Elective Postoperative Ventilation Research Articles

Extubation strategies after esophageal atresia repair

Background/PurposeEarly extubation following repair of esophageal atresia (EA) is desirable unless the anastomosis is under tension, in which case paralysis and post-operative ventilation may reduce the risk of anastomotic leakage. However, complications from emergency reintubations do occur with either strategy. We aim to examine the risk/benefit balance of early and delayed extubation following EA repair. MethodsA seven-year retrospective review of all babies that underwent EA repair was performed. Babies extubated within 24 h of surgery were classified as early extubation (EE). Babies intubated beyond the first 24 h were classified as delayed extubation (DE). The EE group was subdivided into babies extubated in operating room (EIOR), and babies who returned to the neonatal intensive care unit (NICU) intubated but extubated within 24 h (EW24). ResultsForty-six babies were analyzed, and overall 15 (32.6%) required 24 reintubation episodes. Eight (28.6%) babies in the EE group required reintubation. The EIOR group (n = 12) had significantly increased risk of requiring reintubation (OR:7, 95%CI:1.08 to 45.16:p = 0.04) compared to the EW24 group (n = 16). Seven (38.9%) babies in the DE group required reintubation. The complication rate from reintubation after EA repair was 17%. ConclusionsExtubation on the NICU within 24 h of surgery carried the lowest risk of reintubation. For babies with a tight anastomosis, elective postoperative ventilation appeared to confer a protective benefit without incurring a high risk of complications from reintubation.

Undiagnosed hypothyroidism with delayed recovery: A case report.

Sir, We report a case of delayed recovery from general anesthesia, which was later on diagnosed as a case of hypothyroidism. A 60-year female patient was posted for elective open cholecystectomy with heart rate 47/min, blood pressure 140/80 mmHg, and normal electrocardiograph. Patient had no other comorbidities and was not any drugs. Her echocardiography revealed stage I left ventricular diastolic dysfunction with normal systolic functions. Medicine referral was done for bradycardia. On operating table (OT) table, her heart rate (HR) increased to 58/min after injecting atropine 0.6 mg intravenously (IV). Anesthesia was induced with intravenous morphine, thiopentone, and vecuronium with endotracheal intubation and maintained with isoflurane, nitrous oxide, and oxygen uneventfully. At the end, patient recovered well with adequate spontaneous respiration and neuromuscular blockade was reversed with injection neostigmine and glycopyrrolate. However, following extubation, patient became drowsy and apneic. Trachea was reintubated and intermittent positive pressure ventilation was restarted. Fresh reports revealed normal electrolytes and blood gas analysis. Patient was re-evaluated clinically and was observed to have very thick and rough skin (probably missed in preanesthetic evaluation), low body temperature, and bradycardia without thyroid swelling. Suspecting hypothyroidism, blood sample was sent for TSH estimation after 2.5 h of reintubation; and as injectable thyroxine was not available, two tablets of Thyroxin 100 μg each were given through Ryle's tube empirically on emergency basis. Patient recovered well after 4 h of elective postoperative ventilation. She became conscious with adequate spontaneous ventilation. Trachea was extubated. After surgery, corticosteroid replacement therapy was started as 100 mg three times a day and continued as oral therapy, since hypothyroidism is commonly associated with adrenal insufficiency. Her diagnosis was later confirmed as hypothyroidism after receiving reports of TSH level (TSH: 111 μIU/L). She was put on tablet Eltroxin 100 μg daily thereafter. Hypothyroidism may be present in subclinical form. The anesthetic requirement of hypothyroid patients has not been analyzed so far in any study; but clinically, they are found to be more sensitive to anesthetic drugs and sedatives affecting anesthetic management.[12] Clinical signs of hypothyroidism may range from cold intolerance to constipation, depression, lethargy, muscle weakness, slow movement, dry skin, slow gastric emptying, sleep apnea, depression of ventilatory response to hypoxia, and hypercarbia.[3] The normal range of TSH is 0.3–4.5 mU/L. Primary hypothyroidism is diagnosed through detection of a low free T4 and a high TSH level. A rising TSH level is the most sensitive indicator of failing thyroid function.[4] Hypothyroidism causes increased responsiveness to central nervous system depressants and neuromuscular blocking agents. Increased sensitivity may be secondary to reduced cardiac output and blood volume, abnormal baroreceptor function, slowing of drug metabolism, and excretion. Decreased neuromuscular excitability, decreased ventilatory response to hypoxia, and hypercarbia are enhanced by anesthetic agents.[14] Due to depression of vascular and respiratory reflexes, hypotension, cardiac arrest and delayed recovery of spontaneous ventilation is common in hypothyroid patients.[5] Such patients should be rendered euthyroid before the surgery. Regional anesthesia should be preferred, if the surgery cannot be delayed.[5] To conclude, a patient of persistent bradycardia may have other than cardiac cause. In cases of emergency, signs of hypothyroidism may be managed empirically with enteral thyroid hormone replacement state, if parenteral form of thyroxine is not available. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Analysis of clinico-demographic risk factors for postoperative pulmonary complications following gastrointestinal surgery

Background: Postoperative pulmonary complications (PPC) are one of the commonest complications following gastrointestinal surgery. They lead to increased mortality, increased length of intensive care unit (ICU) stay, and higher cost of treatment. Identifying the risk factors of PPC helps in predicting its occurrence and to develop preventive measures. The objectives of the present study were to study the clinical and demographic risk factors for PPC following gastrointestinal surgery.Methods: The study was designed as an observational descriptive analytic study. All the patients ≥18 years of age undergoing gastrointestinal surgery were included. The patients with preoperative lung pathology requiring ICU care or ventilatory support and patients with lung metastasis were excluded. The demographic and clinical parameters at admission were recorded. The details of pulmonary complications like the time of occurrence after surgery and the mode of treatment for pulmonary complications were noted. The risk association was assessed for statistical significance.Results: A total of 100 patients were underwent various gastrointestinal surgeries during the study period. The incidence of PPC was 34% in our study. Age, education status, smoking, and presence of comorbidities were found to be positively associated with an increased incidence of PPCs. The serum albumin of less than 3.5gm and the haemoglobin of less than 8 gm were also associated with an increased incidence of PPC. Pleural effusion was the commonest PPC seen in 15 (44.1%) patients followed by pneumonia in 9 (26.5%).Conclusions: Age, smoking, education status, serum albumin, haemoglobin, emergency surgery, elective postoperative ventilation, nasogastric intubation and blood loss in the intraoperative period were found to associated with increased risk of PPCs.

Liver transplantation for acute liver failure due to hepatitis E in a pregnant patient.

Liver transplantation for acute liver failure due to hepatitis E in a pregnant patient.

Complications related to sitting position during Pediatric Neurosurgery: An institutional experience and review of literature.

Sitting position is preferred during posterior fossa surgeries as it provides better anatomical orientation and a clear surgical field. However, its use has been declining due to its propensity to cause life-threatening complications. This study was carried out to analyze the perioperative complications and postoperative course of children who underwent neurosurgery in sitting position. Medical records of 97 children (<18 years) who underwent neurosurgery in sitting position over a period of 12 years, were retrospectively analyzed. Data pertaining to the perioperative course such as demographics, hemodynamic changes, various complications, duration of intensive care unit (ICU) and hospital stay, and neurological status at discharge were recorded. Statistical analysis was done by chi-square and Mann-Whitney test, and a P value <0.05 was considered as significant. The median age of these children was 12 (3-18) years. Hemodynamic instability was observed in 12 (12.3%) children. A total of 38 episodes of venous air embolism (VAE) were encountered in 21 (21.6%) children; nine experienced multiple episodes. VAE was associated with hypotension in five (23.8%) and desaturation in four (19.1%) children. Six children presented with postoperative tension pneumocephalus; three were managed with twist drill burr-hole evacuation. Brainstem handling was the most common indication (42.5%) for the requirement of elective postoperative ventilation. The duration of ICU and hospital stays were comparable among the children who experienced VAE and those who did not (P > 0.05). Neurological status at discharge was also comparable between these two groups (P = 0.83). This study observed a lesser incidence of VAE and associated complications. Tension pneumocephalus was managed successfully without any adverse outcome. Hence, it is believed that with meticulous anesthetic and surgical techniques, sitting position can safely be practiced in children undergoing neurosurgery.

Strategies for optimizing surgical outcome in patients with esophageal atresia with tracheo-esophageal fistula

Background: There have been major advances in the surgery for esophageal atresia (EA) and tracheo-esophageal fistula (TEF) with survival now exceeding 90%. The standard open approach to EA and distal TEF has been well described and essentially unchanged in last 60 years. Improved survival in recent decades is most attributable to advances in neonatal surgical techniques, anaesthesia and perioperative care. In a prospective randomized trial, we analysed the effect of pleural flap wrap around the anastomosis and post-operative elective ventilation support for 48 hours as main strategies towards improving the outcome in such patients.Methods: Twenty five neonates who were diagnosed as a case on tracheo-esophageal fistula (TEF) on clinical and radiological basis were selected for the study. All babies were more than 2kg weight and were operated within first two days of life after optimization. There was no evidence of any congenital heart disease or any other associated anomaly. In all patients primary esophageal anastomosis was possible which was subsequently covered by pleural flap wrap. All the patients were put post-operatively on ventilator electively for 48 hours. Contrast study was done on post-operative day five and feeding was started subsequently.Results: Postoperative surgical outcome was very good. Out of twenty five cases, 24 patients survived and only one baby died secondary to anastomotic leak and sepsis. Twenty three babies were discharged on post-operative day 8. One baby was on ventilator for 6 days and discharged on postoperative day 15. All patients are on regular follow up.Conclusions: Surgical outcome in patients with esophageal atresia and tracheo-esophageal fistula in neonates can be improved with use of pleural flap wrap and elective post-operative ventilation.

Intra-hospital transfer: Human error and safety concerns with improper setting up of a cylinder-based oxygen delivery system.

Sir, Incident reporting is a key factor in maintaining patient safety in the perioperative scenario. We report an incident of near miss due to human error in an intra-hospital transfer (IHT), which was averted due to the strict adherence to protocols and checklist implementation during the pre-transport phase. A post-thoracotomy patient was to be shifted to the Intensive Care Unit from the operation theatre (OT) on Bain's circuit with a trolley-mounted oxygen cylinder for elective post-operative ventilation. When the anaesthesiologist performed his routine pre-transport check, it was noticed that the standard flowmeter assembly on the oxygen cylinder [Figure 1a] was modified by using a L connector instead of the glass tube. In addition, the regulator knob was found to be defective and completely free [Figure 1b]. When the valve of the cylinder was opened with a spanner, there was no movement of the needle on the regulator gauge, and oxygen was flowing at a high pressure and high flow (litres/min) through the L connector with risk of barotrauma and volutrauma. Figure 1 (a) Normal oxygen cylinder assembly with glass flowmeter and regulator, (b) faulty setup of oxygen cylinder with the L connector and non-functional regulator and gauge The event was investigated and discussed in departmental incident-reporting meet. In general, with a defective regulator, there is either no flow of gas or a stuck turn wheel, with incomplete opening of cylinder, both of which prevent high pressures from being transmitted to the patient. It was found that the error was caused on that particular day because the senior anaesthesia assistant who was in charge of assembling and checking the transport trolleys was busy shifting two other patients and so his work was taken over by a relatively inexperienced technician. It was the practice to assemble the shifting trolley only when demand was raised from the OTs. Post this incident, protocol for IHT was revised so that now, all patient transfer trolleys are kept ready at the beginning of the day by the senior technician in charge. In addition, we have increased the number of IHT trolley assemblies and these are all kept in a designated secure place where they cannot be tampered with. The anaesthesiologist in charge of the case to be transferred personally checks each system again before connecting the patient to it. An incident is an outcome or event which can jeopardise the safety of the patient. Beckmann et al. in an analysis found that 39% of incidents were attributable to equipment problems and 61% to patient and staff management issues including incorrect setup of equipments during IHT.[1] The United kingdom (UK) National reporting and learning system data from 2006 to 2008 revealed that most incidents were as a result of failure of equipment/device and about 0.08% of the incidents occurred due to inadequate check of the equipment and supplies.[2] Our case, according to the UK's National Patient Safety Agency (NPSA) definition, comes under ‘preventive patient safety incident category‘ i.e., prevention of an unexpected and unintended incident, so no harm should occur.[2] Three phases of transport are suggested for critically ill patients, as part of check list i.e. pre-transport, during transport and post-transport phases.[3] Fanara et al. described IHT-related risk factors, of which equipment, team and organisation were the most common determinants.[4] To conclude, the IHT of a patient is fraught with chances of adverse events. The need is for better pre-transport planning with comprehensive training of all the personnel involved in the IHT with strict adherence to the standardised procedures, guidelines and checklists for all the phases of transport. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Resection of olfactory groove meningioma – a review of complications and prognostic factors

Introduction. High complication rates have been cited following olfactory groove meningioma (OGM) resection but data are lacking on attendant risk factors. We aimed to review the complications following OGM resection and identify prognostic factors. Methods. A retrospective review was performed on 34 consecutive patients who underwent primary OGM resection at a single London institution between March 2008 and February 2013. Collected data included patient comorbidities, pre-operative corticosteroid use, tumour characteristics, imaging features, operative details, extent of resection, histology, use of elective post-operative ventilation, complications, recurrence and mortality. Results. Complication rate was 39%. 58% of complications required intensive care or re-operation. Higher complication rates occurred with OGM > 40 mm diameter versus ≤ 40 mm (53 vs. 28%; p = 0.16); OGM with versus without severe perilesional oedema (59 vs. 19%; p = 0.26), more evident when corrected for tumour size; and patients receiving 1–2 days versus 3–5 days of pre-operative dexamethasone (75 vs. 19%; p = 0.016). Patients who were electively ventilated post-operatively versus those who were not had higher risk tumours but a lower complication rate (17 vs. 44%; p = 0.36) and a higher proportion making a good recovery (83 vs. 55%; p = 0.20). Complete versus incomplete resection had a higher complication rate (50 vs. 23%; p = 0.16) but no recurrence (0 vs. 25%; p = 0.07). Conclusion. Risk of morbidity with OGM resection is high. Higher complication risk is associated with larger tumours and greater perilesional oedema. Pre-operative dexamethasone for 3–5 days versus shorter periods may reduce the risk of complications. We describe a characteristic pattern of perilesional oedema termed ‘sabre-tooth’ sign, whose presence is associated with a higher complication rate and may represent an important radiological prognostic sign. Elective post-operative ventilation for patients with high-risk tumours may reduce the risk of complications.

Immediate extubation versus standard postoperative ventilation: Our experience in on pump open heart surgery.

Elective postoperative ventilation in patients undergoing “on pump” open heart surgery has been a standard practice. Ultra fast-track extubation in the operating room is now an accepted technique for “off pump” coronary artery bypass grafting. We tried to incorporate these experiences in on pump open heart surgery and compare the haemodynamic and respiratory parameters in the immediate postoperative period, in patients on standard postoperative ventilation for 8-12 hours. After ethical committee’s approval and informed consent were obtained, 72 patients, between 28 and 45 years of age, undergoing on pump open heart surgery, were selected for our study. We followed same standard anaesthetic, cardiopulmonary bypass (CPB) and cardioplegic protocol. Thirty-six patients (Group E) were randomly allocated for immediate extubation following operation, after fulfillment of standard extubation criteria. Those who failed to meet these criteria were not extubated and were excluded from the study. The remaining 36 patients (Group V) were electively ventilated and extubated after 8-12 hours. Standard monitoring for on pump open heart surgery, including bispectral index was done. The demographic data, surgical procedures, preoperative parameters, aortic cross clamp and cardiopulmonary bypass times were comparable in both the groups. Extubation was possible in more than 88% of cases (n=32 out of 36 cases) in Group E and none required reintubation for respiratory insufficiency. Respiratory, haemodynamic parameters and postoperative complications were comparable in both the groups in the postoperative period. Therefore, we can safely conclude that immediate extubation in the operating room after on pump open heart surgery is an alternative acceptable method to avoid postoperative ventilation and its related complications in selected patients.

Original article: Exomphalos defects : A review of 15 cases

Background : The outcome after repair of exomphalos defects has improved significantly with refinements in surgical techniques, multidisciplinary management and monitoring of intra-abdominal pressures. Methods : A retrospective study of medical records of 15 cases with omphalocele was done. Results : Antenatal diagnosis was available in six cases. There were eight females and seven males with a mean birth weight of 2.2 kg. Nine babies had associated anomalies. There were nine major (defect size > 5 cm) and six minor defects. Immediate closure in neonatal period was carried out in 12 cases. Urinary bladder pressure (UBP) was measured to assess intra-abdominal pressure in cases where primary closure was difficult. Primary closure was omitted in the event of intravesical pressures exceeding 20 mm Hg (∼ 25 cms of water). Primary surgical closure was possible in five (56%) major cases. Two cases were subjected to silo repair followed by delayed primary closure whereas the other two required a Goretex mesh closure. Three minor defects could be repaired primarily whereas the remaining three were managed conservatively and closed at age of 9 to 12 months. There were no significant anaesthetic complications. Elective postoperative ventilation was required in one baby. There were three deaths at ages five, nine and ten months due to unrelated causes. Conclusion : Satisfactory outcome is possible in cases with exomphalos defects with intra-operative intravesical pressure assessment forming a convenient method for excluding abdominal compartment syndrome.

Pro: Early Extubation After Liver Transplantation

HE DECISION TO extubate a patient at the conclusion of surgery or continue ventilatory support generally rests on 2 conditions: the patient’s ability to achieve standard physiologic criteria and the clinicians’ ability to predict early postoperative adverse events. The standard criteria for extubation at the end of surgery and protocols that direct elective ventilatory weaning have good predictive value to identify those patients who will suffer from primary respiratory failure. 1,2 These protocols are universally accepted standards of care for deciding whether to terminate mechanical ventilation. But, they do not assess if other adverse events could occur that can lead to respiratory failure. Adverse events that cause respiratory failure make extubation impractical even if patients fulfill standard physiologic criteria. The decision to extubate is highly influenced by what risk a physician thinks a patient has of experiencing an adverse event that could cause respiratory failure. Because objective variables such as patient and surgical characteristics do not always predict adverse events, the decision to extubate often includes the subjective impression of the physician. Therefore, differences in physician judgment fuel the ongoing debate about the “safety” of early extubation for large procedures such as cardiac surgery, major vascular reconstruction, and liver transplantation. This brief review examines this controversial issue in liver-transplant recipients. The authors summarize the current evidence that supports the broader adoption of early extubation for liver-transplant recipients by showing that early extubation does not negatively affect patient outcome and is cost effective. Physicians often elect to continue mechanical ventilation in patients who have large or complicated procedures because these patients experience a greater number of adverse events that would increase their risk of respiratory compromise. However, routine ventilation treats each individual as though they had an identical risk of experiencing an adverse outcome. The use of routine postoperative ventilation for a particular type of surgery or situation then forces all patients into a single care plan. It actively prevents patients from recovering at a rate faster than dictated by the protocol. Many physicians argue that elective postoperative ventilation provides a longer period of time in which a patient can be optimized and assessed for extubation. They presume that this will prevent complications and improve patient outcome. This type of reasoning underlies the belief that prophylactic postoperative ventilation is inherently safer than early extubation.3 The lack of evidence showing routine ventilation improves outcome conflicts with the evolving demand for evidencebased protocols. Evidence-based protocols are designed to efficiently allocate resources while controlling cost. This approach demands that unnecessary medical interventions are eliminated and that objective evidence is used to allocate resources. How physicians chose to manage postoperative ven

Anesthetic Management For Surgical Excision Of A Cerebellar Infarct In A Patient With Acute Myocardial Infarction

A forty nine year old male who had sustained acute myocardial infarction two days earlier, experienced respiratory arrest and complete heart block and was admitted with a diagnosis of left cerebellar infarct and obstructive hydrocephalus. On examination he was responding to deep painful stimuli with right hemiparesis. ECG indicated acute inferolateral myocardial infarction. Echocardiogram showed an ejection fraction of 63%. Arterial blood gases revealed severe respiratory alkalosis and arterial desaturation. The lungs were ventilated and inotropic support was started to ensure a stable hemodynamic status. Evacuation of the cerebellar infarct was planned as an emergency procedure. Anesthesia was maintained using N2O — O2 — narcotic — neuromuscular blocking drugs sequence. Continuous monitoring of ECG, ST segment, invasive arterial blood pressure, CVP, ETCO2, SaO2 and temperature were instituted. The intraoperative period was uneventful. Elective postoperative ventilation was continued for three days. He was then transferred to the step down intermediate care unit for definitive therapy.