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Ten Sentences on Anesthesiology: Deep Extubation

I suppose that people would be interested in hearing my thoughts on my anesthesia practice. I find these entries to be a bit harder to whittle down into the 10 sentence limit, but it is what it is.

My patients are usually unresponsive when I extubate them after surgery which can confuse anesthesia trainees. They’ll ask, “Was that a deep extubation,” having had the expectation that we were going to “wake the patient up.”

A deep extubation in real life looks like a terminal extubation does in movies – no bucking, no struggle. There are no “open your eyes” or “lift your head” challenges we more typically use to confirm adequate recovery from anesthesia.

It’s an understandable point of confusion b/c experienced practitioners may use lazy language around what’s happening under the surface; it all becomes more straightforward if we apply discrete definitions to these ambiguously used terms.

Light jargon alert: “Anesthetized” and “awake” are not opposites; general anesthesia is not related to or a state of sleep. “Sleep” describes wakefulness; “anesthetized” describes consciousness. “General anesthesia” (GA) is an induced neurological state of unconsciousness – independent of agent or dosage used – where a patient cannot protect his airway w/o assistance.

Here’s what GA isn’t: In an awake (or “lightly sedated”) dental procedure, the clinician suctions the airway for patient comfort and to keep the patient from bucking so he can finish the procedure. No one interprets this as “suction to save you from drowning,” b/c we implicitly grasp that bucking indicates the presence of one’s intact, endogenous, life-preserving airway reflexes.1

Deep extubation more precisely means “removing the endotracheal tube from a currently anesthetized patient before the return of airway reflexes,” (i.e, under GA).2 B/c there is no visible difference in outward appearance b/w levels of unconsciousness and anesthesia, one can understand why clinicians erroneously sometimes refer to this as “still asleep.”

But back to my extubations. My practice and what I teach residents is to split the difference by learning to identify and extubate when the patient is unanesthetized, but still unconscious, w/o awakening him for all the “lift your head,” “show two fingers” stuff.

Why? Firstly, no clinician is guaranteed to always have an expertly staffed recovery room, so deep extubations are sometimes prohibited.2 Minimizing the time the patient breathes off residual inhalational agent outside of the provider’s direct observation is a meaningful strategy to avoid problems.

Secondly, b/c monitors are objective, not intelligent. Assessment of patient safety is a human judgment that is formed first, confirmed by the monitor second. If the trainee can’t wake and challenge the patient for certain information, he’s forced to develop his judgment to obtain it in other clinical ways.

No spot check of six vital signs can identify the "unanesthetized but unconscious" state, or assess adequacy of recovery of muscular strength and airway reflexes, but an extubation that “began twenty minutes ago” very easily can. Awaking the patient to assess recovery at that point should be redundant.


1 The practice of anesthesiology is the temporary, controlled attenuation or cessation of one's life preserving reflexes to allow a person to undergo the trauma of surgery (another controlled injury) w/o sustaining the injury that would be otherwise associated w/ it. The induction of unconsciousness and amnesia are two aspects of complete anesthetic management.

2 Deep extubation isn’t free. It carries a real but manageable risk of airway hyperreactivity (read: reflexive "closure") during the unsecured period of recovery from the anesthetized state.)

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