Difficulty Weaning Research Articles

Influence of Medical Insurance Under the Affordable Care Act on Access to Pain Management of the Trauma Patient.

The Affordable Care Act intended to "extend affordable coverage" and "ensure access" for vulnerable patient populations. This investigation examined whether the type of insurance (Medicaid, Medicare, Blue Cross, cash pay) carried by trauma patients influences access to pain management specialty care. Investigators phoned 443 board-certified pain specialists, securing office visits with 235 pain physicians from 8 different states. Appointments for pain management were for a patient who sustained an ankle fracture requiring surgery and experiencing difficulty weaning off opioids. Offices were phoned 4 times assessing responses to the 4 different payment methodologies. Fifty-three percent of pain specialists contacted (235 of 443) were willing to see new patients to manage pain medication. Within the 53% of positive responses, 7.2% of physicians scheduled appointments for Medicaid patients, compared with 26.8% for cash-paying patients, 39.6% for those with Medicare, and 41.3% with Blue Cross (P < 0.0001). There were no differences in appointment access between states that had expanded Medicaid eligibility for low-income adults versus states that had not expanded Medicaid eligibility. Neither Medicaid nor Medicare reimbursement levels for new patient visits correlated with ability to schedule an appointment or influenced wait times. Access to pain specialists for management of pain medication in the postoperative trauma patient proved challenging. Despite the Affordable Care Act, Medicaid patients still experienced curtailed access to pain specialists and confronted the highest incidence of barriers to receiving appointments.

Tracheostomy Among Infants With Hypoplastic Left Heart Syndrome Undergoing Cardiac Operations: A Multicenter Analysis

Less than 2.7% of infants undergoing congenital heart disease operations have difficulty weaning from invasive mechanical ventilation. In such instances, clinicians may choose to perform tracheostomy. Limited literature has examined tracheostomy placement specifically in infants with hypoplastic left heart syndrome (HLHS). This study evaluated the risk factors for tracheostomy placement in infants with HLHS and examined the outcomes of these infants before their first hospital discharge. This retrospective analysis of the Pediatric Heath Information System data set included infants with HLHS who underwent stage 1 Norwood operation, a hybrid procedure, or heart transplant from 2004 through2013. We identified 5721 infants with HLHS, and 126 underwent tracheostomy placement. Infants in the tracheostomy group had more morbidities and a higher mortality rate across the study period. Diagnosis of chromosomal abnormalities, anomalies of the trachea and esophagus, larynx, diaphragm and nervous system, bilateral vocal cord paralysis, and necrotizing enterocolitis, and procedures including extracorporeal membrane oxygenation support, cardiac catheterization, and gastrostomy tube were independently associated with tracheostomy placement in the study population. Despite an overall increase in rates of tracheostomy performed in infants with HLHS during the study period, the mortality rate did not improve among tracheostomy patients. Several risk factors were identified in infants with HLHS in whom a tracheostomy was placed during their first hospitalization. Despite an overall increase in rates of tracheostomies during the study period, the mortality rate did not improve among these patients. Appropriate family counseling and thorough preoperative case selection is suggested when discussing possible tracheostomy placement in infants with HLHS.

Cardiovascular effects as a result of a physical conditioning protocol on a critical care inpatient, at three medical centers in Bogotá – Colombia

El síndrome de desacondicionamiento físico es una complicación frecuente en los pacientes con reposo prolongado; su principal característica es la atroia muscular que afecta principalmente las ibras musculares tipo II y se asocia a un daño de la placa neuromuscular. Esto conlleva a múltiples alteraciones metabólicas y sistémicas, como la diicultad para abandonar la ventilación mecánica, la fatiga, el retorno tardío a las actividades de la vida cotidiana y períodos de rehabilitación prolongados. El presente estudio tuvo como objetivo describir los cambios cardiovasculares en pacientes hospitalizados en unidades de cuidado intensivo, al aplicar un protocolo de actividad física dirigida como parte de la rehabilitación. Se trata de un estudio descriptivo tipo serie de casos que se realizó en tres unidades de cuidado intensivo de tipo polivalente durante un año con una muestra de 23 pacientes que tuvieron una estancia superior a 72 horas y que como parte del manejo recibieron ventilación mecánica. Se evaluaron como parámetros cardiovasculares la presión arterial y la frecuencia cardíaca antes, durante y después de cada una de las cargas aplicadas, las cuales fueron ajustadas por un especialista en medicina de la actividad física y del deporte de acuerdo a la evolución clínica y posteriormente registradas en una escala del uno al treinta y dos. Se analizaron los datos de las variables cardiovasculares por medio de estadísticas no paramétricas sin encontrar diferencias signiicativas concluyendo que en pacientes críticos, la utilización de cargas orientadas por parte del especialista idóneo, no tiene efecto cardiovascular considerable y puede mantenerse como parte de los protocolos de rehabilitación. MÉD.UIS. 2016;29(2):161-73.

Mitigation of Ventilator-induced Diaphragm Atrophy by Transvenous Phrenic Nerve Stimulation.

Ventilator-induced diaphragm dysfunction is a significant contributor to weaning difficulty in ventilated critically ill patients. It has been hypothesized that electrically pacing the diaphragm during mechanical ventilation could reduce diaphragm dysfunction. We tested a novel, central line catheter-based, transvenous phrenic nerve pacing therapy for protecting the diaphragm in sedated and ventilated pigs. Eighteen Yorkshire pigs were studied. Six pigs were sedated and mechanically ventilated for 2.5 days with pacing on alternate breaths at intensities that reduced the ventilator pressure-time product by 20-30%. Six matched subjects were similarly sedated and ventilated but were not paced. Six pigs served as never-ventilated, never-paced control animals. Cumulative duration of pacing therapy ranged from 19.7 to 35.7 hours. Diaphragm thickness assessed by ultrasound and normalized to initial value showed a significant decline in ventilated-not paced but not in ventilated-paced subjects (0.84 [interquartile range (IQR), 0.78-0.89] vs. 1.10 [IQR, 1.02-1.24]; P = 0.001). Compared with control animals (24.6 μm2/kg; IQR, 21.6-26.0), median myofiber cross-sectional areas normalized to weight and sarcomere length were significantly smaller in the ventilated-not paced (17.9 μm2/kg; IQR, 15.3-23.7; P = 0.005) but not in the ventilated-paced group (24.9 μm2/kg; IQR, 16.6-27.3; P = 0.351). After 60 hours of mechanical ventilation all six ventilated-paced subjects tolerated 8 minutes of intense phrenic stimulation, whereas three of six ventilated-not paced subjects did not (P = 0.055). There was a nonsignificant decrease in diaphragm tetanic force production over the experiment in the ventilated-paced and ventilated-not paced groups. These results suggest that early transvenous phrenic nerve pacing may mitigate ventilator-induced diaphragm dysfunction.

The Effectiveness of Pulmonary Rehabilitation for Critical-Care Ventilator Patients: A Systematic Review

Prolonged of use mechanical ventilators results in respiratory muscle atrophy and difficulties in weaning, which increase mortality rates and psychlogical distress. While pulmonary rehabilitation has been shown to improve respiratory muscle strength, the effects of this intervention in critical-care patients who use mechanical ventilation remain uncertain. The present paper uses a systematic review of the literature to evaluate the effects of pulmonary rehabilitation on the rate of ventilator weaning and on the physical performance of ventilator patients receiving critical care. A systematic review was used. Searches were conducted in databases including: Cochrane Library, Embase, MEDLINE, PubMed and Airit Library. Keywords that were used included: "mechanical ventilation", "pulmonary rehabilitation", "exercise", "weaning", and "activities of daily living". The search focused on articles that were published prior to February 2015. Based on inclusion and exclusion criteria, 7 articles addressing relevant randomized controlled trials were extracted. All of the 7 studies supported that pulmonary rehabilitation interventions improve mechanical ventilation weaning and functional independence activities. Several studies were limited by small sample size and differences in the types of rehabilitations used. Thus, the generalizability of the findings of this review is limited. and further research is required to verify the effects of pulmonary rehabilitation. The results of this systematic review support that pulmonary rehabilitation interventions improved the weaning rate, activities of functional independence, and maximal inspiratory pressure (MIP) in critical patients who had used mechanical ventilators for over 48 hours. Under hemodynamic-stablized and pressure-support mode, inspiratory muscle training is suggested as useful for patients with limited ability to participate in rehabilitation programs.

Surgical Results and Outcomes After Reimplantation for the Management of Anomalous Aortic Origin of the Right Coronary Artery

Anomalous aortic origin of the right coronary artery (AAORCA) has been reported to cause myocardial ischemia, leading to angina, dyspnea, and decreased exercise tolerance. Reimplantation is a repair technique devised to exclude the abnormal intramural portion of the anomalous artery and avoid the known late attrition of saphenous vein grafts. Our study aims to evaluate the medium-term clinical outcomes with this technique. A retrospective review was made of patients who underwent repair of AAORCA by reimplantation between 2002 and 2014 in two institutions in Western Australia. Follow-up computed tomography coronary angiography was used to assess the status of the reimplanted right coronary artery (RCA). Data on survival, freedom from symptoms, cardiac events, and cardiac interventions were also analyzed. Of the 16 patients (aged 17 to 70 years old), 14(88%) were symptomatic before surgery, with angina (50%) and exertional dyspnea (56%) being the most common symptoms. Surgical reimplantation was successful in 15 patients (94%) without operative mortality. One patient required saphenous vein bypass grafting of the RCA intraoperatively after presumed failed repair and difficulty weaning from cardiopulmonary bypass. All patients who had successful reimplantation of AAORCA were symptom-free after surgery, and none had subsequent cardiac events attributable to the RCA or required further interventions. Ten patients (67%) had computed tomography coronary angiography after surgery; none had stenosis, kinking, or compression of the RCA by thepulmonary artery. Two further patients (including thepatient who underwent saphenous vein grafting forpresumed failed reimplantation) underwent conventionalangiography, which demonstrated patent reimplantations. To the best of our knowledge, this is the largest reported series of anomalous RCA managed by surgical reimplantation. Our results suggest that this technique is safe and has excellent medium to long-term results regarding symptom-free survival.

Anaesthetic management of Mowat-Wilson syndrome.

Anaesthetic management of Mowat-Wilson syndrome.

Smart Care™ versus respiratory physiotherapy-driven manual weaning for critically ill adult patients: a randomized controlled trial.

IntroductionA recent meta-analysis showed that weaning with SmartCare™ (Dräger, Lübeck, Germany) significantly decreased weaning time in critically ill patients. However, its utility compared with respiratory physiotherapist–protocolized weaning is still a matter of debate. We hypothesized that weaning with SmartCare™ would be as effective as respiratory physiotherapy–driven weaning in critically ill patients.MethodsAdult critically ill patients mechanically ventilated for more than 24 hours in the adult intensive care unit of the Albert Einstein Hospital, São Paulo, Brazil, were randomly assigned to be weaned either by progressive discontinuation of pressure support ventilation (PSV) with SmartCare™. Demographic data, respiratory function parameters, level of PSV, tidal volume (VT), positive end-expiratory pressure (PEEP), inspired oxygen fraction (FiO2), peripheral oxygen saturation (SpO2), end-tidal carbon dioxide concentration (EtCO2) and airway occlusion pressure at 0.1 second (P0.1) were recorded at the beginning of the weaning process and before extubation. Mechanical ventilation time, weaning duration and rate of extubation failure were compared.ResultsSeventy patients were enrolled 35 in each group. There was no difference between the two groups concerning age, sex or diagnosis at study entry. There was no difference in maximal inspiratory pressure, maximal expiratory pressure, forced vital capacity or rapid shallow breathing index at the beginning of the weaning trial. PEEP, VT, FiO2, SpO2, respiratory rate, EtCO2 and P0.1 were similar between the two groups, but PSV was not (median: 8 vs. 10 cmH2O; p =0.007). When the patients were ready for extubation, PSV (8 vs. 5 cmH2O; p =0.015) and PEEP (8 vs. 5 cmH2O; p <0.001) were significantly higher in the respiratory physiotherapy–driven weaning group. Total duration of mechanical ventilation (3.5 [2.0–7.3] days vs. 4.1 [2.7-7.1] days; p =0.467) and extubation failure (2 vs. 2; p =1.00) were similar between the two groups. Weaning duration was shorter in the respiratory physiotherapy–driven weaning group (60 [50–80] minutes vs. 110 [80–130] minutes; p <0.001).ConclusionA respiratory physiotherapy–driven weaning protocol can decrease weaning time compared with an automatic system, as it takes into account individual weaning difficulties.Trial registrationClinicaltrials.gov Identifier: NCT02122016. Date of Registration: 27 August 2013.

Impact of delirium on weaning from mechanical ventilation in medical patients.

Delirium is an important predictor of negative clinical outcomes in intensive care unit (ICU), including prolonged mechanical ventilation (MV). However, delirium has not yet proven to be directly linked to weaning difficulties. The objective of this cohort study was to evaluate the association between delirium, as observed on the day of the weaning trial, and subsequent weaning outcomes in medical patients. This is a retrospective analysis with prospectively collected data on weaning from mechanical ventilation (MV) and delirium, as assessed by bedside ICU nurses using the Confusion Assessment Method for the ICU (CAM-ICU) between October 2011 and September 2013. During the study period, a total of 393 patients with MV support underwent a spontaneous breathing trial (SBT) according to the standardized protocol. Of these patients, 160 (40.7%) were diagnosed with delirium on the day of the first SBT. Patients without delirium were more successfully extubated than those with delirium (81.5% vs 69.4%, P = 0.005). Delirium was found to be associated with final weaning outcomes, including difficult (OR 1.962, 95% CI 1.201-3.205) and prolonged weaning (OR 2.318, 95% CI 1.272-4.226) when simple weaning was used as a reference category. After adjusting for potential confounding factors, delirium was still significantly associated with difficult weaning (adjusted OR 2.073, 95% CI 1.124-3.822), but not with prolonged weaning (adjusted OR 2.001, 95% CI 0.875-4.575). Delirium, as assessed by the CAM-ICU at the time of first weaning trial, was significantly associated with weaning difficulties in medical patients.

Study on tracheal intubation related severe subglottic stenosis under laryngeal mask by using holmium laser combined with argon plasma coagulation and cryotherapy through bronchoscopy

Objective To explore the operating methods, the effectiveness and safety for 2 cases of tracheal intubation related severe subglottic stenosis under laryngeal mask by using bronchoscopy in the diagnosis and interventional treatment. Methods Two male patients (age at 4 and 11 months)both had difficulty breathing and weaning failure after endotracheal intubation, who were diagnosed with severe subglottic stenosis through CT and bronchoscopy examination.All parents signed their consent after being fully informed of treatment risks.Two cases were treated under bronchoscopic holmium laser combined with argon plasma coagulation and freezing treatment by using the laryngeal mask.The clinical data, complications and postoperative outcome and follow-up were analyzed. Results Two cases were operated successfully, the subglottic granulation tissue of 1 case was completely removed, 2 cases of patients had subglottic narrow annular completely removed, and there was no problem for 4.0 mm bronchoscope to get through, postoperative tracheal catheter was successfully extracted, dyspnea was significantly improved.Two cases immediately showed well open after treatment, 7 d, 30 d and 90 d through endoscopic examination.During the operation, oxygen saturation decreased and heart rate increased fast or slowed down, but after operation and oxygen got resumed, they immediately recovered, and there were no abnormal hemodynamic changes during and after operation.The two cases were still under follow-up. Conclusions The laryngeal mask holmium laser, argon plasma coagulation and cryotherapy can be used to remove acquired granulation tissue hyperplasia caused by subglottic stenosis, which is safe and effective, and the short-term effect was remarkable.Long-term effect still needs to be further assessed through follow-up. Key words: Subglottic stenosis; Laryngealmask; Bronchoscop; Holmiumlaser; Argon plasma coagulation; Cryotherapy; Child

Inspiratory muscle training facilitates weaning from mechanical ventilation among patients in the intensive care unit: a systematic review.

Does inspiratory muscle training improve inspiratory muscle strength in adults receiving mechanical ventilation? Does it improve the duration or success of weaning? Does it affect length of stay, reintubation, tracheostomy, survival, or the need for post-extubation non-invasive ventilation? Is it tolerable and does it cause adverse events? Systematic review of randomised trials. Adults receiving mechanical ventilation. Inspiratory muscle training versus sham or no inspiratory muscle training. Data were extracted regarding: inspiratory muscle strength and endurance; the rapid shallow breathing index; weaning success and duration; duration of mechanical ventilation; reintubation; tracheostomy; length of stay; use of non-invasive ventilation after extubation; survival; readmission; tolerability and adverse events. Ten studies involving 394 participants were included. Heterogeneity within some meta-analyses was high. Random-effects meta-analyses showed that the training significantly improved maximal inspiratory pressure (MD 7 cmH2O, 95% CI 5 to 9), the rapid shallow breathing index (MD 15 breaths/min/l, 95% CI 8 to 23) and weaning success (RR 1.34, 95% CI 1.02 to 1.76). Although only assessed in individual studies, significant benefits were also reported for the time spent on non-invasive ventilation after weaning (MD 16 hours, 95% CI 13 to 18), length of stay in the intensive care unit (MD 4.5 days, 95% CI 3.6 to 5.4) and length of stay in hospital (MD 4.4 days, 95% CI 3.4 to 5.5). Weaning duration decreased in the subgroup of patients with known weaning difficulty. The other outcomes weren't significantly affected or weren't measured. Inspiratory muscle training for selected patients in the intensive care unit facilitates weaning, with potential reductions in length of stay and the duration of non-invasive ventilatory support after extubation. The heterogeneity among the results suggests that the effects of inspiratory muscle training may vary; this perhaps depends on factors such as the components of usual care or the patient's characteristics.

Differential Effects Of Flow Stasis On Flow-mediated Dilation In Diaphragm And Soleus Skeletal Muscle Arterioles

Unlike limb muscle, the diaphragm is active during the entire lifespan of an individual. However, with inactivity from mechanical ventilation (MV), there is a time-dependent reduction in diaphragm blood flow and inability to augment flow with contractions which is not evident in hindlimb locomotory muscle. One potential mechanism for the reduced hyperemia after MV is a diminished vasodilatory capacity due to the prolonged reduction in blood flow in the diaphragm. PURPOSE: The purpose of the present investigation was to test the hypothesis that prolonged flow stasis (i.e., absence of flow through vascular lumen) will elicit a rapid reduction in flow-mediated dilation (FMD) in diaphragm resistance vessels, whereas those from locomotory muscle (soleus) muscle will exhibit a preserved vasodilation. METHODS: Using the isolated microvessel technique, resistance arterioles were harvested from the diaphragm and soleus muscles of female Sprague-Dawley rats (n=8, 4 mo., ∼275 g). After the vessels were cannulated, FMD was measured after 1, 3, and 6 hours of flow stasis in the vessels. RESULTS: Despite no difference in initial diameter after cannulation between muscles, the maximal arteriolar diameter (at the end of the experiment) of the arterioles in the diaphragm was smaller than those of the soleus (165 ± 16 vs. 195 ± 22 μm, respectively; p≤0.05). After 1 hour of stasis, maximal FMD was not different between groups (diaphragm, 49 ± 4, Sol, 44 ± 7%, p>0.1). However, in the diaphragm at 3 and 6 hours of flow stasis, there was a 46 ± 6% and 83 ± 4% reduction in maximal FMD, respectively (both p<0.05 vs. 1 hour). There was no difference in maximal FMD over time in the soleus muscle arterioles. After 6 hours of flow stasis maximal FMD was lower in the diaphragm (8 ± 2%) compared to the soleus (42 ± 9%; p<0.05) muscle arterioles. CONCLUSION: There are several unique vascular properties of the diaphragm in relation to other skeletal muscle which, when coupled with its chronic activation, may expedite the time-course of vasomotor dysfunction with disuse in this muscle. The severely blunted FMD observed herein may predispose patients subjected to MV to weaning difficulties due, in part, to a diminished capacity to increase oxygen delivery to the diaphragm during contractions. Supported by NIH AG-31317 (BJB) and R21 AG044858 (JMD).

Sepsis-Associated Neurologic Dysfunction

Sepsis is a leading cause of morbidity and mortality for infants and children in the United States and is associated with peripheral and central nervous system dysfunction including encephalopathy and paresis. Sepsis-associated encephalopathy (SAE) may be underdiagnosed in children, but the exact incidence is not known because of variable criteria for its diagnosis, which require a high index of suspicion and exclusion of other confounding factors. Neuroimaging and cerebrospinal fluid analysis are often normal. Electroencephalography may correlate with the severity of encephalopathy. Intensive care unit–acquired weakness due to critical illness neuropathy or myopathy develops later, and resolution of weakness is gradual. Difficulty weaning from the ventilator is an early sign. Electroencephalography may be helpful in identifying SAE once other causes of encephalopathy have been ruled out. However, the lack of consensus on the definition of SAE and sparse pediatric data limit the specific evidence-based recommendations, which can be made for the assessment and treatment of this disorder in the emergency department.

Analysis of serious respiratory complications in PICU in children with measles

To evaluate the characteristics of the serious complications of 17 cases with measles in ICU. Seventeen cases with measles with serious complications in ICU in Anhui Provincial Children's Hospital were recruited from May 2012 to May 2013. Clinical characteristics, image finding, and prognosis were analyzed retrospectively. IgM antibody was positive in all the 17 cases, which included 9 male cases, 8 female cases, and their age was from 2 months to 10 years. All the 17 patients received mechanical ventilation because of severe respiratory distress within 1 week of onset, of which 14 cases were complicated with acute respiratory distress syndrome (acute ARDS), 6 cases of tension pneumothorax, 3 cases were complicated with bronchitis, laryngeal obstruction III degrees, and totally 7 cases died. The survived 10 patients were followed up for 1 year, 1 patient with localized pneumothorax, bronchopleural fistula, 1 case of mild pulmonary fibrosis, 1 case of acute laryngitis with persistent hoarseness, and mild inspiratory dyspnea were found. The remaining 7 cases fully recovered. Fourteen cases failed to inoculate measles vaccine. A higher risk of death and poor prognosis were found in children with measles who needed to be treated in PICU, especially for ARDS with pneumothorax. Laryngitis needed long time to cure and had weaning difficulties, and the case associated with pleural effusion or bronchopleural fistula must be treated with surgery, and the patients easily develop secondary bacterial infection.

Parallel Pilot Trials of Screening Frequency for Liberation from Mechanical Ventilation the RELEASE Trial and SENIOR Trial Protocols

Rationale: Reducing the duration of invasive ventilation is a priority in the intensive care unit (ICU). Once daily screening to identify candidates for spontaneous breathing trials (SBTs) is poorly aligned with the continuous care ICU environment. Objectives: The primary objective of the pilot randomized RELEASE and SENIOR trials is to assess our ability to recruit 50 non-elderly ( 65 years) critically ill adults into parallel trials comparing once vs at least twice daily screening. Secondary objectives are to evaluate clinicians’ adherence to the screening protocols, assess current practices related to management of sedation, analgesia, delirium and patient mobilization before screening assessments, identify barriers to enrollment, characterize trial participants based on weaning difficulty, and obtain preliminary estimates of the alternative screening strategies on clinical outcomes. In the SENIOR trial, we will also compare recruitment metrics and intervention effect between elderly (65 to 80 years) and very elderly (>80 years) participants. Methods: In both trials, we will enroll critically ill adults receiving invasive ventilation for at least 24 hours who can initiate or trigger breaths. In both arms, Respiratory Therapists (RTs) will screen patients between 06:00 and 08:00 hours daily to identify SBT candidates. In the ‘at least twice daily screening’ arm, RTs will also screen patients between 13:00 and 15:00 hours with additional screening periods permitted at clinicians’ discretion. We will consider the studies feasible if we can recruit on average, 1 to 2 patients per month per ICU and attain at least 80% protocol adherence. Relevance: Screening patients more frequently and conducting more frequent SBTs has the potential to reduce the duration of time spent on invasive ventilation and in the ICU. Information garnered from these pilot randomized trials will inform the design of a large, future trial. Clinical trial study: The RELEASE Trial ClinicalTrials.gov Identifier: NCT02001220; The SENIOR Trial ClinicalTrials.gov Identifier: NCT02243449

人工呼吸器からの離脱に難渋した中枢性睡眠時無呼吸症候群の1例

人工呼吸器からの離脱に難渋した中枢性睡眠時無呼吸症候群の1例

Investigation of adjuvant treatment for difficult weaning from mechanical ventilation

To investigate the value of drug intervention for difficult weaning from mechanical ventilation. A prospective single-blind randomized controlled trial was conducted. 120 patients with difficult weaning from mechanical ventilation encountered in Department of Critical Care Medicine of Peking University Third Hospital from January 2008 to December 2013 were included, and the patients were divided into treatment group and control group according to random number table, with 60 cases in each group. Patients received furosemide therapy in the treatment group 3 days before weaning up to 48 hours after weaning in order to control negative liquid balance. Enema was given the day before weaning to reduce abdominal pressure. On the weaning day, all of the patients received nitroglycerin and beta blocker or cedilanid to prevent or control elevation of blood pressure and heart rate in the process of weaning. All patients in treatment group received anisodamine in small dosage 2 hours before extubation. The patients in control group received conventional treatment without drug intervention. Baseline indexes of two groups were compared, including the heart rate, respiration rate (RR), mean arterial pressure (MAP), pulse blood oxygen saturation (SpO₂), blood gas, hemoglobin (HG), albumin (ALB) and creatinine (Cr). The main reasons of difficulty in weaning, sedative and analgesic drug selection, presence of abdominal discomfort before weaning, interval between sputum suction before extubation, liquid balance at the beginning of the investigation and at time of weaning, 24 hours and 48 hours after weaning, failures of spontaneous breathing test (SBT), length of mechanical ventilation,length of ICU stay, and total length of mechanical ventilation and total length of ICU stay during hospitalization. There was no statistically significant difference in the heart rate, RR, MAP, SpO₂, blood gas, HG, ALB, Cr at the beginning of the investigation between the two groups. The main reasons for difficult weaning in both groups of patients were respiratory dysfunction, cardiac insufficiency, and central nervous system dysfunction. The use of propofol combined dexmedetomidine in the treatment group was more frequent than the control group [16.7% (10/60)vs. 1.7% (1/60), χ² = 8.107, P=0.004], and there was no statistically significant difference in the use of other combinations of sedative drugs between the two groups. Abdominal discomfort before weaning was milder in treatment group as compared with control group [10.0% (6/60) vs. 25.0% (15/60), χ² = 4.675, P=0.031]. The interval between sputum suction before extubation in the treatment group was significantly longer than that of the control group [hours: 1 (1, 2) vs. 1 (1, 1), Z=-2.209, P= 0.027]. SBT failure was less frequent in treatment group compared with control group [times: 0 (0, 1) vs. 1 (1, 2), Z=-6.561, P=0.000]. Liquid balance was better in the treatment group than the control group at time of weaning, 24 hours and 48 hours after weaning [at time of weaning: -567.71(-755.95,-226.41) vs. 1 256.76 (472.48, 1 796.63), Z=-9.038, P=0.000; 24 hours after weaning: -5.03 (-530.28, 245.09) vs. 342.28 (125.36, 613.25), Z=-4.711, P=0.000; 48 hours after weaning: 115.50 (-450.26,485.00) vs. 330.00 (16.25,575.25), Z=-1.932, P=0.053]. Compared with control group, length of mechanical ventilation [days: 1.0 (1.0, 2.0) vs. 2.0 (2.0, 3.0), Z=-6.545, P=0.000], ICU stay time [days: 3.0 (3.0, 4.0) vs. 4.0 (4.0, 5.0), Z=-6.545, P=0.000], and total length of mechanical ventilation [days: 8.0 (6.0,12.0) vs. 11.0 (8.0, 15.0), Z=-4.091, P=0.000] and total length of ICU stay during hospitalization [days: 12.5 (9.2, 19.0) vs. 17.0 (12.0, 29.5), Z=-2.722, P=0.000] were all significantly shorter in the treatment group. Adjuvant drugs therapy is helpful in patients weaning from the mechanical ventilation, and can shorten length of mechanical ventilation and ICU stay time. Propofol, combined dexmedetomidine, is helpful for weaning.

Impact of oral melatonin on critically ill adult patients with ICU sleep deprivation: study protocol for a randomized controlled trial.

BackgroundSleep deprivation is common in critically ill patients in intensive care units (ICU). It can result in delirium, difficulty weaning, repeated nosocomial infections, prolonged ICU length of stay and increased ICU mortality. Melatonin, a physiological sleep regulator, is well known to benefit sleep quality in certain people, but evidence for the effectiveness in ICU sleep disturbance is limited.Methods/DesignThis study has a prospective, randomized, double-blind, controlled, parallel-group design. Eligible patients are randomly assigned to one of the two treatment study groups, labelled the ‘melatonin group’ or the ‘placebo group’. A dose of 3 mg of oral melatonin or placebo is administered at 9:00 pm on four consecutive days. Earplugs and eye masks are made available to every participant. We plan to enrol 198 patients. The primary outcome is the objective sleep quality measured by the 24-hour polysomnography. The secondary outcomes are the subjective sleep quality assessed by the Richards Campbell Sleep Questionnaire, the anxiety level evaluated by the Visual Analogue Scale-Anxiety, the number of delirium-free days in 8 and 28 days, the number of ventilation-free days in 28 days, the number of antibiotic-free days, ICU length of stay, the overall ICU mortality in 28 days and the incidence and severity of the side effects of melatonin in ICU patients. Additionally, the body stress levels, oxidative stress levels and inflammation levels are obtained via measuring the plasma melatonin, cortisone, norepinephrine, malonaldehyde(MDA), superoxide dismutase(SOD), interleukin-6 (IL-6) and interleukin-8 (IL-8)concentrations.DiscussionThe proposed study will be the first randomized controlled study to use the polysomnography, which is the gold standard of assessing sleep quality, to evaluate the effect of melatonin on the sleep quality and circadian rhythms of ICU patients. The results may recommend a new treatment for ICU patients with sleep deprivation that is safe, effective and easily implementable in daily practice.Trial registrationThis study was registered with ClinicalTrials (NCT; registration number: ChiCTR-TRC-14004319) on 4 March 2013.

Muscle Disease

On the basis of strong research evidence, Duchenne muscular dystrophy (DMD), the most common severe childhood form of muscular dystrophy, is an X-linked recessive disorder caused by out-of-frame mutations of the dystrophin gene. Thus, it is classified asa dystrophinopathy. The disease onset is before age 5 years. Patients with DMD present with progressive symmetrical limb-girdle muscle weakness and become wheelchair dependent after age 12 years. (2)(3). On the basis of some research evidence,cardiomyopathy and congestive heart failure are usually seen in the late teens in patients with DMD. Progressive scoliosis and respiratory in sufficiency often develop once wheelchair dependency occurs. Respiratory failure and cardiomyopathy are common causes of death, and few survive beyond the third decade of life. (2)(3)(4)(5)(6)(7). On the basis of some research evidence, prednisone at 0.75 mg/kg daily (maximum dose, 40 mg/d) or deflazacort at 0.9 mg/kg daily (maximum dose, 39 mg/d), a derivative of prednisolone (not available in the United States), as a single morning dose is recommended for DMD patients older than 5 years, which may prolong independent walking from a few months to 2 years. (2)(3)(16)(17). Based on some research evidence, treatment with angiotensin-converting enzyme inhibitors, b-blockers, and diuretics has been reported to be beneficial in DMD patients with cardiac abnormalities. (2)(3)(5)(18). Based on expert opinion, children with muscle weakness and increased serum creatine kinase levels may be associated with either genetic or acquired muscle disorders (Tables 1 and 3). (14)(15)

Anaesthetic Management of Massive Pulmonary Embolism: Case report and Review

Acute massive pulmonary embolism is a life-threatening emergency with a very high mortality. A 34 year old man, presented in our emergency department with complaints of NYHA class-III dyspnoea, cough, palpitation, and left sided chest pain. The clinical findings and investigations suggest diagnosis of pulmonary embolism followed by confirmation with CT angiography. The patient was taken to the operation theatre with supported hemodynamically with dobutamine infusion. Using required monitors, anesthetic induction was done with etomidate and fentanyl followed by the tracheal intubation with rocuronium. During induction, there was sudden hypotension which was managed with fluid boluses and norepinephrine boluses and continuing infusion of dobutamine. Anaesthesia was maintained with 50% oxygen with air, pancuronium, fentanyl and midazolam. After midline sternotomy, using Cardiopulmonary Bypass (CPB), thromboembolectomy was done on warm beating heart without aortic cross-clamping or cardioplegia. Partially organized thrombi were removed from left and right pulmonary arteries and their distal branches. The patient was weaned successfully from CPB with inotropic supports. The patient was extubated in the surgical ICU. The patient was discharged on the 5th postoperative day uneventfully. The management of pulmonary embolism tests the skills of the anesthetist with respect to rapid haemodynamic management, management during CPB and difficulty in weaning successfully off CPB, using appropriate combination of inotropes and vasodilators.