PACU nurse-led extubation.

[nitroglycerine]

Hi all.
Do PACU nurses extubate patients in your recovery room? Do you proceed with the next case if your previous patient is still intubated in PACU? I mean spontaneously breathing, stable, not on ventilator?
thank you.

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[2Fast2Des]

How hard is it to extubate in the room if you have a spontaneously breathing pt anyway?

 

[deleted162650]

I know of one large free standing Childen's Hospital where all kids get extubated by the nurses in PACU while the Anesthesiologists are off seeing the next patient/getting their next case started.

Only place I've ever heard of this being done though.

 

[TheLoneWolf]

I know of one large free standing Childen's Hospital where all kids get extubated by the nurses in PACU while the Anesthesiologists are off seeing the next patient/getting their next case started.

Only place I've ever heard of this being done though.

Umm our children's hospital for residency it is standard. Tonsils and dentals high volume. Hated it, these are reactive airways that should be extubated in the OR.

 

[nitroglycerine]

How hard is it to extubate in the room if you have a spontaneously breathing pt anyway?

Not hard. Just to let ET sevo to decrease to 0.0, to have some more opiates on board for better early pain control, to have the patient spontaneously wake up prior to extubation to minimize/eliminate risks of premature extubation, and to speed up turnover. Thanks.

 

[nitroglycerine]

Umm our children's hospital for residency it is standard. Tonsils and dental high volume.

How many tonsillectomies and dental cases in a typical day? Private hospital? Thanks.

 

[nitroglycerine]

I know of one large free standing Childen's Hospital where all kids get extubated by the nurses in PACU while the Anesthesiologists are off seeing the next patient/getting their next case started.

Only place I've ever heard of this being done though.

A North American hospital?

 

[narcotics999]

I know of one large free standing Childen's Hospital where all kids get extubated by the nurses in PACU while the Anesthesiologists are off seeing the next patient/getting their next case started.

Only place I've ever heard of this being done though.

Chla?

 

[Justice4all]

At my peds fellowship , the nurse extubated in pacu. Large Midwest program >40k cases per year. But most extubation by nurse are for T&A. The fellow or attending can decide to forgo pacu extubation.

 

[deleted162650]

How many tonsillectomies and dental cases in a typical day? Private hospital? Thanks.

A North American hospital?

Private Free-Standing Full service Children's hospital in major metropolitan North American city.

A LOT of all types of cases every single day.

Chla?

About 75mi off.

 

[urge]

Hi all.
Do PACU nurses extubate patients in your recovery room? Do you proceed with the next case if your previous patient is still intubated in PACU? I mean spontaneously breathing, stable, not on ventilator?
thank you.

Why would you not proceed with the next case? Seems like a strange question.

Nurses extubate all over my hospital and neighboring ones.

Many moons ago I was told by a friend who trained there, BID in Boston never extubated a single patient in the OR. Everyone was brought asleep with a tube to the pacu and the nurses would do the rest.

 

[vector2]

I literally had no idea that routine, nurse-led peds PACU extubation was thing until today. Sounds nuts to me.

 

[abolt18]

I literally had no idea that routine, nurse-led peds PACU extubation was thing until today. Sounds nuts to me.

Totally foreign to me!

 

[XRanger]

Our PACU nurses would freak out if we brought intubated pts to them

 

[nimbus]

Timely article. Not sure I agree with its conclusions.

Exposure to Waste Anesthetic Gases in the PACU

 

[dchz]

Not hard. Just to let ET sevo to decrease to 0.0, to have some more opiates on board for better early pain control, to have the patient spontaneously wake up prior to extubation to minimize/eliminate risks of premature extubation, and to speed up turnover. Thanks.

LOL... The original question was rhetorical.

But waiting for sevo to hit zero seems extreme.

 

[NoodleIncident]

I cannot find the article, but I seem to recall one stating that PACU extubate ons does not improve OR turnover/efficiency and may actually hinder it due to backups in PACU. Anyone else know the one I’m talking about?

 

[MoMoGesiologist]

Nurses extubate all the time in the ICU. As long as there is a doc in the PACU to make sure pt is rdy for extubation and to help out if issues, sounds feasible to me

 

[nitroglycerine]

Chla?

What is “chla”?

 

[nitroglycerine]

I cannot find the article, but I seem to recall one stating that PACU extubate ons does not improve OR turnover/efficiency and may actually hinder it due to backups in PACU. Anyone else know the one I’m talking about?

I don’t know about this article, but my own hospital did not find any significant increase in Sevo concentration in PACU in the presence of intubated patients.

 

[nitroglycerine]

Nurses extubate all the time in the ICU. As long as there is a doc in the PACU to make sure pt is rdy for extubation and to help out if issues, sounds feasible to me

Is the ICU physician continuously physically present in the ICU during tho extubation time? Who does the extubations - nurses or RTs?

 

[deleted162650]

What is “chla”?

It’s like chop only further west.

 

[nitroglycerine]

Timely article. Not sure I agree with its conclusions.

Exposure to Waste Anesthetic Gases in the PACU

Sorry, I sent this to another member by mistake. Our hospital tried to prove that Sevo level is higher in PACU and was not able to. Panients with ETTs and LMAs were routine.

 

[nitroglycerine]

It’s like chop only further west.

What is chop?

 

[nimbus]

Sorry, I sent this to another member by mistake. Our hospital tried to prove that Sevo level is higher in PACU and was not able to. Panients with ETTs and LMAs were routine.

Agree it’s not a concern.

 

[nitroglycerine]

I literally had no idea that routine, nurse-led peds PACU extubation was thing until today. Sounds nuts to me.

I cannot find the article, but I seem to recall one stating that PACU extubate ons does not improve OR turnover/efficiency and may actually hinder it due to backups in PACU. Anyone else know the one I’m talking about?

Do they say in that article that PACU nurses did not disturb the patients until they woke up on their own? This would be the most important thing that makes this process safe. Wait until they respond to voice or light touch. Even if the efficiency did not improve, as long as it did not make it worse it is still beneficial because it is safer for the patients. They get some extra time to wake up properly with a little more narcotic on board to keep the pain away and to tolerate the ETT without coughing. A patient who can tolerate the ETT until they wake up naturally have virtually no risk of any airway complications related to premature extubation. What do you think?

 

[nitroglycerine]

LOL... The original question was rhetorical.

But waiting for sevo to hit zero seems extreme.

Sure, but the closer it is to 0.0 the more narcotics you can give to the patient and still have him breathe spontaneously without major hypercapnea. It’s nice and rewarding when they wake up on their own with minimal pain, opening mouth on demand. Sometimes I think they can deflate their own cuff and remove the tube if I ask them to do so.

 

[Mman]

Is the ICU physician continuously physically present in the ICU during tho extubation time? Who does the extubations - nurses or RTs?

I've never seen nurses extubate anybody in any setting "routinely". in the ICUs I've seen it done by RTs.

 

[woopedazz]

If the aim is gentle emergence with extra opioids onboard on extubation --> Why not just run TIVA?

 

[Modanq]

Not hard. Just to let ET sevo to decrease to 0.0, to have some more opiates on board for better early pain control, to have the patient spontaneously wake up prior to extubation to minimize/eliminate risks of premature extubation, and to speed up turnover. Thanks.

I know of one large free standing Childen's Hospital where all kids get extubated by the nurses in PACU while the Anesthesiologists are off seeing the next patient/getting their next case started.

Only place I've ever heard of this being done though.

What then, if not basic extubation, is exactly the role of the anesthesiologist...wheeling the patient back and forth? Such garbage...to me it represents the lack of an institution's understanding of what anesthesiologists do. Last I checked extubation is one of the most "critical times" in a pt's care. You are one laryngospasm, rpe, or failed emergent reintubation from a respiratory arrest. It only takes one. Why not have the most qualified person doing the extubation. Pathetic.

 

[zero0]

Umm our children's hospital for residency it is standard. Tonsils and dentals high volume. Hated it, these are reactive airways that should be extubated in the OR.

I'm just a pissant 4th year with a few months of anesthesia under my belt but this doesn't seem right. Why leave the patients most at risk for laryngospasm to be extubated in the PACU? My wife's a PACU nurse, I love her and all, but I can't really imagine her running around trying to draw up atropine and sux while a kid spasms.... If they even notice. The general consensus among PACU nurses seems to be kids scare the **** out of them.

 

[Mikkel]

You're only right about the first part of your first sentence.

I'm just a pissant 4th year with a few months of anesthesia under my belt but this doesn't seem right. Why leave the patients most at risk for laryngospasm to be extubated in the PACU? My wife's a PACU nurse, I love her and all, but I can't really imagine her running around trying to draw up atropine and sux while a kid spasms.... If they even notice. The general consensus among PACU nurses seems to be kids scare the **** out of them.

Kids are very unlikely to have laryngospasm well into stage 1 of anesthesia, and you can train nurses to know when that is.


You know what increases the risk of laryngospasm? Pulling the tube out too soon in the operating room because you're trying to get to your next case.

 

[nitroglycerine]

Great discussion, thanks to all who give their opinions, even the insulting ones ( some anger management courses may help although unlikely). I think what is important to find the truth in the situation when there are two completely different approaches is to substantiate each claim with some sort of an argument. And each such argument should be carefully dissected to get to the bottom of the issue. Please keep posting, just ignore the insults.

 

[nitroglycerine]

You're only right about the first part of your first sentence.



Kids are very unlikely to have laryngospasm well into stage 1 of anesthesia, and you can train nurses to know when that is.


You know what increases the risk of laryngospasm? Pulling the tube out too soon in the operating room because you're trying to get to your next case.

Bingo! Have the patient wake up on his own spontaneously breathing, tolerating the tube up to this moment with SpO2 100% - no laryngospasms, no aspiration risk (airway reflexes are back in the awake patient). Can a PACU nurse handle such a patient?

 

[nitroglycerine]

I'm just a pissant 4th year with a few months of anesthesia under my belt but this doesn't seem right. Why leave the patients most at risk for laryngospasm to be extubated in the PACU? My wife's a PACU nurse, I love her and all, but I can't really imagine her running around trying to draw up atropine and sux while a kid spasms.... If they even notice. The general consensus among PACU nurses seems to be kids scare the **** out of them.

You are the one who have to make sure that this will not happen. If you have any doubts do not transfer this patient's care to the PACU nurse. Please see Mikkel's comments.

 

[Mman]

You're only right about the first part of your first sentence.



Kids are very unlikely to have laryngospasm well into stage 1 of anesthesia, and you can train nurses to know when that is.


You know what increases the risk of laryngospasm? Pulling the tube out too soon in the operating room because you're trying to get to your next case.

an issue i have with that is PACU nurses are usually not 1:1 care and kids can self extubate before "stage 1" unless someone is restraining them

 

[Mikkel]

an issue i have with that is PACU nurses are usually not 1:1 care and kids can self extubate before "stage 1" unless someone is restraining them

Self-extubating a properly secured tube indicates a level of cognitive function well within stage 1.

 

[Mman]

Self-extubating a properly secured tube indicates a level of cognitive function well within stage 1.

a squirming 2 year old can certainly self extubate long before having any meaningful alertness. I mean they can move around so much the tube accidentally dislodges without them even grabbing for it. I mean I've seen unintentional extubations during stage 2 with somebody holding their head and the tube.

 

[pgg]

What is chop?

It's like bch only further west and no one calls it bch.

 

[deleted162650]

It's like bch only further west and no one calls it bch.

 

[dhb]

I think what is important to find the truth in the situation when there are two completely different approaches is to substantiate each claim with some sort of an argument.

Most places i've worked at in France had PACU nurses extubate the patients.

 

[nimbus]

an issue i have with that is PACU nurses are usually not 1:1 care and kids can self extubate before "stage 1" unless someone is restraining them

They are 1:1 until extubated. At those institutions, the PACU nurses extubate all day every day. I did my peds rotations at a place that did that and they literally extubate thousands of patients every year without problems. If the system is set up that way and everybody is onboard it works very well. It’s not the same as a place where it rarely happens.

 

[Mman]

They are 1:1 until extubated. At those institutions, the PACU nurses extubate all day every day. I did my peds rotations at a place that did that and they literally extubate thousands of patients every year without problems. If the system is set up that way and everybody is onboard it works very well. It’s not the same as a place where it rarely happens.

oh I'm sure it's not the same, however I would wonder what sort of liability they are setting up for in the event of a bad outcome

 

[JBOB]

They are 1:1 until extubated. At those institutions, the PACU nurses extubate all day every day. I did my peds rotations at a place that did that and they literally extubate thousands of patients every year without problems. If the system is set up that way and everybody is onboard it works very well. It’s not the same as a place where it rarely happens.

Just curious, is there a physician in PACU that evaluates the pt before extubation? Do they place an "extubate" order in the chart or something of that nature?

 

[deleted59964]

how long till the pacu nurse feels pressure to pull the ETT a little early, so they can stop being 1:1?

 

[deleted162650]

Just curious, is there a physician in PACU that evaluates the pt before extubation? Do they place an "extubate" order in the chart or something of that nature?

Nope.

 

[deleted162650]

how long till the pacu nurse feels pressure to pull the ETT a little early, so they can stop being 1:1?

My experience was that the nurses would extubate the kids later than earlier. The kids would be reeeeaaally wake before they pulled the tube. Those nurses extubated more kids in a year than I probably will in my whole career. Their preference was for the kids to come out pretty deep so they had time to finish charting before the kid was waking up.

Still prefer to extubate my own patients regardless of age.

 

[JBOB]

My experience was that the nurses would extubate the kids later than earlier. The kids would be reeeeaaally wake before they pulled the tube. Those nurses extubated more kids in a year than I probably will in my whole career. Their preference was for the kids to come out pretty deep so they had time to finish charting before the kid was waking up.

Still prefer to extubate my own patients regardless of age.

Does not seem great from a patient experience perspective to me, if I were intubated I would prefer to not have the tube in while awake for any longer than is necessary.

 

[PieOHmy]

Nurses extubate all the time in the ICU. As long as there is a doc in the PACU to make sure pt is rdy for extubation and to help out if issues, sounds feasible to me

An OR extubation and an ICU extubation are two seperate animals completely.

 

[PieOHmy]

There is No WAY on god's green earth that this would ever be a routine in my practice.

Extubate the patient in the OR. If you cant do it efficiently, there is something majorly wrong with your technique.

Most of the time (Im not saying all) the use of intra op opiates is the culprit in many delayed emergence instances and the needing to see the patient breathe regularly prior to extubation. Those are two major things that delay emergence.