Elective Patients Should Be Extubated Awake

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Elective Patients Should Be Extubated Awake?

• Dr Harry McFarlane

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Can we extubate patients when deeply
anaesthetised?
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Yes We Can!
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1999 Survey Anesthesiologists

• Deep Extubation
• Rarely 16.2
• More Frequently 64.1
• Never 19.7
• 58.3 response J Clin Anaesth 199911(6)445-442

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Indications

• Avoid Consequences of awakening with tube
• Coughing
• Tachycardia
• Hypertension
• Bronchospasm
• Laryngospasm
• Increased pressure in cavities
• Good Surgical Result

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Little Known Facts About Coughing

• Modified valsalva
• Expiratory velocities of 28000 cms/sec or 500 mls
  /hr
• 85 of speed of sound
• Intrathoracic pressure of 300mmHg
• Can generate 1-25 Joules of energy
• 1/1000 British Thermal Unit

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Contraindications

• Potential Aspiration
• Potential Obstruction
• Existing
• Acquired
• Hazards associated with raised PCO2
• Unfamiliarity

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Alternatives?

• Modify Response
• TIVA
• REMI

Well Hello
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Remifentanil

• clinically versatile opioid
• unless little or no postoperative pain is
  anticipated.
• CNS Drugs.200418(15)1085
• does not seem to offer any advantage for
  lengthy, major interventions but may be useful
  for selected patients
• Anaesthesia 2007 62(12)1266

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Pain Relief after Epidural Excellent 230
(36) Very Good 190 (30) Intermediate 87
(13) Poor 133 (21) Anaesthesia
200156(1)75-81
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The Anaesthetic Room

• Peaceful Haven (Quiet please)
• Patient comfortable
• Fully monitored
• Everyone concentrating
• Everything to hand
• Fully anaesthetised at intubation

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Waking up in theatre

• Level of noise goes up
• Laughter! Relaxation!
• The disappearing assistant
• Monitoring off
• Move patient

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Some interesting observations

• Hoarseness occurs in 14 - 50 of patients
• Permanent in 1
• Laryngeal injury 33 of all airway claims
• Tube size
• Cuff design
• Cuff pressure
• Sex
• Type/duration of surgery
• Movement of tube
• Anesthesiology 2003, 98(5)1049-1056

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Intubation with or without relaxant2 groups of
40 patients

• Hoarseness 44 vs 16
• Days with hoarseness 25 vs 6
• Vocal cord sequelae 42 vs 8
• Days with sequelae 50 vs 5
• Anesthesiolgy 2003, 98(5)1049-1056

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More interesting observationson respiratory
complications

• Induction 4.6
• Immediate post extubation 12.6
• Recovery Room 9.5
• BJA 199880767-775

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And more

• 60 patients 3 groups of 20
• Awake Cough 18 Desat 2
• Anaesthetised Obstruction 17 Desat 1
• LMA Cough 3 Desat 0
• No respiratory complications
• 2 in awake group
• 3 in anaesthetised group
• 16 in LMA group
• Anaesthesia 1998 53(6)540-544

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Basic Anaesthetic Skills

• Timing of extubation awake or deep is part of the
  art of anaesthesia
• Deep extubation requires basic airway skill
• Is the LMA a substitute for basic airway skill?

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Recovery

• Deep extubation Premature extubation?
• Are we devolving responsibility too early
• Are problems merely postponed?
• Does your recovery room practice ABC or CBA?

We expect our patients to be awake in this
recovery room Mr Bond
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Yes We Can!
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Yes We Can!

• Selected Patients
• Selected Surgery
• Nasopharnygeal Airway
• Recovery Room Staff on your side