Extubation by PACU Nurses Stirs Major Reader Debate

David J. Cullen, M.D.; Kathy Porter, R.N.; Robert Laird, CRNA

To the Editor

In response to a question from Mr. Clark A. Fenn, Risk Manager of Holyoke Hospital, concerning the advisability of recovery room nursing staff extubating patients, we believe the following considerations should apply:

  1. As a general principle, the person who extubates the patient should be capable of intubating the patient, or have someone who is capable of intubating the patient immediately available, meaning present in the recovery room.
  2. With proper in-service training and education, we see no reason why PACU nurses cannot extubate patients as long as an anesthesiologist or nurse anesthetist is present to immediately manage airway problems that may arise (See Addendum). This does not necessarily require an increased anesthesia staff. It simply means coordinating the presence of an anesthesiologist or nurse anesthetist in the recovery room at the desired time of extubation.
  3. Will this increase recovery room time for the patient who is waiting to be extubated? generally not, but perhaps a few extra minutes delay will occur while awaiting the presence of an anesthesiologist or nurse anesthetists when the recovery room nurse is ready to extubate
  4. regardless of an educational process developed and implemented by the Chief of Anesthesia for the involved hospital, we advise that recovery room nurses not extubate patients without the immediate backup of an anesthesiologist or nurse anesthetist present in the recovery room at the time extubation.
  5. Otherwise the potential for acute airway dysfunction beyond the experience of a recovery room nurse could occur, with potential for serious sequelae to the patient.

We hope this information is helpful to Mr. Fenn and others dealing with similar questions.

David J. Cullen, M.D. and Kathy Porter, R.N., Head Nurse, Recovery Room, Massachusetts General Hospital, Boston, MA.

Addendum

Massachusetts General Hospital

Department of Nursing

Operating Room Nursing Service

Post Anesthesia Care Unit (PACU)

Policy for Extubation of Patient by PACU Nurses

Only Registered Nurses who have been qualified may extubate patients according to the established procedure Nurses will be qualified by the Head Nurse and Unit Teacher.

This policy will be implemented under the following conditions:

I . An order must be given by a physician.

2. An anesthesiologist or their designee must be present in the unit.

3. The following patients will NOT be extubated by nurses:

A. Pediatric patients.

B. Patients who have had a difficult intubation.

C. Patients who have had thoracic surgery (i.e., tracheal reconstruction, esophagectomies, lobectomies, pneumonectomies).

D. Patients who have had upper airway, oral or nasal surgery.

 

To the Editor

This is in regard to allowing Post Anesthesia Room nurses to extubate patients. In the institutions where I practice, most PAR Registered Nurses are ACLS certified. As an ACLS instructor in airway management, I emphasize the complications of extubation and instruct them in the technique of intubation. The rule is that only those that who “put them in” can take them out. To extubate the patient, the PAR nurse comes to the OR and gives a complete report on the patient’s condition to the anesthesia provider. The decision is then made by that provider whether or not to have the patient extubated.

Some criteria I personally use include level of alertness, ability to swallow on command, good inspiratory and expiratory force, and the general condition of the patient. In actual practice, we have very few patients who are educated by PAR nurses. If you have nurses extubating patients, it is essential to have a policy giving strict guidelines of this procedure

Robert Laird, CRNA

Abilene, TX