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Elective Patients Should Be Extubated Awake?

Elective Patients Should Be Extubated Awake?. Dr Harry McFarlane. Can we extubate patients when deeply anaesthetised?. Yes We Can!. 1999 Survey Anesthesiologists. Deep Extubation Rarely 16.2% More Frequently 64.1% Never 19.7% 58.3% response J Clin Anaesth 1999;11(6):445-442 .

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Elective Patients Should Be Extubated Awake?

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  1. Elective Patients Should Be Extubated Awake? Dr Harry McFarlane

  2. Can we extubate patients when deeply anaesthetised?

  3. Yes We Can!

  4. 1999 Survey Anesthesiologists Deep Extubation Rarely 16.2% More Frequently 64.1% Never 19.7% 58.3% response J Clin Anaesth 1999;11(6):445-442

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

  6. 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

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

  8. Alternatives? • Modify Response • TIVA • REMI Well Hello

  9. Remifentanil “clinically versatile opioid” “unless little or no postoperative pain is anticipated….” CNS Drugs.2004;18(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

  10. Pain Relief after Epidural Excellent 230 (36%) Very Good 190 (30%) Intermediate 87 (13%) Poor 133 (21%) Anaesthesia 2001;56(1):75-81

  11. The Anaesthetic Room • Peaceful Haven (Quiet please) • Patient comfortable • Fully monitored • Everyone concentrating • Everything to hand • Fully anaesthetised at intubation

  12. Waking up in theatre • Level of noise goes up • Laughter! Relaxation! • The disappearing assistant • Monitoring off • Move patient

  13. 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

  14. 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

  15. More interesting observationson respiratory complications • Induction 4.6% • Immediate post extubation 12.6% • Recovery Room 9.5% BJA 1998:80:767-775

  16. 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

  17. 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?

  18. 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

  19. Yes We Can!

  20. Yes We Can! • Selected Patients • Selected Surgery • Nasopharnygeal Airway • Recovery Room Staff on your side

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