Intubation Period Research Articles

A prospective study comparing the efficacy of intravenous clonidine with intravenous dexmedetomidine in attenuating the haemodynamic stress response during laryngoscopy and endotracheal intubation

Introduction: Laryngoscopy and endotracheal intubation are noxious stimuli capable of producing tachycardia, arrhythmias and hypertension. This study was being done to compare the effectiveness of a pre-induction dose of clonidine with dexmedetomidine administered by intravenous infusion inattenuating the haemodynamic stress responses resulting from laryngoscopy and endotracheal intubation. Materials and Methods: Sixty adult patients included in this study were randomly divided into two groups, namely, Group A (Clonidine 4 mcg/kg) & Group B (Dexmedetomidine 1 mcg/kg) using computer generated random allocation chart and haemodynamic parameters were analyzed and recorded quantitatively from preoperative period to 30 mins post – intubation period. In the immediate post operative period and 2 hours after surgery, patient’s recovery was assessed with ALDRETE recovery score and BRUSSEL’S sedation score. Results: Mean heart rate showed fall following dexmedetomidine or clonidine infusion (19% and 23% respectively from the baseline) which was clinically significant in clonidine group but was statistically not significant in both the groups (p>0.05), while the increase in Mean heart rate following intubation was 8% and 10% respectively. In the current study, there was fall in blood pressure following infusion of study drug which was clinically not significant.Following tracheal intubation, maximal average increase was 5% in systolic and 3% in diastolic blood pressure in dexmedetomidine group, as compared to clonidine group in which, it was 6% and 4%, respectively. Isoflurane consumption, propofol requirement and opioid requirement throughout the intraoperative period was reduced in both the Groups. Aldrete recovery score and Brussels sedation score were calculated and found better in group B as compared to group A. Patients were sedated but arousable. Conclusion: Based on our study we conclude that both clonidine and dexmedetomidine are equally effective in attenuating

EFFECTS OF STRUCTURED MANUAL HYPERINFLATION FOR IMPROVING RESPIRATORY PARAMETRS IN POST-OPERATIVE CORONARY ARTERY BYPASS GRAFT PATIENTS

Purpose: Cardiopulmonary physiotherapy plays a crucial role in cardiac rehabilitation after surgeries. The deterioration of respiratory parameters occurs after coronary artery bypass grafting (CABG) procedure. Manual hyperinflation (MHI) is done according to clinical experiences and there are no specific guidelines for it. The objectives were to determine the effects of structured manual hyperinflation for improving respiratory parameters in post-operative CABG patients.
 Methodology: Duration of study was 6 months (January 2019-June 2019) with a sample size of 76 post-operative CABG patients. Non-probability purposive sampling technique was used. Patients were divided into two groups’ i-e MHI and VHI depending upon the treatment protocol. In protocol, endotracheal tube (ETT) suctioning was done followed by MHI and VHI in assigned group in randomized controlled trial design. Respiratory parameters were measured by ABG’S, equations for static lung compliance and alveolar-arterial oxygen tension difference. Data was recorded pre and post ETT suctioning, immediately, 30 min and 60 min post intervention. Both males and females were included. Inclusion criteria involves patient must be intubated, hemodynamically and vitally stable, and age range 55-77 years. Those were excluded who have past medical history of diagnosed pulmonary pathology and any post-operative complications. Patient was withdrawn from the study if any subject who have unstable cardiovascular status and high levels of respiratory support. Data was analyzed on SPSS 21.
 Findings: All the respiratory parameters showed significant differences (p<0.05) in pre and post values of structured MHI. Significant difference (p<0.05) was observed immediately after intervention in terms of acidity (pH), partial pressure of carbon oxide (PaCO2), partial pressure of oxygen (PaO2), oxygen saturation and arterial oxygen to fraction of inspired oxygen ratio between the groups with scores higher for experimental group. HCO3 showed significant difference (p<0.05) immediately after intervention and 30 min and 60 min post intervention with the scores higher for control group. Static lung compliance showed significant difference (p<0.05) at 30 min and 60 min post intervention with scores higher for control group. Alveolar-arterial oxygen tension showed no significant difference (p>0.05) between the groups at any point. No significant difference (p>0.05) was observed between the groups at any other point of measurement for all respiratory parameters. MHI and VHI are both effective in improving respiratory parameters in post-operative CABG patients but the values were more significant in MHI group. But the difference between the groups was not significant and conclusive.
 Recommendations: This study should be conducted in different patient populations having different pulmonary conditions and other types of cardiac surgeries and in other patients who are intubated and mechanically ventilated. Moreover, the effects of both techniques on different variables must be studied after multiple numbers of sessions during the whole period of intubation. 

Postintubation Multisegmental Tracheal Stenosis: A 24-Year Experience

Management of multisegmental tracheal stenosis is challenging. In this 24-year longitudinal single-center study, we present an algorithmic treatment approach. A retrospective analysis of 2167 patients with postintubation tracheal stenosis indicated 83 (3.83%) patients with multisegmental tracheal stenosis. Patients were assigned to 4 management groups according to the length, location, and severity of stenoses; tracheal infection/mucositis; laryngeal function; symptoms; general condition; and comorbid diseases. Type 1 (n= 13): 1-stage resection of both strictures, Type 2 (n= 6): 2-stage resection of both strictures, Type 3 (n= 40): resection of 1 stricture and nonresectional management of the other, Type 4 (n= 24): nonresectional management of both strictures. Outcomes were categorized as Good, Acceptable, or Poor. Univariate analyses for factors predictive of recurrence and outcome were performed. Follow-ups were completed in 70 (84.34%) patients (median, 22.5 months). Outcome was assessed as Good in 56 (82.35%), Acceptable in 10 (14.71%), Poor in 2 (2.94%), and mortality in 2 (2.94%) patients. The median length of airway resection was 46, 67.5, and 40 mm in Types 1-3, respectively. Only 11 (13.25%) patients had no history of tracheostomy or tracheal surgery. By univariate analysis, a shorter intubation period was associated with Good outcome (P= .017). No factors predictive of recurrence or outcome were ascertained. Multisegmental tracheal stenosis, generally caused by performing an inappropriate tracheostomy, is an iatrogenic disease that can be prevented. Although resection of both strictures may be feasible and is associated with Good results, in the majority of cases, a combination of surgical resection and non-resectional methods are sufficient to achieve Good results.

Analysis and Temporal Evolution of Extubation Parameters for Patients Undergoing Single-Stage Circumferential Cervical Spine Surgery.

ObjectiveAirway obstruction after postoperative extubation is a dreaded but uncommon complication in patients undergoing circumferential cervical spine surgery (CCSS). The cuff leak test (CLT) has been utilized to assess air leak around the endotracheal tube which may reflect airway swelling. In this prospective observational study, we analyze the temporal evolution of CLT and perioperative factors that may influence it. MethodsTwenty patients undergoing single-stage CCSS were managed according to our extubation protocol. Patients were maintained intubated overnight following surgery. They were extubated if a CLT > 200 mL and both intensive care unit (ICU) and Neurosurgery teams agreed that it was safe. Patients extubated in the first postoperative day (8 of 20) comprised the early group, and the remaining patients (12 of 20) the delayed group. Patient and operative data were analyzed as a single group and comparing both groups. ResultsThe main indication for surgery was cervical deformity. Median number of levels fused was 5 anteriorly (range, 1–6) and 6 (range, 1–13) posteriorly. Patients were kept intubated for an average of 73.6 hours (range, 26–222 hours) and stayed in the ICU for 119.1 hours (range, 36–360 hours). There were 4 failed extubations and 3 patients (15%) required a tracheostomy. Patient profiles between both groups were very similar across most patient variables but differed significantly regarding infraglottic luminal area (p < 0.05). Patients with larger preoperative cuff leak values tended to have a shorter intubation period (p=0.053). ConclusionThis study objectively demonstrates the difficulties in airway management following CCSS and provides useful insight for preoperative planning and counseling. Local anatomic factors influence airway outcome more than operative factors. The study format does not allow for testing of interventions but we suggest that patients with favorable anatomy (larger infraglottic luminal area) may benefit from a less strict airway management protocol.

Respiratory Distress Syndrome in Infants Delivered via Cesarean from Mothers with Preterm Premature Rupture of Membranes: A Propensity Score Analysis

Objective This study aimed to clarify the effects of cesarean delivery on neonatal respiratory morbidity when women had preterm premature rupture of membranes. Methods This retrospective study included women with preterm premature rupture of membranes who delivered from 23 weeks to 33 weeks of gestation between January 2009 and December 2014. Neonatal outcomes were compared between infants delivered by cesarean section and those delivered vaginally. The primary outcome was respiratory distress syndrome (RDS). Neonatal intubation and mechanical ventilation periods were secondary outcomes. Propensity score matching was used to compare outcomes between cesarean and vaginal delivery cases. Results There were 101 cesarean deliveries and 89 vaginal deliveries. A comparison of the presence or absence of neonatal complications based on the delivery type indicated a higher occurrence of RDS with cesarean deliveries (P = 0.025). The intubation and mechanical ventilation periods were not significantly longer in neonates delivered via cesarean section. Conclusions Cesarean delivery is a risk factor for neonatal RDS in women with preterm premature rupture of membranes. Trials identifying long-term neonatal prognoses are needed to further develop optimal management strategies in such cases.

Comparison of del Nido Cardioplegia and Blood Cardioplegia in Aortic Root Surgery.

To compare del Nido cardioplegia (DNC) with conventional blood cardioplegia (BC) in aortic root surgery. Subjects who underwent aortic root surgery during a 3-year period were included. A DNC group was compared with a matched BC group. A total of 72 subjects were included, 36 who underwent DNC compared with 36 propensity-matched subjects who underwent BC. Fifty-one (70.8%) were male, and 21 (29.2%) were female, with a mean age of 66.19 ± 7.02 years (range 51 to 81). No significant differences in baseline characteristics, preoperative echocardiogram parameters, or intraoperative parameters were found between the groups. For DNC versus BC, cardiopulmonary bypass time, aortic clamp time, cardioplegia volume (all P = .001), and defibrillation (P = .007) were significantly lower. For postoperative biochemical parameters, creatinine levels at hour 24, potassium levels at hours 1 and 24, and glucose levels at hours 6 and 24 did not differ between the groups (P > .05). Creatine kinase-MB and troponin T levels at hours 1 and 24 were significantly lower in DNC versus BC (all P = .001). Hematocrit levels at hours 6 and 24 were significantly higher in DNC (P = .001). The groups did not differ in terms of postoperative inotropic support, postoperative complications, intubation period, or duration of intensive care unit stay (P > .05). Although the need for thrombocyte transfusion did not differ between groups (P > .05), DNC resulted in less use of erythrocyte and fresh frozen plasma transfusions (both P = .001). Postoperative ejection fraction was significantly better in the DNC group than in the BC group (P = .006). The results indicate better intraoperative parameters and better ejection fraction rates with DNC than with BC. DNC is an effective and safe alternative to blood cardioplegia for aortic root surgery.

Tracheotomy in Ventilated Patients With COVID-19.

Tracheotomy in Ventilated Patients With COVID-19.

Tracheal tube size in adults undergoing elective surgery - a narrative review.

Tracheal tubes are routinely used in adults undergoing elective surgery. The size of the tracheal tube, defined by its internal diameter, is often generically selected according to sex, with 7-7.5 mm and 8-8.5 mm tubes recommended in women and men, respectively. Tracheal diameter in adults is highly variable, being narrowest at the subglottis, and is affected by height and sex. The outer diameter of routinely used tracheal tubes may exceed these dimensions, traumatise the airway and increase the risk of postoperative sore throat and hoarseness. These complications disproportionately affect women and may be mitigated by using smaller tracheal tubes (6-6.5 mm). Patient safety concerns about using small tracheal tubes are based on critical care populations undergoing prolonged periods of tracheal intubation and not patients undergoing elective surgery. The internal diameter of the tube corresponds to its clinical utility. Tracheal tubes as small as 6.0 mm will accommodate routinely used intubation aids, suction devices and slim-line fibreoptic bronchoscopes. Positive pressure ventilation may be performed without increasing the risk of ventilator-induced lung injury or air trapping, even when high minute volumes are required. There is also no demonstrable increased risk of aspiration or cuff pressure damage when using smaller tracheal tubes. Small tracheal tubes may not be safe in all patients, such as those with high secretion loads and airflow limitation. A balanced view of risks and benefits should be taken appropriate to the clinical context, to select the smallest tracheal tube that permits safe peri-operative management.

Elective Tracheostomy During Mechanical Ventilation in Patients Affected by COVID-19: Preliminary Case Series From Lombardy, Italy.

The COVID-19 outbreak poses continued struggles due to the unprecedented number of patients admitted to intensive care units and the overwhelming need for mechanical ventilation. We report a preliminary case series of 32 patients with COVID-19 who underwent elective tracheostomies after a mean intubation period of 15 days (range, 9-21 days). The procedure was performed with percutaneous (10 cases) and open (22 cases) surgical techniques. Neither procedure-related complications nor viral transmission to health care workers was observed. Our preliminary experience supports the safety of tracheostomy, provided that appropriate protocols are strictly followed. The postoperative care is still debated, and, prudentially, our protocol includes tracheal tube change not before 2 weeks after tracheostomy, with cuff deflation and decannulation deferred until confirmation of negative SARS-CoV-2 test results. This is the first case series to report on such a rapidly evolving issue and might represent a source of information for clinicians worldwide who will soon be facing the same challenges.

Sclerotherapy for Venous Malformations of the Pharynx or the Tongue Base Without Tracheostomy: Treatment Protocol With Intubation and Outcomes.

Venous malformations (VMs) occurring in the tongue base or pharynx are rare, but can cause airway obstruction. Considering the potential issues or morbidity related to surgical resection in the tongue or pharynx region, sclerotherapy is often preferred. We perform sclerotherapy for such lesions without conducting tracheotomy, but keep patients intubated for a certain period. Outcomes of sclerotherapy, and benefits and cautions related with our protocol were investigated.Our subjects were 10 cases in 9 patients who underwent sclerotherapy for VMs of the tongue base (6 patients) or pharynx (3 patients) from 2008 to 2017. One patient underwent treatment sessions twice. The sclerosants used were absolute ethanol (ET) (3 cases), 5% ethanolamine oleate (EO) (4 cases), or both ET and 5%EO (3 cases).In 5 of 9 patients, postoperative MRI was performed, which revealed lesion volume reduction by 12% to 47%. The intubation period varied according to the sclerosant used: ET, 5 to 11 days; 5% EO, 2 to 12 days; and combination of ET and 5% EO, 8 days. Postoperative complications included fever of unknown (n = 2), acute psychosis (n = 3), vocal cord paralysis (n = 2), and bradycardia induced from the use of a sedative agent (n = 1). One patient complained of mild transient swallowing difficulty that lasted for a month postoperatively.Although our method mandatorily requires careful postoperative management in an ICU, including sedation with anesthetic agents and artificial respiration by intubation for a certain period of time, no serious complications or post-therapeutic morbidities occurred.

Comparison of The Effects of Remifentanil and Fentanyl Combined with Desflurane on Intraoperative Hemodynamic Parameters and Postoperative Recovery Period in Anesthesia for Day Case Surgery

Objective: We aimed to compare the effects of two different opioids, fentanyl and remifentanil with short-acting inhalation agent, desflurane on intraoperative hemodynamics and recovery quality in the postoperative period in anesthesia for day case surgery.Methods: A prospective randomized case control study was carried out at Anesthesia and Reanimation Clinics of The Istanbul Education and Research Hospital with the approval of the local ethics committee between 2001-2002. The study population (n=100) who has arthroscopic knee surgery was composed of patients between the ages of 18-65 classified as ASAI-II. The cases were randomized and divided into two groups. After giving fentanyl to patients in the first group and remifentanil infusion to patients in the second group, induction has administered by propofol and mivacurium was given as a muscle relaxant in both groups. After endotracheal intubation, systemic blood pressure, heart rate and peripheral oxygen saturation (SpO2) values were recorded every five minutes. When the surgery was completed, eye opening, following commands, saying her name, saying her birthday, sitting without help and getting the correct answer to the DSS test was recorded for both groups. Visual Pain Scale (VAS) and Modified Aldrete Score were evaluated and recorded at 0, 15, 30, and 60 minutes. Patients were observed and recorded in terms of side effects such as increased secretion, bradycardia, nausea, vomiting, dizziness, headache, and tremors in both groups.Results : In terms of demographic features there was no statistically significant difference between the two groups. Generally; systemic blood pressures were significantly higher in the fentanyl group. Heart rate was significantly higher in fentanyl group during intubation and intraoperative periods . There was no statistically significant difference between groups in terms of Sp02 . Time until spontaneous breathing, extubation, eye opening, following commands, saying the name, DSST and unassisted sitting were significantly longer in the fentanyl group . The mean values of VAS scores at the 15th and 30th minutes were significantly higher in the remifentanil group . Similarly, the mean Aldrete recovery scale score scores at 15th and 30th minutes were significantly higher in the remifentanil group . When postoperative pathological findings were evaluated, the frequency of bradycardia was significantly higher in the remifentanil group, there was no difference in terms of other side effects. Conclusion: According to the our study results; we concluded that it is a better alternative to use remifentanil together with desflurane which is preferred short-acting inhalation agent in ambulatory anesthesia; in terms of hemodynamic stability during the intubation, peroperative and extubation periods and rapid postoperative recovery.

863 Drug Addiction and Opioid Use in the Acute Burn Patient

Abstract Introduction In light of the opioid crisis, there is an increased interest in the acute pain management of patients with history of drug addiction. There is no consensus on pain management among different burn centers and the amount of narcotic prescription reportedly doubled over a seven year period according to Tully in 20191. Our aim was to study the association of previous drug addiction history and the treatment of acute burn patients with special interest on the daily morphine equivalent requirements. Methods A prospectively maintained database was queried to study acute burn patients admitted in a reference burn center from 2013 to 2018. Patients with a previous history of drug addiction (group 1) were compared to patients without it (group 2). Drug abuse was defined as patients with history of opioids abuse, heroin, cocaine, cannabis, inhalants, and alcoholism, specifically those with diagnostic codes on file. The expected mortality was calculated using the Premier® database. A p0.05 was considered significant. Results A total of 3046 patients were studied, 502 (16.5%) had previous history of drug abuse on file. Compared to group 2, group 1 had: more males - 343 (68.3%) vs 1456 (57.2%) p0.001; was younger - 45.7914.65 vs 52.0219.57 p0.001; required intubation at a higher rate - 100 (19.9%) vs 329 (12.9%) p0.001; longer intubation period - 2.4310.05 vs 1.377.71 p0.001; had a prolonged admission - 13.8728.82 vs 8.4816.58 p0.001; more surgeries - 1.213.30 vs 0.71.58 p=0.002, and a higher daily morphine milligram equivalent requirement - 148.34320.56 vs 56.0297.81 p0.001. The groups had similar expected mortality rates: 3.03% vs 3.56%p=0.483; which may be partly explained by the fact that the drug use history is not accounted for on the formula. No significant difference was seen on the burned area between the groups. Conclusions Drug addiction was associated with increased need for intubation and length of intubation, prolonged admission, increased surgery rate and a higher daily morphine equivalent usage. Further studies are necessary guide the treatment of the specific needs of these increasingly common burn patients subgroup and also to define the need of including the history of drug use on the expected mortality rate formula. Applicability of Research to Practice This study adds to the literature differences in the treatment of burn patients with history of drug addiction and highlights the need for specific protocols for improved care.

Novel Use of a Gas Analyzer Can Reliably Predict the Arterial Oxygen among Emergency Department Patients Undergoing Rapid Sequence Intubation.

To our knowledge, no study has assessed the correlation of fraction of inspired oxygen (FiO2) and end-tidal oxygen (EtO2) values obtained from a gas analyzer during the preoxygenation period of rapid sequence intubation (RSI) to predict partial pressure of oxygen (PaO2) among patients requiring intubation in the emergency department (ED). The purpose of this study was to determine whether a simple equation using EtO2 and FiO2 at time of induction could reliably estimate minimal PaO2 in ED patients undergoing RSI. We conducted an observational pilot study performed in an adult ED utilizing a gas analyzer to obtain EtO2 and FiO2 values in ED patients undergoing RSI from data collectors blinded to our objective. The Pearson correlation coefficient was calculated between the equation's predicted PaO2 and the PaO2 drawn from an arterial blood gas shortly after intubation. A Bland-Altman plot analysis was performed to identify any additional bias. Seventy-five patients were enrolled. The equation's mean predicted minimal PaO2 and mean PaO2 from an arterial blood gas within 3min after intubation was 178mm Hg (95% confidence interval [CI] 145-211mm Hg) and 209mm Hg (95% CI 170-258mm Hg), respectively. The Pearson correlation coefficient between the predicted minimal PaO2 and post-intubation PaO2 demonstrated a strong correlation (r2=0.89). The Bland-Altman plot indicated no bias affecting the correlation between the predicted and actual PaO2. Among ED patients undergoing RSI, the use of a gas analyzer to measure EtO2 and FiO2 can provide a reliable measure of the minimal PaO2 at the time of induction during the RSI phase of preoxygenation.

Involvement of swallowing therapy is associated with improved long-term survival in patients with post-stroke dysphagia.

The effects of swallowing therapy (ST) on long-term clinical outcomes in patients with post-stroke dysphagia (PSD) remain unclear. This study explores the effect of ST, initiated within 6 months of the stroke onset, on long-term pneumonia-free and overall survival rates in PSD patients. Retrospective cohort study. Longitudinal Health Insurance Database. The study included 2994 eligible PSD patients between 2005 and 2013. Among the scrutinized PSD patients, ST was initiated during the nasogastric intubation (NGI) period and was implemented by physician discretion. Therefore, subjects who underwent ST were classified into the ST-intervention (STI) group and those without ST were classified into the non-ST (NST) group. Propensity score matching (PSM) was used to match age, sex, pneumonia events during the NGI period, the Charlson comorbidity index, and the National Institutes of Health Stroke Scale between the two groups. We started to follow all selected PSD patients 6 months after the onset of stroke for four years. Multivariable adjusted Cox regression and Kaplan-Meier estimations were conducted to assess the effects of ST and the ST duration on pneumonia-free and overall survival. Overall, 1497 PSD patients aged approximately 68 years in each group were selected in this study. The pneumonia-free survival rate in STI subjects was 57.4% and was significantly greater (P=0.003) than that (54.2%) in NST subjects during the follow-up (F/U). A significantly improved (P<0.0001) overall survival rate was observed in STI subjects (75.0%) compared to NST subjects (63.7%) during the F/U. In STI subjects, ST duration ≥ 1 month was significantly (P=0.009) associated with reduced pneumonia incidence compared to those with ST duration<1 month. Participation of ST within 6 months of the stroke onset is associated with decreased pneumonia incidence and improved long-term survival in selected PSD patients. In the selected STI subjects, longer ST duration may be valuable in pneumonia prevention. This study reveals that ST initiated within 6 months of the stroke onset may be associated with improved long-term survival in selected PSD patients.

Normothermia versus Hypothermia during Cardiopulmonary Bypass in Cases of Repair of Atrioventricular Septal Defect.

Background:Cardiopulmonary bypass (CPB) used for cardiac surgery is now uniformly carried out under normothermic conditions in adult patients; however, the temperature applied in pediatric CPB vary significantly, ranging from deep hypothermia to normothermia due to the lack of a consistent approach to CPB temperature in pediatric cardiac surgery, which is related to a lack of supportive evidence. Organs protection aim to decrease metabolic requirement and provide energy and oxygen, hypothermia has reached these goals by arresting and cooling the heart, delivering oxygen, and modifying reperfusion. Recently, a large number of studies investigated effect of hypothermia to decrease the negative impact of hypothermia. It has been suggested that the degree of hypothermia affects the inflammatory responses triggered by CPB. However, the use of normothermia during CPB had been introduced and resulted in acceptable results. We hypothesized that the use of normothermia during corrective surgery of AV septal defects improves the outcome of the CPB.Objective:The study aimed to compare the outcome of normothermic technique and mild hypothermic technique during (CPB) in pediatric cardiac patients undergoing repair of atrioventricular (AV) septal defect and their effect on tissue perfusion, serum lactate level, duration of patient intubation, and postoperative hospital stay.Patients and Methods:Forty patients presented for repair of AV defect aged from 1 month to 36 months were divided randomly into two equal groups (20 patients in each): Group I (Normothermic group) of body temperature more than 35°C up to 37°C and Group II (mild Hypothermic group) body temperature between (32°C–35°C). Basal data include complete blood count, electrolytes, arterial blood gases (ABGs), coagulation profile, and liver function tests were collected. Hemodynamic variables, ABG, serum lactate, and activated clotting time (ACT) measured in different time intervals related to CPB. With the termination of CPB, aortic cross-clamping time (minutes), CPB time (minutes), spontaneous regaining of the heart function, need for inotropic administration, and/or vasopressor requirements to wean the heart from CPB were reported in all patients.Results:This study showed statistically significant lower PH and HCO3 levels and significantly higher serum lactate levels in Group II (hypothermic) than Group I (normothermic) after weaning from CPB. Furthermore, ACT level was statistically significantly higher in Group II than Group I after weaning of CPB. During postoperative period, hypothermic group showed significantly higher liver enzymes than the normothermic group. The duration of inotropes administration and duration of intubation were significantly longer in Group II than Group I.Conclusion:Normothermia during CPB showed better global tissue perfusion than hypothermia in elective surgeries for repair of AV defects in the form of less degree of lactic acidosis, less effect on coagulation system, shorter duration of inotropic support, shorter intubation period, and shorter stay in the intensive care unit.

Novel Urinary Biomarkers for Acute Kidney Injury and Prediction of Clinical Outcomes After Pediatric Cardiac Surgery.

Acute kidney injury (AKI) is a serious complication of pediatric cardiac surgery, with high morbidity and mortality. We aimed to evaluate the perioperative risk factors for AKI, and the validity of novel diagnostic urinary biomarkers after pediatric cardiac surgery. We analyzed 103 consecutive pediatric patients (≤ 18years old), who underwent cardiac surgery. AKI was defined by ≥ 50% increase in serum creatinine levels from baseline. Urinary liver-type fatty acid binding protein (L-FABP) and neutrophil gelatinase-associated lipocalin (NGAL) were measured postoperatively at the intensive care unit (ICU) admission, subsequently at 4, 12, and 24h. Areas under the receiver-operating characteristic curves (AUC) were calculated at each assessment time. AKI had developed in 47 patients (45.6%) by the second postoperative day. Univentricular status, aortic cross-clamping time, and intraoperative fluid balance were independently associated with AKI (p = 0.02, 0.01 and 0.01, respectively). Urinary L-FABP and NGAL were significantly higher in the AKI group at each point (p < 0.05). The predictive abilities of both biomarkers (AUC = 0.78-0.90) at ICU admission and 4h after were especially high. The patients with L-FABP greater than the cutoff value at ICU admission and 4h after ICU admission had significantly longer intubation and hospitalization periods (p < 0.05). Those with elevated NGAL levels at admission, and 4h and 24h after ICU admission, had significantly longer intubation, ICU stay, and hospitalization (p < 0.05). L-FABP and NGAL can be useful biomarkers for detecting early AKI after pediatric cardiac surgery and predicting adverse clinical outcomes.

Sedation withdrawal following single stage laryngotracheal reconstruction: Does dexmedetomidine help?

ObjectivesSingle-stage laryngotracheal reconstruction (SS-LTR) requires a period of post-operative intubation, during which time adequate sedation is needed to ensure graft healing. Commonly used agents include benzodiazepines, opioids, and more recently, dexmedetomidine, a centrally-acting α2 adrenoreceptor. This study aims to compare withdrawal outcomes between various sedation regimens following SS-LTR. MethodsRetrospective chart review of 56 patients who underwent SS-LTR between 2008 and 2018 at a tertiary free-standing children's hospital was performed. Of 47 patients with complete records, 18 patients received dexmedetomidine for >75% of their intubation period with midazolam (DexWM), 9 received dexmedetomidine for >75% without midazolam (DexWOM), and 20 received dexmedetomidine for <75% with midazolam (noDex). Results: There was no significant difference in length of PICU or hospital stay between the groups. The noDex group trended toward a higher re-intubation rate of 25%, as compared with 11% of DexWOM and 5.6% of DexWM (p = 0.21). There was no significant difference in days of oral sedation taper required or Withdrawal Assessment Tool (WAT-1) score for post-extubation days 1 and 3. By post-extubation day 5, 100% of the DexWM group had WAT-1 scores <3 as compared with 71.4% of the noDex group (p = 0.037). Notably, lower average daily doses of dexmedetomidine and midazolam were used in the DexWM group, as compared with the DexWOM and noDex groups, respectively. Conclusion: Dexmedetomidine as a primary sedation agent with midazolam allows for adequate sedation following SS-LTR. The combination of the two drugs in the DexWM group not only reduced the dosage of each drug needed, but also significantly improved WAT-1 scores by post-extubation day 5, as compared with the alternative sedation regimens.

ACUTE AIRWAY OBSTRUCTION DUE TO CERVICAL GOITER IN A POST-OPERATIVE PATIENT

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Benign cervical goiter, though very common, is a rare cause of upper airway obstruction. In most cases there is a significant retrosternal extension of the goiter that leads to chronic respiratory failure. Here we present a case of upper airway obstruction due to a cervical goiter causing acute respiratory failure in a post-operative patient. CASE PRESENTATION: A 67-year-old woman with a past medical history of diabetes, hypertension, coronary artery disease and hypothyroidism presented to our facility with palpitations and shortness of breath. She underwent extensive evaluation including cardiac catheterization, which showed triple vessel disease. She was subsequently referred for coronary artery bypass grafting. On the second postoperative day, the patient developed sudden onset of shortness of breath and complained of feeling like her throat was closing. She was intubated for acute respiratory failure and placed on mechanical ventilation. Extubation was attempted twice in the post-operative period, but on both occasions, she relapsed into hypercarbic respiratory failure shortly after withdrawal of the endotracheal tube. After a prolonged period of intubation, she was referred for tracheostomy. She eventually required a subtotal thyroid resection before the trachea could be accessed. She was discharged with the tracheostomy in place DISCUSSION: Our patient had multiple comorbid conditions, underwent a major surgical procedure and received analgesic medications with sedative properties. These elements taxed her physiological reserve. She was therefore unable to maintain the same respiratory effort and could no longer overcome the resistance caused by airway narrowing due to the goiter. After prolonged intubation and failed attempts at extubation, tracheostomy was felt necessary. Benign goiters are very common, but do not often lead to upper airway obstruction. However, in critically ill or in post-operative patients, they can have significant influence on the prognosis. The presence of a large cervical goiter should be viewed as a risk factor for upper airway obstruction during the post-operative period. CONCLUSIONS: Acute respiratory failure due to benign cervical goiter is uncommon. However, in post-operative or critically ill patients, it should be factored as a potential cause of respiratory failure and considered during the pre-operative assessment. Reference #1: Bayhan Z, Zeren S, Ucar BI, et al. Emergency thyroidectomy: Due to acute respiratory failure. Int J Surg Case Rep. 2014;5(12):1251-3. Reference #2: White ML, Doherty GM, Gauger PG. Evidence-based surgical management of substernal goiter. World J Surg. 2008;32(7):1285-300. Reference #3: Ito T, Shingu K, Maeda C, et al. Acute airway obstruction due to benign asymptomatic nodular goiter in the cervical region: A case report. Oncol Lett. 2015;10(3):1453-1455. DISCLOSURES: No relevant relationships by Israel Acosta Sanchez, source=Web Response no disclosure on file for Ali Ashraf; No relevant relationships by Anthony Chahin, source=Web Response No relevant relationships by Jovan Gayle, source=Web Response No relevant relationships by Relin Yang, source=Web Response

The effect of endotracheal tube with injecting medicine to endotracheal and laryngopharynx for topical anesthesia combined with transcutaneous electrical acupoint stimulation on the hemodynamics of the intubation period

Objective To observe the effects of endotracheal tube with injecting medicine to endotracheal and laryngopharynx for topical anesthesia, transcutaneous electrical acupoint stimulation (TEAS), and endotracheal-laryngopharynx for topical anesthesia combined with TEAS on hemodynamics during intubation. Methods One hundred patients that belonged to American Society of Anesthesiologists (ASA) grade Ⅰ or Ⅱ, in accordance with the random number table, were categorized into four groups (n=25). They were endotracheal tube (group A), endotracheal tube with injecting medicine to endotracheal and laryngopharynx (group B), TEAS combined with endotracheal tube (group C) and endotracheal tube with injecting medicine to endotracheal and laryngopharynx combined with TEAS (group D). All patients were monitored continuously on systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), heart rate (HR), cardiac index (CI), systemic vascular resistance index (SVRI) and bispectral index (BIS) respectively in the calm state at timepoints of entering the operation room (T0), before tracheal intubation after intravenous induce anesthetics (T1), immediately after tracheal intubation (T2), 3 min after tracheal intubation (T3), 5 min after tracheal intubation (T4) and 10 min after tracheal intubation (T5). Results ① Compare with timepoint T0, SBP was decreased markedly (P 0.05). Conclusions Both endotracheal tube with injecting medicine to endotracheal and laryngopharynx for topical anesthesia and TEAS can reduce excessive hemodynamic responses during the intubation to some extent, but combination of them will has better effect. Key words: Tracheal intubation; Endotracheal tube with injecting medicine; Topical anesthesia; Acupoints; Transdermal electrostimulation; Hemodynamics

A Standardized Care Pathway following Mandibular Distraction in Infants Less Than 3 Months of Age

To assess for differences in postoperative care following mandibular distraction osteogenesis (MDO) in infants before and after implementation of a standardized protocol. Retrospective chart review. Urban tertiary pediatric hospital. The inpatient charts of infants who underwent MDO before 90 days of age were assessed for metrics such as postoperative length of stay (LOS), duration of mechanical ventilation, and the choice and duration of sedating medications. Over a 6-year period, 16 patients met inclusion criteria. The first 4 consecutive patients were managed at the discretion of the critical care staff. The remaining 12 infants were managed with a planned 4- to 6-day period of postoperative intubation, during which a standard protocol determined the choice, dosage, and duration of sedating medications. The mean age was similar between groups (preprotocol: mean, 26.5 days; protocol: mean, 20.3 days; P = .51). The mean postoperative LOS was 13.3 days less among infants managed with the protocol (P = .06), and the mean number of midazolam boluses was fewer among protocol patients (P < .01). A more consistent postoperative LOS, duration of mechanical ventilation, and exposure to sedating medications was observed among protocol subjects (P < .01). The LOS for 2 patients in the preprotocol group was extended due to iatrogenic withdrawal syndrome. There were no instances of accidental extubation or anoxia in either group. Among infants undergoing MDO, standardizing postoperative airway and sedation practices may offer a more predictable postoperative course as compared with a case-by-case management philosophy.