Extubation Criteria O Hg, PaCO Delayed Emergence

1 Extubation Criteria - OR. 1. Adequate Oxygenation SpO2 > 92%, PaO2 > 60 mm Hg Extubation Criteria 2. Adequate Ventilation VT > 5 ml/kg, spontaneous RR > 7 bpm, ETCO2 < 50 mm & Hg, PaCO2 < 60 mm Hg 3. Hemodynamically Stable Delayed Emergence 4. Full Reversal of Muscle Relaxation Sustained tetany, TOF ratio > Sustained 5-second head lift or hand grasp 5. Neurologically Intact Follows verbal commands Intact cough/gag reflex Extubation Criteria - OR Extubation Criteria - ICU. Subjective Criteria 6. Appropriate Acid-Base Status Underlying disease process improving. pH > Objective Criteria 7. Normal Metabolic Status Adequate mentation (GCS > 13, minimal sedation). Normal electrolytes Hemodynamically stable, on minimal pressors ( Normovolemic dopamine < 5 mcg/kg/min). SaO2 > 90%, PaO2 > 60 mm Hg, PaO2/FiO2 > 150 on 8.

2 Normothermic PEEP < 5-8 cm H2O and FiO2 < Temp > PaCO2 < 60 mm Hg, pH > 9. Other Considerations Ventilator Criteria (during SBT). Aspiration risk RSBI (RR/VT) < 100, NIF > 20 cm H2O. Airway edema VT > 5 ml/kg, VC > 10 ml/kg Awake vs. Deep ( NOT in Stage II) RR < 30 bpm 51. Approach to Difficult Extubation Potential Difficult Extubation If intubation was technically difficult ( multiple DLs, History of difficult intubation FOI), consider maintaining a pathway to the trachea OSA. ( bougie, FOB, Airway Exchange Catheter). Maxillofacial trauma Generalized edema If airway edema is suspected due to fluids or traumatic Paradoxical vocal cord motion (preexisting) intubation, consider performing a Cuff-Leak Test . Post-procedural complications: Deflate cuff, occlude ETT, observe whether patient can Thyroid surgery (~4% risk of RLN injury, late hypocalcemia).

3 Breath around the tube. Diagnositc laryngoscopy +/- biopsy (laryngospasm, edema) A failed leak test does NOT always lead to failed Extubation , Uvulopalatoplasty (edema) but may warrant further patient observation; likewise, passing Carotid endarterectomy (hematoma, nerve palsies) a leak test does NOT guarantee successful Extubation . ENT surgeries (hematoma, jaw wires). Cervical decompression (edema). Stages of Anesthesia Delayed Emergence Historical terminology to describe depth of anesthesia upon gas induction. Today, more important for Emergence . Definition Stage 1 Failure to regain consciousness as expected within 20-30. Sedated, intact lid reflex, follows commands minutes of the end of a surgical procedure. Stage 2 Causes Excited/disinhibited, unconscious, unable to follow commands or exhibit 1. Residual drug effects purposeful movement Absolute or relative overdose Irregular breathing & breath-holding, dilated & disconjugate pupils, Potentiation of agents by prior intoxication ( EtOH, illicit drugs) or conjunctival injection medications ( clonidine, antihistamines).

4 Increased incidence of laryngospasm, arrhythmias, and vomiting. Organ dysfunction ( renal, liver) interfering with metabolism/excretion. Stage 3 2. Hypercapnia and/or Hypoxemia Surgical anesthesia 3. Hypothermia (<33 C). Stage 4. Medullary depression, cardiovascular/respiratory collapse 4. Hypo-/Hyperglycemia 52. Delayed Emergence Diagnosis and Treatment Ensure adequate oxygenation, ventilation, and hemodynamic Causes stability first, then proceed with: 5. Metabolic Disturbances 1. Administer reversal agents . Acid-base, hyponatremia, hypo-/hypercalcemia, hypomagnesemia Naloxone mg 2 mg IV Q 2-3 minutes. 6. Organ Dysfunction If no response after 10 mg, reconsider narcotic overdose as cause of Delayed emergency Renal failure, liver failure ( hepatic encephalopathy) Flumazenil mg IV bolus Q 45-60 seconds over 15 seconds 7.

5 Neurologic Insults May repeat doses. Maximum of 1 mg IV bolus. No more than 3 mg total in Seizure/post-ictal state one hour. Physostigmine 1-2 mg IV (for central cholinergic syndrome). Increased ICP. Neostigmine maximum of 5 mg IV. Give with glycopyrrolate. 8. Perioperative Stroke 2. Ensure patient is normothermic Risk factors: AFib, hypercoagulable state, intracardiac shunt Use Bair Hugger Incidence: in low-risk procedures; in high-risk procedures 3. Check ABG for PaO2, PaCO2, glucose, and electrolytes 4. Consider neurological insults Perform pertinent neurologic exam Consider further workup ( CT, MRI, EEG). Consider Neuro consult References Feeley TW and Macario A. The postanesthesia care unit. In Miller RD (ed), Miller's Anesthesia, 6th ed. Philadelphia: Elsevier Churchill Livingstone, 2005. MacIntyre NR et al.

6 2001. Evidence-based guidelines for weaning and discontinuing ventilatory support: a collective task force facilitated by the ACCP, AARC, and the ACCCM. Chest, 120: 375S-95S. Rashad Net University ( ). Rosenblatt WH. Airway management. In Barash PG, Cullen BF, and Stoelting RK (eds), Clinical Anesthesia, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2006. 53.