Assessment of Common Criteria for Awake Extubation in Infants and Young Children
In this prospective observational study, the value of commonly used predictors of fitness for extubation were measured in 600 infants and young children under the age of 7 who had undergone general anaesthesia for a variety of surgical procedures using volatile anaesthesia.
Separating the study population into those successfully extubated from those requiring minor and major airway intervention, the authors have highlighted several predictors that reached statistical significance. These included: facial grimace, purposeful movement, conjugate gaze, eye opening and tidal volume greater than 5 ml/kg. Those patients with a recent upper respiratory tract infection or midazolam premedication or elevated end tidal carbon dioxide at extubation were all more likely to require airway intervention post extubation. While these findings may not be surprising to many, they also conclude that using a multiple of these predictors increases the likelihood of success rather than relying on singular signs.
Discussion
While the anaesthetist involved with the care of children on a daily basis will be very familiar with the extubation of young children, there will be those whose practice is part-time or occasional who may benefit from the findings of this study which has nicely defined a number of predictive signs for a successful extubation following inhalational anaesthesia. However there are a number of limitations that should be considered. This was a single centre observational study with the conduct of the anaesthetic left to the discretion of the anaesthetist. The study findings apply to those children under 7 years having inhalational anaesthesia, and do not address the increasing use of total intravenous anaesthesia, other sedatives such as alpha 2 agonists and ketamine. It also excludes those patients electively extubated ‘deep’, those administered propofol prior to extubation or the use of laryngeal topical local anaesthesia.
Take Home Message
Getting the timing right relies on clinical judgement and previous experience and although this may be more straightforward for the regular paediatric anaesthetist the article does provide a more objective approach to the decision making process.
Reviewed by: Dr Phil Wolstencroft
