CRNA 149 | Awake Extubation

In this special episode, our guest host David Warren continues his discussion about waking someone up from anesthesia. After explaining deep extubation, which is only applicable for a certain population, he now explores the process of awake extubation. Listen as David breaks down this method that many practitioners are typically used to in most ICU situations. He talks about the two primary methods in performing awake extubation: Nitrous Wake-Up and the Propofol Wake-Up.

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Emergence And Extubation: Waking Someone Up From Anesthesia Part 2 Awake 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 on the CSPA show. 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, 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 and clinical topics. Maybe even things like time management and stress management.

These episodes are going to be gold and I hope you enjoy as much as I always do hearing from current students. I know for a fact that the reason why CRNA School Prep Academy is where it is now and the reason why I have learned so much is from diving in and listening to students along with CRNAs share a wealth of information and taking all of that information in compiling 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, 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 and welcome back to this episode. I’ll be your guest host. We’re continuing part two of our three-part discussion on emergence and extubation. If you didn’t read part one, go back and have a read to that episode. First, we discussed some basic principles of emergence and extubation, then took a deep dive into doing deep extubation and what that looks like. This episode will probably make a little bit more sense.

We’re going to continue right where we left off by talking about emergence and extubation. We’re going to talk about doing awake extubation. As you recall in our part one episode, we took a deep dive into doing deep extubations. I told you there are a few different ways that you can wake people up, but there are two big, broad, 30,000-foot view main ways and that is doing a deep extubation where the patient is under a full MAC of gas. They’re still under general anesthesia and we pull the tube deep and let them wake up slowly.

That’s good for patients who are appropriate for it. We defined what that was and we’re not going to go down that rabbit hole again. That’s what we talked about in the last episode. We’re going to take a deep dive into doing awake extubation. That sounds like just what it is, doing an awake extubation. This is honestly what you’re used to in the ICU. It’s waking people up and extubating them when they’re able to breathe on their own and not doing it when they’re not under general anesthesia.

In the ICU, people are awake when they’re extubated unless they’re terminal. We’re going to take a deep dive into that section of emergence and extubation doing it awake. The real question becomes, why would we do this overdoing, say, deep extubation? That’s a good question. As we mentioned in the last episode, doing a deep extubation is good for a certain population. People, again, who are not obese or who don’t have sleep apnea. People who are in easy mask ventilation. After we paralyze or put you to sleep, how easy is it to mask you? How easy of an intubation are you? Am I able to DL you in one try or do I need to hold cricoid pressure? Do I need to take a couple of passes to even get a view? Do I need to get the glide scope? What was the intubation like?

Going into the case, we can think about an emergency extubation but we don’t know if you’re a good candidate for deep extubation until we bag off masking intubate you then get a good sense of how easy or how difficult that was. On the flip side of that, also for deep extubation, somebody who’s not a big aspiration risk, so no GERD, and people without full stomachs. That covers the deep extubation criteria.

On the awake extubation side, that’s our alternative. It’s to wake somebody up. There are clinical scenarios in which that is very good and that’s what we want to do. I will say this. You probably won’t ever be faulted for doing an awake extubation on somebody. If it’s somebody super young and healthy, they have a twenty-minute surgery, is under general anesthesia, and everything is completely perfect, somebody may question why you didn’t pull it deep, but you would never be faulted for doing an awake extubation.

There are several different criteria. There are textbook and clinical criteria. It’s what you see in real practice versus what you’re reading in the textbook. We’ll go in and take a deeper dive into that here in a little bit as well. An awake extubation sounds like what it is. The patient is awake enough that they are able to control their own airway. The theory is the aspiration risk is significantly lower or almost zero. If they do start vomiting, they’re able to control their airway. It’s not like they have flaccid airway muscles and everything piles back into the glottis, down the trachea, and the patient is going to aspirate. That’s the benefit of doing an awake extubation. The patient is able to maintain their own airway.

When doing an awake extubation, the patient maintains control of their own airway. Click To Tweet

If they do vomit, they can control that and they’re not going to aspirate. That’s what the awake part of an awake extubation looks like and the benefits of it. As I said, you’re not going to be faulted for doing an awake extubation on anyone. As I said in the last episode, the way you emerge and extubate is going to be culture-dependent at your facility. There are some facilities that may not deep extubate anybody regardless. Everybody gets woken up.

There may be facilities where you deep extubate everybody and you don’t wake anybody up unless they don’t meet those specific criteria. Again, the specific criteria for deep extubation are also fluid. It’s not a cut-and-dry. It’s very much gray and you will find that out when you get into the clinical setting as well. That’s all I’ll say about that. As far as the awake extubation, you’re not going to be faulted for waking a patient up to where they can manage their own airway.

That’s the preface. That’s the start of what an awake extubation is. Now we’re going to jump back into our clinical scenario and talk through awake extubation. Our clinical scenario, I believe in episode one, was a 40-year-old with no past medical history and a laparoscopic cholecystectomy. We will take it from there. We’ll say that the surgeon is pulling out the gallbladder now. After the surgeon pulls the gallbladder out, the trocars are going to come out of the abdomen and they’re going to start closing the skin. We’re going to be done, depending on who’s closing, probably in about fifteen minutes. We have about fifteen minutes to get this patient woken up and ready to go to PACU, or our OR nurses are going to be looking at us, dinging their clocks, waiting for us to move things along.

This is a side note but always do what’s best for the patient. It seems like everyone would know this but you would be surprised, especially as a nurse anesthesia resident. When you’re in the OR, hopefully, your CRNAs are with you when you are extubating. It can be easy for the staff to rush you along and try to push you to do things that may not be in the best interest of the patient.

Maybe you need to stay there an extra 5 or 10 minutes to do whatever you’re doing. Make sure the patient is stable enough to be transported to PACU. Whatever that is, don’t let the time or the pressure for production get in the way of doing what’s best for the patient. Sometimes, that’s hard to do with pushy people in the OR. Remember, you have a duty to that patient, and the duty is to do no harm. You need to be very careful and take extreme caution, especially in the period of emergence and extubation because that’s when things can go wrong.

Take your time and make sure the patient is stable enough to go. Don’t let the production pressure you into doing something that may be unsafe for the patient. We’ll leave that at that. The gallbladders out. We know that the surgeon is about to start closing skin and we’re going to be done here shortly. There are a few different ways to wake the patient up. I’m going to talk to you about two of the most common ways.

Nitrous Wake Up

The first way is a nitrous wake-up and the second way is a propofol wake-up. We’ll start with a nitrous wake-up. I’ll walk you through what that looks like then we can talk more about the technique and that thing here in a few minutes. Again, the gallbladder is coming out. The surgeons are about to be closing here shortly. At this point in time, after the gallbladder is out, trocars are out of the abdomen. I would put the patient on 100% FiO2s. We mentioned in our first episode that we tend to run the patients at about 50% to 55% FiO2.

We would switch the patient to 100% FiO2, so two liters of oxygen. We could check our twitches and see where we are with our paralytics. When did we last give roc? Is the patient paralyzed? We’ll say that we have two twitches back, and at this point, we’ll go ahead and reverse. Our gas is still on. We’re still at a MAC of gas. We’ll go ahead and reverse with either Sugammadex or Neoglyco.

After we’re reversed and the appropriate time has elapsed for that, so about 10 minutes for stigma glycopyrrolate and maybe 2 minutes for Sugammadex, we’ll check our twitches again and we’ll say that we’re fully reversed. The gold standard is quantitative training for monitoring. However, in my clinical rotations, I have never seen quantitative training for monitors. I have seen a lot of qualitative training for monitors.

Ensure that the patient is adequately reversed and the patient is still on the vents. The patient is not breathing now. We’ll go ahead and suction the patient out and put it in an oral airway or in a nasal airway. Typically, for awake extubation, I put in an oral airway because we don’t want the patient to bite down on the ET tube. Remember, in our last episode, we briefly mentioned a laryngospasm, which is where the muscles that control the vocal cords will spasm and snap shut.

One of the consequences of that is negative pressure pulmonary edema because the patient is trying to breathe against negative pressure or is trying to breathe against a closed glottis that creates a lot of negative pressure inside the thorax. I can pull that fluid into the alveoli and it can be a form of non-cardiogenic pulmonary edema. It can be lethal. We want to avoid that. The same thing can happen if the patient bites down on the ET tube. There’s no airflow going and they try to breathe against a bitten ET tube. It creates the same effect as the chords being snapped shut in a laryngospasm. They will not be exchanging air and create a bunch of negative pressure. This can cause negative pressure pulmonary edema.

A person sitting up in their bed coughing
Awake Extubation: Unlike in deep extubation, there is no risk of laryngeal spasm in awake extubation since the patient is trying to breathe against negative pressure.

All of that to say, put in an oral airway on the patients that you’re fully waking up because they’re going to be chomping at the tube at some point, especially if they’re young and relatively healthy. Older people tend not to bite the tube as much. That’s been my clinical experience and some will just use nasal airways. In my experience, I use an oral airway, especially if I’m waking somebody all the way up. Suction out and the oral airway goes in. They’re on 100% FiO2. We’ve reversed already.

At this point, we’re doing a nitrous wake-up. There are a few different ways to do this. You can do 50/50 nitrous and turn your gas halfway down, or you can do 70/30 nitrous and cut your gas completely off. This, again, depends on the patient. How much anesthetic does the patient require? 70/30 nitrous is going to give you about 0.8 MAC, which should be adequate for closing the skin. If they’re in the abdomen, you’re not going to be running nitrous on the laryngospasm case anyway. If they’re in the abdomen and they’re still manipulating things, that may not be enough but there’s not a lot of stimulation from suturing, so 0.8 MAC should be plenty. I tend to run 70/30 nitrous on the wake-up. What that looks like is 3 liters of nitrous and 1 liter of oxygen. That’s around 21% or 22% FiO2.

Our anesthesia machine has a hard stop not allowing you to create a hypoxic mixture, meaning you can’t just turn on 10 liters of nitrous and 1 liter of oxygen. You’re setting a hypoxic mixture meaning you’re going below what room air, so 21% FiO2. Our machine won’t allow us to set the hypoxic mixture, and we’ll turn on 3 liters of nitrous and 1 liter of oxygen. That’s the most you can run of nitrous. That’s 70/30 mixture. You can turn the flows up so you can do 10 liters of nitrous and 7 liters of oxygen.

However, the principle or the mixture is still the same. You’re just running the lower flows. Now, if you want to get that on faster, you can certainly do higher flows. It depends on how much time you have. In this case, we’ll turn 70/30 on, so 3 liters nitrous and 1-liter oxygen, and turn the gas completely off. Typically, for running gas, we’re not going to wake up on that. It’s very fast anyway.

Regardless, turn our gas all the way off. This is not a pharmacology lecture. I’m certainly not a pharmacologist or anything expert in Pharmacology, but I will share the small amount of information that I do know from school. Nitrous will help us with our wake-ups in a few different ways. It has some analgesic effects. Part of its property is an NMDA receptor antagonist. It’s going to give us a little bit of pain control.

There’s something called the second gas effect. Nitrogen is the most abundant substance in our atmosphere. Thus, the most abundant substance in our lungs is the most abundant atom simply because it outnumbers oxygen. Nitrous oxide is 34 times more soluble than nitrogen. Nitrous oxide will replace all of that nitrogen in your alveoli. It will hasten the onset of our volatile anesthetics. We can use this at induction. We’re talking about emergence and extubation now.

Nitrogen is the most abundant substance in our atmosphere. Therefore, it is also the most abundant substance in the human lung. Click To Tweet

We do that on pediatric patients or even adult patients. The same clinical effect will happen whenever we’re trying to onset the gas and when we’re trying to pull the gas off. Nitrous oxide will hasten the onset meaning more sevoflurane will get into the alveoli faster with nitrous than just sevoflurane alone. The opposite of that is true as well. We’re using nitrous to wake somebody up. Putting nitrous in there replaces all of the molecules of sevoflurane. Sevoflurane will come off faster out of the alveoli versus turning the gas off and letting the patient breathe it off. Turning nitrous on pulls that sevoflurane faster, and it allows us to turn the gas off sooner. More gas is getting off and our gases follow that concentration gradient.

There’s a lot of concentration of gas in the brain now because there’s a steady flow of it coming in through the alveoli or coming in through the blood up to the brain. Once that flow is stopped or once we turn the gas off, the reverse is true. That concentration gradient switches because not a lot is coming in now. More of that gas is going to start coming off. Once more comes off, more is going to follow because the concentration gradient reverses.

We’re replacing all that sevoflurane with nitrous oxide and the gas is coming off. The whole point of doing an awake extubation is we are trying to pull off that gas as quickly as we can because that’s what’s keeping the patient asleep under general anesthesia. Nitrous, as we established earlier, is very soluble, meaning it’s very fast on and very fast off. Whenever we’re pulling off that sevoflurane, the sevoflurane is what’s keeping our patient asleep.

A man sleeping in his hospital bed
Awake Extubation: Awake extubation allows you to pull off gas as quickly as possible. Since nitrous is very soluble, it can be turned on and turned off fast.

Once all the sevoflurane gets off, the patient is going to wake up and they’re going to breathe. At this point, we’ve turned our sevo off. We have 3 liters of nitrous going to 1 liter of oxygen, and now we essentially wait for all of the gas to blow off. We can watch this by our entitled sevo concentration. We’ll see this on our monitor. We can see the inspire, Fi sevo, and the ET or the entitle of sevoflurane. The MAC value of sevoflurane is around 2%. If we’re at a MAC, we’ve got 2% XXpire sevoflurane.

Once we turn that gas off, it’s going to wean off pretty fast because, as we said a few minutes ago, nitrous oxide is going to help pull that gas off even faster. Our goal is to get that gas off as fast as we can and the nitrous oxide is going to provide enough of a sedative effect that the patient is hopefully not going to wake up or move.

With that being said, this all depends on the anesthetic requirements of the patient. If you realize that the patient requires a lot of narcotics, a higher MAC value, and maybe 1.1 MAC or something like that to tone their autonomic nervous system down, you may have to work in either more narcotic or more fentanyl. Preferably not more in narcotic because that is going to be a respiratory depressant. You can start titrating narcotics whenever the patient is breathing. You can also titrate in some propofol as well. You have 10, 20, and 30 milligrams if they are trying to buck on the tube or whatever they’re doing.

I’m saying that 90% of patients are fine with 70/30 nitrous. They’re not going to be moving around. There’s that 5% or 10% that may do that. Again, titrate in whatever you can to chill that out. Most patients, in my experience, aren’t going to be bucking around at 70/30 nitrous. Again, you have to take it patient by patient.

Where we’re at now, we’ve turned our gas off and our nitrous is on 70/30. At this point, a very important step needs to happen. That is we need to leave the patient on the ventilator. We can turn them to SINV. I see some people put on pressure support to try to get the patient back to breathing. That delays the gas coming off because the patient is not breathing. You’re not ventilating. You’re trying to build CO2. The gas isn’t going to come off very fast.

My technique is to leave them on the ventilator like they were and maybe switch to SINV. As they are ventilating, that gas is going to blow off faster, which is going to hasten your wake-up if they’re on pressure support and they’re only breathing 3 or 4 times a minute while you’re trying to raise their CO2 level because that’s the drive to breathe, not oxygen. If you’re trying to raise that CO2 level and you’re not ventilating, gas is not going to be coming off. Leave them on the vent, SINV, then let the gas blow off because patients will start breathing whenever the gas is off. They’ll probably start breathing before the gas is off, but patients will breathe when the gas is off, given that they are not narcotized or anything of that nature.

We have our vent going and we’re not necessarily worried about the patient breathing on their own. We’re just trying to get the gas off. They’re still closing the skin. At this point, whenever the sevoflurane gets to point 0.3, 0.4, or 0.5, somewhere in there, then I’d switch them over to pressure support and see where they are. I’ll see at this point if they even breathing over the vent if they’re in SINV. If they’re not breathing over the vent, I’ll switch over to pressure support. Now, I’ve got the gas down to a manageable level and I’ll see what they do.

We can turn our trigger down to one or we can leave it at two and see where the patient is breathing. Start a pressure support of 8 to 10 and see what tidal volumes are pulling. Usually, by this point, when I switch to pressure support, they start breathing. They’re going to get better with time. We’ll say our patient is breathing now. She’s pulling 300 tidal volumes with a rate of about 12. Again, as we mentioned in our last episode, we can look at the minute relation.

This is where we’re going to titrate in our pain medication if we’re seeing signs of the patient’s pain. We’re trying to keep our minute ventilation between 3 and 5 liters per minute. If they’re over five, that’s a good indication that we probably should do something about it pain medication-wise. There are a few different ways you can handle it. You do something like Toradol. You can do any agent pain medication, or you can jump to the narcotics. You can do something fast-acting like fentanyl.

However, fentanyl is going to be off in about 45 minutes or you can do something longer acting like Dilaudid or morphine. If you’re doing some opioid-sparing techniques, a block after the procedure, or you did a block pre-procedure, you can do Tylenol, magnesium, or ketamine. There’s a wide variety of ways you can address that. The most common by far is probably going to be titrating and a narcotic if that minute ventilation is over about five or so. Let’s say the patient wasn’t pulling good tidal volumes. There would be a few different pathways. We would have to go down to try to troubleshoot that, and that is, is the patient fully reversed from their muscle relaxant?

Go down that pathway and make sure we’ve got a full reversal on board. Is a patient too comfortable? How much narcotic did you give? What all have we given him for pain? Maybe we should consider reversing some of that just enough to get them breathing. Those are the pathways you have to work down if they’re not pulling it to a tidal volume. We’ll say this patient is pulling great tidal volume. Her depression support is 8, so we’ll drop her down to 5 and we’ll see where we’re at with that.

After they’ve started suturing skin, they’re on their last little port site and they’re stitching that up, the patient is breathing fine pulling 300 or 400 tidal volumes that are a rate of 8 to 10, I would cut the nitrous and turn the flows all the way up, so 15 liters, 20 liters per minute, or whatever the flows go to. Depending on the time, you can let the patient breathe the nitrous off.

There’s still going to be some sevo coming off but the vast majority is going to be off. Depending on the timing that you have, you can pull your bag off of the anesthesia machine and empty it out because that bag in our anesthesia machine is essentially rebreathing circuit or rebreathing a lot of gas that’s been in there. Pull that bag off, empty the bag, put it back on, and then flush it with our oxygen flush valve while the patients are in bag mode. Fill it up with fresh oxygen.

At this point, if the patient is doing good on pressure support, I’d switch them over spontaneously. Put them in the bag and see where they’re at. Again, the tidal volumes, you are going to start small and get bigger with each subsequent breath. For extubation, at this stage, we’re going to make sure that the patient can follow commands. That’s the point of doing an awake extubation and they’re in control of their own airway. Unfortunately, awake extubation tends to be less pretty than deep extubation because the patient will feel the endotracheal tube in their throat. They may do some coughing, gagging, or bucking. Typically, their pain is adequately controlled. They’re not going to do as much bucking or coughing on the endotracheal tube.

Another thing that we would consider going back to induction is we can do tracheal lidocaine. There are these kits called LTA kits. It’s essentially 5% lidocaine and 5 ml with this long tube. It looks like the little pop-off caps. They’re like the crash cart to screw it in. It’s got this long tube. It’s probably 12 inches long. When you’re intubating, you get your view.

Once you get your view, stick it down to trachea and then push the lidocaine. The lidocaine sprays out into the trachea. This essentially anesthetizes the trachea and all of the nerve endings that are in there and that cause sympathetic stimulation, bucking, gagging, and coughing. However, the caveat to that is that lidocaine only lasts about an hour. A procedure that’s over an hour or hour and a half, maybe two hours tops, it’s not productive to use the trachea lidocaine because it’s going to be worn off by the time you extubate anyway.

The trachea lidocaine is a good thing to use if the procedure is short enough to tolerate it. I’ve done my own study here on the patients that I’ve seen. When I don’t use that, there is significantly more bucking and coughing than when I do use that. It makes a difference, again, if the procedure is short enough so that it’s not worn off by the time you extubate.

At this point, going back to what we said, we have our nitrous completely off. It flows all the way up and the patients breathe on their own. We’re looking for good tidal volumes and we’re essentially waiting for the patient to wake up. The criteria that we would use for this is, can the patient follow commands? There are some textbook criteria that we had to learn in school about when the patient is extubatable. Can they lift their head off the bed for nine seconds? Can they hold a tongue blade between their teeth? There are all these random criteria that we don’t use in the clinical setting. You have to know it for your exams and for boards, but not something that’s necessarily used in the clinical setting.

The short answer is, can the patients follow commands? If you tap the patient on the forehead, do they open their eyes? Do they respond? Can you say, “Mrs. Jones, open your eyes for me.” Does the patient open their eyes? Can they squeeze your fingers? Are they moving around? Do they have purposeful muscle movements? Are they reaching up to try to pull the endotracheal tube themselves? If that’s the case and they have these purposeful movements, you’ll know that the patient is extubatable and they’re in control of their own airway.

Again, make sure the patient is breathing adequately on their own. One thing you have to look for here is has the patient has gone through stage two. We talked about the stages of anesthesia in our last episode. Stage two, being the period of hyperreactivity, meaning when the patient is tachycardic, their breath-holding, and has a disconjugate gaze.

It’s that period where you’re more prone to developing a laryngospasm. We don’t want to extubate in that period, especially in somebody who may be difficult to mask or a difficult intubation. For whatever reason, we’re waking the patient up. We will say that we don’t want to pull that stage two because maybe they’re difficult masks. The way to break that laryngospasm is going to be positive pressure and bagging the patient.

If they’re not breathing, we’re bagging them in general. We don’t want to have to deal with that. Make sure they’re not in stage two and not breath-holding. If they open their eyes, are their pupils pointed in opposite directions? All those things are signs that they’re in stage two. Let them wake up a little further. They might be coughing and gagging on the tube. If that’s the case, you can give a little bit of propofol to calm that down.

You can also bag the patient through this if their breath-holding and they are de-sating. You’ll see this, especially in obese people. They’re coughing and gagging on the tube. They’re not breathing. Their FRC is not good to begin with. They’re going to de-sat very fast. Bag the patient. Bag them through that, and eventually, they’re going to make it to where there are some purposeful muscle movements. They’re reaching up to try to pull the tube out. They’re opening their eyes and trying to sit up.

At that point, have everything ready. Maybe they need one last suction. Remember, we suctioned early when we put in the oral airway. That will also stimulate them to breathe. Have our mask and syringe ready to pull the air out of the pilot balloon and we’re on 100% FiO2. At this point, the patient is extubatable.

She’s lifted her head off the bed. If she’s reaching up and tried to grab the tube herself, we’ll pull the air out, disconnect our circuit, pull the tube out, and we’ll put the circuit on our mask. We’ll hold some pressure and do a jaw thrust, holding the mouth with two hands, and essentially waiting for the patient to breathe. Typically, if they are awake enough and they’re following commands, they’re going to start breathing immediately.

We’ll say our patients are breathing great, we will pull our mask off, put a non-rebreather on, off to PACU and we go. That’s what a nitrous wake-up looks like. I will say this; I already did cover this a few minutes ago, but after we turned our nitrous off and when we turned our flows up, we wanted to wait until that nitrous was blown off all the way. Typically, if you’re waking the patient all the way up, whether they’re opening their eyes or about to pull the tube themselves, the gas and the nitrous will almost always be all the way off.

In deep extubation, once the patient comes back breathing, it is pretty easy to pull the tube and go. With awake extubation, it can be variable from the time when gas is reading zero to when they are actually awake. Click To Tweet

It’s very rare that somebody is going to have some nitrous left and they’re still trying to open their eyes and pull the tube out. They may make non-purposeful movements. They may be coughing and bucking on the tube or there’s a little bit of gas and nitrous left, let them breathe that off or breathe for them again if they’re breath-holding or de-sating all of those things. Especially in obese people, the sevoflurane, the isoflurane, the desflurane, or whatever gas we’re using is very soluble in the fat. Obese people have a lot of reserve as far as fat. A lot of sevoflurane leeches out into that fat and that concentration gradient reverses. It’s going to take some time for that sevoflurane to get off.

You may be there or you probably will be there a lot longer if you’re trying to wake somebody all the way up versus if you’re doing a deep extubation. That’s one of the things of the deep extubation. Once you come back breathing, it’s pretty easy. Pull the tube and go. With awake extubation, it can be so variable from the time your gas is reading 0, 0.1, or 0.2 MAC to the time that they’re awake, ready to go, following commands, and doing all those things that would be the extubation criteria.

Propofol Wake Up

You are going to be there a little bit longer if you’re doing a true awake extubation versus if you’re doing a deep extubation. That’s what one way of doing an awake extubation looks like. Here’s the second way, and that’s doing a propofol wake-up. We’ll go back to our original scenario. The surgeons pulled the gallbladder out. After the gallbladders are out, trocars are out. They are about to close the abdomen or to close the port sites. We’ll suction our patient out, oral airway in, 100% FiO2, cut the gas completely off, and then we will reverse the patient.

Make sure they’re fully reversed. Check our twitches and then we’ll leave our vent on like we did last time. Another thing here is everything is the same as our nitrous wake-up except we’re not turning on nitrous. Only cutting the gas off. At this point, leave the vent on because we want to get the gas off. As the gas is coming off, when we get to about 0.5 MAC, I would probably give 10, 20, 30, or maybe 40 or 50 milligrams of propofol, depending on the patient.

Again, this all depends on how much anesthetic the patients require. Some patients get away with 20 milligrams and some may need 50 milligrams of propofol. After you’re about at 0.5 or 0.6 MAC, give a little propofol. The propofol is essentially working like the nitrous except the propofol is not pulling off the sevoflurane like the nitrous is. The propofol is going to keep the patient asleep enough that the gas comes off but they’re not bucking and coughing while the surgeons are trying to close the skin.

We’re achieving the same purpose here except the propofol is not pulling off sevoflurane. Nitrous will help pull that gas off, which works in our favor. Propofol just keeps the patient asleep a little longer or sedated enough that the gas is coming off so they’re not going to start waking up. I will say this is very much an art form. I haven’t done this as much as I’ve done the nitrous wake-ups. I do like this wake-up. You can honestly turn the gas off while the abdomen is still inflating. You just need to make sure you’re giving propofol to keep the patient asleep. Timing the gas is the key here. Maybe you’ll shut your gas off right when they deflate the abdomen before the gallbladder is out so you buy yourself a few more minutes.

A nurse checking the pulse of an older patient in a hospital bed
Awake Extubation: You can turn the gas off while the patient’s abdomen is still inflated. Make sure you’re giving propofol to keep the patient asleep.

As you’re turning the gas off, we’re bumping propofol, that 20, 30, 40, and 50 milligrams every 5 or 6 minutes or maybe sooner depending on the patient. It’s all very patient-dependent. It’s not black and white. It’s very gray. We’ll work in that propofol. Everything else essentially remains the same. We are trying to pull that gas off as fast as we can. There are a few different ways we can speed that up. We can turn our flows all the way up to 15 liters per minute. That’s going to hasten the offset of that sevoflurane because we’re forcing oxygen in and that concentration gradient even further out because we’ve turned the flows up. We can take the bag off. Empty the bag and put it back on. Flush it with the other two valves. All the same principles apply to getting the patient breathing again.

Once we’re at that 0.4 or 0.5 MAC, put them on pressure support. See if the patient is breathing. Depending on how much propofol you’ve worked in, they probably will be breathing. Again, the propofol is being titrated to that minute ventilation. Our minute ventilation is between about 3 and 5. If your minute ventilation is seven, treat maybe with some fentanyl, morphine, or Dilaudid. Give a little propofol and titrate that to that minute ventilation of about 3 to 5.

If you’re giving 50 milligrams and you take their minute ventilation down to one, you know you’ve probably overshot it a little bit. Maybe give 30 next time and see once they start breathing in about five minutes and see what their minute ventilation is. That’s the other way to do an awake extubation. All the same principles apply. Once the gas is off, the surgeon is essentially done, and they’re on their last stitch, don’t give any more propofol because the patient needs to wake up. Propofol is going to last five minutes maybe, depending on how much you give, and then let the patient wake up. It will essentially do the exact same thing we’re doing on the nitrous wake-up. Make sure the patients follow commands.

Two nurses getting their surgical gowns, masks and gloves on
Awake Extubation: Once the gas is off and the surgeon is done, do not give the patient any more propofol. They already got the amount they need to wake up.

Can they lift their head off the table? Can they open their eyes? Can they squeeze your hand? Are they trying to reach up? Are they making purposeful movements? You know then that the patient is extubatable. Again, get them through that breath-holding stage. Get them through stage two. Maybe get a little more propofol for that. Get them past that stage while the gas is coming off and then pull the tube. Have everything ready, deflate our pilot balloon, pull the tube out, put the mask on, and do the jaw thrust. Make sure the patients are exchanging. Put a non-rebreather on and off to the PACU you go.

Awake Extubation: The Gold Standard

That’s what awake extubation looks like. Again, you’re not going to be faulted for doing an awake extubation on anyone because that’s the gold standard. If the patient has a difficult mask or a difficult tube or if you have any trouble with the patient at all, waking the patient all the way up is never the wrong answer. This is going to be facility-dependent or culture-dependent on where we work. This is when you graduate, pass your boards, and you’re a CRNA.

As a nurse anesthesia resident, it may be up to you to determine what your plan for emergency extubation is, or your preceptor may say, “We’re going to deep extubation or an awake extubation.” If you’re a nursing anesthesia resident, I would encourage you to come up with that plan on your own and tell your preceptor your plan at the beginning of that case. Be like, “Here’s my plan. I plan to deep extubate this patient. Here are the reasons why and I’ll let you know for sure as soon as we mask and deep intubate the patient if that’s still a good plan or not.”

There have been patients that I’ve had that I’m like, “This is a perfect deep extubation patient.” I mask easily. Everything is good and I go to look and I see nothing. It takes a couple of times DL. Maybe I use a GlideScope and I’m like, “We’re going to abort the deep extubation plan,” because if all else fails and they’re under a MAC of gas, still, you pull the tube. The alternative is to intubate the patient again. That’s why you need to know if a patient has an easy airway or not.

Again, you’ll never be faulted for waking a patient all the way up. That’s what an awake extubation looks like. You do the nitrous wake-up or propofol wake-up. The other alternative to that is to turn the gas off. You have to time right if you’re not giving propofol. You turn the gas off while the surgeons are still trying to close and if the patient is still bucking and moving around, you’re going to hear about it. They’re like, “Do something.”

The propofol tends to work well if you’re not using nitrous. I will say out of the two, nitrous is probably my favorite. Nitrous is known to cause post-operative nausea and vomiting. That’s if you’re running it for the entire case over 45 minutes or so. At the end of the case, if you’re running it for ten minutes to wake somebody up, it doesn’t cause post-operative nausea and vomiting.

I’ve followed up with my patients on this and they aren’t nauseated and vomiting from the nitrous. If somebody has a significant history of that, I would forego that. If the patient doesn’t have a significant history of PONV, I wouldn’t worry about it, honestly, because I haven’t seen it much, especially with a wake-up. That’s how I do the awake extubations. Nitrous probably being my top one. Propofol is a close second then turning the gas off.

Again, you have time that correctly. I’m not that good. I can’t time it perfectly all the time. That’s another option. Cut the gas off. Don’t do anything else and let the gas blow off itself. That’s a good overview of doing an awake extubation. If you have any comments, I would love to hear your comments on this. Especially if you’re a CRNA or a nurse anesthesia resident, I’d love to hear your thoughts about doing an awake extubation either with nitrous or without nitrous, with propofol, or turning the gas off and winging it. Comment if you have questions. Thank you so much for reading.

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