and respond to tube but won’t take breath and desat (in this case turn off gas and leave on vent as long as can to keep airway open)
What can happen if a patient is bucking?
- hypoxia
- increased CSF pressure (cerebral congestion)
- increased intra-abdominal tension (strain on sutures)
What med might you considering giving prior to extubation and why?
Lidocaine 1-l.5mg/kg IV two minutes before extubation may help the coughing, hypertension and tachycardia associated with emergence
(wait until regular respirations before administering Lidocaine - can deepen anesthesia)
As a SRNA what should always be present prior to extubating a patient?
Instructor
What are indications for an awake extubation?
- full stomach
- actual or potential for airway swelling
- difficult intubation or mask ventilation
- surgery involving airway
- oral surgery and/or intermaxillary fixation
- obese patient
- vomiting pre-op
- NG-tube in place
- intestinal obstruction
- intoxicated pre-op
- any patient who required an awake intubation for reasons not surgically corrected
- any question about the airway***
- hx of OSA
What is the criteria used to evaluate if patient is ready to be extubated?
- able to hold eyes open
- responds to commands
- sustained head lift (> 5 sec.)***
- equal, strong hand grasps
- + TOF and sustained tetany
What are the steps to extubation?
- Pre-oxygenate with 100% O2
- suction pharynx, and ET tube as indicated; administer O2
- deflate cuff completely
- ask patient to take a deep breath and gently remove the tube on inspiration while vocal cords are open and the lungs inflate with O2
- ask patient to take a deep breath to assure adequate ventilatory exchange
- **Immediately administer O2 by face mask
- a little PEEP on the bag; let patient take a breath; DON’T TRY TO VENTILATE
- May transport with oxygen
What are some variations used in extubating patients that are obese that may obstruct?
- Extubation over cook catheter (tube changer can ventilate through)
- Reverse Trendelenberg position/HOB elevated (can’t tolerate laying flat)
- Article says Extubation in the left lateral, head-down position is the position least likely to be associated with aspiration and therefore is the position that should be used in unstarved patients undergoing emergency surgery. (Grade B)
What are indications for deep extubations?
- asthmatic patients
- eye cases (to avoid coughing increases in IOP)
- neuro cases (particularly cases where you don’t want to increase ICP)
- hernia repair (usually LMA cases though)
- any procedure where coughing/bucking could be detrimental (neck surgery, facial procedures).
- pediatrics (reactive airways) – not always
If you did not perform induction should you extubate deep?
Probably not, not sure of anatomy and difficulty if needed to reintubate, only if you can really trust person giving you report
What is the criteria for a deep extubation?
- spontaneous respirations (small Vt)
- no anticipated airway difficulties -thin -easy to ventilate on induction
- depressed cough and airway reflexs
- NPO patient
- Control of the airway; table turned where you can ventilate/reintubate in case of problems.
- Airway free of secretions, blood (if secretions now awake extubation)
