New anesthesiology guidelines address extubation readiness and risk

In 2022, the American Society of Anesthesiologists (ASA) issued new Practice Guidelines for Management of the Difficult Airway.

Anesthesiologists are physicians with extensive training in the administration and monitoring of anesthesia during surgery. They are also airway specialists with expertise in intubation, which is placement of an endotracheal or breathing tube to secure the airway, and extubation, which is removal of the endotracheal tube.

Patients with difficult airways are those who have anatomy or medical conditions that would present challenges to a trained anesthesiologist attempting to intubate or secure the airway.

In addition to detailed recommendations for planning for intubation and other emergencies, the new guidelines include a useful discussion about extubation.

For difficult airway patients, extubation planning can be virtually as important as getting ready for an emergency intubation. Here at Painter Law Firm, we recently worked on two medical malpractice cases were premature extubation was a key issue.

The first case was a medical negligence wrongful death matter where a patient died in an outpatient surgical facility after a shoulder surgery. The anesthesiologist and certified registered nurse anesthetist (CRNA) involved in his pre-anesthesia assessment and care noted that the patient had a thick neck and obstructive sleep apnea, which placed him at risk for having a difficult airway.

The surgery itself went well, but after the surgeon left the room, the patient became agitated as he was emerging from anesthesia. The CRNA decided to extubate him immediately. Our anesthesiology expert explained that this violated the standard of care for managing a difficult airway patient. Instead, the CRNA should have sedated the patient and allowed a controlled emerging from anesthesia and extubation.

After the patient was extubated, he closed his eyes and went into respiratory arrest. The CRNA and nursing staff noticed and transported him to the recovery room without any monitoring. By the time he was reconnected to monitoring the recovery room, he had a prolonged period of hypoxia (insufficient oxygen) and respiratory arrest. Resuscitation efforts were tragically unsuccessful.

In a second case, a pediatric patient with a well-documented history of a difficult airway was hospitalized for a cardiac catheterization procedure at a major academic hospital. After the successful procedure, the patient was sent to a regular pediatric intensive care unit (PICU) bed, instead of the specialized cardiac PICU that had normally treated him after surgeries.

The medical records reflected that the patient had poor lung compliance, meaning the ventilator was on a high setting to keep him breathing adequately. He wasn’t sufficiently awake and alert, had blood gas results from venous blood, and fluid retention that made it difficult for his lungs to expand properly. Despite these factors, the team of residents and fellows, who were still in the clinical training as physicians, rushed to extubate the patient.

As soon as they removed the breathing tube the patient crashed.  It had a prolonged period of insufficient oxygen. This caused a permanent brain injury.

The new ASA guidelines were informed by studies of successful extubations versus failed extubations (those where patients had to be reintubated), and seek to improve patient safety by encouraging anesthesiologists and anesthesia providers to:

• Assess patient readiness for extubation

• Make sure a skilled individual is present to assist with extubation

• Select an appropriate time and location for extubation

• Plan ahead for possible reintubation

• Consider an elective tracheostomy

• Consider awake extubation or super aquatic airway removal

• Administer supplemental oxygen throughout the extubation process

• Consider extubation within airway exchange catheter or super aquatic airway

Securing the patient’s airway is a critical function of anesthesiologists and nurse anesthetists. Any delay in properly managing emergency can mean the difference between a normal life and death or permanent brain injury from a lack of adequate oxygen.

If you’ve been seriously injured because of poor anesthesia care in Texas, then contact a top-rated experienced Texas medical malpractice lawyer for free consultation about your potential case.

Robert Painter
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Robert Painter

Robert Painter is an award-winning medical malpractice attorney at Painter Law Firm Medical Malpractice Attorneys in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits all over Texas. Contact him for a free consultation and strategy session by calling 281-580-8800 or emailing him right now.