What medications are recommended for a smooth extubation?

Medications for Smooth Extubation

For routine extubation in uncomplicated patients, administer propofol 0.5 mg/kg IV 60 seconds before extubation to significantly reduce laryngospasm and coughing, ensuring the patient is breathing regularly and reacting to the tracheal tube. 1

Primary Pharmacologic Strategy

Propofol for Laryngospasm Prevention

• Propofol 0.5 mg/kg IV given 60 seconds before extubation reduces laryngospasm from 20% to 6.6% in pediatric patients undergoing tonsillectomy 1
• This subhypnotic dose inhibits airway reflexes without causing re-sedation 1
• Extubation should occur when the patient is breathing regularly and reacting to the tracheal tube 1

Alternative Propofol Strategies

• For patients already on propofol infusions, continue until 30 minutes before planned extubation, then discontinue while maintaining reduced opioid/benzodiazepine infusions 2
• In cardiac surgery patients, propofol target-controlled infusion (1.5-2 mcg/mL) combined with remifentanil allows scheduled extubation with spontaneous breathing achieved 15±5 minutes after propofol discontinuation 3

Laryngospasm Treatment Protocol

If laryngospasm occurs despite prophylaxis, follow this escalating approach 4:

1. Apply continuous positive airway pressure with 100% oxygen while maintaining airway patency 4
2. Larson's maneuver: Apply deep pressure in the "laryngospasm notch" between the posterior mandible and mastoid process while performing jaw thrust 4
3. Propofol 1-2 mg/kg IV for persistent laryngospasm (larger doses needed for severe/total cord closure) 4
4. Suxamethonium 1 mg/kg IV for worsening hypoxia with continuing severe laryngospasm unresponsive to propofol 4
5. Alternative routes if no IV access: intramuscular (2-4 mg/kg), intralingual (2-4 mg/kg), or intraosseous (1 mg/kg) 4

Lidocaine Considerations

Prophylactic IV lidocaine is NOT recommended for routine extubation 5:

• Prophylactic lidocaine 1 mg/kg IV prior to extubation showed no significant reduction in post-extubation cough (20.7% vs 28.7% placebo) with only 28.1% efficacy 5
• Therapeutic lidocaine 0.5 mg/kg IV is effective if cough occurs post-extubation (80% success vs 38.5% placebo) 5
• Topical lidocaine sprayed on vocal cords at induction may reduce laryngospasm risk following short procedures 4

Opioid Management

For Immediate Post-Extubation Analgesia

• Remifentanil 0.1 mcg/kg/min started immediately after discontinuing anesthesia provides effective analgesia in 60% of patients 6
• Incremental increases of 0.025 mcg/kg/min every 5 minutes can treat moderate-severe pain 6
• Decrease infusion by 50% if respiratory rate falls below 12 breaths/min to minimize respiratory depression (4% incidence with this threshold vs 12% with threshold of 8 breaths/min) 6
• Median time to extubation with remifentanil is 5-6 minutes 6

Transition Strategy

• Administer morphine 0.15 mg/kg in divided doses 5 and 10 minutes before discontinuing remifentanil to prevent rebound pain 6
• Without transition opioid, effective analgesia decreases to 34% within 30 minutes of remifentanil discontinuation 6

Neuromuscular Blockade Reversal

Quantitative Train-of-Four (TOF) must be >90% before extubation 4:

• Lack of reliable signal (calibration error, patient movements, defective sensors) should prompt systematic antagonism 4
• Short-acting muscle relaxants or those rapidly inactivated should be used when difficult intubation is anticipated 4

Post-Extubation Stridor Management

• Inhaled epinephrine should be used to treat post-extubation stridor in conscious patients 4
• No recommendation for routine prophylactic methylprednisolone to prevent stridor 4

Adjunctive Medications

• Antinauseants should be ordered PRN with opioids 4
• No recommendation for routine anticholinergic medications to prevent upper airway secretions 4
• No recommendation for routine furosemide to prevent congestive heart failure post-extubation 4

Critical Pitfalls to Avoid

Do not use bolus doses of remifentanil or incremental increases ≥0.05 mcg/kg/min in the immediate postoperative period, as this leads to respiratory depression and muscle rigidity 6. When midazolam doses exceed 2 mg (4-8 mg range), remifentanil dose should be decreased by 50%, though this increases respiratory depression incidence to 32% 6.

Avoid deep extubation in routine cases as the risk of laryngospasm is greatest during lighter planes of anesthesia 4. Suction should be performed under direct vision with the patient deeply anesthetized, with no further stimulation until the patient is awake 4.