The Intubator's Deep Extubation Technique

The Intubator doesn't just intubate, he also knows how to extubate deep!

Here's a step-by-step guide to The Intubator's Deep Extubation technique. Use it for your next hernia or thyroid, and when the patient wakes up silky smooth, you'll look like a boss! (disclaimer: these notes are only intended for use by fully-trained anesthesia providers). To the best of The Intubator's knowledge, this technique has never been described in the literature! 

There are three easy conditions which must be satisfied:

1. You must have access to the airway and you know the patient is an easy mask. 

2. The patient must not be an aspiration risk.

3. There are no contraindications to succinylcholine.

Ok, now that you've satisfied those conditions, let's get to the steps. 

1. When the surgeon is closing, get the patient breathing spontaneously (optional, but it helps).

2. Reverse the patient with Sugammadex. 

3. When the surgeons are almost done, give succinylcholine IV: 1 mL (20 mg) for smaller adults, 2 mL (40 mg) for larger adults.

4. After about 45 - 60 seconds, the EtCO2 tracing will start getting smaller, and the patient may become apneic, or near apneic. 

5. When the EtCO2 is at its nadir, suction the oropharynx thoroughly; try to suction deeply (residual secretions will cause coughing).

6. Immediately after suctioning, deflate the ETT pilot balloon and extubate the patient. Insert an oral airway and begin mask ventilating the patient. There should not be any issues masking the patient since you already know they are maskable, and the succinylcholine will prevent any laryngospasm from the extubation.

7. Turn off all anesthetic agents, put up your flows, and continue masking the pt and supporting their ventilation.

8. After about 3-5 minutes, the patient will begin breathing again and their tidal volumes will start increasing, at which point you can start decreasing your ventilatory support. You can either take them to the PACU asleep, or have them wake up in the OR! Your patient should wake up smoothly!

I know you've got questions, so here are the FAQs:

Aren’t you concerned about laryngospasm or aspiration with this technique?

Regarding laryngospasm: the use of succinylcholine eliminates the risk of laryngospasm during extubation, which is when the risk is highest. A very small risk of laryngospasm does exist while the patient is emerging from anesthesia, but the most likely trigger would be secretions, which we have done our best to suction. Consider a dose of glycopyrrolate if you want to hedge your bets regarding secretions.

Regarding aspiration: this technique is not for patients who are an aspiration risk. Having said that, consider this: once the patient is extubated, the risk of aspiration isn't any greater than the time period when you're mask ventilating after induction and before intubation; if the patient is appropriately NPO and not otherwise at risk for aspiration, the risk of aspiration should be exceedingly small.


Why do you use succinylcholine?

The temporary paralysis that succinylcholine provides is very predictable, and it allows you to suction the oropharynx and extubate the patient without any bucking or laryngospasm.


Why use Sugammadex and not neostigmine?

Neostigmine will lengthen the duration of action of the succinylcholine, whereas Sugammadex has no interaction with succinylcholine.


Why not use propofol instead of succinylcholine?

You could, but a large amount of propofol may be required to achieve a deep enough level where the patient won’t respond to deep suctioning and extubation. In addition, a bolus of propofol so close to emergence will definitely delay your wakeup.


Some people just insert an LMA after extubating—why not just do that?

You could, but there are several downsides: 1) you’re throwing out an LMA after using it for a few minutes; 2) the patient is more likely to react to an LMA than an oral airway; 3) any lubricant used on the LMA runs the risk of becoming secretions which will lead to coughing; and 4) if you don’t have a good seal with the LMA, this will add time and energy to troubleshoot.


What’s the benefit of using such a small dose of succinylcholine?

The duration of action of succinylcholine is directly related to the dose. The less you use, the shorter the duration of action.


Isn’t laryngospasm a concern when you have the oral airway inserted and the patient is emerging from anesthesia?

I suppose it’s a theoretical risk but not one I’ve ever seen during emergence after deep extubation. Even if it were to occur, you would notice it right away, and you’re fully prepared to act with succinylcholine and mask ventilation.


Should I use IV lidocaine or an LTA?


I would not use an LTA. This just puts more fluid in the trachea, which is a great way to make a patient cough. A bolus of IV lidocaine 1-2 mg/kg supposedly helps decrease the coughing response but I can’t say I’ve been impressed with its action despite many years of using it.