Background, Responsibility and Implications for PACU Practitioner and Nurse led extubation
Background, Responsibility and Implications for PACU Practitioner and Nurse led extubation
A review of current literature highlighted the lack of national or local guidelines for Post Anaesthetic Care Unit (PACU) Practitioners/Recovery Room Nurses to extubate their own patients. Extubation is described as the discontinuation of an artificial airway. An artificial airway can be described as a plastic or rubber device that can be inserted into the upper or lower respiratory tract to facilitate ventilation or the removal of secretions (Farlex Inc 2011).
Reviewing the Code of Professional Conduct (Nursing and Midwifery Council (NMC 2008) and the Health Professional Council (HPC 2008) raised concern about practice with regards to extubating post-operative patients. The NMC and HPC both state that as professionals, we are personally accountable for actions and omissions within our practice, must always be able to justify our decisions, act lawfully, deliver care based on best available evidence, act as an advocate and treat people with dignity. Failure to comply with the code may bring fitness to practise into question and endanger registration.
A systematic literature review of patient extubation by PACU Nurses was undertaken. Systematic literature reviews optimise practice from the evidence of effectiveness and efficiency within the field of Health Care (Black et al 2000) and Gray (2001) suggests that a critically assessed, high quality literature review forms the basis of evidence based clinical practice.
As suggested by Aveyard (2007) and Cronin et al (2008), the first stage in conducting a literature review is to identify an appropriate topic. The topic for this literature review was “PACU Practitioner/ Nurse led patient extubation for Endotracheal tubes (ETT’s)”. Electronic literature only was reviewed due to timescales. . Electronic searching is quick and convenient, allowing for articles to be sourced more rapidly than alternative methods (Page 2008).
The literature review was undertaken with a view to producing an evidence based, best practice guideline booklet for PACU Practitioners (Nurses, Nursing students, Operating Department Practitioners (ODP), ODP students and trainee Doctors) working within the PACU area, that are involved in patient extubation with EndoTracheal Tubes (ETT). The Association of Anaesthetists of Great Britain and Ireland guidelines (AAGBI 2002) and the American Association for Respiratory Care (AARC 2007) for general ETT extubation were also read for pertinent information.
The Department of Health (DoH 2001) published A Framework for Lifelong Learning in the NHS. It states that as Nurses, we need to be able to reflect, evaluate and modify our practice, ensuring that we are up to date and with current research and legislation. Gray (2009) suggests that a critically assessed, high quality literature review forms the basis of evidence based clinical practice.
The first review of the literature highlighted a lack of national guidelines and standards for Nurses/Perioperative Practitioner to undertake ETT extubation, however The Association of Anaesthetists of Great Britain and Ireland (2002) stated that an appropriately trained Nurse may remove a Laryngeal Mask Airway (LMA) but that an Anaesthetist must remove an Endotracheal Tube.
The Anaesthetist that administers the anaesthetic remains responsible for the removal of the ETT from the patient, whether that is within the Theatre or PACU setting (AAGBI 2002). The Association for Perioperative Practitioners (AfPP 2007) recommend that if the responsibility is delegated to a PACU Practitioner, that the practitioner should have received validated training and be deemed competent to perform the task. As no national, validated training package is available for PACU Practitioners, a local training package to develop and validate knowledge and skills around airway management was developed by myself following a systematic literature review and discussions with local Consultant Anaesthetists.
Delegation is a two way process. If an Anaesthetist delegates an intubated patient to the care of a PACU Practitioner and they accept that delegation, that practitioner must have the knowledge and skills to be aware of the consequences of the delegation. Their performance in this skill will be judged against the performance expected by Anaesthetists. The person to whom the task is delegated has a duty to inform the Anaesthetist delegating the task if the task is outside their area of competence (Burnard, Morrison 1994).
The AAGBI guidelines (2002) further state that when care or treatment is delegated, the Anaesthetist must be satisfied that the person to whom they delegate has the qualifications, experience, knowledge and skills to provide the care or treatment involved and that the Anaesthetist must always pass on enough information about the patient and the treatment they need, as they will still be responsible for the overall management of the patient.
According to Rassam et al (2005) and Karmarker and Varshney (2008), airway related complications at extubation, are more common than problems at intubation, many aspects of which are controversial with no clear guidelines, giving cause for concern for patient safety and training. Reviewing the numerous complications that can arise in the immediate post extubation period reinforces the responsibility for the individual undertaking the extubation and is a critical time for vigilant nursing assessment and care (Ead 2004). Airway complications include; laryngospasm, laryngeal oedema, bronchospasm, aspiration and pulmonary oedema as well as anatomical changes, including short neck, sleep apnoea, cleft palate, small chin and obesity.
The New NHS (DoH 1997) made it clear that practitioners must accept responsibility for developing and maintaining standards within their local NHS organisations. The AAGBI (2002) state that practical training and maintenance of skills must supplement theoretical knowledge and training should be tailored to meet the needs of the individual and recovery room. Providing suitably trained practitioners would cover the Clinical Governance aspects specific to education, training and continuous professional development.
By broadening the literature review search to include cardiac surgery some articles around Nurse led, fast track extubation of cardiac patients were found with documented protocols to perform patient extubation within ICU settings. The criteria for extubating cardiac patients is comprehensive and involves blood loss, blood pressure, heart rate and rhythm, arterial blood gases, sedation breaks, ventilator weaning procedures, respiration rates, neurological assessment and medication. Once all those criteria are satisfactory, the protocol dictates how the patient should be extubated ie, with the trailing suction catheter. If Nurses were able to follow an agreed protocol to be able to extubate patients in the ICU setting, could those skills be transferrable to the PACU setting?
The PACU Practitioner
It was deemed that in order to undertake patient extubation, knowledge of the patient’s anatomy and physiology was needed. This includes airway anatomy, inspired oxygen concentration, pulse oximetry, tidal volume, hypoxia and expired carbon dioxide as well as heart anatomy and physiology, heart rate and blood pressure. The PACU Practitioner also needs to understand how to maintain a clear airway as well as how to manage an airway obstruction ie. undertaking an effective head tilt, chin lift, jaw thrust, inserting appropriate nasal and/or oral airways and the use of suction. Knowledge of pharmacology related to anaesthesia and analgesia is required to enable the PACU Practitioner to safely extubate a patient. For example, recurarisation is a phenomenon of recurrence of neuromuscular block and it may occur where the reversal agents wear off before a neuromuscular blocking drug is completely cleared (Schultheis 1989). This is important to understand as it has implications for airway management. The PACU Practitioner also needs to understand the differences and implications of Total IntraVenous Anaesthesia (TIVA), which can cause apnoea and hypotension and gaseous anaesthetics which increase nausea and vomiting, in order to manage the extubation process.
When preparing to extubate a patient, clinical considerations for the possible management of post extubation hypoventilation, airway compromise and obstruction should be taken into account. Clinical practice standards for endotracheal tube removal include attentive post extubation monitoring, prompt identification of respiratory distress, maintenance of a patent airway and, if clinically indicated, attempts to successfully establish an artificial airway by reintubation or in rare situations, surgical technique (AARC 2007).
Airway obstruction in the conscious patient is easily recognised as it leads to strenuous efforts on the part of the patient to overcome it. However, airway obstruction in the unconscious patient may not exhibit classical compensatory signs. Paradoxical chest movement, where the upper abdomen and chest see-saw (the chest retracting and the abdomen sticking out) during attempted inspiration can be seen. Air movement cannot be detected by listening at the mouth due to the lack of air entry and exit. The patient will eventually become cyanosed if left untreated.
Conclusion and limitations of the Literature Review
The literature review has a number of severe limitations. The most valid and high quality literature reviews are normally conducted by a team of experienced researchers who have access to a wide range of skills, experience and knowledge. This review could have been significantly strengthened if it was conducted with the support of a team to duplicate the literature search and validate the application of inclusion criteria and critical appraisal in order to minimise the risk of bias. In addition, the sources of literature were focused entirely on electronic sources and therefore many other potential sources of relevant literature were not considered.
Changes to Practice
Following the systematic literature review, Consultant Anaesthetists were liaised with and the information gained with regards to extubation, was utilised. A PACU Practitioners guide to extubation was subsequently written. This literature review informs the written guidelines in respect of Privacy and Dignity, Administration of Medicines, Safety in the Environment and Safeguarding Vulnerable Adults in relation to the DoH’s Essence of Care (DoH 2010). A comprehensive flow chart with the essential information with regards to patient extubation with ETT’s as a quick reference guide for the Nurses to refer to, was then developed from the information realised from the literature review.
Once the PACU Practitioner guidelines were written, the Airway Management training, including knowledge, skills and competency assessment was developed after liaising with the Anaesthetists. These are in relation to the ability to maintain a patent airway, ventilate a patient, use of artificial airways (oral/nasal/i-gel LMA) and through discussion around causes and management of airway obstructions.
Whilst there remains a lack of national guidance for PACU Practitioners to extubate patients, the local guidance now written will standardise practice and give guidance on dealing with the problems that they face on a daily basis.
The actual PACU Practitioner/Nurse led extubation guidelines handbook, algorithm and competencies can be purchased from
American Association of Respiratory Care 2007 AARC Guideline: Removal of the Endotracheal Tube Respiratory Care Vol 52 (1)
Association of Anaesthetists of Great Britain & Ireland 2002 Immediate Postanaesthetic Recovery London The Association of Anaesthetists of Great Britain and Ireland
Aveyard H 2007 Doing a literature review Maidenhead Open University Press
Black N, Brazier J, Fitzpatrick R, Reeves B 2000 Health Service Research Methods. A guide to best practice London BMJ Books
Burnard P, Morrison P 1994 Nursing research in action Basingstoke Palgrave Macmillan
Cronin P, Ryan R, Coughlan M 2008 Undertaking a literature review: a step-by-step approach British Journal of Nursing Vol 17 (1) pp 38 – 43
Department of Health 1997 The New NHS London DH
Department of Health 2001 A Framework for Lifelong Learning for the NHS London DH
Department of Health 2010 Essence of Care London DH
Ead H 2004 Post-anesthesia tracheal extubation. Canadian Association of Critical Care Nurses 15 (3), pp 20-25
Farlex Inc. 2011 Medical Dictionary. The free dictionary [online] The Free Dictionary Available: http://medical-dictionary.thefreedictionary.com/artificial+airway [11/5/11]
Gray JAM 2001 Evidence Based Health Care: How to Make Health Policy and Management Decisions 2nd Ed. London Churchill Livingstone
Health Professional Council (HPC) 2008 Standards of conduct, performance & ethics London HPC
Karmarkar S, Varshney S 2008 Tracheal Extubation British Journal of Anaesthesia: Continuing Education in Anaesthesia, Critical Care and Pain Vol 8 (6) pp 214 – 220
Nursing and Midwifery Council (NMC) 2008 The code: Standards of conduct, performance and ethics for nurses and midwives London NMC
Page D 2008 Systematic Literature Searching and the Bibliographic Database Haystack The Electronic Journal of Business Research Methods 6 (2) pp 171 - 180
Rassam S, Sandbythomas M, Vaughan RS, Hall JE 2005 Airway management before, during and after extubation: a survey of practice in the United Kingdom and Ireland. Anaesthesia 60 (10) pp 995-1001
Schultheis H 1989 When and how to extubate in the recovery room American Journal of Nursing 89 (8) pp 1040-1047
About the author
I qualified in 2001 and have worked predominantly within the Cardio-Thoracic specialty both on the Wards and in Recovery, in the UK and the USA. I have, to date, published three articles, with a fourth in the wings, as well as presented my PACU/Nurse led extubation work three times in different venues. I am always looking for ways to enhance patient care and am an advocate to patients too.
My MSc is almost complete and I have also undertaken a teaching certificate. I love to learn and share knowledge and imparting it is helping me to grow and learn as well as others.