Extubation in OR SHAJI SAINUDEEN RASHID HOSPITAL, DUBAI

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Transcript of Extubation in OR SHAJI SAINUDEEN RASHID HOSPITAL, DUBAI

  • Slide 1
  • Extubation in OR SHAJI SAINUDEEN RASHID HOSPITAL, DUBAI
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  • Difficult extubation : 208 references Difficult intubation : 3022 references (x 14.5) Is tracheal extubation a problem ? NO Morbidity factor related to anesthesia YES
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  • Incidence of death, brain damage, and nerve injury as a percentage of total claims Cheney FW Anesthesiology 1999
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  • Incidence of respiratory, cardiovascular, and equipment- related damaging events as a percentage of the total claims for death and brain damage
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  • T : 1/145 500P : 1/21 200
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  • Peterson GNet al. Anesthesiology 2005 Management of the Difficult Airway A Closed Claims Analysis
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  • Respiratory complications associated with tracheal intubation or extubation InductionExtubation ORExtubation PACU Cough 1.5 % 6.6 % 3.1 % SpO 2 < 90 1.1 %2.4 % 2.2 % Laryngo- Spasm 0.4 % 1.7 % 0.8 % DV 1.4 % -- DI 0.8 % -- Airway Obstruction - 1.9 % 3.8 % Asai et Col BJA 1998 1 compli- cation 4.6 % 12.5 %9.5 % N=1005
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  • An Analysis of Reintubations from a Quality Assurance Database of 152,000 patients P Lee et al J clin Anesth 2000 N=191 (1/1000) OR PACU OR+PACU% Respiratory 48 64 11258 complications Unintentional 25 0 2513 Extubation Surg Compl. 10 6 16 8 Neurom. blocking 4 7 11 6 Opiod residual 2 7 9 5 Upper airway obst. 8 0 8 4 Cardiac complications 2 0 2 1
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  • EMERGENCY TRACHEAL INTUBATION IN PACU 13593 admission to PACU from October 1986-Oct 1988. 26(0.19%) required reintubation in PACU. 20/26 (77%) within 1hr of extubation and/or admission to PACU. Reintubation was common in extremes of age. 54% more than 60yrs, 19% less than 3yrs. 23% of the reintubated underwent ENT procedures. 18/26 (69%) were directly related to anaesthetic management. Mathew, Anesth Analg. 1990
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  • 315 incidents or accidents (0,4%) 111 totally related to anesthesia 27 during recovery (oxygen desaturation, airway patency problem) and 8 totally due to anesthesia Inappropriate extubation : residual effect of muscular relaxant or anesthetetic agents (misjudgment), laryngospasm or bronchospasm aspiration All problems related to anesthesia were considered preventable
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  • Analysis of reintubations 1.Respiratory complications were the most common cause of reintubation in the perioperative period. 2.More reintubations occured in the immediate post extubation phase. 3.Muscle relaxant effect and opioid effect are rare causes of respiratory failure in the anaesthetized patient in the immediate postoperative period. 4.Anaesthesia related problems in immediate post extubation phase is preventable
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  • CAUSES OF FAILED EXTUBATION Several attempts for difficult intubation. Traumatic intubation. Large diameter,overinflation,malposition of endotracheal tube. Prolonged surgery( more than 4hrs). Emergency surgery. Cervicomaxillofacial surgery. Prolonged trendelenberg position Radiotherapy and neck dissection.
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  • EXTUBATION FAILURE Prevention better than treatment. Be aware of the factors that predict extubation outcome to improve clinical decision making. Rapid reinstitution of ventilatory support in patients who fail extubation may improve outcome. Rothar and Epstein- current opinion in crit care, 2003
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  • Management of extubation Extubation criteria Appropriate technique Anticipate difficult extubation(DE) Management of DE
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  • Tracheal Extubation criteria No residual neuromuscular blockade Respiratory Criteria Cardiovascular Criteria General criteria Level of conciousness
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  • Tracheal Extubation criteria No residual neuromuscular blockade Head lift 5 sec TOF ratio > 0.9 +++ DBS 2
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  • Debaene B et Col Anesthesiology 2003 37 Residual Paralysis in the PACU after a Single Intubating Dose of Nondepolarizing Muscle Relaxant with an Intermediate Duration of Action Residual paralysis rate
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  • Train-of-four (TOF) ratios measured immediately before tracheal extubation and again on admission to the postanesthesia care unit (PACU). Murphy G S et al. Anesth Analg 2005;100:1840-1845 2005 by Lippincott Williams & Wilkins
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  • Residual paralysis at the time of tracheal extubation. Murphy G.S Complete recovery from neuromuscular blockade is rarely present at the time of tracheal extubation. Respiratory and pharyngeal function do not normalize until TOF ratios of 0.81.0 are obtained. Anesth Analg.Anesth Analg. 2005 Jun;100(6):1840-5
  • Slide 20
  • Tracheal Extubation criteria Respiratory Criteria - steady spontaneous breathing without difficulty - VT > 6 ml.kg -1 - respiratory rate 12 to 25 c/min -1 - negative inspiratory pressure < -20 -30 cmH 2 O - SpO 2 >95 % (air)
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  • Tracheal Extubation criteria Cardiovascular Criteria HR and arterial pressure 20 % of baseline values No vasopressor or inotropic drug General criteria temperature > 36 C pain control no surgical complications (bleeding, hematoma)
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  • Tracheal Extubation criteria Level of conciousness Fully awake vs deep extubation Considerations Any difficulty in controlling airway Any risk of aspiration Awake Incidence of respiratory complication less Deep Sympathetic response less Increased airway complications
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  • Tracheal Extubation Appropriate Technique Extubation manoeuvre Position ???..... Oxygnation F i O 2 =1 during few minutes buccal, pharyngeal and tracheal suctions 3 periods : 2 to 3 deep inspirations (recruiting manuvre) deflate cuff of ET take off the ET at the end of inspiration to minimize the risk of laryngospasm (without suction+++)
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  • How to anticipate a difficult tracheal extubation? Difficult Intubation - Anticipate Difficult Extubation Complications related to the patient and/or surgery
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  • Related to the patient Difficult mask ventilation during induction Difficult Intubation Traumatic Intubation Upper airway oedema or tumor Risk factors of difficult tracheal extubation Increased risk number of attempts > 3 ++++
  • Slide 27
  • Related to the surgery (ENT, head and face ) Local : oedema, hematoma, VC paralysis Expected difficulties : jaw immobilisation Risk factors of difficult tracheal extubation
  • Slide 28
  • Predicting difficult extubation.. VT expired < VT inspired Leak with deflated cuff LEAK = 0 Oedema VT expired = VT inspired Tracheal intubation > 48 h leak > 12-15 % OK leak < 12-15 % increased risk of stridor and/or reintubation Jaber S et Col Intensive Care Med 2003 Cuff-leak test
  • Slide 29
  • Predicting difficult extubation.. Cuff-leak test Cuff-leak test for the diagnosis of upper airway obstruction in adults: a systematic review and meta-analysis. A positive cuff-leak test (absence of leak) should alert the clinician of a high risk of upper airway obstruction. Intensive Care Med,2009
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  • Laryngeal ultrasound: a useful method in predicting post-extubation stridor Ding LW Eur Respir J.2006
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  • Laryngeal ultrasound- no oedema
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  • Laryngeal ultrasound- with oedema Inflated cuff Deflated cuff
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  • Predicting difficult extubation.. Spontaneous Breathing trial T piece 30 45 minutes
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  • Contribution of the Endotracheal Tube and the Upper Airway to Breathing Workload STRAUS C et al. AM J RESPIR CRIT CARE MED 1998 Total WOB A 2-h trial of spontaneous breathing through an ETT tube well mimics the WOB performed after extubation
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  • Strategies for difficult extubation Tracheal tube exchange catheter/gum elastic bougie Extubation over flexible bronchoscope through an LMA
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  • Cook airway exchanger Anticipated difficult extubation
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  • Slide 39
  • Conclusion Respiratory adverse events are more frequent during tracheal extubation than during anesthesia induction. Tracheal extubation is a routine manuvre but required full attention to prevent respiratory complications. Difficult intubation = anticipate difficult extubation Difficult extubation should be anticipated with a predefined strategy.
  • Slide 40
  • Safe landing is equally important