criteria for extubation
TRANSCRIPT
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CRITERIA FOR EXTUBATION
Dr. Devi priyaMd2
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ROUTINE EXTUBATION-Operating Room:
-RETURN OF CONCSIOUSNESS AND SPONTANEOUS RESPIRATION
-RESOLUTION OF NEUROMUSCULAR BLOCKADE
-ABILITY TO FOLLOW SIMPLE COMMANDS
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SUBJECTIVE:
-FOLLOWS COMMANDS
-CLEAR OROPHARYNX/HYPOPHARYNX( BLEEDING,SECRETIONS)
-INTACT GAG REFLEX
-SUSTAINED HEAD LIFT FOR 5 SECS,HAND GRASP
-ADEQUATE ANALGESIA
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OBJECTIVE
CLINICAL:
● CARDIOVASCULAR AND HEMODYNAMIC STABILITY
● ABSENCE OF EXCESSIVE SECRETIONS
● NORMOTHERMIA
● APPOROPRIATE ACID-BASE STATUS
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VENTILATORY CRITERIA:
● PaCO2< 50 mm hg
● Vital capacity > 10 ml /kg
● Spontaneous tidal volume > 5 ml/kg
● Spontaneous RR <30 / mt
● Minute ventilation < 10L/ min with satisfactory ABG
● Max insp. Pressure > -30 CM H20 in 20 secs
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OXYGENATION CRITERIA:
-Pao2 >60 mm hg
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FULL REVERSAL OF MUSCLE RELAXATION:
T4/ T1 RATIO >0.9
SUSTAINED TETANIC CONTRACTION> 5 SECS
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ICU SETTING:
SUBJECTIVE:
● Underlying disease process improving
OBJECTIVE:
● GCS>13
● Pao2 without PEEP : - >60 mm hg at Fio2 upto 0.4
● With PEEP - > 100 mm hg at fio2 upto 0.4
● Sao2 >90% at fio2 of 0.4
● ALVEOLAR- ARTERIAL O2 tension GRADIENT :(FIO2 1.0) <350 mm hg
For every 50 mm hg difference, shunt percent is 2%
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● DEAD SPACE TO TIDAL VOLUME RATIO : < 0.6
PaCO2-PeCO2/ PaCO2
● Horowitz index for lung function (P/F) > 150 mm hg
● RAPID SHALLOW BREATHING INDEX < 100 breaths/min/L
● SPONTANEOUS BREATHING TRIAL
● Airway resistance - suction/ bronchodilator
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SPONTANEOUS BREATHING TRIAL :
● May use T tube,CPAP, OR low level pressure support
● Automatic tube compensation- “electronic extubation”
● Let patient breathe for 30 mins spont
Assess patient
● If patient tolerates- normal resp pattern,adeqaute gas exchange-consider
extubation when blood gases and vital signs are satisfactory.
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EXTUBATION PROTOCOL:
4 P’s -
Plan- low risk / high risk
Prepare-patient factors/ monitoring/equipments/assistance/extubation check list
Perform
Post extubation care
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SITUATIONS PRESENTING INCREASED RISK FOR COMPLICATIONS AT
EXTUBATION:● Tracheomalacia
● Certain surgeries- thyroid,uvulopalatoplasty,cervical vertebrae
decompression,carotid endareterectomy, maxillofacial surgeries
● OSAS
● Hypoventilation syndromes-polio/GBS/MG/morbid obesity/severe COPD
● Hypoxemic syndromes- v/q mismatch,intracardiac/pulmonary shunting,severe
anemia etc
● Generalized edema, anaphylaxis.
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-Patient position- supine/semi upright/ lateral/ prone
-Timing of extubation
-Bite blocks
Awake vs deep - assess the relative risk of aspiration vs coughing / straining vs UAO
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AWAKE EXTUBATION:
DEFINITION:”tracheal extubation after appropriate response to verbal stimuli with recovery of protective airway reflexes”
● 100% oxygen● Suction adequate● Bite block● Position appropriately● Antagonise NMB● Regular adeq spontaneous breathing● Wait until awake,obeying ● Positive pressure,deflate cuff● extubate● Check airway patency,adeq breathing● Continue o2 supplement
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DEEP EXTUBATION:
Definition- “tracheal extubation in spontaneously breathing patients under the absence
of any protective respiratory reflexes”
● Ensure there is no surgical stimulation
● Adequate analgesia
● 100% oxygen
● Ensure adequate depth of anesthesia
● Antagonize NMB
● REMOVE SECRETIONS ,IDEALLY UNDER DIRECT VISION
● Deflate cuff ,apply positive pressure,extubate
● Maintain airway patency until pt is fully awake
● Continue oxygen until recovery is complete
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COMPLICATIONS DURING AND POST TRACHEAL EXTUBATION:
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-Cardiovascular response
Dexmed infusion 1mcg/ kg 10 mins prior
fentanyl infusion 1 mcg/kg 10 mins prior
Magnesium 40 mg/kg 5 mins before extubation
lidocaine 1mg/kg over 2 mins
esmolol 0.5 mg/kg an be used 2 mins prior to extubation
- Increased pressures- ICP/IAP/IOP
- Risk of surgical complications
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APPROACH TO DIFFICULT EXTUBATION:
PREPARATION OF STANDBY EQUIPMENTS FOR RE INTUBATION
POST EXTUBATION AIRWAY COMPETENCY: cuff leak test- doubtful on the reliability
Steroids
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EXCHANGING A LARYNGEAL MASK
EXTUBATION OVER A FLEXIBLE BRONCHOSCOPE
AIRWAY EXCHANGE CATHETERS CAN ALSO BE USED
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Aintree intubation catheter
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Airway exchange catheter
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A patient post cervical spine fusion, with
AEC in situ.
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Conclusion
- Judgement on timing of extubation depends on patient factors, surgical factors and
anesthetists preference.
- The anesthetist must evaluate every patient in terms of potential for problems
during extubation in the same manner that he prepares for an unanticipated
difficult airway. !
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Thank you!