EXTUBATION AND
TRANSFERING TO ICU
PREPEARED BY :
AHMAD ULLAH
HIDAYAT ULLAH
LAVIZA NOOR
NOOR KHALID
6TH SEMESTER
ANESTHESIA
EXTUBATION
• Extubation is described as the discontinuation of an artificial airway.
• It is the final step in liberating the patient from mechanical
ventilation.
• It is an elective process and should be carried out in a controlled
manner with the same standards of monitoring, equipment and
assistance that are available at induction.
AIRWAY PROTECTION
• Airway protection is the ability to guard against aspiration during
spontaneous breathing.
• It requires sufficient cough strength and an adequate level of
consciousness , each of which should be assessed prior to extubation
because airway protection is significantly more difficult when
secretions are increased.
CRITERIA FOR EXTUBATION
1. HEMODYNAMICALLY STABLE
optimal fluid balance
No dysrhythmias
minimal inotropes requirement
2. ADEQUATE VENTILATION AND OXYGENATION
FIO2 < 0.5
Vital capacity of > 10ml/kg
Tidal volume > 5ml /kg
Respiratory rate < 25 BPM
3. ARTERIAL BLOOD GASES
PCO2 < 6kpa
PH with a normal range ( 7.35 – 7.45 )
Others are :
Patient must be neurologically intact. Awake, well motivated , follows
verbal commands and intact gag/ cough reflex .
Take into consideration aspiration risk and airway edema.
Factors Associated With Increased Risk of
Extubation Failure
1. Advanced age ( 70 y).
2. Duration of ventilation before extubation.
3. Anemia (hemoglobin 10 g/dL, hematocrit < 30).
4. Severity of illness at time of extubation.
5. Semirecumbent positioning after extubation.
6. Use of continuous intravenous sedation.
7. Need for transportation outside the ICU.
8. Unplanned extubation.
Causes of Extubation Failure
• Extubation failure is often caused by mechanisms that affect upper
airway patency, including laryngospasm, vocal cord dysfunction,
laryngeal edema, airway trauma, and pharyngeal obstruction.
• In cases of severe upper airway obstruction, negative-pressure
pulmonary edema can develop, requiring re-intubation.
• Other causes include excess respiratory secretions, inability to protect
the airway, cardiac failure or ischemia, encephalopathy, residual effects
of neuromuscular blockade or sedative medications, and aspiration.
• Weaning failure that was not present or recognized before extubation
can also present as extubation failure.
EXTUABTION AFTER
CARDIOTHORACIC SURGERY
• After minor cardiothoracic surgeries the patient status should be
check If the patient is stable on all parameters which is discuss
previously , so extubate the patient.
• And if the surgery is major like open heart surgeries the patient will
shift to ICU with mechanical ventilation.
• After 1 week if the patient is stable hemodynamically , neurologically
with good Glasgow coma scale, normal ABGS and there is no
bleeding so extubate the patient and if not stable so go towards
tracheostomy.
• Extubation should not be performed until it has been determined that
the patient's medical condition is stable, a weaning trial has been
successful, the airway is patent, and any potential difficulties in
reintubation have been identified.
• Patients cannot be extubated unless the condition for intubation is
improved and the clinical criteria for weaning have been met.
CRITERIA FOR EXTUBATION IN ICU
• Adequate oxygenation and gas exchange
• Pao2 >60mmHg on FiO2 <40%
• PEEP 5-8cmH2O
• CXR is stable or improving
NEUROLOGICALLY
• The patient must be :
• Awake , cooperative , alert and oriented
• Able to lift his/her head off the pillow
• GCS > 13, minimal sedation
W
• Able to move all limbs and obey simple verbal command
RESPIRATORY
• The patient must have :
• Adequate and equal chest movement / breath sounds
• Peak end expiratory pressure/continues positive airway pressure (CPAP) 5 to
8mmHg
• Tidal volume 6-8ml/kg
• Able to protect airway ( cough, gag and shallow reflexes intact )
• Positive cuff leak test
• Minimal secretion
• A strong effective cuff
BLOOD GAS PARAMETERS
• PH 7.35-7.45
• PaCO2 < 45mmHg
• HCO3 20-30mmol/L
• O2 sat >95%
CARDIOVASCULAR
• The patient must have :
• Absent or low dose inotropes / vasopressor
• A stable blood pressure in a setting position
• A stable cardiac rhythm
• Adequate perfusion
VENTILATOR CRITERIA
• RSBI (RR/VT) < 100
• NIF > 20 cm H2O
• VT > 5ml/kg
• VC > 10ml/kg
• RR < 30 BPM
METABOLIC
• The patient temperature must be greater then 36 degree C and less
than 39 degree C.
SURGICAL
• Less than 100ml per hour draining from intercostal drain and or no
evidence of tamponade.
SUBJECTIVE CRITERIA
• Underlying disease process improving / resolving.
GLASGOW COMA SCALE
• The Glasgow Coma Scale (GCS) is used to objectively describe the
extent of impaired consciousness in all types of acute medical and
trauma patients.
• The scale assesses patients according to three aspects of
responsiveness: eye-opening, motor, and verbal responses.
• This is very important for extubation , if the patient have good score
of it so extubate the patient.
TRANSFERING TO ICU
• Transporting patients with critical illness from the operating room to
the ICU is a consistently nerve wracking and occasionally hazardous
process that is complicated by the possibilities of monitor failure over
dosage or interruption of drug infusions and hemodynamically
instability.
• Portable monitoring equipment , infusion pumps , and a full oxygen
cylinder with a self inflating bag for ventilation should be readied
prior to the end of the operation.
• Minimum monitoring during transportation includes the ECG, arterial
blood pressure and pulse oximetry.
• A spare Endotracheal tube, laryngoscope, succinylcholine, and
emergency resuscitation drugs should also accompany the patient.
• Upon arrival in the ICU, the patient should be attached to the
ventilator, Breath sounds should be checked, and an orderly transfer
of monitors and infusions should follow.
MONITORING
ECG
ARTERIAL BLOOD
PRESSURE
PULSE OXIMETRY
• The handoff to the ICU staff should include a brief summary of the
procedure which performed in operating room, current drugs therapy,
and any expected difficulties.
• Many centers insist on a standard protocol for the “handoff”, and we
strongly recommend this practice.
THANKS
