The edition · Anaesthesiology
New international extubation guidelines treat taking the tube out as a planned procedure
The Project for Universal Management of Airways has published guidelines framing every planned extubation as elective and deferrable, a network meta-analysis names intravenous dexamethasone the first-line drug for preventing rebound pain after nerve block, and an umbrella review supports propofol and rocuronium for caesarean general anaesthesia.
The edition in brief
Guidance dominates this period. The Project for Universal Management of Airways has published international multidisciplinary guidelines on tracheal extubation, generated by structured expert consensus with an advisory group that included airway assistants and human factors experts, and graded by the American Heart Association classification. Risk evaluation covers hypoxaemia, pulmonary aspiration and harm from airway stimulation, assessed against the patient's baseline and any change since intubation, alongside team and situational risk. Two propositions stand out: planned extubation is always elective, so timing, environment and resources can be controlled, and deferring is recommended where that meaningfully reduces risk. Where one airway lifeline replaces another, conversion procedures that maintain a continuous guide are preferred over replacement procedures. A network meta-analysis of 24 randomised trials and 2,130 patients across eight interventions found intravenous dexamethasone most likely to reduce rebound pain after single-injection peripheral nerve block, with a SUCRA of 0.91 and judged definitely superior to control. Perineural dexamethasone and dexmedetomidine ranked highest for delaying onset. Pre-emptive opioids were probably inferior to control. An umbrella review of obstetric general anaesthesia supports short-acting opioids at induction, propofol over thiopental on the grounds of less accidental awareness with equivalent neonatal resuscitation need, and rocuronium at 1 mg/kg or more as comparable to suxamethonium. The European Malignant Hyperthermia Group has issued consensus guidance on perioperative management of inherited myopathies.
PUMA guidelines: extubation is a planned procedure with a backup plan
New international guidelines frame every planned extubation as an elective procedure that can be deferred, requiring a documented risk assessment and a backup plan, with conversion techniques preferred over replacement in the at-risk airway.
Intravenous dexamethasone is the first-line drug against rebound pain
Give intravenous dexamethasone to patients receiving a single-injection peripheral nerve block: it ranked first for preventing rebound pain, and pre-emptive opioids were probably worse than nothing.
For caesarean general anaesthesia, propofol and rocuronium hold up
For caesarean general anaesthesia the evidence supports short-acting opioids at induction, propofol over thiopental, and rocuronium at 1 mg/kg as an alternative to suxamethonium — but it excludes the emergency cases where general anaesthesia is most often needed.
Quadratus lumborum block after caesarean: better early pain, unclear overall
Adding a lateral quadratus lumborum block to intrathecal morphine improved early pain after caesarean delivery, but with 58 women across three arms this is a signal to test rather than a protocol change.
Decide the extubation plan before you need it
Plan extubation like an induction: decide the timing, place and staffing in advance, reassess what has changed since intubation, and treat deferring as a legitimate option rather than a failure.
Read the rest in the app
You have read your two free briefings this month. The app carries all 27 specialties, every morning, free — and this one is waiting in it.
Scan to keep reading on your phone. No account needed to start.
Tomorrow morning, before your first patient
One edition a day for anaesthesiology, written by the desk, every claim tied to its paper. Six minutes.
Get the app — free