Extubation in OR vs. During Recovery
Extubation, the process of removing a patient’s endotracheal tube after surgery, is a critical step in the perioperative care of patients undergoing surgical procedures. The timing and location of extubation have been topics of debate, especially in regard to operating room productivity [1]. Traditionally, extubation has been performed in the operating room (OR) immediately following surgery, but there have been studies demonstrating the role and efficacy of extubating patients in the post-anesthesia care unit (PACU) or recovery room [1,2]. In addition to safety, factors that come into play with extubation outside of the OR include patient outcomes, cost-effectiveness, and resource utilization.
Extubation in the OR has been the standard practice for decades. It offers several advantages, including rapid emergence, as extubating in the OR allows for immediate assessment of the patient’s airway, breathing, and circulation, and any complications can be promptly addressed. Further, the OR is a controlled environment equipped with advanced monitoring equipment and skilled anesthesia providers who can manage potential complications such as airway obstruction or hemodynamic instability [1].
On the other hand, in recent years, extubation in the recovery room has gained popularity for a variety of reasons, as an alternative to in the OR. Extubation in the OR often requires the presence of an anesthesia provider, which may limit their availability for other cases. Extubating in recovery allows for more efficient use of anesthesia resources and can help streamline the surgical process, potentially reducing OR time, which is essential in high-demand settings [1]. When comparing safety in the OR to safety in the PACU, studies have suggested that extubation in PACU may not only be as safe as in the OR but also may result in less premature extubations and as a result, fewer harmful airway events [1]. Further, studies looking at PACU extubation vs OR extubation in children found no difference in PACU length of stay [3]. Thus, PACU extubation may be more efficient and cost friendly.
Overall, the evidence suggests that both approaches are safe and result in similar patient outcomes. Studies have shown respiratory events when extubating during recovery to be infrequent and having a similar incidence as with OR extubation [4]. Although extubation in the OR offers immediate access to medical professionals and equipment in case of complications, extubation in recovery is generally considered safe for low-risk patients undergoing routine surgeries and has begun to be led by anesthetists and nurses in the PACU setting. The cost-effectiveness of extubation in the PACU has demonstrated a reduction in hospital and OR costs, with some hospitals reporting the ability to save more than $1 million in 2 years [4]. Extubation in the operating room and in recovery have differing advantages depending on individual patient needs, surgical complexity, and resource availability. Ultimately, the choice between extubation in the OR and in recovery should be guided by a multidisciplinary approach, considering the specific circumstances of each surgical case and the available resources.
References
- Oviedo P, Engorn B, Carvalho D et al. The impact of routine post-anesthesia care unit extubation for pediatric surgical patients on safety and operating room efficiency. Journal of Pediatric Surgery 2022; 57 (1): 100-103.
- Memon Z, Gladney A, Thomas J, Lal S. Nurse Led Extubation in Adult PACU – A Lean Process. Pak J Med Sci. 2022 Jan-Feb;38(1):330.
- Kako H, Corridore M, Seo S, Elmaraghy C, Lind M, Tobias JD. Tracheal extubation practices following adenotonsillectomy in children: effects on operating room efficiency between two institutions. Pediatric Anesthesia. 2017 Jun;27(6):591-5.
- Oviedo P, Engorn BM, Carvalho D et al. The Impact of Extubation Setting on Operating Room Efficiency, Hospital Costs, and Patient Safety in a Children’s Hospital. Journal of the American College of Surgeons 2021; 233 (5, Supplement 1): S181-S182.