Newly Published
Perioperative Medicine  |   July 2019
Assessment of Common Criteria for Awake Extubation in Infants and Young Children
Author Notes
  • From the Department of Anesthesiology (T.W.T., E.J.G-D., M.G.D., T.E.S., L.B.T., S.H.P., D.E.H., J.J.O’B., D.H.M, A.E.L., P.R.T., D.G.R.); and the Department of Biostatistics and Data Science (C.J.M.), Wake Forest School of Medicine, Winston-Salem, North Carolina. Current affiliation for D.H.M. is the Edward Via College of Osteopathic Medicine, Spartanburg, South Carolina.
  • Submitted for publication December 27, 2018. Accepted for publication June 3, 2019.
    Submitted for publication December 27, 2018. Accepted for publication June 3, 2019.×
  • Correspondence: Address correspondence to Dr. Templeton: Department of Anesthesiology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina 27157-1009. Email: ttemplet@wakehealth.edu. Information on purchasing reprints may be found at www.anesthesiology.org or on the masthead page at the beginning of this issue. Anesthesiology’s articles are made freely accessible to all readers, for personal use only, 6 months from the cover date of the issue.
Article Information
Perioperative Medicine / Airway Management / Pediatric Anesthesia
Perioperative Medicine   |   July 2019
Assessment of Common Criteria for Awake Extubation in Infants and Young Children
Anesthesiology Newly Published on July 19, 2019. doi:10.1097/ALN.0000000000002870
Anesthesiology Newly Published on July 19, 2019. doi:10.1097/ALN.0000000000002870
Abstract

Editor’s Perspective:

What We Already Know about This Topic:

  • Emergence from anesthesia and extubation is a critical time in pediatric anesthesia when there is an increased risk of adverse events

  • Complications are more likely if extubation occurs prematurely during light anesthesia

  • Predictors of successful extubation have been identified in critically unwell children and in the intensive care environment but these predictors have related to presence of ongoing cardiopulmonary embarrassment rather than judgement of appropriate plane of anesthesia

What This Article Tells Us That Is New:

  • For an awake-extubation in a child that has had volatile anesthesia, facial grimace, purposeful movement, conjugate gaze, eye opening, and tidal volume greater than 5 ml/kg are all associated with successful extubation

  • The chances of successful extubation steadily increase as more of these features are present

Background: Practice patterns surrounding awake extubation of pediatric surgical patients remain largely undocumented. This study assessed the value of commonly used predictors of fitness for extubation to determine which were most salient in predicting successful extubation following emergence from general anesthesia with a volatile anesthetic in young children.

Methods: This prospective, observational study was performed in 600 children from 0 to 7 yr of age. The presence or absence of nine commonly used extubation criteria in children were recorded at the time of extubation including: facial grimace, eye opening, low end-tidal anesthetic concentration, spontaneous tidal volume greater than 5 ml/kg, conjugate gaze, purposeful movement, movement other than coughing, laryngeal stimulation test, and oxygen saturation. Extubations were graded as Successful, Intervention Required, or Major Intervention Required using a standard set of criteria. The Intervention Required and Major Intervention Required outcomes were combined as a single outcome for analysis of predictors of success.

Results: Successful extubation occurred in 92.7% (556 of 600) of cases. Facial grimace odds ratio, 1.93 (95% CI, 1.03 to 3.60; P = 0.039), purposeful movement odds ratio, 2.42 (95% CI, 1.14 to 5.12; P = 0.022), conjugate gaze odds ratio, 2.10 (95% CI, 1.14 to 4.01; P = 0.031), eye opening odds ratio, 4.44 (95% CI, 1.06 to 18.64; P= 0.042), and tidal volume greater than 5 ml/kg odds ratio, 2.66 (95% CI, 1.21 to 5.86; P = 0.015) were univariately associated with the Successful group. A stepwise increase in any one, in any order, of these five predictors being present, from one out of five and up to five out of five yielded an increasing positive predictive value for successful extubation of 88.3% (95% CI, 82.4 to 94.3), 88.4% (95% CI, 83.5 to 93.3), 96.3% (95% CI, 93.4 to 99.2), 97.4% (95% CI, 94.4 to 100), and 100% (95% CI, 90 to 100).

Conclusions: Conjugate gaze, facial grimace, eye opening, purposeful movement, and tidal volume greater than 5 ml/kg were each individually associated with extubation success in pediatric surgical patients after volatile anesthetic. Further, the use of a multifactorial approach using these predictors, may lead to a more rational and robust approach to successful awake extubation.