Oral airways in pacu

[Simba1711]

What’s your guys policy with oral airways in pacu ? The pacu nurses are complaining that patients are coming out too sleepy with oral airway in place and it’s a safety issue. Surprised because this was never an issue at other hospitals I practiced at. We cover many hospitals but this was in issue at a fast turnover private practice ambulatory surgical center…

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[IMGASMD]

What’s your guys policy with oral airways in pacu ? The pacu nurses complained that patients are coming out too sleepy with oral airway in place and it’s a safety issue. Surprised because this was never an issue at other hospitals I practiced it. We cover many hospitals but this was in issue at a fast turnover private practice ambulatory surgical center…

Some of the PACU nurses are green as fuk and I can’t stand it! There are days now, I have to make sure they’re fuking “comfortable” with the airway before I leave.

I’ve had very seasoned PACU nurse literally shoo me away when the patient is breathing at the rate of less than 10 and said, they’re PACU nurses, they suppose to know how to manage airways…..

It’s facility and nurse dependent.

 

[Urzuz]

Oral airways in pacu are fine, and quite frankly are much preferable to NOT having an oral airway and having intermittent obstruction.

I wouldn’t leave the building until the airway is out though and patient is “stable” (awake, coherent, pain and N/V under control, etc). Basically when I’m confident I can manage everything remotely over the phone I’ll leave for the day.

 

[cchoukal]

One experienced RN told me the issue at our shop was that with an airway in place, he couldn’t leave the bedside. Since they have two patients and not all slots are directly adjacent, it becomes an impediment.

 

[UscGhost]

Oral airways in place in pacu.

Many pacu nurses just stare at the pulse ox and can't tell if a patient is obstucting. So I don't trust them with no OA

 

[Hoya11]

Oral airways in pacu are fine, and quite frankly are much preferable to NOT having an oral airway and having intermittent obstruction.

I wouldn’t leave the building until the airway is out though and patient is “stable” (awake, coherent, pain and N/V under control, etc). Basically when I’m confident I can manage everything remotely over the phone I’ll leave for the day.

you leave the ASC with patients still in PACU? no crna? im trying to accomplish this.. i have to wait until they leave the building

 

[IlDestriero]

If I extubate or pull an LMA deep, which I do very often in my peds practice, I send them out with an Oral airway in place >90% of the time. I don’t think it’s unsafe practice, it’s safe practice.
We can’t leave the ASC until the patient is discharged.

 

[pgg]

My only gripe with oral airways in the PACU is that there's a cohort of people who make zero effort to ever wake up patients in the OR. They pull the tube, put in a OPA, and take patients to PACU to emerge there 10-30 minutes later. 100% of the time. Essentially offloading the emergence task to the PACU RN.

They think they're slick and cool with efficient deep extubations. I think they're just lazy and unskilled.

Better an OPA than no OPA in a patient who needs one. Best to not have patients who need them.

(Adult patients.)

 

[Greenbayslacker]

take patients to PACU to emerge there 10-30 minutes later

How do the PACU nurses handle laryngospasm, bronchospasm, emergence delirium, etc?

 

[gunnershow]

How do the PACU nurses handle laryngospasm, bronchospasm, emergence delirium, etc?

All of those are significantly less likely without plastic in the throat

 

[pgg]

How do the PACU nurses handle laryngospasm, bronchospasm, emergence delirium, etc?

They do a fine job for the most part, leaving the patients alone to quietly emerge. I mean, they get a lot of practice at it.

I think it's just a weird local culture thing with some of them. End of case, sevo still at 2.4%, tube or LMA out, OPA in, PACU here we come. It is efficient for the OR turnover, I guess.

Sometimes the OPA is in for the whole case as a bite block and palate-ischemia-izer device, which also grinds my gears.

 

[UscGhost]

you leave the ASC with patients still in PACU? no crna? im trying to accomplish this.. i have to wait until they leave the building

Thankfully we can leave before discharge.

I never understood the purpose of requiring us to be there. Once the patient is responding to commands, any additional scenarios can simply be handled by telephone

Maybe a 1/1000 chance that my physical presence would be unexpectedly required. And I would gladly drive back that one time than be held hostage after every case.

 

[Maverikk]

LMA is the best OPA…one place I was at, great pacu nurses, a lot of people brought them back with the LMA if they weren’t awake. No one kept the gas on but instead of obstructing and having to put in another piece of equipment they left the LMA in, took it out in pacu, a lot of times the nurses did. Better than extubating deep and putting in the plastic OPA. Made me focus more on getting them spontaneous and taking good TV without pressure support. It was small and pacu was across the hall, never had an issue but if there was people would’ve been available. Miss those pacu nurses, never mucked around, awake and pulmonary toilet quickly

 

[nimbus]

LMA is the best OPA…one place I was at, great pacu nurses, a lot of people brought them back with the LMA if they weren’t awake. No one kept the gas on but instead of obstructing and having to put in another piece of equipment they left the LMA in, took it out in pacu, a lot of times the nurses did. Better than extubating deep and putting in the plastic OPA. Made me focus more on getting them spontaneous and taking good TV without pressure support. It was small and pacu was across the hall, never had an issue but if there was people would’ve been available. Miss those pacu nurses, never mucked around, awake and pulmonary toilet quickly

We did this a lot before COVID. An LMA with a soft bite block is an almost foolproof airway. Our nurses were savvy enough to leave the patients alone until they spit out the LMA. Miss those days.

 

[nimbus]

you leave the ASC with patients still in PACU? no crna? im trying to accomplish this.. i have to wait until they leave the building

We leave when PACU discharge criteria are met. We don’t wait around for them to physically exit the building after their ride shows up 2 hours later. We often have cases waiting for us at the hospital across the parking lot.

 

[DrOwnage]

I usually pull the LMA deep while they're closing up under the drapes and immediately stick an oral airway in and a FM at 10LPM. With the 5-10 minutes of washout the patient usually is waking up and I pull the OA 75-90% of the time while giving sign out. If they're uncomfortable with it they can Suggommadick.

 

[pgg]

I usually pull the LMA deep while they're closing up under the drapes and immediately stick an oral airway in and a FM at 10LPM. With the 5-10 minutes of washout the patient usually is waking up and I pull the OA 75-90% of the time while giving sign out. If they're uncomfortable with it they can Suggommadick.

Why replace a good supraglottic airway with an OK supraglottic airway at all?

Seems like if you're going to do that, just leave the LMA in.

 

[ProPropofol]

Leaving an oral airway in place in the PACU is a cardinal sin at my shop. It results in a complaint being made by the nursing staff and an apology letter needing to be written by the attending anesthesiologist. The nursing staff forced one of our more spineless attendings to write an apology letter directly to the patient admitting wrongdoing for the patient requiring an oral airway in PACU. The patient then freaked out on receiving the letter as they had no memory of the event. It was the silliest thing. They don't even stock oral airways, nasal trumpets, or LMAs in the PACU which I think is ridiculous considering we are a big academic center.

My practice now is everyone is able to protect their own airway without one on arrival to PACU since the nurses are "uncomfortable" with managing them. It is little things like this that really irk me.

 

[IMGASMD]

Leaving an oral airway in place in the PACU is a cardinal sin at my shop. It results in a complaint being made by the nursing staff and an apology letter needing to be written by the attending anesthesiologist. The nursing staff forced one of our more spineless attendings to write an apology letter directly to the patient admitting wrongdoing for the patient requiring an oral airway in PACU. The patient then freaked out on receiving the letter as they had no memory of the event. It was the silliest thing. They don't even stock oral airways, nasal trumpets, or LMAs in the PACU which I think is ridiculous considering we are a big academic center.

My practice now is everyone is able to protect their own airway without one on arrival to PACU since the nurses are "uncomfortable" with managing them. It is little things like this that really irk me.

It’s lack of training and just plain laziness. We are letting all that bull slide. This happens when I am at university hospital, when new grads only stay for that year of training. Then they wise up and move to surgery centers for less grueling schedule.


How can you not know how to insert of remove airway in PACU after patient goes under general anesthesia is beyond my comprehension.

 

[DesiredMemberName?]

Leaving an oral airway in place in the PACU is a cardinal sin at my shop. It results in a complaint being made by the nursing staff and an apology letter needing to be written by the attending anesthesiologist. The nursing staff forced one of our more spineless attendings to write an apology letter directly to the patient admitting wrongdoing for the patient requiring an oral airway in PACU. The patient then freaked out on receiving the letter as they had no memory of the event. It was the silliest thing. They don't even stock oral airways, nasal trumpets, or LMAs in the PACU which I think is ridiculous considering we are a big academic center.

My practice now is everyone is able to protect their own airway without one on arrival to PACU since the nurses are "uncomfortable" with managing them. It is little things like this that really irk me.

This is one of the most absurd things I’ve ever heard. Thank you for sharing!

 

[Simba1711]

Leaving an oral airway in place in the PACU is a cardinal sin at my shop. It results in a complaint being made by the nursing staff and an apology letter needing to be written by the attending anesthesiologist. The nursing staff forced one of our more spineless attendings to write an apology letter directly to the patient admitting wrongdoing for the patient requiring an oral airway in PACU. The patient then freaked out on receiving the letter as they had no memory of the event. It was the silliest thing. They don't even stock oral airways, nasal trumpets, or LMAs in the PACU which I think is ridiculous considering we are a big academic center.

My practice now is everyone is able to protect their own airway without one on arrival to PACU since the nurses are "uncomfortable" with managing them. It is little things like this that really irk me.

I have a feeling my shop is heading in this direction. We have to stay until patient walks out the facility. Some of my colleagues got reported and written up because they left when the patient had changed to street clothes.

 

[Howard888]

you leave the ASC with patients still in PACU? no crna? im trying to accomplish this.. i have to wait until they leave the building

Absolutely. This is a big area of abuse of anesthesiologists around the country. Facilities take discharge to mean departure. It does not. ASA actually released a statement on this recently. You only need to stay at a facility until phase 2 discharge and be available by phone after that. You do NOT need to stay until patient departure. That makes no sense and can lead to tons of unpaid time. Think about 23 hour obs ASCs. You leave after discharge right? No difference in patient condition Vs someone going home after discharge. Only nurses with patients. Do not be taken advantage of.

With regards to oral airways that’s ridiculous. A lot of nurses post Covid using terms “they aren’t comfortable”. That’s their job. Stand up and be firm people.

 

[pgg]

The nursing staff forced one of our more spineless attendings

Cowards die many times before their deaths.

 

[Simba1711]

Do you have a link for this. Tried searching for it online. I may bring this up to my colleagues. The rn who wrote up my colleagues is on a power trip. Reporting us for not labeling iv bags , oral airways , and recording what time we interview patients as we get blamed for late starts.

Absolutely. This is a big area of abuse of anesthesiologists around the country. Facilities take discharge to mean departure. It does not. ASA actually released a statement on this recently. You only need to stay at a facility until phase 2 discharge and be available by phone after that. You do NOT need to stay until patient departure. That makes no sense and can lead to tons of unpaid time. Think about 23 hour obs ASCs. You leave after discharge right? No difference in patient condition Vs someone going home after discharge. Only nurses with patients. Do not be taken advantage of.

With regards to oral airways that’s ridiculous. A lot of nurses post Covid using terms “they aren’t comfortable”. That’s their job. Stand up and be firm people.

 

[neutro]

Leaving an oral airway in place in the PACU is a cardinal sin at my shop. It results in a complaint being made by the nursing staff and an apology letter needing to be written by the attending anesthesiologist. The nursing staff forced one of our more spineless attendings to write an apology letter directly to the patient admitting wrongdoing for the patient requiring an oral airway in PACU. The patient then freaked out on receiving the letter as they had no memory of the event. It was the silliest thing. They don't even stock oral airways, nasal trumpets, or LMAs in the PACU which I think is ridiculous considering we are a big academic center.

My practice now is everyone is able to protect their own airway without one on arrival to PACU since the nurses are "uncomfortable" with managing them. It is little things like this that really irk me.

Im assuming this is not an asc?

Turnovers don’t seem very efficient if you’re forced to do this.

It’s comfortable for the patient to wake up smoothly. If it’s a reassuring airway, there is no paralytic use or reversal on board, why not use an oral airway (or lma?).

You’re telling me your pacu nurses want the patient completely awake in pacu even after long anesthetics? Like 6-10 hour plastic cases?

Their insistence is not scientific or standard and seems unreasonable to me. You’re probably losing a lot of key time at the end of the case to have to do this. I bet the patients are screaming in pacu with pain.

 

[ucladoc2b]

Im assuming this is not an asc?

Turnovers don’t seem very efficient if you’re forced to do this.

It’s comfortable for the patient to wake up smoothly. If it’s a reassuring airway, there is no paralytic use or reversal on board, why not use an oral airway (or lma?).

You’re telling me your pacu nurses want the patient completely awake in pacu even after long anesthetics? Like 6-10 hour plastic cases?

Their insistence is not scientific or standard and seems unreasonable to me. You’re probably losing a lot of key time at the end of the case to have to do this. I bet the patients are screaming in pacu with pain.

Ours actually prefer a semi sleepy patient with an OPA. They get a few minutes to process before the patient starts demanding pain meds. Makes their job slightly easier.

 

[Howard888]

No

Do you have a link for this. Tried searching for it online. I may bring this up to my colleagues. The rn who wrote up my colleagues is on a power trip. Reporting us for not labeling iv bags , oral airways , and recording what time we interview patients as we get blamed for late starts.

No link but I was told they issued the guideline at this recent ASA meeting. It’s been a hot topic on ASA message boards and huge issue given anesthesia economic pressures and it being unpaid time.

Should be easy to find. If not reach out to the ASA meeting folks…just may not be published yet as was just done

 

[ProPropofol]

Im assuming this is not an asc?

Turnovers don’t seem very efficient if you’re forced to do this.

It’s comfortable for the patient to wake up smoothly. If it’s a reassuring airway, there is no paralytic use or reversal on board, why not use an oral airway (or lma?).

You’re telling me your pacu nurses want the patient completely awake in pacu even after long anesthetics? Like 6-10 hour plastic cases?

Their insistence is not scientific or standard and seems unreasonable to me. You’re probably losing a lot of key time at the end of the case to have to do this. I bet the patients are screaming in pacu with pain.

Correct, not an ASC. The ASC branch of the hospital is okay with OPAs but you still get side-eyed when a patient comes out with one. Very green nurses there but they aren't part of the union so they remain un-brainwashed.

I 100% agree. If not swayed by nursing policies/admin BS, I would use an OPA not for every case but occasionally when I think it would lead to a smooth, safe, and quick emergence.

And yes, they want them to fully protect their airway and be talking so they can get them out of phase 1 as quickly as possible and not have to take care of the patient. It's a case of anesthesia being blamed for cases going so late; PACU phase 1 gets backed up and unable to transfer patients to the PACU (also not enough phase 1 nurses), patients recovered in the OR instead of going to PACU, then cases finish later in the day because the OR was used as a PACU. People wait so long to extubate then on top of that we can't even take them to the PACU lolz

It's a double edged sword as they are talking on arrival but often, as you alluded, their pain control is less than optimal. It's poor efficiency and poor quality care at the same time. I hate academic centers and plan to leave soon.

 

[UscGhost]

Ours actually prefer a semi sleepy patient with an OPA. They get a few minutes to process before the patient starts demanding pain meds. Makes their job slightly easier.

Haha same here.

I like the patient to wake up so I can pull out the OA or LMA before I go home, but sometimes the nurses get mad (jokingly) for that exact reason you stated.

 

[Simba1711]

The facility that nurses complained is a busy private practice surgical center for us. That’s why it’s aggravating. If it’s a slow turnover hospital I totally get it. But when you’re churning out 10-15 short Lma cases it can get difficult without comprising fast turnover.

 

[PpfSuxTube]

Aldrete 9 and my car is already a mile down the road...
The last patient is always light, usually blocked, often bypass pacu. **** that ****. I'm not hanging around at the whim of some pacu nurse whose shift doesn't finish for 3 hours, that's not even gonna consider discharging the patient for another hour until they are 'settled'.. wtf is even that


Oral airways in pacu are common and no issue. But why are ppl having their adult patients so deep that they need an opa for 15 mins... I extubate to opa often in the OR but by the time we've transferred to pacu, the patient has spat them out already...

 

[jwk]

We don't have a policy. If we bring patients in with an OPA or NPA, too bad. After all it's called the POST ANESTHESIA care unit.

That being said - in a quick turnover ASC, I'd be making the effort to have them more awake by the time we hit PACU.

 

[PpfSuxTube]

We don't have a policy. If we bring patients in with an OPA or NPA, too bad. After all it's called the POST ANESTHESIA care unit.

That being said - in a quick turnover ASC, I'd be making the effort to have them more awake by the time we hit PACU.

Exactly right. It's counterproductive to bring patients out slammed, with an opa or lma for 10 or 15 mins... you will eventually either screw yourself or your partners when pacu is full...

I have younger more boisterous partners that insist it's safe to bring out lmas... but they're missing the point. Time in pacu isn't exactly time in the OR but it's all in the calculations somehow..

Sure lmas and opas etc are safe in pacu, but aldrete 9 leaving the OR is even safer... and doable, reasonably often