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CRNA 148 | Deep Extubation

In this special episode, our guest host David Warren, SRNA breaks down the basics of doing a deep extubation, one of the two common ways of waking someone up from anesthesia. Tune in as he goes beyond textbook information and discusses the step-by-step process from the day-to-day perspective of a nurse anesthesia resident. David also explains the stages of anesthesia, the hardest part of doing deep extubation, and everything you must take into consideration once the process is done.

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Emergence And Extubation: Waking Someone Up From Anesthesia Part 1 Deep Extubation

I have a very special episode lined up for you, and it is part of our guest host series where I am bringing current SRNAs on the show for you as a guest host. My thought process behind doing this is I wanted you to hear from a variety of current students who are at different stages of their CRNA journey and allow you to step into their world and hear them talk about what it’s like to be a current student dealing with things like difficult preceptors or different anesthesia topics, clinical topics, and maybe even things like time management and stress management.

These episodes are going to be gold, and I hope you enjoy them as much as I always do hearing from current students. I know for a fact that the reason why the show is where it is now and the reason why I have learned so much is from diving all in and listening to current students along with CRNAs share a wealth of information, take all of that information, and compile it into the system that we have created. I know that you’re doing the same thing by tuning into the show 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.

I’m David Warren. Welcome back to this episode. I’ll be your guest host. We’re talking about a very interesting topic, and that is emergence and extubation, or what we would refer to as waking somebody up from anesthesia. This is an interesting topic. It’s something that we spend a lot of time learning about all the intricacies of while in CRNA school, but I don’t want to dive into the textbook. I don’t want to give you all of the textbook answers. I want to go into the OR with you. I want to tell you, walk you through, and show you how we emerge and extubate patients in the OR on a day-to-day basis.

Before we dive into that, there are some ground rules that I want to cover with you. Just as there are a million different ways to induce general anesthesia and to put a patient to sleep and most of them are right, there are a million different ways to emerge and extubate a patient from general anesthesia, and most of them are right. There are multiple different ways to go about doing this. However, for the sake of this episode, I want to share with you two of probably the most common ways that we see. This is going to be a two-part series. This is take one on emergence and extubation.

Whenever we think about waking somebody up or emerging and extubating a patient, there are two big broad ways to go about doing that. There’s a big 30,000-foot view from the airplane. There are two ways to emerge and extubate a patient. The first is to do what we call a deep extubation, and the second is to do what we call an awake extubation. I want to cover the basics of doing a deep extubation.

There are multiple intricacies to each one of those but I want to give you a big and broad overview on how we emerge and extubate a patient in the OR. We’re going to start with doing a deep extubation. That sounds very much like what you probably think. A deep extubation is when we extubate somebody, and they are under general anesthesia. They’re in a deep plane of anesthesia. We’re going to go into what all that means and what that looks like here.

Before we do that, I’ll give you a case scenario so we’re all on the same page. We’re going to say this is a 40-year-old female with no past medical history. She’s having a laparoscopic cholecystectomy. We have already induced the patient. She’s already intubated. She’s on sevoflurane. She’s on a volatile anesthetic. She is undergoing an operation. The surgeon is getting ready to pull the gallbladder out. The surgery is wrapping up.

The first point I want to make to you about emergence and extubation is you need to know your procedure. This is highly important, especially as a nurse anesthesia resident. You need to know your procedure. Know the steps and where you’re at in that procedure because that’s going to dictate when you start trying to emerge, not necessarily extubate. You have to know the timing of the surgery that you’re in.

CRNA 148 | Deep Extubation
Deep Extubation: A nurse anesthesia resident must know the medical procedure you are doing. It will dictate when you must start trying to emerge and extubate your patient.

A good thing to do the night before is to look up your cases and find out what the steps in that surgery are. If you’ve done the surgery before, then you have a big upper hand because you know exactly where you’re at in the procedure. If you’re not in anesthesia, and you’re looking to go to anesthesia school, you’re going to do about a million gallbladders. You’re going to get very familiar with doing laparoscopic cholecystectomies. You’re going to know that like the back of your hand timing-wise. Whenever you see the clips going in, and they’re cutting the gallbladder and they’re about to pull it out, you know things are about to start wrapping up.

Whenever you know your procedure, you can proceed with knowing exactly where you’re at and what your timing is going to be. You don’t want to be two hours into whatever procedure you’re doing. You think you’re done, and you start trying to get things in order to emerge your patient, and then come to find out you’ve still got three hours left. You don’t want to do that. You also don’t want to be on the flip side of that. They’re closing the skin, and your patient is still not ready to be woken up or not ready to emerge yet.

You want to know where you’re at in the procedure because that’s going to dictate a lot of what you do. Let’s say the gallbladder is coming out. They’re getting ready to pull it out of the abdomen. After that, the trocars are going to come out. They’re going to close up, and we’re going to be done. If the surgeon is closing, we’ve got 15 to 20 minutes left. The stretcher is going to roll in, and we’re going to be out the door. We have to plan for that accordingly.

MAC Gas

There are two broad ways that we are going to emerge a patient. That’s in a deep extubation or an awake extubation. A deep extubation is what we’re going to cover, and that’s where the patient is fully deep. They are under what we call a MAC of gas or a MAC and a half of gas. I’m not going to dive super deep into all the details of what this means but I’ll give you an overview of what the gases are, where we’re at with a MAC value, and what all that means.

The MAC value or MAC is the Minimum Alveolar Concentration. To provide general anesthesia for surgical stimulation, we usually want the patient between about 0.8 and 1.2 MAC. Somewhere in that range, we will provide general anesthesia to where they don’t have that autonomic stimulation, meaning that whenever the surgeon makes an incision, they’re not going to have significant tachycardia or hypertension and things like that. We’re going to keep the patient around 0.8 to 1.2 MAC.

CRNA 148 | Deep Extubation
Deep Extubation: To provide general anesthesia for surgical simulation, you would want the patient between about 0.8 or 1.2 MAC Gas.

This is not a pharmacology lecture. I’m not going to go into all the details about what MAC is, all the gases, and all of that. We want the patient around 1.8 to 1.2 MAC for surgical stimulation. We’re going to extubate the patient when they are at 0.8 to 1.2 MAC. We want them under that deep plane of anesthesia when we pull the ET tube. We will have them slowly breathe off that gas as we’re wheeling them to PACU, and they will wake up naturally in PACU.

100% Fio2

That’s the general idea of doing a deep extubation. We’re still under that deep plane of anesthesia. We will get into why that’s important here. We want the patient under the deep plane of anesthesia. Let’s say the gallbladder is coming out again. Our vital signs are stable. Everything is looking great. We are at 1 MAC. That’s perfect. The next thing we would do is we would want to switch the patient to 100% FiO2.

Typically, in these surgeries, we’re running one liter of oxygen and one liter of air, which is roughly 55%-ish FiO2. There’s a calculation we can do to figure that out. It’s not exactly 50% and 50%. It’s 54% to 55%. Typically, we keep patients at about 50% FiO2 for round numbers. At this point, we would switch the patient to 100% FiO2. We will cut the air and turn on two liters of oxygen.

One Last Look

This becomes important because we will look at our monitors to see what our end-tidal oxygen level is. As we look at our end-tidal CO2 level, we also look at our end-tidal oxygen level. Once that end-tidal oxygen level reaches about 80%, we will know that the patient can be safely extubated, and the patient is adequately preoxygenated. That’s super important. We’re going to go down these little rabbit holes as we’re talking about these sidetracks.

The reason we want to put the patient on 100% FiO2 is because most of the room air is composed of nitrogen. The FRC or Functional Residual Capacity in our lungs, the air that is residual in our lungs from our breathing, is mostly composed of nitrogen. Whenever we wash out all that nitrogen and fill it with 100% oxygen, we buy ourselves a significant amount of time that the patient could be apneic and still remain well-oxygenated up to the point of being 100% on their SPO2.

That can last anywhere from about 5 to 9 minutes. You can buy yourself a lot of apneic time with 100% FiO2 and the end-tidal O2 of greater than 80%. If for whatever reason the patient is not stimulated to breathe, we will buy ourselves minutes while we are trying to rectify that situation. That’s the reason we want to put the patient on 100% FiO2. We will cut the air and turn on two liters of oxygen.

For doing a deep extubation, we want to keep that full MAC of gas on board so that when we pull the ET tube, there’s not that airway stimulation that we will see if the patient is super light, and they’re coughing and gagging on themselves. That’s the advantage of doing a deep extubation, especially on an abdominal surgery. Chances are if you’re tuning in to this, you probably have seen patients extubated because you’re working in the ICU. You know that they cough and gag. It’s not a pretty scene, especially with abdominal surgeries, hernia repairs, and anything in the abdomen.

Identifying The Right Patient

If they’re coughing and gagging, that abdominal wall pressure is super intense, and you don’t want to blow that mesh out that the surgeon put in there with their hernia. Doing a deep extubation on these patients is quite preferred in the right patient. We will get into that here as well. We want to make sure that the patient is a good candidate for deep extubating in the first place.

The purpose of deep extubation is to prevent airway stimulation, increases in intracranial pressure, increases in intra-abdominal pressure, and blowing out everything that the surgeon fixed in the abdomen. Those would be reasons that we would want to do a deep extubation. To do a deep extubation, we would decide this before we went to sleep, or as we were going to sleep. As we’re inducing general anesthesia, we would then decide, “How are we going to wake this patient up?” We’re always looking 5 or 6 steps ahead.

To do a successful deep extubation, the patient needs to be an easy mask, meaning that when we are putting the patient to sleep, and we’re mask-ventilating, is it an easy mask? Are we having a two-handed mask? Are we having to put in an oral airway? Are we having to reposition the head? Are we having trouble masking? That’s what it comes down to. If we are having difficulty in mask-ventilating the patient, the patient is not a candidate for doing a deep extubation.

Let’s say we have a full MAC of gas on board. The patient is not awake. The patient is not responding to our commands, not following commands, and not in control of their airway. If the patient stops breathing, we would have to breathe for them. If there’s an emergency such as a laryngospasm, which we will get into here in a little bit, we would need to mask and ventilate the patient. If you can’t mask and ventilate the patient, initially, you need to wake the patient up. You shouldn’t be deep extubating those patients.

The second thing is, “Does the patient have a difficult airway? Did I have trouble intubating the patient whenever I DL-ed, whenever I used the GlideScope, or whatever it was? Was the patient a difficult airway?” Typically, if the patient is difficult enough that I need to get the GlideScope, they’re probably not a candidate for a deep extubation. There are exceptions to probably all of the things that I’m telling you but broad picture, if the patient is difficult enough that I need to grab the GlideScope, they’re probably not a good candidate for doing a deep extubation.

However, if it’s somebody that is an easy mask or an easy airway, I do a DL and get a grade-one view, and I’m able to put in the tube with no problems, they’re a great candidate based on those criteria for doing a deep extubation. The next thing is, “How high of a risk of aspiration is this patient? Do they have uncontrolled acid reflux? Do they have uncontrolled diabetes? Do they have autonomic neuropathy? Are they on medicines that would prolong gastric emptying?”

You want to think about those aspiration risks as well. If this patient has uncontrolled GERD, and they wake up in the middle of the night with acid coming up in their throat, that’s not a candidate for deep extubation. Our patient here we’ll say she was an easy mask and an easy tube with no GERD and no medical problems. She’s the ideal person. You’re probably not going to do surgery on these types of people. Usually, it’s sicker patients. For the sake of this scenario, we will say the patient is healthy with no medical problems. They’re the perfect candidate for doing a deep extubation.

End-Tidal CO2

After we have confirmed that we can do a deep extubation, and we turned on 100% FiO2, we then want to build our end-tidal CO2. During the procedure, we typically keep our end-tidal CO2 around 30% to 35%, usually on the low end because as you all know, our drive to breathe in normal physiologic conditions is CO2. It’s not oxygen. Those hydrogen ions will directly stimulate the brainstem to cause respiration. That’s greatly oversimplified but that’s what happens. Building that end-tidal CO2 is what will cause that drive to breathe to kick in.

Our drive to breath in normal physiologic condition is CO2 and not oxygen.. Click To Tweet

What we can do is a few different things. We can drop our respiratory rate and our tidal volume. We can look at our end-tidal CO2, and we want to build our end-tidal CO2 anywhere from about mid-40%, 45%, 50%, to 55%, somewhere in that region. We want to build that end-tidal CO2, and that will increase that drive to breathe. This is where it gets gray a little bit, and just because you’re building the end-tidal CO2 doesn’t guarantee that the patient is going to breathe. There are multiple factors that will play into getting your patient back breathing.

I will tell you from experience that the most difficult part of doing a deep extubation is getting your patient back to breathing. Building that end-tidal CO2 is the first step in doing that. We will drop our tidal volume a little bit and our respiratory rate, and then after that, we will reverse our paralytic if we use paralytic. Typically, in a laparoscopic abdomen case, the patient will be relaxed. We will reverse that relaxation and either use sugammadex or neostigmine and glycopyrrolate.

This is not a pharmacology lecture. We’re not going to go into the odds and ends of the pharmacology but know that we will reverse our patient at this point. We want to make sure that we’re done with the surgery. Make sure that the gallbladder is out and the trocars are out. They’re about to close up and then reverse. You don’t want to reverse when trocars are still in the abdomen or the gallbladder is still in the abdomen. They’re trying to pull everything out. Make sure that we’re done. They don’t want to blow back up, put the camera back in, and take a last look or anything. We need to make sure that we’re done.

You will get to know the surgeon. Honestly, some surgeons, after the gallbladder is out, will reinsert the trocars, reinflate the abdomen, and take one last look to make sure there are no bleeders. Most don’t do that. Make sure that everything is out before you start reversing. After you have reversed, you would want to make sure you’re adequately reversed. You could check twitches with your Train of Four monitors if you have a quantitative or qualitative monitor. That would be the ideal way to do that.

You would see a bump. We will move on to that. Make sure you’re adequately reversed with a Twitch monitor. We can see how our end-tidal CO2 is doing and see if we’re building our end-tidal CO2. We would likely have the patient on SIMV or Synchronized Intermittent Mandatory Ventilation so that the patient can breathe over the vent. At this point, we will look at our monitors and see if the patient is initiating any breaths. We can lower our trigger down to 1 or leave it at 2, whatever you would like to do. Typically, if the patient is not breathing, I’ll lower the trigger down to one, and that’s the effort that the patient must make to trigger a breath or that pressure support on top of the SIMV.

Pressure Support

We would see, “Is the patient breathing over the vent?” At this point, we can switch the patient to pressure support to see what they do. We switch them over to pressure support and see if they’re back breathing. Typically, in somebody young and healthy, I’ll start with a pressure support of somewhere from 8 to 10. If they’re breathing over the vent, sometimes I go to five but in older people, you’re probably going to need to start from 10 to 12 with a trigger of 1 and then slowly wean them down. On somebody young and healthy, you could probably start at a pressure support of 5 and a trigger of 2 and see where they are.

This is where some of the art form comes in. You will look at your monitors and see what their tidal volumes are. What kind of tidal volumes are they pulling with a pressure support of 5 or a pressure support of 8, whatever you decide to go on? What is their respiratory rate? More than that, I find that a lot of people get caught up in their respiratory rate. There is another number on there that is way more important than the tidal volume or their respiratory rate, and that is their minute ventilation. What is their minute ventilation? It’s the respiratory rate times the tidal volume.

If you have low tidal volume, you’re going to compensate by having an increased respiratory rate but your minute to ventilation may be normal. You want to look at that number as well. We’re targeting anywhere from 3 to 5 in that range, usually over 5, the patient is probably in pain. There are other reasons that can be but that’s the most common thing. After surgery, the patient may be in pain. This is the time when we’re looking and assessing, “What is our tidal volume? What is our respiratory rate? What is the minute ventilation?”

If our minute ventilation is low, we will be thinking of things like, “Is the patient too comfortable? How much narcotic have we given? Are we fully reversed? How much reversal did we give? Do we give sugammadex or neo/glyco?” Make sure the patient is fully reversed. If our minute ventilation is 7, and our tidal volume is 600, and they’re breathing 15 times a minute, when was the last time you gave narcotic? What other adjuncts have we given to control their pain? Have we done blocks?

Getting The Patient Back Breathing

Those are the things that we’re thinking about at this point. I don’t want to gloss over this because this is the hardest part of doing a deep extubation, and that is getting the patient back breathing. If you can get the patient back breathing, you’re golden. You’re good. Things are great but the problem of this comes whenever they’re closing the skin, you’re trying to build your tidal, you switch into pressure support, and they’re still not breathing. You have to make a decision, “Am I going to continue to try to get them back breathing and do a deep extubation? Am I going to wake the patient up?”

Ninety-nine percent of patients are going to breathe when the gas comes off. That’s one thing that I found fascinating in anesthesia school. You can take adequate tidal volume and respiratory rate under a full MAC of gas. That was super interesting to me that it doesn’t necessarily completely wipe out your respiratory drive. It will decrease it a little bit but it’s not going to completely wipe it out in most patients. There are some patients that will but usually, you can breathe with good tidal volume and respiratory rate under a full MAC of gas. That’s something I found super interesting in anesthesia school.

Going back to what we’re talking about in our scenario, getting the patient back to breathing is the hardest part of doing a deep extubation. If you can get the patient back breathing, then you’re good. You can cruise but you have that decision to make, “Am I going to continue trying to get the patient back breathing? Am I going to wake them up?”

The thing about the OR is you’re constantly under production pressure to turn over, get the patient out, get the patient to pack, and move on to your next case. That’s the production pressure of the OR, and that’s something that we have to deal with on a daily basis. You have to make a decision at this point. Are you going to abort the mission and wake the patient up? Are you going to try to get them back breathing? That’s something you have to decide at the moment.

For our scenario, we will say the patient is breathing. Let’s say the patient is on pressure support. She’s on 100% FiO2. She’s been fully reversed. She’s pulling 300 tidal volumes with a rate of 10, and her minute ventilation is appropriate. At this point, we can put her on spontaneous. When we say that, that’s where we will flip the switch on our anesthesia machines over to manual, which is where we would be bagging the patient. We would let the patient breathe on their own with no help from the ventilator. They’re breathing on the bag.

We could look at our anesthesia bag and see if the patient is breathing. At this point, we will be looking at our monitor as well. Is the patient taking adequate tidal volumes? Is the patient breathing spontaneously? What’s the respiratory rate? What’s the minute ventilation? We would still be looking at all those things that we talked about earlier. Mainly, I want to see how much their tidal volume dropped when we went from that five of pressure support to spontaneous ventilation.

I will tell you this from experience that you will see smaller tidal volumes initially but with each breath, it will get bigger. In the first few breaths, you’re going to see probably a cut-in-half tidal volume. If she were taking 300 tidal volumes with a 5 of pressure support, you would probably see tidal volumes of 100 to 150 initially, and then it will slowly start getting bigger. You let the patient get to that 200 to 300 tidal volume range. That’s where you want to see them when they’re breathing spontaneously.

Suctioning The Patient Out

The hard part is over with. We’ve got the patient back breathing, they’re fully reversed from relaxation. She’s at 100% FiO2. At this point, I would go up to the patient and suction the patient out. All of the time, whenever we put an ET tube in, there are going to be secretions that develop in the back of the oropharynx around the ET tube. We will take our suction catheter, slide it in, and suction all the goodies out in there, and then we will put in either an oral airway or a nasal airway.

This is a little more important on the timing of the oral airway if you’re waking somebody up but we will get to that in another episode. We’re doing deep extubation. The patient is under a full MAC of gas. We can suck everything out back there. If this is a normal anatomy person, not somebody who has a BMI of 50, somebody who’s normal-sized, easy-mask, and easy-tube, and a candidate for deep extubation, usually, you can get by by putting a nasopharyngeal airway in. Those are less stimulated than an oral airway. Sometimes I’ll slide in an NPA or nasal trumpet and put that in.

Other times, you can put in an oral airway if you want. Most of the CRNAs that I’ve learned from will put in oral airways over a nasopharyngeal airway but the nasal trumpet is less stimulating. When you’re waking up, you don’t want gagging and all that. Putting in the nasal trumpet is fine. You can do either. It’s not a big deal. If you’re concerned that the patient may obstruct, and everything is going to fall back, put in the oral airway. You will fix that problem immediately.

At this point, we have suctioned out. We have put in our nasal trumpet or our oral airway. We will take one last look at our monitor. We’re looking at a few things here. What is our end-tidal CO2? What is our SPO2? What kind of tidal volume is a patient taking? What is their respiratory rate? What is their minute ventilation? Lastly, we will look at our gas. We will look at our MAC value. What MAC value are we at? Are we at 0.8, 1.2, 1.6, or 0.7? We want to at this point assess if the patient is deep enough to extubate. When I say deep enough, whenever we put in that suction catheter to suction out the back of their throat, are they stimulated by that? Do they breath-hold? Do you see them stop breathing? Do you see them start moving and coughing?

This is a very rough estimate in my opinion but probably 90% of patients are not going to be bucking and moving at a MAC of gas if you’re suctioning them. I’ve had a patient who was at a MAC of gas. I suctioned his oropharynx out, and he started coughing and coming off the table. I’m like, “You’re under a MAC of gas. How are you moving? What didn’t move at all through the procedure?” This is why you assess these things. Make sure the patient is deep enough.

Stages Of Anesthesia

Let’s say we suctioned out, and the patient was coughing. You can see the patient moving a little bit and breath-holding. You would know now is not the time to pull that tube because the chances of them being in stage two are very high. This is where I want to go on this little spiel about the stages of anesthesia. We have stages 1, 2, and 3. There’s a fourth stage that we don’t deal with. Stage one is from induction when we push our meds to when the patient goes to sleep.

Stage two is what we call the period of hyperactivity. Especially with our volatile anesthetics, this is where we see the patient get tachycardic. They breath-hold. They have a disconjugate gaze. The muscles spasm a little bit. This is where we see what we call the period of hyperreactivity. This is very obvious in our pediatric population, especially when we’re doing what we call inhalation induction. On peds, a lot of the time, we won’t start an IV in pre-op. We will do what’s called an inhalation induction.

This is all to tell you a point. When we do an inhalation induction, we will put the mask over the patient’s face. We can do this for adults but it’s not as common. It’s very common in kids. We will put the mask over the patient’s face and gas them down. We will crank our gas up, turn some nitrous on, and let the patient breathe themselves down with gas.

As they’re going through the stages of anesthesia, it’s very obvious when they are going through stage two because they get very tachycardic up to the 180s. After they’re through that hyperreactive stage or stage two, you will see their heart rate drop back down. That’s when they’re getting into that deep plane of anesthesia, and that deep plane of anesthesia is where you’re at a MAC of gas.

Going back to our scenario, our patient is in a deep stage of anesthesia because they’re under a MAC of gas. However, we want to make sure that they are as deep as we think they are. Suction out the mouth. See their response to that. That gives us a very good idea of exactly how deep the patient is. Another thing you can do is deflate the pilot balloon on the ET tube. That’s stimulating because that’s right up against the tracheal wall. As you deflate that balloon, if they have no response and continue breathing, you will know based on it that they are deep enough and that they’re not in stage two. If they start coughing and bucking, you will know that they are likely in stage two.

The big reason that we want to avoid pulling a tube in stage two is because we can get what we call a laryngospasm. A laryngospasm is where the muscles that open and close the vocal cords will spasm, and the cords will snap shut. When the cords snap shut, that becomes a very big problem because we’re not moving any air at all. You will see the patient tugging their supraclavicular. You will see them making a stridulous noise. You will also see a drop in your SPO2 if this happens long enough.

This becomes a very big problem for the patient and us because a laryngospasm can lead to negative pressure pulmonary edema. The ultimate road that the patient will go down if this is not fixed in a timely manner is negative pressure pulmonary edema. That’s where the patient is attempting to breathe against a closed glottis. Once those cords snap shut, and the patient tries to breathe, all of the negative pressure that they are creating in their thorax will pull fluid into the alveoli and cause pulmonary edema.

As you know from the patient you’ve taken care of in the ICU, this is not what you want. This is a non-cardiogenic pulmonary edema but it can be lethal in certain patients, and it’s something that we greatly want to avoid if possible. The whole reason we want to make sure the patient is deep enough and not in stage two is because we want to prevent a laryngospasm. This is not an episode about how to treat a laryngospasm or all the intricacies of that but that’s something that we would want to be aware of. Make sure our patient is deep enough.

Final Steps

To recap, our patient’s vitals are all stable. She’s under a MAC of gas. She’s on 100% FiO2. She’s fully reversed. She has four twitches back and sustained tetany. On the Twitch monitor, she’s pulling good tidal volumes, a normal respiratory rate, and a normal minute ventilation. We suctioned her out. We either have an OPA or an NPA in place. She’s breathing spontaneously and doing fabulous. We’re waiting for the surgeon to be done with whatever they’re doing. This is when they’re closing the skin, putting the last sutures in, and putting the dressing on. Next, the stretcher is going to roll into the room, and we need to be ready to move over to the bed and go to PACU. That’s where we’re at.

At this point, we’re also thinking about our adjunct pain medication or our narcotic pain medication. We’re looking at our minute ventilation, respiratory rate, tidal volume, blood pressure, heart rate, and all those autonomic signs. Since the patient is intubated and under general anesthesia, they can’t tell us when they’re hurting. We look at these other autonomic signs to give us clues about how the patient is doing. We would also work on extra pain medication if we needed to. We covered that earlier looking at our tidal volume, minute ventilation, and respiratory rate. We would titrate our narcotics or our pain medication based on that.

This is not the scenario for this but I would always say, “Start slow. You can always give more. Give a little bit. See how the patient responds.” We want to titrate it until the patient is at a normal physiologic status. All of that has been done. The surgeon is putting the dressings on. We’re getting ready to move over. At this point, we will pull our monitors off. We can pull the heart rate monitors off. We can disconnect our blood pressure. All we have left to do is pull the tube.

When doing deep extubation, start slow. Check how the patient responds. Click To Tweet

Next, I would make sure I have everything ready. I’ll pull the machine closer to me. I will take my mask and my syringe, lay them there, and pull the trash can over. We have already suctioned the patient. At this point, we’re ready to extubate, and there are a few different ways to do this as well. I’ll walk you through the easiest way to extubate a patient. Once you determine that they’re ready to be extubated, and everything is physiologically normal, they’re appropriate to be deep extubated. We will look one last time. Our MAC value is appropriate. They’re deep enough.

At this point, we turn up our flows to fifteen liters per minute and turn our gas all the way off, and then we will extubate. We will deflate our balloon, disconnect the circuit, pull the ET tube, throw the ET tube in the trash, connect the circuit to our mask, and then hold the mask on the patient. I’m doing a two-handed mask and a little bit of a jaw thrust with these fingers here. I’m holding that two-handed mask and a little bit of a jaw thrust, and then I will look at my monitor to see, “Is the patient still breathing spontaneously?” We have already established that they were breathing spontaneously through the ET tube on the bag.

Once the tube is pulled, usually, you will see bigger tidal volumes because they’re not breathing through a tiny ET tube. They’re breathing normally through their big trachea, and they can exchange a lot of air. I will make sure the patient is still pulling 300 to 400 tidal volumes and has a normal respiratory rate. When I pull out the ET tube, I’m also looking for, “Did the patient move? Did the patient cough? Did the patient grimace? If that happened, then I will know there’s a high chance that this patient may spasm, and I would be very much on the lookout for that in this period of post-extubation minutes after.”

CRNA 148 | Deep Extubation
Deep Extubation: When you pull out the ET tube, look if the patient moves, coughs, or grimaces. If they do, there’s a high chance that they may spasm.

As I’m holding the mask on the patient, I’m doing a little bit of a jaw thrust. I’m assessing, “Is the patient ventilating? Are they moving air? Are they exchanging? If they’re not, then we have to go down that pathway. Why are they not breathing? Do they need a minute to start breathing? Should I help out a little bit and squeeze the bag a couple of times? Are they spasming?” Those are the scenarios that we look down on.

These few minutes post-extubation are very important. This is when you’re truly paying 100% attention to what’s going on, “Is the patient moving air?” That’s the biggest question. Our patient is doing fine. She’s moving air and pulling great tidal volumes with a good respiratory rate. At this point, I would move from my two-handed mask with a jaw thrust down to a chin lift. I’ll use my fingers to lift her chin, hold the mask on, and still see if she’s moving air and pulling the same tidal volume. I will then hold the mask on her face with no assistance and see if she’s still pulling those same end-tidal volumes.

If she’s not and she’s requiring some assistance, a jaw thrust, a chin lift, or something like that, then I will know. As I’m going to PACU, I’m going to have to hold a jaw thrust or a chin lift on this patient. Remember, this patient is still under a MAC of gas. She’s still under that deep plane of anesthesia. The advantage of this is we get the ET tube out. There’s not that stimulus in the back of her throat in her trachea causing her to cough and wake up terribly. The advantage of this is she’s slowly blowing off the gas over time, and it’s going to make it so much easier for her to wake up.

After that, we will put a non-rebreather on the patient, move the patient over, and disconnect the rest of our monitors. The pulse ox is the last thing that comes off, and then we will drive on to PACU. Once we get to PACU, we will give the nurse a report, hook the patient up, get a set of vital signs, and make sure that our patient is still moving air. As we’re driving to PACU, we’re looking at that non-rebreather, making sure that we’re still seeing the fogging, and making sure that she’s still exchanging. We’re done with our case.

That is the rudimentary basics of how you would do a deep extubation. This is going to be a multi-part series. Next, we will talk about doing an awake extubation. There are some things that are similar but there are some things that are different that go along with waking a patient all the way up. Thank you so much for tuning in. If you have questions about this, I would love to hear your thoughts and your questions. As far as choosing which way you’re going to emerge and extubate your patient, either deep or awake, it’s largely going to depend on the culture of the place where you work.

I’ve rotated at sites where they’re like, “We deep extubate everybody who’s appropriate. We will wake some patients up that need it but if you’re a candidate for deep extubation, you get deep extubated.” I’ve rotated through some places where they’re like, “We wake everybody up. Nobody gets deep extubated here.” It’s largely going to depend on the culture of where you’re at and the group in which you’re working. That’s the rudimentary basics of how to do a deep extubation. Thank you so much for reading. I hope you enjoyed this episode. I’ll see you next time.

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