Assessment of Common Criteria for Awake Extubation in Infants and Young Children

T. Wesley Templeton, Eduardo J. Goenaga-Díaz, Martina G. Downard, Christopher J. McLouth, Timothy E. Smith, Leah B. Templeton, Shelly H. Pecorella, Dudley E. Hammon, James J. O'Brien, Douglas H. McLaughlin, Ann E. Lawrence, Phillip R. Tennant, Douglas G. Ririe

Research output: Contribution to journalArticlepeer-review

16 Scopus citations


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.

Original languageEnglish
Pages (from-to)801-808
Number of pages8
Issue number4
StatePublished - Oct 1 2019

Bibliographical note

Funding Information:
The authors would like to acknowledge Forrest A.Roberson, B.S., East Carolina School of Medicine, Greenville, North Carolina, and Marina Lin, B.S., Department of Anesthesiology, Wake Forest University, Winston-Salem, North Carolina, for assisting with extensive data collection; Addie Larimore, B.A., Department of Anesthesiology, Wake Forest University, for editorial assistance in preparing manuscript; and would like to acknowledge the Study Coordinator Pool, Biostatistics Core, and Regulatory Knowledge & Support Program of the Wake Forest Clinical and Translational Science Institute, which is supported by the National Center for Advancing Translational Sciences, National Institutes of Health (Bethesda, Maryland) through grant No. UL1TR001420.

Publisher Copyright:
Copyright © 2019, the American Society of Anesthesiologists, Inc. Unauthorized reproduction of this article is prohibited.

ASJC Scopus subject areas

  • Anesthesiology and Pain Medicine


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