sethinaWhen do you know when to extubate (in theatre)? What steps do you use? Where do you stand? When are you happy to remove tube? When have you seen things go wrong? #anaesthesia #anesthesiology
Dave Jones@sethina My aim for straightforward cases is to extubate them on the table while deep just as the final dressing goes on and let them wake up in their own sweet time with either an iGel or guedel in their mouth.
Hypnotic@sethina I use TIVA quite a lot. So I extubate, awake on the bed in theatre. I usually say open your eyes and as soon as they do I deflate the cuff and extubate. Sometimes I use an NP but I find they just breathe. I do think extubation is under recognised as a critical decision. Interested to learn about others practice! #anaesthesia #Extubation #CriticalDecisionMaking #Learning #LifeLongLearning #CPD
Sam Khanna@sethina my default is sat upright in bed, with eyes open reaching for the tube following commands breathing spontaneously.
I do a lot of TIVA at the moment and I find you get a lot more margin for error as there is less laryngospasm if you pull the tube too early, however I worry it also means you have less laryngeal reflexes and a higher risk of aspiration.
If it's a very straightforward patient then I may deviate from this but then I've probably used an LMA in most of those circumstances
Nicholas Ivin@sethina being fairly new to anaesthesia I like to get the patient breathing, insert an OPA and suction on the table, then transfer to bed, wean to unsupported breathing, and extubate once eyes open/following commands/leaning forward/coughing/going for tube. Deep extubation currently scares me and have seen laryngospasm requiring propofol >50% of the time a senior has tried to demonstrate it…
brisgasdoc 
@sethina I think this is one of the hardest things to teach as I don’t think I was every really “taught” it - one learns by doing, really. It’s far less algorithm based than intubation.
Anna Simpson@sethina I had to essentially figure this back out when I returned to anaesthesia after 6 years. Definitely more of an art form than a protocol. So I now have strong opinions with minimal evidence beyond personal practice! FWIW I stand to one side. TIVA is much more forgiving. Bite block for the win, and if in doubt, wait longer. Deep extubation is a whole separate game...sadly not often relevant to me currently. What do you do?
Magicalbaby@sethina Truely an art to finding the magical moment isn’t it. I want the tube gone before their ability to form memory kicks in, and before they make strong flexing movements against the tube. Fentanyl helps them tolerate the he tube until fully awake. Earlier use of glyco helps to dry up secretions that could cause laryngospasm.
Jimothy 🐢@sethina
At QVH (east grinstead), you can leave the ETT in, patient apnoeic and drop the patient in recovery being bagged and let the recovery nurses do it for you!
At QVH (east grinstead), you can leave the ETT in, patient apnoeic and drop the patient in recovery being bagged and let the recovery nurses do it for you!
@jimothy I've not heard of this in UK. Interesting. Any problems?
@sethina
It only works because the anaesthesia is standardised: 100% tiva and high dose remifentanil (0.5mcg/kg/min) so never get laryngospasm.
It only works because the anaesthesia is standardised: 100% tiva and high dose remifentanil (0.5mcg/kg/min) so never get laryngospasm.
@jimothy Thank you! What training is given? What is recovery staff turnover like?
@sethina
From memory (was a reg there a few years back) most staff had been there forever so it wasn’t seen as odd at all.
Another quirk was that maybe about half the tubes were nasal (maxfax/dental).
Nurses couldn’t extubate children - had to stay with them until tube out (in recovery or theatre).
From memory (was a reg there a few years back) most staff had been there forever so it wasn’t seen as odd at all.
Another quirk was that maybe about half the tubes were nasal (maxfax/dental).
Nurses couldn’t extubate children - had to stay with them until tube out (in recovery or theatre).
@jimothy @sethina Wow! That’s really interesting & with the TIVA & Remi I can appreciate that it works. At our trust we can’t get all the consultants to use TIVA so no chance of this happening! But fascinating to know about other practices and options! #anaesthesia #Extubation #TIVA
Raj AC@sethina Wait until they're clearly half-awake but not really breathing then pull to the tube to keep things exciting.
Dr Rita Agarwal@sethina #pedsanesthesia , I do mostly deep extubation, stand at the head of the bed, also use mostly TIVA, so less laryngospasm, and less emergence delirium