Reclaiming the Etiquette of Extubation or the landing is as important as takeoff
Shyam J. Deshpande, MD and Justin L. Lockman MD MSEd
Today’s PAAD was written by Drs. Shyam Deshpande and Justin Lockman of the Children’s Hospital of Philadelphia. As many of our regular readers know, Justin is a member of the PAAD’s executive council and a regular contributor to the PAAD. Shyam completed his residencies in Pediatrics and Anesthesiology and is currently a fellow in both pediatric anesthesiology and critical care medicine. Additionally, he recently got married and is the son of Dr. Jayant Deshpande and Patti Scott making him a 2nd generation pediatric anesthesiologist and intensivist! Congratulations and Mazel Tov to Shyam and the entire Deshpande/Scott family! Myron Yaster MD
Original article
Wakabayashi K, le Roux JJ, Jooma Z. Reclaiming the Etiquette of Extubation. Anesthesia & Analgesia. 2023;136(6):1220-1226. PMID: 37205806
Imagine your typical day in the operating room: You crafted a meticulous anesthetic during a pre-operative conversation with the resident, including a thoughtful induction and laryngoscopy plan. The anesthesia machine has been checked and the OR fully prepared for the choreography of the procedure. The patient enters, and a well-coordinated team carefully prepares for induction, gets the patient off to sleep, and the operation progresses.
Now fast forward to the end of the same case: The circulator is on the phone with the PACU nurse, the scrub nurse is hurriedly counting instruments, dirty drapes being torn down from poles by the surgical resident, the surgical attending turned away from the patient dictating the operative report, and music blaring. The volatile anesthetic is being impatiently flushed out by the resident when the patient begins to cough – and becomes tachycardic and red in the face. The endotracheal tube is yanked out just in time for the monitor cable to be ripped off by the circulating team, and the patient is moved to a stretcher and wheeled out of the OR while the cleaning crew starts mopping the floor.
We’d like to think this never happens. Like us, you may be thinking: Of course it doesn’t happen in my operating rooms! But more likely, it sometimes does. And, there are certainly times when we all feel rushed at the end of a case, and where the planned choreography of an artful induction seems a distant memory compared to the chaos of an unruly emergence. Today’s PAAD by Wakabayashi and colleagues [1] is a perspective piece in June’s edition of Anesthesia and Analgesia, focusing on just this issue – the importance of expert preparation and execution of emergence and extubation.
Emergence and extubation represent a critical epoch of an anesthetic. Approximately one quarter of all perioperative airway complications occur during emergence and recovery, most commonly a result of upper airway obstruction or airway soiling. [2] The often-forgotten physiologic derangements experienced at emergence and extubation mirror those of induction and intubation, including tachycardia, hypertension, and increased myocardial oxygen consumption. Patients are at risk of respiratory complications (including aspiration, laryngospasm, bronchospasm, pulmonary edema, airway trauma) but are also at risk of surgical complications such as surgical site bleeding and wound dehiscence. Not to mention the risk of intracranial hypertension in some neurosurgery patients, the risk of orbital injury in some ophthalmology patients, and other organ-specific issues. Despite these risks, emergence and extubation are inconsistently respected in anesthesiology texts and commonly lack institutional guidelines and checklists. And unfortunately, fatigue at the end of a case, attempts at multitasking, and time pressure to turn over the OR can lead to the dangerous combination of high-risk situation, unstructured expectations, and inattentive personnel.
To mitigate these risks, Wakabayashi and colleagues advocate that we credit emergence and extubation with the gravity they deserve, using two concepts borrowed from the aviation industry. First, they recommend the use of a “sterile cockpit” during emergence and extubation, as many also recommend during induction/intubation. The concept includes minimizing extraneous noise, avoiding non-essential activities, and maintaining effective team communication (including limiting non-critical conversation), factors that have been shown to reduce complications in the OR. [3] Second, the authors emphasize the need for all members of the OR team to have “situational awareness” during this phase of the anesthetic (what is happening, how is the patient responding, what is the patient’s expected trajectory). Clear communication and a shared mental model (i.e., having everyone on the same page) allow for the group of people in the operating room around a patient to actually function as a team, with vigilance around patient safety and insights that help the team perform better. The authors remind us that multidisciplinary training and simulation focused on situational awareness can improve patient safety.
Next, Wakabayashi and colleagues recommend the use of pre-planned, structured techniques for emergence and extubation. They recommend crafting an individualized emergence/extubation plan for each patient, analogous to the well-crafted induction/intubation plan discussed during pre-operative planning. The authors propose that anesthesiologists should anticipate and plan for complications. They suggest that emergence and extubation ideally should occur in the OR where corrective action can most easily take place (we acknowledge that this is not always feasible and may depend on local practice). The patient should remain on all standard monitors, be positioned appropriately for possible reintubation, and be preoxygenated prior to extubation. Airway debris should be cleared. Train-of-four monitoring should be employed in all cases using neuromuscular blockade to prevent post-operative residual curarization (note: we believe that quantitative monitoring is far superior to qualitative ToF monitoring as discussed in previous PAADs). And, anesthesiologists may want to consider administration of medications to facilitate smooth emergence, such as intravenous lidocaine or dexmedetomidine (we note that there may be debate about whether maintaining deep sedation with dexmedetomidine after extubation counts as emergence or just deep extubation). The authors suggest that an extubation checklist may be considered to reduce the cognitive burden and role of human error during this fraught anesthetic phase; to us, this seems like a no-brainer given what we know about high acuity environment and human factors. We think a basic extubation checklist would be a great project for the SPA Quality and Safety Committee to consider in the future, and we would be happy to help.
The authors also suggest three non-pharmacologic techniques that may be considered in the right settings to aid with smooth emergence, including deep extubation, Bailey’s maneuver (exchanging an endotracheal tube for a supraglottic airway), and the “no-touch” technique (allowing emergence without stimulation). We have mixed feelings about the risks and benefits of each of these, but think that each of them has a place in the armamentarium. Finally, Wakabayashi and colleagues highlight that extubation is an elective procedure – it should not be rushed, and conditions should be optimized with back-up plans defined prior to proceeding.
Emergence and extubation are the culmination of most general anesthetics – a high risk phase that deserves the same planning, patience, and vigilance as induction or maintenance. By understanding the dynamic patient physiology and the competing environmental demands on the anesthesiologist, we can reframe emergence and extubation as a key component of the meticulous anesthetics our patients deserve, instead of as “the end of our anesthetic.”
We certainly want our pilots to care as much about landing as about takeoff! What do you think? Are you willing to try a sterile cockpit today in the OR for both induction and emergence? Are you already practicing this way? Do you already use an extubation checklist? If so, would you be interested in sharing/collaborating to build something even better? Email Myron at myasterster@gmail.com and he’ll post in an upcoming Friday Reader Response. We’d also like to hear from readers who work in practices in which patients are extubated in the PACU by PACU nurses!
References
[1] Wakabayashi K, le Roux JJ, Jooma Z. Reclaiming the Etiquette of Extubation. Anesth Analg. 2023 Jun 1;136(6):1220-1226.
[2] Cook TM, Woodall N, Frerk C; Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia. Br J Anaesth. 2011 May;106(5):617-31.
[3] Cook TM, Woodall N, Frerk C. A national survey of the impact of NAP4 on airway management practice in United Kingdom hospitals: closing the safety gap in anaesthesia, intensive care and the emergency department. Br J Anaesth. 2016;117(2):182-190.