Leaving Regional Block Patients Alone, Nurses Extubating Seen Acceptable

Kenneth R. Noel, M.D.

To the Editor

I find myself strongly disagreeing with the views expressed by Dr. Jene regarding leaving a patient in the operating room unattended, and the view of Mr. Clark Fenn regarding extubation of patients in the recovery room by the recovery nursing staff (APSF Newsletter, June 1988).

The issues involved in leaving a patient unattended in the operating room are those of safety and comfort for the patient. I will readily agree with Dr. Jene that patients having general anesthesia or central neuraxis blocks (spinals or epidurals) should not be left alone until they are safely back on the ward after recovery from the anesthetic.

Peripheral nerve blocks are another matter entirely. Many times, and in many institutions, such blocks are done by surgeons in clinical settings where monitoring is done by a nurse or aide or not at all while the procedure is done. Then the patient is sent home or to a ward bed to complete the recovery from his block. I see no difference between this and doing a peripheral nerve block in the operating room and leaving the patient after the adequacy of the block is demonstrated.

Certainly safeguards are appropriate to ensure safety. These must include observation for at least a half hour after the injection of the block to ensure that there is no evidence of a toxic reaction to the local anesthetic used. There must also be at least a half hour of observation after any sedation. In no circumstances should a patient be left alone if he is so sedate that he is essentially asleep. But the patient who is awake, comfortable, who speaks when spoken to, and whose vital signs are stable within acceptable limits may be safely left without an anesthesiologist in personal attendance. Our experience confirms the safety of this practice

The issue of having nurses extubate patients in the recovery room is reminiscent of the arguments about nurses giving hypodermic injections or starting intravenous lines. These arguments over the legally defined scope of practice beg the issue of whether the patient is being cared for properly, and revolve around “turf protection”.

In our facility we have a protocol established for nurses to use in deciding to extubate and in carrying it out. It is set up to guide their judgment to ensure that the patient after extubation will continue to maintain an adequate airway and breathe effectively. In the use of this protocol over the past four years we have had no serious problems. In fact, we have not had to reintubate any patients because a nurse following this protocol has made an inappropriate decision.

Kenneth R. Noel, M.D. Anesthesia Department Naval Hospital San Diego, CA