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    Extubation Criteria & Delayed Emergence

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    Anonymous OlS0WZw
    The document provides criteria for extubation in the operating room and intensive care unit. It lists 9 criteria for extubation in the OR, including adequate oxygenation, ventilation, hemodynamic stability, and reversal of muscle relaxation. For the ICU, it includes subjective and objective criteria such as adequate mentation, hemodynamics, oxygenation measures, and ventilator criteria during a spontaneous breathing trial. It also discusses potential difficult extubations, approaches to difficult extubations including a cuff leak test, stages of anesthesia, causes and treatment of delayed emergence from anesthesia.

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    Extubation Criteria & Delayed Emergence

    Uploaded by

    Anonymous OlS0WZw
    350 views3 pages
    The document provides criteria for extubation in the operating room and intensive care unit. It lists 9 criteria for extubation in the OR, including adequate oxygenation, ventilation, hemodynamic stability, and reversal of muscle relaxation. For the ICU, it includes subjective and objective criteria such as adequate mentation, hemodynamics, oxygenation measures, and ventilator criteria during a spontaneous breathing trial. It also discusses potential difficult extubations, approaches to difficult extubations including a cuff leak test, stages of anesthesia, causes and treatment of delayed emergence from anesthesia.

    Original Description:

    anestesi

    Original Title

    Kriteria ektubasi

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    The document provides criteria for extubation in the operating room and intensive care unit. It lists 9 criteria for extubation in the OR, including adequate oxygenation, ventilation, hemodynamic stability, and reversal of muscle relaxation. For the ICU, it includes subjective and objective criteria such as adequate mentation, hemodynamics, oxygenation measures, and ventilator criteria during a spontaneous breathing trial. It also discusses potential difficult extubations, approaches to difficult extubations including a cuff leak test, stages of anesthesia, causes and treatment of delayed emergence from anesthesia.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    350 views3 pages

    Extubation Criteria & Delayed Emergence

    Uploaded by

    Anonymous OlS0WZw
    The document provides criteria for extubation in the operating room and intensive care unit. It lists 9 criteria for extubation in the OR, including adequate oxygenation, ventilation, hemodynamic stability, and reversal of muscle relaxation. For the ICU, it includes subjective and objective criteria such as adequate mentation, hemodynamics, oxygenation measures, and ventilator criteria during a spontaneous breathing trial. It also discusses potential difficult extubations, approaches to difficult extubations including a cuff leak test, stages of anesthesia, causes and treatment of delayed emergence from anesthesia.

    Copyright:

    © All Rights Reserved
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    of 3

    Extubation Criteria - OR

    1. Adequate Oxygenation

    Extubation Criteria
    &
    Delayed Emergence

    SpO2 > 92%, PaO2 > 60 mm Hg

    2. Adequate Ventilation

    VT > 5 ml/kg, spontaneous RR > 7 bpm, ETCO2 < 50 mm


    Hg, PaCO2 < 60 mm Hg

    3. Hemodynamically Stable
    4. Full Reversal of Muscle Relaxation

    Sustained tetany, TOF ratio >0.9


    Sustained 5-second head lift or hand grasp

    5. Neurologically Intact

    Extubation Criteria - OR
    6. Appropriate Acid-Base Status

    pH > 7.25

    7. Normal Metabolic Status

    Normal electrolytes
    Normovolemic

    8. Normothermic
    Temp > 35.5

    9. Other Considerations

    51

    Aspiration risk
    Airway edema
    Awake vs. Deep (i.e. NOT in Stage II)

    Follows verbal commands


    Intact cough/gag reflex

    Extubation Criteria - ICU


    Subjective Criteria
    Underlying disease process improving.

    Objective Criteria
    Adequate mentation (GCS > 13, minimal sedation)
    Hemodynamically stable, on minimal pressors (e.g.
    dopamine < 5 mcg/kg/min)
    SaO2 > 90%, PaO2 > 60 mm Hg, PaO2/FiO2 > 150 on
    PEEP < 5-8 cm H2O and FiO2 < 0.4-0.5
    PaCO2 < 60 mm Hg, pH > 7.25

    Ventilator Criteria (during SBT)


    RSBI (RR/VT) < 100, NIF > 20 cm H2O
    VT > 5 ml/kg, VC > 10 ml/kg
    RR < 30 bpm

    Potential Difficult Extubation

    History of difficult intubation


    OSA
    Maxillofacial trauma
    Generalized edema
    Paradoxical vocal cord motion (preexisting)
    Post-procedural complications:

    Thyroid surgery (~4% risk of RLN injury, late hypocalcemia)


    Diagnositc laryngoscopy +/- biopsy (laryngospasm, edema)
    Uvulopalatoplasty (edema)
    Carotid endarterectomy (hematoma, nerve palsies)
    ENT surgeries (hematoma, jaw wires)
    Cervical decompression (edema)

    Approach to Difficult Extubation


    If intubation was technically difficult (e.g. multiple DLs,
    FOI), consider maintaining a pathway to the trachea
    (e.g. bougie, FOB, Airway Exchange Catheter).
    If airway edema is suspected due to fluids or traumatic
    intubation, consider performing a Cuff-Leak Test
    Deflate cuff, occlude ETT, observe whether patient can
    breath around the tube.
    A failed leak test does NOT always lead to failed extubation,
    but may warrant further patient observation; likewise, passing
    a leak test does NOT guarantee successful extubation.

    Stages of Anesthesia
    Historical terminology to describe depth of anesthesia upon gas
    induction. Today, more important for emergence.
    Stage 1
    Sedated, intact lid reflex, follows commands

    Stage 2
    Excited/disinhibited, unconscious, unable to follow commands or exhibit
    purposeful movement
    Irregular breathing & breath-holding, dilated & disconjugate pupils,
    conjunctival injection
    Increased incidence of laryngospasm, arrhythmias, and vomiting.

    Stage 3
    Surgical anesthesia

    Stage 4
    Medullary depression, cardiovascular/respiratory collapse

    52

    Delayed Emergence
    Definition
    Failure to regain consciousness as expected within 20-30
    minutes of the end of a surgical procedure.

    Causes
    1. Residual drug effects

    Absolute or relative overdose


    Potentiation of agents by prior intoxication (e.g. EtOH, illicit drugs) or
    medications (e.g. clonidine, antihistamines)
    Organ dysfunction (e.g. renal, liver) interfering with metabolism/excretion.

    2. Hypercapnia and/or Hypoxemia


    3. Hypothermia (<33C)
    4. Hypo-/Hyperglycemia

    Delayed Emergence

    Diagnosis and Treatment

    Causes

    Ensure adequate oxygenation, ventilation, and hemodynamic


    stability first, then proceed with:

    5. Metabolic Disturbances

    1. Administer reversal agents

    Acid-base, hyponatremia, hypo-/hypercalcemia, hypomagnesemia

    6. Organ Dysfunction

    Renal failure, liver failure (e.g. hepatic encephalopathy)

    7. Neurologic Insults

    Seizure/post-ictal state
    Increased ICP

    8. Perioperative Stroke

    Risk factors: AFib, hypercoagulable state, intracardiac shunt


    Incidence: 0.1-0.4% in low-risk procedures; 2.5-5% in high-risk
    procedures

    2. Ensure patient is normothermic

    Feeley TW and Macario A. The postanesthesia care unit. In Miller RD (ed),


    Millers Anesthesia, 6th ed. Philadelphia: Elsevier Churchill Livingstone, 2005.
    MacIntyre NR et al. 2001. Evidence-based guidelines for weaning and
    discontinuing ventilatory support: a collective task force facilitated by the
    ACCP, AARC, and the ACCCM. Chest, 120: 375S-95S.
    Rashad Net University (www.rashaduniversity.com/delem.html)
    Rosenblatt WH. Airway management. In Barash PG, Cullen BF, and
    Stoelting RK (eds), Clinical Anesthesia, 5th ed. Philadelphia: Lippincott
    Williams & Wilkins, 2006.

    53

    Use Bair Hugger

    3. Check ABG for PaO2, PaCO2, glucose, and electrolytes


    4. Consider neurological insults

    References

    Naloxone 0.40 mg 2 mg IV Q 2-3 minutes.


    If no response after 10 mg, reconsider narcotic overdose as cause of delayed
    emergency
    Flumazenil 0.2 mg IV bolus Q 45-60 seconds over 15 seconds
    May repeat doses. Maximum of 1 mg IV bolus. No more than 3 mg total in
    one hour.
    Physostigmine 1-2 mg IV (for central cholinergic syndrome)
    Neostigmine maximum of 5 mg IV. Give with glycopyrrolate.

    Perform pertinent neurologic exam


    Consider further workup (e.g. CT, MRI, EEG)
    Consider Neuro consult

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