Extubating Dementia or Confused Pt.

All4Seasons · Nov 16, 2008

Yes,it certainly is trickier to assess pts for readiness for extubation who have issues such as this, but many of the same criteria can still be used,and,actually,these would all need to be in the back of the mind when admitting a patient into PACU...compos mentis or otherwise. Generally,here are the details that I'd make myself aware of and indications that I'd look for for safe extubation(these are not necessarily in order of priority):

- In initial PACU admission report:

...I'd find out if anesthesia had any difficulty intubating the pt, and whether they have any specific concerns about the airway... that would definitely suggest extra caution in removing an ETT

...did the pt receive neuromuscular blockade,and was it reversed?

...were there any complications intraoperatively? MI/ large blood loss/fluid resucitation/unstable vital signs/ CVA?/poor blood gases?

...did they breathe spontaneously, or were they ventilated through the case?

...was it a short (and hour or less) or a long case...a lengthier intraop course may mean they'll need more time to awaken.

...how much sedation and analgesia did they receive intraop? (though the MD was likely conservative with these in light of mentation/age/neuro status). Do they have any hx of being particularly sensitive to opiods and do they seem to be in significant pain now? If these are the case,you may want to manage pain/assess respiratory response to opiod before removing the airway,in case you need to support respirations with bagging,etc. Even if sensitivity is unknown,we can assume it in the elderly,children,those with compromised liver function,etc

...what was the pt's neuro status preoperatively?...did they repond in any meaningful way to commands,what was their level of strength - did they show good limb and neck strength,even if it wasn't to command? If they are confused AND combative the return to their norm should become apparent as they wake. Are they actively trying to remove the airway themselves? I find that I need to refer to the nurses' notes for good detail as often the anesthetists know only the broad picture***

...what is their medical history - do they have any conditions which could play a role in the development of respiratory complications...were there any concerns preoperatively that the pt couldn't sufficiently protect his airway? any recent hx of aspiration or of a URTI with secretion production? This wouldn't necessarily mean they'd need to be intubated for a longer period of time,but you may need to suction well/give inhalation tx before extubation

...what is their level of respiratory function now?...what is respiratory rate,depth, & quality, any accessory muscle use, are respirations regular, any apnea noted,what are the oxygen saturations,and how do they compare to preop levels? How much supplemental O2 are they requiring now for saturations realistic for them? I'd auscultate breath sounds if there are any concerns,too

...is there a hx of PONV,which,combined with a decreased LOC,could present problems with airway protection

...what is their medical history - do they have any conditions which could play a role in the development of respiratory complications... - were there any concerns preoperatively that the pt couldn't sufficiently protect his airway? any recent hx of aspiration or of a URTI with secretion production?

...is there a hx of PONV,which,combined with a decreased LOC,could present problems

I have found that sometimes anesthetists can be a little hasty/cavalier with extubation - and perhaps wouldn't consider some of these items to be of any real concern. Though I don't think it necessary to prolong extubation if the pt is awake/alert enough (& responses are back to preop levels) for extubation,I do believe that we nurses should be a little cautious,especially in cases which are not so straight forward. The assessments I've mentioned should be like a reflex for PACU nurses and so, minimally time consuming.

I'm sure I've missed something,but I'm like you - I never hesitate to ask a colleague for an opinion if I'm at all in doubt about anything in post anesthetic care. I hope this helps a little...I see your post was made more than a month ago,so you may have given up on getting a response!:)

jen

mimi55 · Nov 17, 2008

Thanks so much for your feedback! Honestly I would not have thought to ask half of the things you brought up and I don't know why other than inexperience in extubating. We rarely get report from anesthesia heck we sometimes don't even get report from the circulators.

But everything you brought up of course would affect the extubation and the Docs. would definately fill me in if I asked the right questions. Sometimes they will say if the intubation was difficult or the case was longer than they thought it would be.

Thanks again:)

All4Seasons · Nov 17, 2008

:) you're very welcome!

jen