I’m never very convinced by the surgical arguments against coughing. If coughing is going to cause re-bleeding of surgical sites, perhaps the hemostasis was not adequate in the first place. Even if we extubate without coughing, what are the chances the patient will cough during their postoperative course? For surgeries like a thyroidectomy, does coughing actually increase local arterial and venous pressure at the site of surgery?
The hemodynamic arguments I buy more, but we have medications to treat hypertension.
On the flip side, if a patient is extubated deep, larygospasms, and has a bad outcome, how would one defend that in a legal case? It strikes me that deep extubation is something we do to give surgeons (and perhaps the patients?) a questionable benefit while bearing all the potential risk.
I think I’d agree with you. More and more I’ve seen what appears to be a transition to deep extubation being the new standard, and most often the reasoning is “because they meet the criteria” or simply out of convenience. My default is still waking the patient up.
I’d be curious to hear your thoughts and strategy when it comes to cases with LMAs? Do you pull them deep or wake the patient up? Similarly to GETA cases, I notice most providers opt to pull LMAs deep.
I make sure my patients are awake before removing the ETT or LMA more than 99% of the time. It is rare for me to extubate someone deep even when a surgeon asks for it. I just don’t see why I should take on that risk for what I perceive to be a lack of benefit. The most reliable way to prevent coughing while extubating away is to have the patient on a remifentanil infusion until all the other anesthetic has worn off and then turn off the remi. But again, is coughing clinically impactful? Is that patient going to increase intra-abdominal pressure while straining to poop on opioids or while vomiting in the PACU? And if surgeons aren’t overly worried about those issues, why are they worried about extubation? I don’t know if there is a clear answer to this and that’s partly why I’m so skeptical.
People in private practice often like to extubate deep and bring patients to PACU with an oral airway because they perceive this to speed turnover. Having worked in private practice, I can say most of the time I can wake patients up just as fast (there are always patients who take longer than expected to awaken). But most of this is about communicating with the surgeon about when they’ll be done so you can time letting the anesthetic wear off.
From a medical legal standpoint, leaving a patient in PACU with an oral airway and only the nurse watching in is indefensible should something happen such as laryngospasm or hypoxemia.
I’m never very convinced by the surgical arguments against coughing. If coughing is going to cause re-bleeding of surgical sites, perhaps the hemostasis was not adequate in the first place. Even if we extubate without coughing, what are the chances the patient will cough during their postoperative course? For surgeries like a thyroidectomy, does coughing actually increase local arterial and venous pressure at the site of surgery?
The hemodynamic arguments I buy more, but we have medications to treat hypertension.
On the flip side, if a patient is extubated deep, larygospasms, and has a bad outcome, how would one defend that in a legal case? It strikes me that deep extubation is something we do to give surgeons (and perhaps the patients?) a questionable benefit while bearing all the potential risk.
I think I’d agree with you. More and more I’ve seen what appears to be a transition to deep extubation being the new standard, and most often the reasoning is “because they meet the criteria” or simply out of convenience. My default is still waking the patient up.
I’d be curious to hear your thoughts and strategy when it comes to cases with LMAs? Do you pull them deep or wake the patient up? Similarly to GETA cases, I notice most providers opt to pull LMAs deep.
I make sure my patients are awake before removing the ETT or LMA more than 99% of the time. It is rare for me to extubate someone deep even when a surgeon asks for it. I just don’t see why I should take on that risk for what I perceive to be a lack of benefit. The most reliable way to prevent coughing while extubating away is to have the patient on a remifentanil infusion until all the other anesthetic has worn off and then turn off the remi. But again, is coughing clinically impactful? Is that patient going to increase intra-abdominal pressure while straining to poop on opioids or while vomiting in the PACU? And if surgeons aren’t overly worried about those issues, why are they worried about extubation? I don’t know if there is a clear answer to this and that’s partly why I’m so skeptical.
People in private practice often like to extubate deep and bring patients to PACU with an oral airway because they perceive this to speed turnover. Having worked in private practice, I can say most of the time I can wake patients up just as fast (there are always patients who take longer than expected to awaken). But most of this is about communicating with the surgeon about when they’ll be done so you can time letting the anesthetic wear off.
From a medical legal standpoint, leaving a patient in PACU with an oral airway and only the nurse watching in is indefensible should something happen such as laryngospasm or hypoxemia.