Deep Extubation

Introduction

Deep extubation is a technique used to obtain a smooth, uneventful, and successful extubation. Although the definition of a "smooth extubation" is not a consensus, it entails extubation with no straining, coughing, breath holding, laryngospasm, or other complications. Complications of extubation include respiratory, hemodynamic and traumatic. Different approaches to extubation have been described to prevent such events, and deep extubation is a common practice amongst anesthesiologists.

Definition

Deep extubation occurs when the patient has their ETT or LMA removed while still anesthetized, as opposed to awake extubation, in which the patient is fully awake. A meta-analysis of 1881 pediatric patients showed that deep extubation was associated with reduction of airway complications (odds ratio (OR) 0.56, 95% confidence interval (CI) 0.33⁻0.96, p = 0.04), cough (OR 0.30, 95% CI 0.12⁻0.72, p = 0.007) and desaturation (OR 0.49, 95% CI 0.25⁻0.95, p = 0.04) in children after general anesthesia. However, deep extubation increased the risk of airway obstruction compared with awake extubation (OR 3.38 CI 1.69⁻6.73, p = 0.0005). No difference was observed in the incidence of laryngospasm and breath-holding between the two groups regardless of airway device..

Techniques

Difficult Airway Society Guidelines to Deep Extubation:

Sequence for ‘low-risk’, deep extubation. Deep extubation is a technique that should be reserved for spontaneously breathing patients with uncomplicated airways and only performed by clinicians familiar with the technique.

1 Ensure that there is no further surgical stimulation

2 Balance adequate analgesia against inhibition of respiratory drive

3 Deliver 100% oxygen through the breathing system

4 Ensure adequate depth of anaesthesia with volatile agent or TIVA as appropriate

5 Position the patient appropriately

6 Remove oropharyngeal secretions using a suction device, ideally under direct vision

7 Deflate the tracheal tube cuff. Airway responses such as cough, gag or a change in breathing pattern indicate an inadequate depth and the need to deepen anaesthesia

8 Apply positive pressure via the breathing circuit and remove the tracheal tube

9 Reconfirm airway patency and adequacy of breathing

10 Maintain airway patency with simple airway manoeuvres or oro-/nasopharyngeal airway until the patient is fully awake

11 Continue delivering oxygen by mask until recovery is complete

12 Anaesthetic supervision is needed until the patient is awake and maintaining their own airway

Desflurane and Remifentanil:

A clinical trial of 62 patients compared deep extubation using desflurane alone (1.5 minimum alveolar concentration desflurane) to lower dose desflurane (1.0 minimum alveolar concentration of desflurane) with remifentanil (1.0 ng/mL effect-site concentration of remifentanil). The group that received remifentanil showed reduced recovery time (P < .001) and respiratory complications (48% vs 3.8%; P < .001).

Sevoflurane, Remifentanil and Dexmedetomidine:

Another study compared deep extubation in 74 adults undergoing elective otologic surgery. Three groups were assigned: a sevoflurane-remifentanil (Group SR, 1.0 MAC and 0.03 μg/kg/min respectively), sevoflurane-dexmedetomidine (1.0 MAC and 0.5 μg/kg over 10 min infusion respectively) (Group SD5, n = 24), and sevoflurane-dexmedetomidine (1.0 MAC and 0.7 μg/kg over 10 min infusion respectively) (Group SD7, n = 25). The results showed that combined with 1 MAC sevoflurane, dexmedetomidine in higher doses 0.7 ug/kg and remifentanil provided similar rates for smooth tracheal extubation. Dexmedetomidine exhibited opioid-sparing effects postoperatively and was associated with less PONV than remifentanil.

Sevoflurane and Dexmedetomidine:

A double blinded trial of 60 pediatric patients undergoing adenotonsillectomy compared deep extubation with a single dose of IV dexmedetomidine (0.5 μg/kg 5 min before extubation) to placebo. The children in both groups were induced and mantained with sevoflurane, and the group that received dexmedetomidine showed less agitation, pain, and cough (P < 0.05). Both groups showed similar postoperative vomiting. Times to emergence and extubation were significantly longer in the dexmedetomidine group (P < 0.05).

Isoflurane and Sevoflurane:

A study of 40 children compared deep extubation with isoflurane (1.5 MAC) and sevoflurane (1.5 MAC). It showed that deep extubation can be safely performed with both anesthetics. The advantages of using sevoflurane included sooner arousal (10.1 + 6.5 vs 16.3 + 9.9 min) and less breath holding. Both groups showed similar desaturation episodes, airway complications, and emergency delirium.

Sevoflurane and Desflurane:

A study of 48 children compared deep extubation with sevoflurane (1.5 MAC) to desflurane (1.5 MAC). The desflurane group showed more coughing episodes, incidence of complications after extubation, higher arousal scores, and narcotic administration in the postanesthesia care unit. No serious complications occured in either group. Readiness for discharge and actual time to discharge were not significantly different between groups.

Relevant Article Depot:

Depth of Anesthesia

A randomized controlled trial comparing Laryngeal Mask Airway removal during adequate anesthesia and after awakening in children aged 2 to 6 years. Smooth Extubation and Smooth Emergence Techniques: A Narrative Review

Extubation of children in the operating theatre

The effect of deep vs. awake extubation on respiratory complications in high-risk children undergoing adenotonsillectomy: a randomised controlled trial

Smooth Extubation Techniques in Pediatric Patients After LeFort I Osteotomy

Complications associated with removal of airway devices under deep anesthesia in children: an analysis of the Wake Up Safe database

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