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Precision in care planning is the heartbeat of nurse anesthesia—a symphony of choices that safeguards every patient’s journey through surgery. In this episode, we have guest host David Warren, NAR, to explore the process of preparing care plans in CRNA. By sharing his extensive experience and learnings, David sheds light on the critical decisions CRNAs make when it comes to patient care. David lays out the pivotal factors CRNAs consider when choosing between endotracheal tubes and LMAs for airway management. He discusses the art of induction, choosing the right medications, the delicate balance between maintaining consciousness and ensuring patient comfort, and more. Tune in now and learn how to develop the right care plans for your patients.
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Preparing Care Plans In CRNA School With Guest Host David Warren, NAR
I have a very special episode lined up for you. It is part of our guest host series where I am bringing SRNAs on the show for you as a guest host on the show. My thought process behind doing this is I wanted you to hear from a variety of students who are at different stages of their CRNA journey and allow you to step into their world. I want you to hear them talk about what it’s like to be a student dealing with things like difficult preceptors, different anesthesia topics, clinical topics, or maybe even things like time management, stress management, and things like that.
These episodes are going to be gold. I hope you enjoy it as much as I always do hearing from students. I know for a fact that the reason why CRNA School Prep Academy is where it is and the reason why I have learned so much is from diving all in, learning with students along with CRNAs share a wealth of information, and taking all of that information and compiling it into the system that we have created. I know that you’re doing the same thing by reading week after week and developing your own method, strategy, and system for success. I hope you enjoy these guest episodes. Let’s go ahead and get into the show.
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What’s up, everyone? I’m David Warren. Welcome to the show. I’ll be your guest host. I’m a second-year nurse anesthesia resident out on the West Coast in California. I’m in my second clinical rotation. In this episode, I want to talk to you about how to prepare care plans for your patients in anesthesia school. I want to tell you first what this episode is not going to be about. This episode is not about how to stay up late and how to write the perfect care plan. That’s not at all what I’m talking about. I want to focus on showing up to clinical, being presented with a patient, and then developing a plan of care based on that patient. I’ll give you some real-life examples of that.
At my clinical site and my previous sites, I did not have access to my patients the night before. I couldn’t go in and look up anything about the patients. I couldn’t even go and look up the surgery. I show up on day 1 of clinical, day 2, or whatever day it is. I’m presented with a list of surgeries and patients and I have to come up with a plan of care. Sometimes, the CRNAs wouldn’t show up until about fifteen minutes before the patient rolled back. I really had to, from scratch, develop that plan of care myself.
There are some sites where you go or where I will go where we have access to look up the patients the night before, and that certainly helps. I really want to focus on the nuts and bolts of showing up to clinical, being presented with a case, and then being able to develop a plan of care pretty much on the spot for that case.
I will preface this episode with this as well. This is not referring to your specialty rotation, so we’re not going to be talking about transplant anesthesia, cardiac anesthesia, or any of the big, major surgeries. I want to focus on 90% of the surgeries that you will do as a CRNA. You can work in specialty areas as a CRNA, but if you’re working in a community hospital, a critical access hospital, or an independent CRNA practice, there are a handful of surgeries that you’re going to be doing 90% of the time. Those are the cases that I want to focus on and talk to you about.
This is more of a broad general overview. It’s not necessarily getting into the weeds of how to develop those care plans on the fly. It’s more of a broad general 30,000-foot view of how to develop a plan of care for your patient whenever you haven’t seen them and you don’t know anything about them, and you’ve got about an hour to do it. That’s what I want to dive into. I want to take you through my process of how I do it and how I break it down in clinical.
I’m in my second rotation. I will show up at the hospital and find out the day of what procedures or what surgeries I’m going to be doing that day. When I go into the hospital, I’ll get changed to my OR scrubs. I’ll grab a list or look on the computer and see what room I’m assigned to. I will then take the first case of the day and then see what that particular case is. Let’s say it’s a laparoscopic cholecystectomy. That’s going to be the first case of the day.
I’ll look at that from the standpoint of, “What broad type of surgery am I going to be doing? Is it general surgery? Is it urology? Is it GYN? Is it robot surgery? Is it orthopedic surgery? Am I in OB?” All of those different types of surgeries pull my brain in different directions as to what I can expect and what I can do during those cases.
I will say this. I’m four months in and it takes some time to be able to look at a surgery and say, “I’m going to do X, Y, and Z for this patient.” You do learn some of that in school, but it’s a little bit different whenever you show up in the clinical setting and you’re doing that within an hour. It’s not like in a sim lab where you have weeks to develop something before your checkoff. It’s a little bit different. You do get some of that background in school, but it is different showing up, being presented with a case, and saying, “I’m going to do X, Y, and Z.”
I will start by looking at whatever that first surgery is. Let’s say it’s a laparoscopic cholecystectomy and it’s robot-assisted. I will know based on that that I’m going to be doing general endotracheal anesthesia. That’s where I start. I’m like, “What broad type of anesthesia do I want to do for this case? Do I want to do a general anesthetic? Do I want to do a sedation like a MAC or a moderate to deep sedation? Do I want to do neuraxial anesthesia? Do I want to do regional anesthesia with some sedation?” There are many different ways that you can break that down as to what you want to do.
Based on that surgery, I will then say, “If it’s a laparoscopic cholecystectomy, I know I’m going to be doing general endotracheal anesthesia. I know based on the fact that they’re going to be insufflating the abdomen that it’s going to put significant pressure on the lungs and the airway, so I need an ET tube. I’m not going to be doing that under LMA.”
Side note, there are some countries that do laparoscopic procedures under LMA. However, in the United States, it’s not common at all. I’ve never seen a laparoscopic case under LMA. Maybe you have it at your institution. Maybe that’s something you practice. That’s another point. There are about 10,000 different ways to do anesthesia. There are maybe 5 or 6 of those ways that are wrong, and the majority of them are right. They’re just different.
Depending on what rotation you go to and what hospital you’re at will dictate some of the odds and ends of what anesthesia you’re going to do because the culture at one particular hospital may be completely different than the culture at your next rotation. You are going to be doing different anesthesia for very similar, if not the same procedures. That’s good because you get a different experience of doing different methods of anesthesia for the same procedure. You can see what you like and see what you don’t like.
You'll get a different experience from doing different methods of anesthesia for the same procedure and you can see what you like and what you don't like. Click To TweetIt’s frustrating initially. I can see how it would be frustrating to say, “I had this plan lined up. I want to do X, Y, and Z,” and then somebody says, “We need to do this and this.” That can initially be frustrating, but it’s really cool to see that you can do different things for the same procedure and it still works out. One may work better than the other. If it does, then you’ll know that’s what you want to do the next time. I start by looking at that procedure, and that will determine for me what type of anesthetic I need to provide. Do I need to do general anesthesia? Can I get away with sedation, neuraxial, or regional? That’s how I started initially. I get that initial plan in my mind like, “I’m going to be doing a general.”
The next question I would answer is do they need an endotracheal tube or can we do an LMA? A pretty hard and fast rule at my clinical site and most clinical sites is if the patient requires paralysis, then you’ll not use an LMA. You don’t want to give 50 of roc and then put in an LMA, and then risk the patient aspirating. Over 90% of people that I’ve talked to and places that I’ve been, you don’t paralyze with an LMA. That may be different where you rotate. There may be places out there and people out there that do that. That’s not necessarily wrong. I could make an argument that it is wrong, but it’s not necessarily wrong.
Endotracheal Tube Or LMA?
That’s my next question. Do I need an endotracheal tube or can I get away with an LMA? That’s for general anesthesia. If I’m doing sedation, I don’t need an airway at all. Maybe I need an oral airway or something of that nature, but the patient will be spontaneously breathing. I’ll determine whether I need an endotracheal tube or whether I need an LMA.
There are a lot of cases that you could make an argument for either. You would never be faulted for intubating somebody. If your gut instinct says, “This patient needs to be intubated,” then you should probably intubate the patient. If you have to talk yourself out of doing an intubation, you should probably intubate the patient.
Some of the factors and some of the things that we look at on LMA versus endotracheal tube are going to be things like acid reflux. Do they have GERD? I go talk to the patient. Usually, I know for our laparoscopic cystectomy that they’re going to get a tube no matter what. Even if they didn’t have GERD or they didn’t have a full stomach, they were going to get a tube anyway. That’s a moot point for this particular case.
In any other case for a general anesthetic, I would ask, “Do they need a tube or can we get away with an LMA?” There are a dome of things that would differentiate that like acid reflux and GERD. Does the patient have daily acid reflux or have they had acid reflux now or last night? That would let me know, “If they lay down and they have stuff coming up in their throat, I should intubate the patient because they’re at high risk for aspiration.”
LMA versus ET tube comes down to what is their risk for aspiration. Do they have a full stomach? Are they a trauma patient? Do you know when they last ate? If they’re a trauma patient, they’re going to get an ET tube like you consider a trauma patient full stomach. You consider a pregnant patient a full stomach by 19 to 20 weeks. You would RSI and endotracheally intubate those patients.
Care Plans: LMA versus ET tube really comes down to the patient’s risk for aspiration.
Otherwise, if they are at a low risk for aspiration, so they don’t have GERD and they’re not on a GLP-1 agonist like Wegovy semaglutide or something like that where they could be considered to have a full stomach, then you could opt for an LMA. If they have uncontrolled diabetes, they’re going to have autonomic neuropathy, delayed gastric emptying, and gastroparesis, and they’re at a high risk for aspiration. You could certainly make the argument for an uncontrolled diabetic or a diabetic that is controlled. They had diabetes for years and autonomic neuropathy. The safer option would be to intubate the patient.
There’s so much gray area here. I’ve been with preceptors at my prior site where if the patient even looked like they might have diabetes, they got an endotracheal tube. I was with other preceptors when we had a patient who was 300 pounds, had uncontrolled Type 2 diabetes, and was on semaglutide. The preceptor was like, “Do an LMA. It will be fine.” The case was fine. The LMA worked well, but things work well until they don’t.
Whenever you have that bad aspiration with an LMA that you probably should have intubated, you probably won’t make that mistake again. It really comes down to what is their risk of aspiration when it comes to airways. Pretty much any laparoscopic case is going to get the endotracheal tube, so I would know. It is lap chole, getting an endotracheal tube, and doing general anesthesia.
What Is Your Induction Going To Look Like?
The next question would be what is my induction going to look like? What do I need to do for induction? There are a million different ways to do this. You want a medication that would blunt the sympathetic response to laryngoscopy. We can do things like fentanyl. You can do esmolol, a selective beta-1 antagonist. You can do dexmedetomidine.
In my experience with fentanyl, if you give 100 milligrams of fentanyl at induction and then you give the rest of your induction meds where you got them intubated, you hook them up to the circuit, and you turn your gas on here in a few minutes, they will go very hypotensive. My experience with fentanyl is if you give the 100 milligrams at induction, expect some hypotension pre-incision and post-induction. You would have to treat that. That’s something you keep in mind.
Is there a right way to do it? It really depends on the patient. If you have somebody that has labile blood pressure to begin with, it’s probably best to not give them 100 milligrams of fentanyl and tank their blood pressure even more. That goes into some of the art of anesthesia and knowing based on the patient’s comorbidities and risk factors what my induction meds need to look like. If they have aortic stenosis, you don’t want to slam 200 milligrams of propofol and kill the patient. Maybe we would opt for a ketamine induction.
Somebody that’s otherwise healthy, you can get away with a lot of different things and it not be right or wrong. This becomes an issue when you have sick patients who are hemodynamically unstable and have significant comorbidities in their lives. Those are the patients for whom you would alter your induction plan. This comes down to doing the preoperative assessment. Do a good pre-op, talk to the patient, go through each system, and find out what medical problems they have. Do they have heart problems, lung problems, etc.? That will guide your induction sequence and what medications you would use.
Doing a really good pre-op will guide your induction sequence and what medications you would use. Click To TweetIf it were a young person, twenty-something years old with no medical problems, you could get away with any induction that you wanted to do. If it’s a 90-year-old with an ejection fraction of 20%, aortic stenosis, and all the things, then we probably shouldn’t be doing an elective case on that person. If it’s an emergent case, that’s a different story. You would change your induction plan to be a little bit different and more hemodynamically stable than you would be for say somebody who’s twenty-something years old.
Your induction plan comes next. What are you going to do for induction? We would have fentanyl or something of the like to blunt the sympathetic response to laryngoscopy. We would often give lidocaine IV. Lidocaine does two things. It will also help blunt the sympathetic response to laryngoscopy, and it will also help numb up the venous tract where propofol will follow right behind. Propofol is very irritating. It burns. The lidocaine will help decrease some of that.
We then would give something to render the patient unconscious. That’s something like propofol, ketamine, etomidate, or something of that nature. You could even do a fentanyl induction. I’ve read about that. I’ve never seen a fentanyl induction done. They do that on some cardiac patients. The fentanyl becomes a problem when you combine it with other agents.
Fentanyl alone is not going to cause significant hypotension, but fentanyl combined with 200 milligrams of propofol and gas will cause significant hypotension. That comes down to what induction agent you want to use to render the patient unconscious. You can paralyze. Do you want to use propofol? If so, how much propofol do you plan to give? Do you want to use ketamine? Do you want to use ketafol? Do you want to use ketamine and propofol mixed together? You will eliminate some of the hypotensive effects caused by propofol when you mix those two drugs together because you’re giving a little bit of each and not a whole lot of one. They even each other out.
What Paralytic Are You Going To Use?
What paralytic are you going to use? How long do you expect the procedure to be? Is this going to be a 30-minute procedure? Can you get away with doing succinylcholine and then giving 10 to 20 milligrams of roc to toe the line? Paralytic-wise, a lot of that is going to depend on whether or not or what reversal you have available. Do you have sugammadex available, or are you going to be reversing with neo-glyco?
Knowing your pharmacology really comes in handy in anesthesia in general, but especially during the induction phase as to what medications you’re going to give. If this is a ten-minute laparoscopic procedure, I’m not going to give 50 milligrams of roc if I don’t have sugammadex available. I may give 70 to 100 of sux up front. I may give 10 to 20 milligrams of roc to keep the patient slightly relaxed but not fully paralyzed. If I have sugammadex available, maybe I will give that 50 of roc, and then I could reverse in 30 minutes to 1 hour when the procedure’s done with sugammadex. I can still have and still keep the patient very densely blocked all the way up until I want to reverse.
The procedure length and duration will determine what paralytic you use. There’s no right or wrong way to do that. Can you use succinylcholine if it’s not contraindicated? Sure. Can you use rocuronium on pretty much any patient? There’s not a contraindication to it. You can, but you have to think, “What reversal agent do I have available? How long is a procedure going to be when it comes to paralysis?” If you don’t have sugammadex available, you can bite yourself very easily by giving that 50 milligrams of roc and then the procedure being done in 15 minutes. You’re like, “I’m not going to have any twitches back.”
For those of you who haven’t had that pharmacology sequence to reverse with neostigmine and glycopyrrolate, you need at least one twitch back. They can’t be super densely blocked to reverse with neostigmine and glycopyrrolate. However, with sugammadex, they can have zero twitches back and be very densely blocked. You can give sugammadex right at the last second and they will be back within about a minute or two.
It really down to what reversal agents you have available and what’s the culture. At my first clinical site, the culture was to give every single person sugammadex. At my clinical site, it’s an unwritten rule. Nobody gets sugammadex unless there’s some compelling reason. If it’s a 90-year-old grandma who has a bunch of comorbidities, sugammadex is fine. If it’s a twenty-something-year-old person and they already have one twitch back before you reverse, give them neo-glyco. A lot of that’s going to be culture-dependent. That will also guide your paralytic choice as to what reversal agents you have available.
After induction, you want to know, “What type of airway am I going to do?” We covered this earlier. You’re like, “Am I doing general endotracheal or am I going to be doing an LMA?” If you’re doing an LMA or an endotracheal tube, then have everything laid out and ready to go. After you’ve induced, you slide that in. This episode is not about having the appropriate setup. It’s more of developing that plan of care.
Maintenance Phase
We go onto the maintenance phase. What is your plan for maintenance for this patient? There are two broad categories that we can talk about. That is do you want to do gas or do you want to do a TIVA? Gas is going to be either sevoflurane, desflurane, or isoflurane. In 99% of cases, you’ll use sevoflurane unless there’s some compelling reason to use something else.
This is a side note. At my clinical site, I looked at my numbers and I have 200-something cases of using sevoflurane, 13 cases of using isoflurane, and 12 or 13 cases of using desflurane. At my clinical site, I went and found an isoflurane vaporizer. I was like, “I’m going to start using isoflurane to get used to it,” because I’ve used it as many times as I can count on one on two hands. I really want to get used to all the gases.
I made a pact with myself on my clinical side. I was like, “I’m not going to use sevoflurane for the rest of the quarter. I’m going to use isoflurane or desflurane.” For sevoflurane, you can use that on pretty much anybody. There’s one major contraindication to any volatile anesthetic, and that is malignant hyperthermia. As long as the patient doesn’t have MH or a risk factor for MH like close family history, then you can use volatile anesthesia.
Sevoflurane is super common. You’re going to use that in 90% of your cases. You do have desflurane and isoflurane. Isoflurane is older. It’s very slow on and slow off, which makes it somewhat unappealing, but it’s there nonetheless. For me, I wanted to try it and see how it works. I wanted to see if I liked it. I know that it’s not used very frequently. It’s used in cardiac anesthesia and neuroanesthesia, but that’s about it. I really wanted to try it and get used to it.
If you’re going to be using gas anesthesia, determine what kind of gas you’re going to use. Sevoflurane would probably be the most common one. Desflurane is very fast on and very fast off, but it is a respiratory irritant. You don’t want to use it on somebody who has asthma, smokes, has COPD, or has any kind of airway pathology because it will cause airway irritation. After extubation, they’d be coughing. They can have that sympathetic response with tachycardia and hypertension. Typically, we avoid desflurane in patients with any kind of airway issue. That’s asthma, COPD, or smoking history. That’s my personal guideline.
If I’m doing gas anesthesia, I’ll use sevoflurane. Side note, you can also use sevoflurane for an inhalation induction. We talked about earlier giving the fentanyl, the propofol, and the rocuronium that renders a patient unconscious. You can also do what we call an inhalation induction. That’s using the volatile anesthetic. You’ll put the mask on the patient and have them take some deep breaths as you’re turning the gas on, and that will also render them unconscious. You then could paralyze and intubate. Sevoflurane is the only volatile anesthetic that we can use for an inhalation induction because isoflurane is also a respiratory irritant, not to the extent that desflurane is. We’re not going to use desflurane or isoflurane for an inhalation induction. Sevoflurane would be the only one that we would use for that.
The other option is a TIVA, a Total IV Anesthesia. Most commonly, we would use propofol for this. Typically, you can get away with doing propofol and then working in some fentanyl or ketamine throughout the case as well. You wouldn’t want to use propofol because you don’t have any analgesia there as well. You would have to supplement the analgesia in some form or fashion with either IV opioids, Tylenol, or Toradol, using your adjuncts as well.
If you’re doing a TIVA, you could also use remifentanil, which is a very fast-acting opioid that’s metabolized by non-specific esterases. It’s got a half of 3 to 5 minutes, so it’s very fast on and fast off. We usually use the TIVAs in spine cases. Whenever we think about the maintenance phase, we want to know one big question, and that is will there be neuromonitoring?
Care Plans: Whenever we think about the maintenance phase, we really want to know one big question, and that is, “Will there be neuromonitoring?”
If there’s neuromonitoring, that’s very common in any kind of spine surgery. Cranies, necks, backs, or anything like that, you’re going to be doing neuromonitoring. Around the thyroid where the recurrent laryngeal nerve resides on each side, you would be doing neuromonitoring for that as well. Most often, we opt for TIVAs with that because our gas interferes with neuromonitoring. Paralysis also interferes with neuromonitoring. We’re not paralyzing those patients. We may paralyze initially to facilitate tracheal intubation, but through the procedure itself, we’re not going to be paralyzing.
These are the types of things that you learn in school. This is not something that you would be expected to pull out without ever learning in school. You would know that if you have a spine case coming up, you’re probably going to be doing neuromonitoring and you need to do a TIVA. With some neuromonitoring, you can do what we call a dirty TIVA, which is half a MAC of gas and then a propofol infusion at half of what we consider a MAC. Usually, about 100 MACs per kilo per minute is considered a MAC. We would do maybe 50 MACs per kilo per minute plus half a MAC of gas. You could usually get by with neuromonitoring.
However, the safest option for neuromonitoring is to do a complete TIVA. Propofol infusion, remifentanil, ketamine, PRECEDEX, or whatever other adjunct you want to use. Know that if you’re doing something neuro-related where there needs to be monitoring, you’ll be doing TIVA. There are a million different ways to do a TIVA. Time would fail us to talk about all the ways to do a TIVA. Know big, broad general that you’ll be doing a TIVA if you need neuromonitoring.
The next question during maintenance is does the patient require ongoing paralysis? If you’re in a laparoscopic case, the chances are they will require ongoing paralysis. You’re going to have to re-dose your rocuronium or you’re going to have to give them some vecuronium, cisatracurium, or whatever you want to give. Give them something long-acting, not succinylcholine. We don’t want to paralyze it for five minutes and then come right back. Give them something longer acting so that they will remain paralyzed.
Think about pain control during this phase as well as during the maintenance phase. You’re like, “Am I working in some adjuncts? Am I giving IV Tylenol or IV Toradol? Am I giving magnesium? Am I giving the analgesic dose of ketamine? Am I going to be working in some Dilaudid or some more fentanyl?” Think about those things during the maintenance phase. You’re like, “How am I going to control their pain?” That wraps up the maintenance phase. The big questions that I would ask myself during maintenance are, “Am I going to be doing gas? Am I going to be doing a TIVA? Do they require ongoing paralysis?” That will guide you in the appropriate way.
If the patient doesn’t require ongoing paralysis and they’re doing some kind of spine surgery, you want to keep the patient deep. The last thing you want is the patient bucking or moving around if they get too light. You really want to stay on top of your drips and your BIS monitor. Your BIS monitor will monitor that level of anesthesia. You want to stay on top of those things and know that if the patient’s getting light, get them deep because the last thing you want is them bucking around. They’re not paralyzed. They will start moving if they get too light on anesthesia.
Emergence And Extubation
We move on to emergence and extubation. There are really two broad schools of thought when it comes to emergence and extubation. We’ll walk through the emergence first. Emergence is going to be emerging the patient out of that deep plane of anesthesia. The two different ways of doing that are, are we going to be doing a deep extubation or are we going to be doing an awake extubation? There’s so much that we could cover in regards to deep and awake extubations. We’ll save that for another episode.
However, I will say this. The reason we do deep versus awake is in awake, the patient is able to follow commands. They’re able to open their eyes, lift their head off the bed, and squeeze your fingers. We would know that if we’re waking somebody all the way up, they’re able to protect their airway. When we pull the ET tube out, they can spontaneously breathe and protect their airway, meaning they’re at a low risk for aspiration.
On the counterpart to that, you can do what we call deep extubation, which is where the patient is still in stage three anesthesia. They are under a full MAC of gas or they are breathing spontaneously on their own. We would pull the tube then and let them, after the tube is out, slowly blow off that gas with a face mask of oxygen on, and then take them to PACU. Those are the two different ways to wake somebody up.
This is going to be largely dependent on the institution where you either work or where you’re doing your clinical rotations. What is the culture there? Is the culture to wake everybody up all the way up, or is the culture to do deep extubations? Where I’m at, the culture is to deeply extubate anybody that’s appropriate. That’s really the question. How are we going to wake this patient up? What are the contraindications to each? For contraindications to awake extubation, there are not any. You could wake anybody up and you wouldn’t be wrong.
If you’re doing a deep extubation, you don’t want to do that on somebody who is at a high risk for aspiration. Somebody with a full stomach, somebody that has autonomic neuropathy, gastroparesis from semaglutide, and things like that, or has GERD, we don’t want to risk that aspiration. We would wake them all the way up where they’re able to follow commands, and then we can pull the tube and they can protect their airway. They could still potentially aspirate, but the risk is significantly lower than that of someone who we deep extubate and they don’t have control over their own airway. They’re still out. They’re still in stage three anesthesia and still blowing that off.
In deep extubation, anybody with a full stomach or at risk for aspiration, we don’t want to do that. Also, somebody that’s a difficult mask. This really comes back to induction. Whenever we give our induction meds and our paralytics and we’re bagging the patient, how easy of a mask is it? Can we bag them effectively? Can we exchange? Do we have positive end-title or are they a difficult mask? Are you not getting any exchange? Do you have to two-hand mask?
Care Plans: We don’t want to do deep extubation on anybody who’s at full stomach or at risk for aspiration.
If they’re a difficult mask, then you don’t want to deep extubate somebody. One of the risks of doing deep extubation is if they have a laryngospasm, you would need to be able to mask the patient. This is not the episode to talk about all the complications of anesthesia, emergence, and extubation. I’m briefly touching on them.
If they are an aspiration risk, a difficult mask, or a difficult airway that if you go in and look with your DL and you can’t get the tube in, and you have to get the GlideScope, it is probably best to wake that patient all the way up. If something happens and you have to re-intubate the patient, then you would have less of a risk of having to re-intubate the patient if they’re already awake and protecting their airway versus if you pull it deep and then they spasm. You go down that road of having to break the spasm. If you can’t break the spasm, you have to re-paralyze them and intubate them.
For anybody that’s difficult to airway, difficult mask, or high risk for aspiration, don’t deep extubate them. This is largely going to be dependent on your institution where you’re rotating and what your preceptor’s comfort level is as far as doing wake-ups and extubations. That’s the broad 30,000-foot view of how we develop a plan of care for that emergency extubation phase.
I will briefly touch on this. You don’t want to wake somebody up in what we call stage two. Stage two of anesthesia is the hyperactive stage. That’s where the patient is transitioning from that deep plane of surgical anesthesia. There’s not an autonomic response to that hyperactive phase where they’re coughing, bucking, and breath holding, and they’re tachycardic and you can see them moving a little bit. That’s stage two anesthesia.
You don't want to wake somebody up in stage two of anesthesia. Click To TweetIf you pull the tube in stage two anesthesia, you’ll get a laryngospasm and you’ll have to break that. Either deepen them and get them in stage three or wait for them to wake all the way up. If they can follow commands, open their eyes, move their hands, and do whatever you say, then you can pull the tube. You know they’re out of that stage two, that hyperactive and hyper-reflexive state.
That really is what it comes down to. A good way to assess that is to either wiggle the ET tube or deflate the cuff and then inflate the cuff. If you see them breathe hold, gag on the ET tube, or move, then you know they’re not deep enough. You should be able to wiggle the ET tube and pull the air out of the balloon. If the patient does not move and does not do anything, then you know they’re deep enough. Typically, that’s going to be at about a MAC to a MAC and a half gas for them to be at that deep plane of anesthesia for you to extubate successfully.
After we pull the ET tube, we will wheel the patient off to PACU for them to wake up. There are other things that we need to consider, and that is some of our adjunct pain medications. What have we given for adjunct pain? Have we given IV Tylenol, Toradol, magnesium, PRECEDEX, ketamine, and then our anti-emetics as well? Have we given Zofran? Have we given Decadron? Do they have a history of PONV, so Post-Operative Nausea and Vomiting? Do they have a scope patch on? These are things that you would also think about during induction or preoperative phase as well. You’re like, “What do I need to do to address that history of post-operative nausea and vomiting?”
That’s a very broad general overview of how I develop plans of care when I’m presented with a patient on day one. I show up and they’re like, “Here’s your lap chole,” or, “Here’s this. What plan are you going to do? What plan are you going to implement to safely take care of the patient?” This is a broad overview. Maybe we’ll do subsequent videos on getting deeper into some of those issues because there is so much that we could talk about at induction, maintenance, and the emergence and extubation on how to manage those emergencies.
Thank you so much for reading. If you are new here, thank you for reading. If you’re a return guest, thank you also for reading. Comment below and let us know if there are any topics that you want me to cover. I would be more than happy to talk about them. Thank you, again, for reading. I’ll see you next episode.
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