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Page 1: Extubation in OR SHAJI SAINUDEEN RASHID HOSPITAL, DUBAI.

Extubation in OR

SHAJI SAINUDEEN

RASHID HOSPITAL, DUBAI

Page 2: Extubation in OR SHAJI SAINUDEEN RASHID HOSPITAL, DUBAI.

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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Cheney FW Anesthesiology 1999

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 : 1/145 500 P : 1/21 200

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Peterson GNet al. Anesthesiology 2005

Management of the Difficult AirwayA Closed Claims Analysis

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Respiratory complications associated with tracheal intubation or extubation

Induction Extubation OR Extubation PACU

Cough 1.5 % 6.6 % 3.1 % SpO2< 90 1.1 % 2.4 % 2.2 %Laryngo-Spasm 0.4 % 1.7 % 0.8 %DV 1.4 % - -DI 0.8 % - -AirwayObstruction - 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 64 112 58complications

Unintentional 25 0 25 13ExtubationSurg Compl. 10 6 16 8Neurom. blocking 4 7 11 6Opioïd residual 2 7 9 5Upper 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 bronchospasmaspiration

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 IntubatingDose 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 0.8–1.0 are obtained.

Anesth Analg. 2005 Jun;100(6):1840-5

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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 à -30 cmH2O

- SpO2 >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 ???.....Oxygénation FiO2 =1 during few minutes

buccal, pharyngeal and tracheal suctions 3 periods :

• 2 to 3 deep inspirations (recruiting manœuvre)

• 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 ++++

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Related to the surgery (ENT, head and face )

Local : oedema, hematoma, VC paralysis

Expected difficulties : jaw immobilisation

Risk factors of difficult tracheal extubation

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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

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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 theWOB 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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Conclusion

Respiratory adverse events are more frequent during tracheal extubation than during anesthesia induction.

Tracheal extubation is a routine manœuvre but required full attention to prevent respiratory complications.

Difficult intubation = anticipate difficult extubation

Difficult extubation should be anticipated with a predefined strategy.

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Safe landing is equally important