ExtubationCriteria.pptVIP

Extubation Criteria J. Prince Neelankavil, M.D. Case 71 y.o. male s/p laparascopic surgery presents to the PACU intubated. Pt. remained intubated secondary to residual neuromuscular blockade H/O HTN, DM When should we extubate? General Principles Why was the patient intubated in the first place? Inadequate oxygenation/ventilation/airway protection. Patient should have adequate respiratory drive, respiratory muscle strength, cough reflex to clear secretions, laryngeal function and clearance of sedative and neuromuscular blocking medications. Adequate Gas Exchange? Adequate arterial partial pressure of oxygen: [PaO2/FIO2] ratio 150-200 Appropriate pH (pH 7.25) and arterial partial pressure of carbon dioxide during spontaneous ventilation Pass a Breathing Trial? 30–120 minute spontaneous breathing trial with low level of CPAP (e.g. 5 cm H2O) or low level of pressure support (e.g. 5-7 cm H2O) Show gas exchange (ABG), hemodynamic stability, and subjective comfort Pass These Numbers? RR 35 Vital capacity than 10 mL/kg NIF -20 Tidal Volume 5mL/kg Minute ventilation 10L/min Thoracic compliance 25 mL/cm H2O Able to Protect Airway? Appropriate level of consciousness Adequate airway protective reflexes (cough, swallow, vocal cord movement) Adequate managed secretions All Systems Go? Hemodynamic Stability (+/- 20%) Nutritional status allowing for respiratory muscle strength Risk Factors for Failed Extubation ICU patient Age 70 or 24 months Hemoglobin 10 mg/dL Longer duration of mechanical ventilation Medical or surgical airway condition Frequent pulmonary toilet Loss of airway protective reflexes What do you need to extubate? Oxygen source Suction Oral/Nasal airways Face masks Endotracheal tubes LMA Pulse ox Cardiac Monitors CO2 detectors Ambu bags What did we do before we extubated our patient? Ensured proper equipment needed for reintubation Monitoring BP, HR, Sat, RR Used a twitch monitor to demonstrate no fade on TOF/sustained tetany Turned off th