The art of deep extubation

Fair warning — this post is likely to be of interest only to professionals who administer anesthesia or may have to deal with laryngospasm in emergency situations.

There are two schools of thought about how to extubate patients at the conclusion of general anesthesia:

Allow the patient to wake up with the endotracheal tube in place, gagging on the tube and flailing like a fish on a line, while someone behind the patient’s head bleats, “Open your eyes!  Take a deep breath!”

Or:

Remove the endotracheal tube while the patient is still sleeping peacefully, which results in the smooth emergence from anesthesia like waking from a nap.

It will not require much subtlety of perception to guess that I prefer option 2. It is quiet, elegant, and people who’ve seen it done properly often remark that they would prefer to wake from anesthesia that way, given the choice.

There is art and logic to it, which I had the pleasure of learning from British anesthesiologists at the Yale University School of Medicine years ago.

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19 COMMENTS

Rahmat

Thank you for the article..I just succesfully extubated my patient with poorly controlled asthma by using this technique. A Very smooth emergence achieved.

Eduardo

Excellent topic of an usually underrated issue! Very useful for everyday practice. Thanks!

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I wish I knew who coined the term “DRexit” so I could send flowers or a bottle of whiskey as a thank-you gift. There couldn’t be a more perfect term to describe the growing exodus of physicians from our beloved profession, which is turning into a morass of computer data entry and meaningless regulations thought up by people who never touch a patient.

The one bright note on the horizon for me is that physicians are starting to wake up to the trap of MOC, or mandatory maintenance of certification. It’s surprising that the Federal Trade Commission hasn’t recognized already that this is quite a racket, forcing physicians to do CME activities dictated by monopolistic certification boards which profit handsomely.

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3 COMMENTS

Dr. Phil (#thereal)

Wow! Great! I mentioned revising the way we do MOCA or board certification to another Sullivan (Dr. Erin Sullivan - u of Pitt/in the ASA/brilliant dr) a few years back. The next thing I know they (the ABA) changed the way the 10 year recertification was done going from the archaic one time test every 10 years test that cost $2100 to just take. It didn't factor in cost to prepare, time, travel, etc. If you pass ur ok, but if u didn't ...Read More
Burnout and DRexit occur when the insurance, pharma, med mal, hospital, EHR and professional medical boards prevent physicians from optimizing value=outcomes/costs with their patients. https://www.linkedin.com/pulse/american-physicians-putzes-howard-green-md

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How reporter Jan Hoffman and the New York Times manage to insult female physicians and get their facts about anesthesia so wrong all at the same time.

My husband and I, both anesthesiologists, enjoy our Sunday mornings together — coffee, the New York Times, a leisurely breakfast. No rush to arrive in the operating room before many people are even awake.

Today, though, seeing reporter Jan Hoffman’s front-page article in the Times — “Staying Awake for Your Surgery?” — was enough to take the sparkle out of the sugar. Her article on how much better it is to be awake than asleep for surgery reminded me why I left a plum job as a reporter for The Wall Street Journal to go to medical school — because reporters have to do a quick, superficial job of covering complex issues. They aren’t experts, but seldom admit it.

Physician anesthesiologists across the country are likely to face patients on Monday morning who wonder if they ought to be awake for their surgery. The answer to that question may well be “no”. But according to Ms. Hoffman, that answer reflects “physician paternalism”, and makes us opponents of the “patient autonomy movement”, because a patient should have the right to choose to be awake.

It’s not that simple.

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12 COMMENTS

Michael deCamp

Thankful to have missed Ms. Hoffman's article and certainly agree with your delightful rant. I did have my total knee done under epidural anesthesia without sedation; had a nice quiet chat with the Anesthetist at the head...I had helped train her 20 years before...and had my cataract replaced with an IOL under topical without sedation as well. I was told I could not drive after surgery, but as the Chief of the Outpatient Anesthesia department had done, I said that I never had an ...Read More

pam price

Your coverage regarding "eyes wide open" anesthesia brings up issues that never crossed my mind, however some curious patients might find their viewing these procedures terrific cocktail chatter. Personally, it could come down to a personal choice at some point, with all of the cost cutting in medical care one of the prevailing issues. Recovering from an operation/anesthesia whether the patient observes the process or not? Personally, I wouldn't want to observe any of it, I would ...Read More

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In the interests of full disclosure, I acknowledge with delight that I have a non-time limited board certificate from the American Board of Anesthesiology (ABA), issued before the year 2000. I can just say “no” to recertification.

The more I learn about the American Board of Medical Specialties (ABMS) and its highly paid board members, the more disillusioned I’ve become. It’s easy to see why so many physicians today have concluded that ABMS Maintenance of Certification (MOC) is a program designed to perpetuate the existence of boards and maximize their income, at the expense primarily of younger physicians.

Lifelong continuing education is an obligation that we accepted when we became physicians, recognizing that we owe it to ourselves and our patients. That is not at issue here. We have an implicit duty to read the literature, keep up with new developments, and update our technical skills.

The real danger of MOC is this:  It is rapidly evolving into a compulsory badge that you might soon need to wear if you want to renew your medical license, maintain hospital privileges, and even keep your status as a participating physician in insurance networks. If physicians don’t act now to prevent this evolution from going further, as a profession we will be caught in a costly, career-long MOC trap. The only other choice will be to leave the practice of medicine altogether, as many already are doing.

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10 COMMENTS

willy miller

HYPOCRITS! that's what the members of the AMA, ACGME, Specialty Colleges and academics are. TOOLS, interested in their income, stature and professional advancement. Boards are a joke, useless and serve no purpose. But US medical system has become the most corrupt business in the US due to these tools. FIGHT BACK. SUE. Inform the media to investigate these organizations.

Alieta Eck, MD

I have a certification in Internal Medicine that is not time limited. I will never participate in MOC. My husband was Board Certified in Family Medicine which expects repeated testing, but he brushed it off. One hospital suddenly decided this was a big deal and told him he needed to take the test in order to retain privileges. The Board wanted him to pay for all the tests he missed before they would allow him to sit for the current test. He refused, and after 25 ...Read More

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Six-year-old Caleb Sears:  His death was preventable

I’m not a pediatric anesthesiologist. Most of us in anesthesiology – even those who take care of children in the operating room or the ICU every day – probably will never give anesthesia to a child in a dentist’s or oral surgeon’s office. So why should we care what happens there? Dental anesthesia permits and regulations, after all, are under the authority of state dental boards, not medical boards.

The reason we should care is that healthy children have died under anesthesia in dental office settings, children like Marvelena Rady, age 3, and Caleb Sears, age 6. Unfortunately, they aren’t the first children to suffer serious complications or death in our state after dental procedures under sedation or general anesthesia, and unless California laws change, they won’t be the last.

In 2016, officers and past presidents of the California Society of Anesthesiologists (CSA) have made multiple trips to meetings of the Dental Board of California (DBC) to discuss pediatric anesthesia. We’ve provided detailed written recommendations about how California laws concerning pediatric dental anesthesia should be updated and revised. We’ve explained in testimony before the Dental Board, and in meetings with lawmakers, why we believe so strongly that the single “operator-anesthetist” model (currently practiced by dentists and oral surgeons in many states) cannot possibly be safe.

The DBC on December 30 published new recommendations for revision of California laws pertaining to pediatric dental anesthesia, posted them on its website, and sent them to the Senate Committee on Business, Professions, and Economic Development. But these recommendations ignored many of our concerns, and don’t go nearly far enough to protect children.

Further, the DBC cites statistics claiming that pediatric dental anesthesia is currently safe. But there is no database! The Dental Board has admitted to discarding records after review. They have reported on “only nine” recent cases involving death, ignoring other tragic cases of permanent brain damage and prolonged ICU admissions. Pediatricians in California recently surveyed 100 of their members and found that 29 of them — nearly one-third — knew of patients in their practices who had experienced adverse events in a dental office.

What is a single “operator-anesthetist”?

You may never have heard of a single “operator-anesthetist” because such a thing doesn’t exist in medical practice.

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4 COMMENTS

Alan Schneider M.D.

The real shocking statistic is that there are not more deaths if Dentists, along with their assistants, are allowed to provide sedation to children. Because one thing for sure it will not be moderate sedation in a child. I am amazed they are even able to get the IV started I trained decades ago as a pediatric anesthesiologist, although supervise mostly adults now, but even my adrenaline would be pumping if I provided sedation to a child in an office setting
Unnecessary dental sedation deaths persist. The practice of single-operator anaesthetist should have been stopped many many years ago. Thank you for an excellent article.

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