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  1. “pulling it out is more satisfying these days than putting it in.”

    - scott weingart

    here’s his extubation algorithm, pulled from

    http://blog.emcrit.org/podcasts/extubation/

    Inclusion:
    - Resolution of clinical issue requiring intubation
    - Sp02 > 95% on FiO2 ≤40%, PEEP ≤5 cm H20
    - RR < 30, SBP > 100, HR <130
    - Patient not known to be a difficult intubation

    Preparation:
    - Turn off sedatives
    - Leave opioids on at a low dose (e.g. fentanyl 50 mcg/hr)
    - Allow patient to regain full mental status
    - If patient shows signs of discomfort, consider administering more pain medication
    - Patient should be able to understand and respond to commands

    Testing for readiness:
    - Ask patient to raise arm and leave in the air for 15 seconds
    - Ask patient to raise their head off the bed
    - Ask patient to cough, they should be able to generate a strong cough
    - Place patient on pressure support at a setting of 5 cm H20 and sit patient up to at least 45 degrees
    - Observe for 15-30 minutes, if SpO2 < 90%, HR > 140, SBP > 200, severe anxiety, or decreased LOC >> discontinue extubation attempt

    Procedure:
    - Have a nebulizer filled with normal saline attached to a mask
    - Sit patient up to at least 45 degrees
    - Suction ETT with bronchial suction catheter
    - Suction oropharynx with Yankauer suction
    - Deflate ET tube cuff
    - Have the patient cough, pull the tube during cough [[make sure pt is end-inhalation at the moment you pull tube -- rjs]]
    - Suction oropharynx again
    - Encourage patient to keep coughing up secretions
    - Place nebulizer mask on patient at 4-6 liters per minute

    After extubation:
    - Patient should receive close monitoring for at least 60 minutes
    - If patient develops respiratory distress, NIV will often be sufficient to avoid reintubation
    reuben at November 19, 2010 2:36 am Reply
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