The LITA tube is an expensive way to perform the "Kempen technique" of lidocaine

installation via any  existing ETT. That LITA ETT has an injection port just

above the cuff, and you must have one of these expensive tubes in place to do

the lidocaine injection. My technique uses only ANY Standard ETT as the mode of

injection (see last post).

I have heard the statement: " I have never regretted NOT extubating a patient,

but have regretted an extubation". I personally do not agree with this as some

signficant pertubations can be caused by an in situ ETT. Also, although we take

great care in trying to "minimize hemodynamic pertubations at intubation" the

area regarding minimizing hemodynamic and respiratory pertubations at EXTUBATION

is often deemed a "fact of life" or otherwise acceptable consequence of avoiding

laryngospasm by waiting till awake.  I routinely assess the airway during

induction for the purpose of eliminating the ETT as soon as practical. LIdocaine

will obliterate the stimulus, which can become the cause of reflex=laryngospasm!

Traveling down the hallway to a distant PACU with an ETT or even LMA can lead to

significant hemodynamic and ventlatory pertubations in an unanesthetized airway.

Hence my personal preference to extubate as soon as possible in the OR and

observe to

  assure airway patency in the spontaniously ventilating patient-some jaw thrust

can be required! At the same time if agent is eliminated early and after the ETT

tracheal tissues have been anesthetized, you can typically go to very minimal

level of anesthesia (i.e. N2O alone) or emerge the patient to "open your eyes

and stick out your toung" to then pull  the ETT without any pertubation. The

great thing is the ability to assess the numbness vie "the cuff Test" while the

ETT is still in and airway assurred!

Gotta try it to appreciate it. The key is hjaving a good 3 liter of gass pass up

through the cords while actively bagging at a pressure of 20-30 minimum to carry

the slowly injected 5 cc of 2% lidocaine up from the tip of the ETT toward the

tounge!



P Kempen

Cleveland

The LITA tube is an expensive way to perform the "Kempen technique" of lidocaine installation via any  existing ETT. That LITA ETT has an injection port just above the cuff, and you must have one of these expensive tubes in place to do the lidocaine injection. My technique uses only ANY Standard ETT as the mode of injection (see last post).
I have heard the statement: " I have never regretted NOT extubating a patient, but have regretted an extubation". I personally do not agree with this as some signficant pertubations can be caused by an in situ ETT. Also, although we take great care in trying to "minimize hemodynamic pertubations at intubation" the area regarding minimizing hemodynamic and respiratory pertubations at EXTUBATION is often deemed a "fact of life" or otherwise acceptable consequence of avoiding laryngospasm by waiting till awake.  I routinely assess the airway during induction for the purpose of eliminating the ETT as soon as practical. LIdocaine will obliterate the stimulus, which can become the cause of reflex=laryngospasm! Traveling down the hallway to a distant PACU with an ETT or even LMA can lead to significant hemodynamic and ventlatory pertubations in an unanesthetized airway. Hence my personal preference to extubate as soon as possible in the OR and observe to
assure airway patency in the spontaniously ventilating patient-some jaw thrust can be required! At the same time if agent is eliminated early and after the ETT tracheal tissues have been anesthetized, you can typically go to very minimal level of anesthesia (i.e. N2O alone) or emerge the patient to "open your eyes and stick out your toung" to then pull  the ETT without any pertubation. The great thing is the ability to assess the numbness vie "the cuff Test" while the ETT is still in and airway assurred!
Gotta try it to appreciate it. The key is hjaving a good 3 liter of gass pass up through the cords while actively bagging at a pressure of 20-30 minimum to carry the slowly injected 5 cc of 2% lidocaine up from the tip of the ETT toward the tounge!

P Kempen
Cleveland

The LITA tube is an expensive way to perform the "Kempen technique" of lidocaine installation via any  existing ETT. That LITA ETT has an injection port just above the cuff, and you must have one of these expensive tubes in place to do the lidocaine injection. My technique uses only ANY Standard ETT as the mode of injection (see last post).
I have heard the statement: " I have never regretted NOT extubating a patient, but have regretted an extubation". I personally do not agree with this as some signficant pertubations can be caused by an in situ ETT. Also, although we take great care in trying to "minimize hemodynamic pertubations at intubation" the area regarding minimizing hemodynamic and respiratory pertubations at EXTUBATION is often deemed a "fact of life" or otherwise acceptable consequence of avoiding laryngospasm by waiting till awake.  I routinely assess the airway during induction for the purpose of eliminating the ETT as soon as practical. LIdocaine will obliterate the stimulus, which can become the cause of reflex=laryngospasm! Traveling down the hallway to a distant PACU with an ETT or even LMA can lead to significant hemodynamic and ventlatory pertubations in an unanesthetized airway. Hence my personal preference to extubate as soon as possible in the OR and observe to
assure airway patency in the spontaniously ventilating patient-some jaw thrust can be required! At the same time if agent is eliminated early and after the ETT tracheal tissues have been anesthetized, you can typically go to very minimal level of anesthesia (i.e. N2O alone) or emerge the patient to "open your eyes and stick out your toung" to then pull  the ETT without any pertubation. The great thing is the ability to assess the numbness vie "the cuff Test" while the ETT is still in and airway assurred!
Gotta try it to appreciate it. The key is hjaving a good 3 liter of gass pass up through the cords while actively bagging at a pressure of 20-30 minimum to carry the slowly injected 5 cc of 2% lidocaine up from the tip of the ETT toward the tounge!

P Kempen
Cleveland

So you have enough ventilators in the PACU to cover virtually all of your beds?

We extubate in the OR unless the pt is going to stay ventilated, and seldom have

more than 2 or 3 vents going at once. Getting any more is a major hassle.





Sanford M. Miller, MD

sanford.miller@...



________________________________



	 From: Anesthideas@yahoogroups.com [mailto:Anesthideas@yahoogroups.com] On

Behalf Of James DuCanto

	 Sent: Friday, July 03, 2009 5:56 AM





	 Our practice of extubation in the OR vs recovery room is largely dictated by

the culture of the institution.  The recovery room nurses at my institution are

all ICU trained, so they don't flinch when a patient arrives that needs a

ventilator or a t-piece.

	 Jim

So you have enough ventilators in the PACU to cover virtually all of your beds? We extubate in the OR unless the pt is going to stay ventilated, and seldom have more than 2 or 3 vents going at once. Getting any more is a major hassle.


Sanford M. Miller, MD
sanford.miller@nyumc.org

________________________________

From: Anesthideas@yahoogroups.com [mailto:Anesthideas@yahoogroups.com] On Behalf Of James DuCanto
Sent: Friday, July 03, 2009 5:56 AM


Our practice of extubation in the OR vs recovery room is largely dictated by the culture of the institution. The recovery room nurses at my institution are all ICU trained, so they don't flinch when a patient arrives that needs a ventilator or a t-piece.
Jim

Get an RT specifically assigned to the PACU? Buy enough ventilators to supply

the PACU if most pts come in intubated? In the midst of a hiring/purchasing

freeze? Try to persuade the PACU nurses that it's OK for us to do this? Get the

administration to understand thta this may be ultimately a money-saving

proposition? Make our municipal hospital (where the residents do the actual

work) more like a surgicenter?



Even in one's wildest dreams, it won't happen. Hard enough to get pts into the

ORs on time in the morning. Efficiency isn't happening.





Sanford M. Miller, MD

sanford.miller@...









________________________________



	 From: Anesthideas@yahoogroups.com [mailto:Anesthideas@yahoogroups.com] On

Behalf Of Ivan Hronek

	 Sent: Friday, July 03, 2009 1:13 PM



		 You can do that - these don't have to be sophisticated ventilators but usually

you can get most patients breathing spontaneously towards the end of the case

which then becomes the 'challenge' for us to achieve. Like Jim says, it's all

just what you get people used to doing - then they consider that normal. If you

get a respiratory tech assigned to PACU with a sufficient amount of circuits and

explain the advantages of such an arrangement everyone understands - the

administration, the surgeons and the anesthesiologists will all be happier as

they get more done in a shorter period of time and the OR becomes more like an

efficient surgicenter - look at the smoothness and low level of frustration in

those in comparison with regular ORs.