Appendix

A
Extubation Protocol
 CTICU guidelines:
Extubation Protocol

AIM:
To provide a guideline for extubation of post-operative cardiac surgery patients.

BACKGROUND:
Early extubation of cardiac surgery patients leads to shorter length of ICU stay and reduces the
risks associated with mechanical ventilation. It is our goal to extubate all appropriate patients
within 4-6 hours of ICU admission. This policy is written to facilitate patient selection for early
extubation and direct extubation procedures.

MANAGEMENT:
1. Patients that should be excluded from early extubation:
• Significant post-operative bleeding, >100mls per hour
• Left ventricular ejection fraction <30%
• Signs of worsening cardiovascular dysfunction (eg. rising inotrope
requirements)
• Emergency cases with pre-operative respiratory failure
• High inotrope and vasoconstrictor use (eg. >0.1 mcg/kg/min of both
adrenaline and noradrenaline, or equivalent)
• Persistent acidosis with pH <7.30
• Prolonged high post-operative oxygen requirement (FiO2 >0.5) that does not
respond to recruitment
• Anuric renal failure patients with no dialysis access
• Difficult endotracheal intubation (grade IIIb or IV)
• Patients who require suctioning every hour or more frequently for secretions
• Prolonged cardiopulmonary bypass times (> 180 minutes)
• Aorta surgery (eg. for dissection or thoracic aortic aneurysm)

Matthew Cove, Juvel Taculod

Approved by G MacLaren
Page 1 of 3
December 2013
2. Identifying that a patient is ready for extubation is a team effort:
2.1 Role of Nurse
• On arrival to CTICU, patient warming to normothermia should be initiated
• Once the patient is stable and normothermic, sedation should be weaned;
aiming for a calm, cooperative, comfortable patient.
• On SIMV/VC with no complications
• Pain should be well controlled
• Inform RT if patient is ready for spontaneous breathing trial (SBT)
2.2 Role of RT
• Initiate SBT, pressure support 10, PEEP 5, FiO2 ≤0.4
• After 30 minutes assess arterial blood gas, respiratory pattern, and patient’s
ability to take deep breaths on pressure support.
• Alert CTICU fellow if patient ready for extubation
2.3 Role of CTICU fellow
• Assess neurology (is patient awake? following commands?)
• Rule out acidosis, alkolosis and severe electrolyte disturbances
• Asses upper airway control (able to lift head and attempt to open mouth to
command? Can patient take a deep breath to command?)
• Assess respiratory pattern (comfortable? Accessory muscle use? Paradoxical
chest wall movement?)
• Acceptable gas exchange on ≤FiO2 0.4 (PaO2>60, SaO2 ≥96%)
• Inotrope support <0.05 adrenaline and noradrenaline and on downward trend.
• No new pathology on chest x-ray (eg. pulmonary infiltrates or
pneumothorax)

3. Extubation Procedure
• Prepare and ensure the following equipment is at the bedside prior to extubation and
in good working condition: suction machine, suction catheter, Bag-valve-mask
attached, nasal cannula/ Venturi mask.
• Physician written order required to extubate.
• Sit patient upright, suction oral cavity, hypopharynx and endotracheal tube (ETT).

Matthew Cove, Juvel Taculod

Approved by G MacLaren
Page 2 of 3
December 2013
 • After the above are completed, proceed with removal of ETT and put patient on nasal
cannula at 4 L/min or Venturi Mask 0.4, depending on the PaO2 prior to extubation
4. Post-extubation monitoring
• Monitor for signs of respiratory distress; increased heart rate, high blood pressure,
cool peripheries, progressive tachypnoea or increased work of breathing
• Check ABG 30-60 minutes after extubation
• Re-check ABG if patient drowsy or dysnoeic

5. Summary table

Clinical signs patient ready to extubate Measures patient ready to extubate:

• Awake, follows commands, able to
support upper airway
• Can take deep breath on command
• Comfortable respiratory pattern.
• No signs of significant bleeding
• Stable haemodynamically
• Appropriate gas exchange - PaO2 >60, PaCO2
<50 with normal pH, SaO2 ≥96% on FiO2 ≤0.4
• Inotropes weaning and on minimal levels
(adrenaline and noradrenaline <0.05)
• Absence of acidosis or alkalosis or severe
electrolyte disturbances
• No significant CXR changes

Matthew Cove, Juvel Taculod

Approved by G MacLaren
Page 3 of 3
December 2013