Extubation and emergence are high-risk phases of anaesthesia which accounted for 28% of the anaesthesia cases reported to the Fourth National Audit Project of the Difficult Airway Society and the Royal College of Anaesthetists. Problems generally relate to the patient’s anatomy, physiology or to the context in which extubation is carried out. Minor issues such as coughing and breath-holding are common, more serious complications such as aspiration, laryngospasm, post-obstructive pulmonary oedema and hypoxic brain injury are often preventable with proper planning. In this chapter we discuss how to formulate an extubation strategy including risk stratification, planning, awake and deep extubation and modifications aimed at reducing the risk of complications. An awake extubation is suitable for most patients but special techniques such as supraglottic airway exchange, remifentanil infusion or the use of an airway exchange catheter may be helpful in high-risk situations. Post-operative care does not end when the tracheal tube has been removed, handover and documentation are essential components of the extubation plan.

INTRODUCTION

Patients with chronic graft versus host disease (cGVHD) experience a variety of health needs that result directly from the physical, functional, and psychosocial effects of the disease, are produced as side effects of immunosuppressive treatments, or derive from the late treatment effects of high-dose therapy and hematopoietic stem cell transplantation (HSCT). The achieving optimal outcomes for patients with cGVHD requires the coordinated efforts of an interdisciplinary team delivering a comprehensive range of clinical services in both community-based and specialty care settings. The services must be designed to promptly detect, effectively mitigate, and, where possible, prevent these sequelae. This chapter focuses on the principles of interdisciplinary practice in the care of patients with cGVHD. The chapter examines seven fundamental elements for successful interdisciplinary practice in cGVHD. These elements address (1) the composition, functioning, leadership, and coordination of the team, (2) the organizational service delivery model, (3) communication and collaboration, (4) eliminating barriers to access to needed services, (5) the development of standards of care, standard operating procedures, and evidence-based guidelines, (6) involvement of patient and family, and (7) coordination and continuity of care between specialty care centers and community. Case vignettes illustrate the application of the principles of interdisciplinary care and analyze the features of interdisciplinary team functioning that contribute to optimal clinical outcomes in HSCT survivors with cGVHD and the family members and communities who are caring for them.