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My Two Methods Of Extubation

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Category: Working Anesthesiologist Assistant's
Forum Name: AA's At Work
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Topic: My Two Methods Of Extubation
Posted By: JCole
Subject: My Two Methods Of Extubation
Date Posted: 30 Aug 2009 at 4:28pm
I have seen two methods of extubation:

1. One is using lots of suction.
You suck out the mouth, nose and throat well. Then you stick a suction catheter down the tube, put it on suction and pull the tube. As the catheter comes out through the cords it sucks out all the mucus remaining in the back of the throat. The disadvantage of that method is it almost always gets them bucking on the tube before you pull it and as you pull the tube you ensure minimal volume is left in the lungs.

2. The other method which I now use is to suck out the nose, mouth and throat well. Hyperventilate the patient a little bit and get their oxygen sat as high as possible then pull the tube with positive pressure. The patient almost always coughs and I have the suction ready to get whatever they cough up. The advantage of that is they get extubated with maximum volume in the lungs.

With a tube down the nose, you can use an old English trick. Do like #2 above, except only pull the tube out about 2 inches, keeping the end of it in the back of the throat. Do everything else the same. If the patient then needs ventilation, you can hold the mouth shut, plug the other nostril and ventilate through the nasal tube to the back of the throat. (I think that may even be where they got the idea of the LMA.) That way you do not have to fight to get a mask fit should things go bad and you can sometimes just creep the nasal tube down the "groove" it has formed in the back of the throat and get it right back through the cords.

However, no matter how you do it, there is still the possibility you have to stick the tube back in. I usually have a clean ET with stylette, scope, succ and propofol (pentothal in the old days) ready to go.

Frankly, if her tidal volume was OK, her blood gases were OK, her negative inspiratory pressure was OK prior to extubation and it was only 45 seconds from the time you pulled the tube until she coded (cardiac arrest?) I would consider looking else where for the cause, not only at the inability to ventilate. She may have thrown a clot and that caused the PEA.

One thing I have found is once someone gets burned in a particular way, they take steps not to get burned that way again. A professional evaluates what they did and if they see any way to improve their care in the future, they do it. I have a big fishing box I bring with me as I know what is in it so I know what I got and have what I like.

Another of those "rules" I use to teach is be paranoid and believe in Murphy's Rule. If you are ready for bad stuff, it usually does not happen. If you are not ready, sure as shooting it is going to happen.

------------------------------------------------------------------------------------------------------------------- - = Doctorate Of Nurse Anesthesia Practice


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