Extubation Criteria

A lot of attention is placed on intubations, however extubation of a patient is just as important and requires diligence and preparation in order to avoid complications. Routine extubation at the end of a surgical procedure is generally very safe, but it is reasonable to have back up equipment readily available or know where it is to grab in the case of needing to reintubate. If you go about this process in an organized and systematic manner, you can create a safe scenario for the patient to be transferred to the PACU for remainder of their recovery. Most providers pick up on this process quickly in training and do many of the right moves without thinking about it, but let’s review the steps that go into extubating a patient.

First you must decide if you want to wake the patient up fully (majority of scenarios) or extubate under a deep level of anesthesia. The big benefit of extubating under a deep plane of anesthesia is avoiding coughing which may increase blood pressure, intracranial and intrabdominal pressures, or risk disrupting surgical sutures around the head/neck/chest regions. Saving time is not a good enough reason on it’s own to justify a deep extubation. A patient is still at risk for airway obstruction either from soft tissue collapse or laryngospasm after extubation and needs to be monitored closely. In order to safely perform a deep extubation, ensure that your patient:

• Has no remaining neuromuscular blockade

• Had a good airway with an easy intubation

• Has no increased risk for aspiration

• Is normothermic with normal vital signs

• Is breathing with little to no positive pressure support and achieving adequate tidal volumes

Patients who you may not want to perform a deep extubation on include scenarios with:

• difficult airways/intubations

• residual neuromuscular blockade

• COPD

• Full stomachs (ie. recent food ingestion, pregnant, obese, diabetic patients)

For most patients, you will wake them up fully with little to no anesthetic left in their system. Learning when to discontinue the anesthetic based on the progression of the end of a surgery is an art that gets easier with experience. It is not an on and off switch and waking up a patient requires undivided attention. Here are some of the steps performed during extubation:

• Discontinue anesthetics

• Reverse the paralytic or ensure that the paralytic has worn off using a twitch monitor and performing a “train-of-four” (TOF >0.9 is necessary to ensure complete reversal)

• Place a bite block to avoid having the patient bite on the tube

• Suctioning out the mouth helps reduce any airway sections that can lead to laryngospasm

• Coughing ensures a gag-reflex and ability to protect airway

• Allow the patient to breathe on their own with little to no support from the ventilator with adequate tidal volumes

• Grimacing, furrowing of eyebrows, and swallowing are signs that the patient is close to being awake

• Ideally your patient is able to follow commands (ie. open their eyes, squeeze a hand)

• Sometimes patients can wake up delirious and it is safer to extubate than waiting for them to follow a command

Leaving a patient intubated after a surgical procedure is not an easy decision. It uses resources (ie. ICU bed) and can be stressful for the patient’s family. However, it may be what is safest for the patient at the time. Majority of these situations get better with time and the patient can be extubate in a timely manner. Here are some examples of when to keep your patient intubate after surgery:

• Unresolved hypoxemia

• Excessive hypercarbia

• Hypothermia

• Residual neuromuscular blockade (ie. Pseudocholinesterase deficiency)

• Hemodynamic instability, critically ill

• Difficult intubation

• Excessively long surgery

• Unable to protect airway