Assessment of Common Criteria for Awake Extubation in Infants and Young Children

Summary by Jaime Freiburger DO, 09.15.22
https://pubs.asahq.org/anesthesiology/article/131/4/801/909/Assessment-of-Common-Criteria-for-Awake-Extubation


Take Home Point:

  • Induction and emergence remain two of the most critical times when caring for pediatric patients because of the increased risk of adverse events at these transition points.

  • 5 Predictors that were significantly associated with a successful extubation

    • Facial Grimace

    • Conjugate Gaze

    • Purposeful Movement

    • Eye opening

    • Tidal Volumes greater than 5ml/kg

  • Positive predictive value for number of predictors present for successful extubation

    • 1 out of 5 – 88.4%

    • 2 out of 5 – 88.4%

    • 3 out of 5 – 96.3%

    • 4 out of 5 – 97.4%

    • 5 out of 5 – 100%

Summary:

Background: 

  • Previous studies on child extubation were done in PICU or for kids undergoing high-risk procedures, thus less applicable to normal everyday GENA cases.

  • Common criteria for awake extubation: eye-opening, facial grimace, movement other than coughing, purposeful movement, conjugate gaze, EtVolatile anesthetic below the predetermined level, adequate O2, NMB reversal, and laryngeal stimulation test (return to spontaneous ventilation in <5s after gentle stimulation of glottis by wiggling ET tube while pt is ventilating spontaneously= indicated pt may have passed through stage 2 and is ready for extubation)

__________

Study Design: Prospective observational study

Patient population: 600 pediatric (0-7y/o) awake extubations over 10 months at 1 institution with representative surgical subspecialty cases.

 __________

Exclusion criteria:

  • Age >7

  • Known difficult airway

  • Tracheostomy in situ or nasotracheal intubation

  • anticipated ongoing vent needs

  • undergoing deep extubation

  • TIVA anesthetic/ prop bolus just prior to extubation

__________

 Intervention

Observation of routine practice extubations by an observer not a part of anesthesia care teams

Data points collected:

  1. Eye opening**

  2. Facial grimace**

  3. Pt movement other than coughing

  4. Conjugate gaze**

  5. Purposeful movement**

  6. Et anesthetic less than

  7. (Sevo <0.2%, Iso <0.15%, Des <1.0%)

  8. O2 sat >97%

  9. + laryngeal stimulation test

  10. Vt >5mL/kg**

Also noted:

  • Presence of URI?

  • Benzo premedication

  • Absence of asthma

Extubation was then graded based on specific criteria and assigned a value of successful, intervention required, or major intervention required.

_______

 Outcomes: 

1°: Which factors individually or collectively are most important in the awake extubation of young pediatric patients emerging from inhalation anesthesia?

2°: URI/versed admin/asthma absence?

 ________

Results

  • Eye-opening, facial grimace, conjugate gaze, purposeful movement, and tidal volumes >5ml/kg were significantly associated with awake extubation success were significantly associated with awake extubation success, and if you wait for >3/5 of these to exist in the pt prior to awake extubation, your PPV% increases, owing to successful extubation.

  • Positive predictive value for number of predictors present for successful extubation

    • 1 out of 5 – 88.4%

    • 2 out of 5 – 88.4%

    • 3 out of 5 – 96.3%

    • 4 out of 5 – 97.4%

    • 5 out of 5 – 100%

  • +URI and midazolam premedication were found to be associated with intubations that required intervention.

  • EtCO2 >55 mmHg associated with intervention - major intervention required group. 

  • +/- asthma, NMB reversal choice, inhalational agent choice, age <1, airway procedures, and emergency cases were associated with awake extubations ultimately requiring intervention. 

Discussion: 

  • If you wait for at least 3/5 of the characteristics mentioned/bolded/starred above, then you’re most likely to have successful extubation without the need for intervention