Consultant decision that a patient is ready for extubation.
Enteral feeds stopped at least four hours prior to planned extubation.
IV sedation stopped at least four hours prior to extubation. There may be exceptions - e.g. long term patients who have developed tolerance who are on a weaning programme. In babies who are challenging, the use of chloral hydrate should be considered. Older children may have a Propofol infusion under the direction of a consultant.
The doctor performing the extubation must have a plan of how the patient will be reintubated if the patient fails extubation. If the doctor is not an anaesthetist, competent in managing a child of that age, the PICU consultant will need to be in the hospital at the time of extubation (if the consultant is called out on retrieval and therefore not available, the extubation will have to be delayed until his/her return. This may require the patient to be re-sedated).
Immediately prior to extubation
- Aspirate NG tube
- Ensure all equipment ready:
Bag and mask
Calling the anaesthetist on bleep 6000 (or the adult ITU registrar with the event of them being busy) is for emergencies only.
A failed planned extubation should not be an emergency.
Post extubation stridor
nebulised adrenaline 0.5ml/kg 1 in 1000 (max 5ml)
and dexamethasone 0.5mg/kg IV (max 10mg).
Prophylaxis against post extubation stridor
Used in patients with history of failed extubation due to upper airway obstruction, and in some ENT cases
Dexamethasone: 0.5mg/kg IV qds (max 10mg) Start 6 - 12 hours prior to extubation, up to 6 doses may be given.
A lower dose is sometimes given at Consultant's discretion.
Monitor glucose and BP carefully.