PACU nurse-led extubation.

[MoMoGesiologist]

In your opinion if somebody who is not constantly in PACU but available within 1-2 minutes and whose scope of practice includes intubations can come if a PACU nurse calls for help, do you think it is acceptable?

That sounds ok as long as the system is set up to be safe and people are trained. Sounds like this is how it happens at some places. The idea sounds feasible. Doesn’t mean it’s good or bad, but sounds possible to do safely

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[nitroglycerine]

I still didn't’ figure out what to say to this but in a meantime wanted to share this with you. This is British I believe. And the “Medical Practitioner “ means an MD?

And the ASA and CAS postoperative care guidelines do not say who should be extubating the patients. I thinnk FANZA got too restrictive without any good reason, mostly on emotional grounds. If I am wrong I would like to see the evidence they use. I will study the references they refer to.

 

[nitroglycerine]

“The anesthesiologist should accompany the patient to the PACU, communicate necessary information to the PACU nurse(s) as part of a structured handover of care protocol, and write appropriate orders. Continuous monitoring of patients is recommended during the perioperative period appropriate to the clinical situation. If clinically indicated, supplemental oxygen, portable pulse oximetry, and other appropriate monitoring devices should be applied during transport to the PACU or intensive care unit. The anesthesiologist should delegate care to the PACU nurse only when assured that nursing staff may safely observe and care for the patient. The anesthesiologist or designated alternate is responsible for providing anesthetic-related care in the PACU. Discharge from the PACU is the responsibility of the anesthesiologist; this responsibility may be delegated in accordance with facility policy.”
From Canadian Anesthesiology society 2019 guidelines.

 

[woopedazz]

I still didn't’ figure out what to say to this but in a meantime wanted to share this with you. This is British I believe.

Fair enough; absolutely not allowed in Australia/NZ though. A completely alien concept to us.

And the “Medical Practitioner “ means an MD?

Yes, it means doctor (MD/MBBS). But also it also refers to "within scope of practice," which in effect it refers to a doctor who is airway trained - eliminating most junior doctors and senior physicians, surgeons, etc. The only "airway trained" doctors who might be dropping off intubated cargo in PACU are anaesthestists and the odd ICU/ED doctor who is rotating through the unit to get their skills up. So effectively they're saying "anaesthetists extubate."

Because, the way I see it, you can control the sedative component more precisely by watching Sevo ET Mac . How do you do your TIVAs? Remifentanil?

I run Schnider with variable opioids depending on the patient and what I feel like that day; Remi - Minto, Remi - mcg/kg/min, Fent +/- oxy bolus.
I'm yet to decide what I like best, they all work fine, but I really like the remi wakeup. Most of the attendings I worked with when I started liked the simplicity of fentanyl bolus.
I aggressively down titrate propofol during the case and cease it very early. I keep the remi running until 2-5 minutes of targetted extubation time. Eyes open and first few spont breaths anywhere between wet packs and the final shift onto the ward bed. Very rarely miss the timing; early wakeup is the bigger risk and I normally just bolus 20mg of propofol and keep the Remi high if I think I'm cutting it too fine.
I'm still learning though. My logbook shows 140 TIVAs, so I've probably done ~150

 

[nitroglycerine]

Fair enough; absolutely not allowed in Australia/NZ though. A completely alien concept to us.


Yes, it means doctor (MD/MBBS). But also it also refers to "within scope of practice," which in effect it refers to a doctor who is airway trained - eliminating most junior doctors and senior physicians, surgeons, etc. The only "airway trained" doctors who might be dropping off intubated cargo in PACU are anaesthestists and the odd ICU/ED doctor who is rotating through the unit to get their skills up. So effectively they're saying "anaesthetists extubate."


I run Schnider with variable opioids depending on the patient and what I feel like that day; Remi - Minto, Remi - mcg/kg/min, Fent +/- oxy bolus.
I'm yet to decide what I like best, they all work fine, but I really like the remi wakeup. Most of the attendings I worked with when I started liked the simplicity of fentanyl bolus.
I aggressively down titrate propofol during the case and cease it very early. I keep the remi running until 2-5 minutes of targetted extubation time. Eyes open and first few spont breaths anywhere between wet packs and the final shift onto the ward bed. Very rarely miss the timing; early wakeup is the bigger risk and I normally just bolus 20mg of propofol and keep the Remi high if I think I'm cutting it too fine.
I'm still learning though. My logbook shows 140 TIVAs, so I've probably done ~150

Sounds good, a little too labor intensive, but effective. I used to do Remifentanil but stopped. I believe in acute opioid tolerance. Sufenta is my favorite. What is Minto and OXY boluses? Did you ever work in South Africa?

 

[nitroglycerine]

That sounds ok as long as the system is set up to be safe and people are trained. Sounds like this is how it happens at some places. The idea sounds feasible. Doesn’t mean it’s good or bad, but sounds possible to do safely

Ok, good. So if in a rare situation when somebody needs to be reintubated in recovery room, and all the anesthesia doctors are busy, it's acceptable as a back up plan to call code blue and get a Respiratory Technician who's scope of practice include intubations?

 

[MoMoGesiologist]

Ok, good. So if in a rare situation when somebody needs to be reintubated in recovery room, and all the anesthesia doctors are busy, it's acceptable as a back up plan to call code blue and get a Respiratory Technician who's scope of practice include intubations?

I’ve never worked at a place where someone somewhere from anesthesia wasn’t available. So to answer your question, such a place wouldn’t be set up for nurse-led PACU extubation. TBH, if there isn’t an anesthesia provider available at all for PACU, then that place may not be set up for any type of anesthesia care...

 

[nitroglycerine]

I’ve never worked at a place where someone somewhere from anesthesia wasn’t available. So to answer your question, such a place wouldn’t be set up for nurse-led PACU extubation. TBH, if there isn’t an anesthesia provider available at all for PACU, then that place may not be set up for any type of anesthesia care...

Right, this would be extremely unlikely. But all the anesthetists at some moment of time could be all in the ORs and there is no separate anesthetist assigned to PACU. So theoretically there isn't an anesthesia provider available for PACU. But an RT who's job description includes intubations IS available if this very rare situation occurs. It never happened at my place but it may happen. So is it important that the guy with the intubating skills should be a physician or an RT will do?

 

[MoMoGesiologist]

RT will do if they’re credentialed to intubate. Sure why not?

 

[deleted171991]

RT should never intubate an awake patient. They are usually credentialed only to intubate during codes. I doubt that they are allowed to use induction drugs.

Any extubation should require the presence or proximity of an airway expert who could easily reintubate the patient. That also applies to the ICU.

 

[MoMoGesiologist]

RT should never intubate an awake patient. They are usually credentialed only to intubate during codes. I doubt that they are allowed to use induction drugs.

Any extubation should require the presence or proximity of an airway expert who could easily reintubate the patient. That also applies to the ICU.

So all ICUs should have an anesthesiologist in the unit for extubation?

 

[deleted171991]

So all ICUs should have an anesthesiologist in the unit for extubation?

Most (if not all) intensivists are credentialed to intubate, and should be around for the extubation of their patients. I can see few juicier lawsuits than for a patient who got brain damage because s/he failed an extubation by amateurs, with anesthesia in a different galaxy.

As I teach my residents: just because you can doesn't mean you should.

Btw, all my patients get extubated with the code box nearby. Especially since one should aim for a certain failure/reintubation rate (otherwise one may be keeping one's patients intubated for too long).

 

[MoMoGesiologist]

I dunno... our SICU has a lot of surgical attendings... I don’t feel confident in their intubating skills. Nor do I feel confident in pulm/CC. ED people seem good at airway stuff

 

[deleted171991]

I dunno... our SICU has a lot of surgical attendings... I don’t feel confident in their intubating skills. Nor do I feel confident in pulm/CC. ED people seem good at airway stuff

Me neither. That's another reason why anesthesia runs the ICUs in almost all countries.

 

[SterlingMaloryArcher]

All patients extubated in OR at our private hospital.

 

[woopedazz]

I dunno... our SICU has a lot of surgical attendings... I don’t feel confident in their intubating skills. Nor do I feel confident in pulm/CC. ED people seem good at airway stuff

In Australia all ICU senior doctors have fellowship in the ICU college or are anaesthesia docs who got grandfathered into ICU when the college was setup. At minimum they have 6-12 months core airway skills; there is always someone on who knows how to do an awake FOI/other more technical stuff and they handle all their own airway stuff. The US seems weird as hell with their pigeon-holed midlevels who can only do certain aprts of each procedure and non-ICU ICU doctors with lack of airway skills. Is this is true even in your large hospital closed ICUs? Or is this lack of skillset only in the "Open ICUs" I've heard about?

That said, I wouldn't trust our ED docs to tube someone unless they were stone-cold dead. Grade 4 views using video and unable to pass bougies = Grade 1 with direct blades once they call for help. They're really good at most things, but airways are lackluster because they don't get as much experience.

 

[nitroglycerine]

Patients who are to be extubated by a PACU nurse after general anesthesia are not the ICU patients. They are stable and their course is predictable. The patients who may have postoperative airway problems anesthetist would watch and make sure they are stable before proceeding with the next case. The vast majority of patients cann be safely extubated by a PACU nurse. In the rare case of problems the airway may be supported without intubation. Get all the gas out of the patients system and he is no different than anybody who was given a narcotic for pain and now is comfortable and sleeping. You dont need an experienced intubator to watch the patients on the floor.