Late Extubation Research Articles

Effect of lactate levels on extubation time in coronary artery bypass grafting surgery.

In current practice, fast-track protocols are gaining importance in patients undergoing cardiac surgery. For this purpose, besides different application techniques, biomarkers are frequently examined in the peri-operative period. We aimed to examine whether serum lactate levels at different peri-operative intervals had an effect on the extubation time. The patients were analysed in two groups according to the extubation time (early < 6 hours, and late extubation > 6 hours). Individual characteristics, co-existing diseases, blood transfusion, inotropic support, intra-aortic balloon pump, cardiopulmonary bypass time, aortic cross-clamp time, and the serial measurements of serum lactate levels were recorded. Correlations of serial measurements of lactate levels and the peri-operative variables with extubation times were analysed. No significant differences were observed between the groups in terms of co-existing diseases and individual characteristics. However, cardiopulmonary bypass, aortic cross-clamp times and all lactate levels after aortic cross-clamping were found to be significantly different (p = 0.001). A statistically significant correlation was found between the cut-off value of 1.7 for serum lactate levels after aortic-cross clamping (L2); 1.9 for levels after aortic cross-clamp removal (L3); 2.2 for levels after cardiopumonary bypass (L4); 2.1 for levels after intensive care admission (L5); 1.7 for levels after first postoperative hour in the intensive care unit (L6), and 1.8 for the difference between pre-operative levels (L0) and the peak level of lactate in the peri-operative period (ΔL) in predicting extubation time (p < 0.01). We concluded that cardiopulmonary bypass and aortic cross-clamp times, and intra-operative serum lactate levels were important in predicting early extubation after isolated coronary artery bypass graft surgery.

Prediction of mechanical ventilation outcome by early abdominal-visceral-blood-flow-and-function score in critically ill patients after cardiopulmonary bypass in the ICU: A prospective observational study

BackgroundAbdominal organs are important organs that sense and respond to ischemia and hypoxia, but there are few evaluation methods.We use ultrasonography to evaluate abdominal organ function and blood flow in patients with mechanical ventilation (MV) after cardiopulmonary bypass and to obtain a semiquantitative score for abdominal organ function and blood flow. MethodsPatients with cardiopulmonary bypass in the Critical Care Department of Peking Union Medical College Hospital in China from March to July 2021 were enrolled in this prospective observational study. The correlation of the abdominal-visceral-blood-flow-and-function score (AVBFS) with the duration of MV, number of days spent in the intensive care unit (ICU), acute physiology and chronic health evaluation II (APACHE-II), sequential organ failure assessment (SOFA), lactate, epinephrine, and norepinephrine use was analyzed, and the results were used to assess the predictive value of the receiver operating characteristic curve (ROC) regression analysis score for the duration of MV. ResultsOf the 92 patients who underwent cardiopulmonary bypass, 41 were finally included. The AVBFS were significantly correlated with the duration of MV, number of days spent in the ICU, APACHE-II score, SOFA score, and norepinephrine use time. The AVBFS in a group of patients using ventilators ≥36 h were significantly higher than those obtained for a group of patients using ventilators <36 h (P <0.05). The evaluation results for the AVBFS at 0-12 h after ICU admission were as follows: area under the ROC curve (AUC)=0.876 (95% confidence interval [CI]: 0.767 to 0.984), cut-off value=2.5, specificity=0.842, and sensitivity=0.773. ConclusionsAbdominal visceral organ function and blood perfusion can be used to evaluate gastrointestinal function. It is related to early and late extubation after cardiac surgery.

Association of post-operative ICU requirements with early extubation in the fontan procedure.

This study investigated the association between early extubation (EE) and the degree of postoperative intensive care unit (ICU) support after the Fontan procedure, specifically evaluating the volume of postoperative intravenous fluid (IVF) and vasoactive-inotropic score (VIS). Retrospective analysis of patients who underwent Fontan palliation from 2008 to 2018 at a single center was completed. Patients were initially divided into pre-institutional initiative towards EE (control) and post-initiative (modern) cohorts. Differences between the cohorts were assessed using t-test, Wilcoxon, or chi-Square. Following stratification by early or late extubation, four groups were compared via ANOVA or Kruskal-Wallis Test. There was a significant difference in the rate of EE between the control and modern cohorts (mean 42.6 versus 75.7%, p = 0.01). The modern cohort demonstrated lower median VIS (5 versus 8, p = 0.002), but higher total mean IVF (101±42 versus 82 ±27 cc/kg, p < 0.001) versus control cohort. Late extubated (LE) patients in the modern cohort had the highest VIS and IVF requirements. This group received 67% more IVF (140 ± 53 versus 84 ± 26 cc/kg, p < 0.001) and had a higher median VIS at 24 hours (10 (IQR, 5-10) versus 4 (IQR, 2-7), p < 0.001) versus all other groups. In comparison, all EE patients had a 5-point lower median VIS when compared to LE patients (3 versus 8, p= 0.001). EE following the Fontan procedure is associated with reduced post-operative VIS. LE patients in the modern cohort received more IVF, potentially identifying a high-risk subgroup of Fontan patients deserving of further investigation.

Non-interventional Feasibility Assessment for Fast-Track Cardiac Anesthesia.

Background The introduction of fast-track extubation procedures following cardiac surgery has significantly shortened hospitalization duration in intensive care units (ICUs). Early extubation is the most crucial step in getting out of the ICU early and providing ideal patient circulation. In times of crisis such as pandemics, it is vital to provide rapid flow through the hospital to prevent the postponement or inability to operate on patients awaiting surgery. This study aimed to determine the obstacles to early extubation in patients undergoing cardiac surgery and the perioperative characteristics that were affected in terms of fast-track extubation. Methodology This was an observational, cross-sectional study with data collected prospectively from October 1 to November 30, 2021. Preoperative data and comorbidities were recorded. Intraoperative and postoperative data were recorded and analyzed. Intraoperative cross-clamp duration, cardiopulmonary bypass duration, length of operation, and erythrocytes (red blood cells) transfused were recorded for each patient. Early postoperative clinical conditions were defined in patients whose mechanical ventilation duration exceeded eight hours (such as pulmonary complications, cardiovascular complications, renal complications, neurological conditions, and infective complications ). The length of ICU stay (hours), length of hospital stay (days), return to the ICU, reasons for return to the ICU, and overall hospital mortality were investigated. A total of 226 patients were included in the study. Patients were divided into two groups: extubated within eight hours (FTCA, fast-track cardiac anesthesia) and late extubation (after eight hours) postoperatively, and the data were evaluated accordingly. Results While 138 (61.1%) of the patients were extubated in eight hours or less, 88 (38.9%) patients were extubated after more than eight hours. The most common complications (55.7%) in patients with late extubation were cardiovascular complications, followed by respiratory complications (15.9%), and the surgeon's refusal (15.9%). In the logistic model created with the independent variables affecting the extubation time, the American Society of Anesthesiologists score and red blood cell transfusion were risk factors for longer extubation time. Conclusions In our research to reveal the feasibility of and barriers to FTCA, it was found that cardiac and respiratory problems were the most common reasons for delayed extubation. Due to the refusal of the surgical team, it was observed that some patients remained intubated despite meeting the FTCA requirements. It was considered the most improvable obstacle. Regarding cardiovascular complications, the team should aim to optimally control patient comorbidities in the preoperative period, reduce the use of red blood cell transfusions, and ensure that the entire team is updated on current extubation protocols, in particular surgeons and anesthesiologists.

Early extubation protocol post-coronary artery bypass graft &amp; open heart surgery

Fast-tracking in cardiac care refers to the complex intervention including early extubation, care during anesthesia, mobilization and hospital discharge to reduce perioperative morbidity, costs, and length of stay in the intensive care unit and the hospital. This review was designed to evaluate early extubation protocols, the differences in early and late extubation, the safety and efficacy of early extubation among the patients in surgical intensive care after coronary artery bypass graft (CABG) surgery. The analyzed studies showed many significant differences in the mortality and postoperative complications of time-directed extubation practices and low dose-based general anesthesia in patients with low to moderate risk undergoing early extubation (fast-track) and the conventional care methods. Different fast-track interventions could diminish extubation time, costs, and the length of hospital stay. However, several factors including patient’s stay in the intensive therapy ward vs general ward, patient selection, skills and experience of the staff, and fast-track anesthesia methods could be considered to perform safe fast-tracking in patients undergoing cardiac surgery. On the other hand, to achieve this safety for high-risk cardiosurgery patients multidisciplinary coordination is needed.

Is early extubation after esophagectomy safe? A systematic review and meta-analysis.

There is no consensus on the timing of extubation after esophagectomy. There is a fear that premature extubation may result in a high risk of urgent reintubation. On the other hand, there is a risk of lung damage in prolonged intubation. The present systematic review compares early and late extubation. Five articles were selected. Early extubation after esophagectomy does not increase the risk of reintubation, mortality, complications, and length of stay.

Con: Extubating in the Operating Room After Cardiac Surgery Is Not Necessary

CARDIAC SURGERY PATIENTS are among the highest risk patients for postoperative pulmonary complications, acute kidney injury, and increased length of hospital stay. 1 Pahwa S Bernabei A Schaff H et al. Impact of postoperative complications after cardiac surgery on long-term survival. J Card Surg. 2021; 36: 2045-2052 Crossref PubMed Scopus (3) Google Scholar In an attempt to decrease these risks, enhanced recovery or fast-track pathways after cardiac surgery have gained traction in recent years. Early extubation is one area of such a pathway that has been shown to decrease the length of stay and reduce healthcare costs in this population. 2 Higgins TL. Pro: Early endotracheal extubation is preferable to late extubation in patients following coronary artery surgery. J Cardiothorac Vasc Anesth. 1992; 6: 488-493 Abstract Full Text PDF PubMed Scopus (113) Google Scholar While most will agree that extubation within 6 hours is ideal after uncomplicated cardiac surgery, there has been an increasing push to take it one step further and provide routine on-table extubation (OTE) after cardiac surgery. To date, there are no randomized controlled trials to support that OTE provides any further benefit over standard fast-track extubation and, thus, should not be routinely performed.

Is the asynchronous phase of thoracoabdominal movement a novel feature of successful extubation? A preliminary result.

Mechanical ventilation is necessary to maintain patients' life in intensive care units. However, too early or too late extubation may injure the muscles or lead to respiratory failure. Therefore, the spontaneous breathing trial (SBT) is applied for testing whether the patients can spontaneously breathe or not. However, previous evidence still reported 15%~20% of the rate of extubation fail. The monitor only considers the ventilation variables during SBT. Therefore, this study measures the asynchronization between thoracic and abdomen wall movement (TWM and AWM) by using instantaneous phase difference method (IPD) during SBT for 120 minutes. The respiratory inductive plethysmography were used for TWM and AWM measurement. The preliminary result recruited 31 signals for further analysis. The result showed that in successful extubation group can be classified into two groups, IPD increase group, and IPD decrease group; but in extubation fail group, the IPD value only increase. Therefore, the IPD decrease group can almost perfectly be discriminated with extubation fail group, especially after 70 minutes (Area under curve of operating characteristic curve was 1). These results showed IPD is an important key factor to find whether the patient is suitable for extubation or not. These finding suggest that the asynchronization between TWM and AWM should be considered as a predictor of extubation outcome. In future work, we plan to recruit 150 subjects to validate the result of this preliminary result. In addition, advanced machine learning method is considered to apply for building effective models to discriminate the IPD increase group and extubation fail group.Clinical Relevance- The finding of this study is that the patients whose average IPD of 95 to 100 minutes was smaller than average IPD of first 5 minutes of SBT could be 100% successful extubation. In addition, ability of discrimination of average IPD after 70 minutes presents AUC 1.

666 EARLY EXTUBATION AFTER ESOPHAGECTOMY IS SAFE. A SYSTEMATIC REVIEW AND META-ANALYSIS

Abstract Esophagectomy has high morbidity and mortality, mainly due to pulmonary complications. Consequently, ventilatory support is a cornerstone in postoperative management. However, there is still no consensus on the timing for extubation. There is a fear that untimely extubation would lead to a high risk for an urgent reintubation. On the other hand, there is a risk for pulmonary damage in prolonged intubation. Thus, the present study aimed to compare early and late extubation after esophagectomy. Methods A systematic review was carried out on PubMed, Lilacs, Cochrane Library Central, and Embase, comparing early and late extubation after esophagectomy. The primary outcome was reintubation. Secondary outcomes included mortality; complications; pulmonary complications; pneumonia; anastomotic fistula; length of hospital stay; and ICU length of stay. The inclusion criteria were: a) clinical trials and cohort studies; b) adult patients (&amp;gt; 18 years); and c) patients with esophageal cancer undergoing esophagectomy. The results were summarized by risk difference and mean difference. 95% confidence interval and random model were applied. Results Four articles were selected, comprising 490 patients. Early extubation did not increase the risk for reintubation, with a risk difference of 0.01 (95%CI -0.03; 0.04). Also, there was no difference for mortality −0.01 (95%CI -0.04; 0.03); complications −0.09 (95%CI -0.22; 0.05); pulmonary complications −0.05 (95%CI -0.13; 0.03); pneumonia −0.06 (95% CI-0.18; 0.05); anastomotic fistula −0.01 (95% CI -0.09; 0.08). In addition, there was no significant mean difference for: length of hospital stay −0.10 (95%CI -0.38; 0.1); and ICU length of stay 0.00 (95%CI -0.22; 0.22). Conclusion Early extubation after esophagectomy does not increase the risk for reintubation, mortality, complications, and lenght of stay.

Role of fast tract Extubation in Enhanced Recovery after Cardiac Surgery: Associated Factors and Outcomes

Objective: To assess the impact of fast track extubation versus late extubation in cardiac surgery patients being operated in Bahawal Victoria hospital, Bahawalpur, Pakistan.Methods: This analytical cross-sectional study was conducted in department of cardiac surgery, Bahawal Victoria Hospital, Bahawalpur, from March 2018 to March 2020. All patients who underwent cardiac surgical procedures were consecutively enrolled. Fast-track extubation (FTE) and delayed extubation (DE) in these patients were recorded. Moreover, information regarding baseline and clinical characteristics was collected and outcome like reintubations, hospital stay, and mortality were observed.Results: Of 86 patients, FTE was successful in 70 (80.14%) patients, while DE was observed in 16 (18.6%) patients. High dose inotropes 6 (37.50%) and increase drain output 5 (31.25%) were the most common cause of FTE failure among 16 patients. NYHA class was found to be significantly higher in DE group as compared to FTE group (pvalue 0.002). The mean ventilation time in FTE group was significantly higher as compared to DE group, i.e., 2.7±1.6 hours vs. 6.5±4.4 hours respectively (p-value 0.001). While, inotropic support (p-value 0.047), drain volume at 4 hours (p-value 0.039), and drain at the time of removal (p-value 0.002) were significantly lower in FTE group as compared to DE group. There was a single reintubation (1.16%) and mortality (1.16%).Conclusion: FTE is a safer technique in planned cardiac surgical procedures resulting in least morbidity and mortality.

Reimbursement After Congenital Heart Surgery in Germany: Impact of Early Postoperative Extubation.

Duration of mechanical ventilation is an important variable used by German Diagnosis-Related Groups (G-DRG) system to establish cost weight values for reimbursement after congenital heart surgery. Infants are commonly ventilated after open heart surgery. As of year 2015, we strived to achieve early postoperative extubation. This work studies how this approach impacted reimbursement after infant open heart surgery. Data of infants who underwent surgery on cardiopulmonary bypass (CPB) from 2014 to 2018 were reviewed. Successful early extubation was defined as end of mechanical ventilation within 24 hours postoperatively, without reintubation at a later point. Mean cost weight values (case mix index [CMI]) of achieved DRGs were used for estimation of reimbursement. Evolutions over years of early extubation and of reimbursement were compared. A total of 521 infants underwent operations on CPB. Of these, 161 (31%) procedures were of higher risk Society of Thoracic Surgery and the European Association for Cardio-Thoracic Surgery (STAT) categories 3 and 4. Early extubation was achieved in 205 (39%) patients. The rate increased from 14% (year 2014) to 57% (year 2018). Case mix index amounted to 8.87 ± 7.00 after early extubation, and 12.37 ± 7.85 after late extubation: P value <.0001. It was 8.77 ± 6.09 after early extubation in patients undergoing lower risk STAT categories 1 and 2 operations, and 8.09 ± 2.95 when categories 3 and 4 procedures were performed (P = .18). An overall 14.4% decrease in hospital reimbursement per patient was observed. Early extubation could be progressively obtained in the majority of infants. This resulted in lower reimbursement. Surgical complexity was disregarded. The current G-DRG system appears to favor longer mechanical ventilation durations after infant open heart surgery.

Early extubation after thymectomy is good for the patients with myasthenia gravis

ObjectivesPatients with myasthenia gravis (MG) often benefit from thymectomy, but the optimal timing of extubation following thymectomy in these patients remains unknown. This study of MG patients compared the effect of early and late extubation following thymectomy on clinical outcome.MethodsWe performed a study of data from 96 patients with MG who received thymectomy procedures, followed by early (< 6 h) or late (> 6 h) extubation, at our institution between October 2011 and November 2017. Patient clinical and demographic characteristics, preoperative data, and postoperative clinical outcomes were analyzed. Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.ResultsThe patients in the early extubation group (n = 53) and late extubation group (n = 43) had similar preoperative clinical and demographic characteristics. However, the early extubation group had a significantly longer duration of MG (24 months vs. 12 months, P < 0.013) and a lower incidence of reintubation (11.3% vs. 37.2%, P = 0.003). Postoperative pulmonary infection was significantly more common in the late extubation group (39.5% vs. 11.3%, P = 0.001; adjusted odds ratio = 6.94, 95% CI 1.24–38.97). Also, patients in the late extubation group had a longer duration of ICU stay (6.4 ± 4.0 h vs. 4.3 ± 1.8 h; P = 0.003) and had a longer adjusted duration of ICU stay by 0.93 days (95% CI 0.02–1.85).ConclusionsOur analysis of patients with MG who received thymectomy procedures indicated that early extubation was associated with improved clinical outcomes, in particular with reduced risk of postoperative pulmonary infection and reduced ICU stay.

Studying the Effects of the Length of Using Cardiopulmonary Pump on Early Extubation Following the Operation among Patients Candidated for Coronary Artery Bypass Graft

Prolonged mechanical ventilation is a really important complication among patients candidated for coronary artery bypass grafting. It also accounts for higher death toll, longer periods of hospitalization, and reduced life quality of patients. As a result, early extubation is a common desire among these patients. One of the factors affecting this process is the length of utilizing pump. The present research seeks to study the effect of the length of utilizing pump on the length of extubation among patients undergoing coronary artery bypass grafting. This is a cross sectional - analytical research conducted on 360 patients candidated for CABG selected based upon the inclusion criteria. The length of pump utilization and Aorta cross clamp, and the length of extubation since entering ICU (after they were moved to ICU) were recorded in research questionnaires and the resulting information was finally analyzed. As it turned out, a longer period of hospitalization would result in a significantly longer time of extubation for patients. The average extubation time for those patients who were under pumping for more than 120 minutes was longer than 2 hours (P = 0.01). A longer period of pumping was significantly associated with higher mortality rates and a linear correlation is observed between these two variables. The mean length of pumping among those patients who had passed away was 169.8 +/- 7.8 minutes (P = 0.0001). A study of these patients illustrated the fact that as the length of using pump grows longer, the possibility of atrial fibrillation also goes up (P = 0.01). Longer use of pump results in longer extubation time and causes late extubation.

Lung function influenced the prognosis of cardiac surgery in patients with chronic obstructive pulmonary disease

Objective: To investigate the value of lung function for the prognosis of cardiac surgery in patients with chronic obstructive pulmonary disease(COPD). Methods: A retrospective analysis was conducted on the hospitalized patients with coronary heart disease or valvular heart disease in Beijing Anzhen hospital during Janury 2013 to December 2015. The relationship between lung function and extubation time, time of staying in ICU, second time tracheal incubation, tracheotomy and mortality rate were analyzed. Results: There were 355 patients without surgery in a total 1 729 of patients, of which 65 (18.31%)suffered from severe pulmonary dysfunction. There were 242 patients with obstructive ventilation dysfunction, 75 with mild, 127 with moderate, and 40 with severe and very severe obstructive ventilation dysfunction. There were significant differences in the rates of planned extubation and late extubation between patients with normal lung function (81.6% and 10.7%) and those with abnormal lung function(74.4% and 12.8%). In patients with different GOLD classification (Ⅰ, Ⅱ, and Ⅲ-Ⅳ), there were significant differences in the rates of early extubation 14.7%, 14.2% and 5%, planned extubation (80%, 74% and 65%) and late extubation (5.3%, 11.8% and 30%). By comparison with patients without COPD, the extubation time of COPD patients increased by 20.3%, the time of staying in ICU prolonged by 14.2%, and the mortality rate increased to 180%(P<0.05). However, there was no significant difference in the rate of second time tracheal incubation or tracheotomy. Conclusion: There was a close relationship between GOLD classification and prognosis of cardiac surgery patients with COPD. Cardiac surgery needs to be cautious because of increase in incidence of postoperative adverse events in patients with severe pulmonary dysfunction.

Effects of inhalational anesthesia on blood gases and pH in California sea lions

AbstractDespite the widespread use of inhalational anesthesia with spontaneous ventilation in many studies of otariid pinnipeds, the effects and risks of anesthetic‐induced respiratory depression on blood gas and pH regulation are unknown in these animals. During such anesthesia in California sea lions (Zalophus californianus), blood gas and pH analyses of opportunistic blood samples revealed routine hypercarbia (highest PCO2 = 128 mm Hg [17.1 kPa]), but adequate arterial oxygenation (PO2 &gt; 100 mm Hg [13.3 kPa] on 100% inspiratory oxygen). Respiratory acidosis (lowest pH = 7.05) was limited by the increased buffering capacity of sea lion blood. A markedly widened alveolar‐to‐arterial PO2 difference was indicative of atelectasis and ventilation‐perfusion mismatch in the lung secondary to hypoventilation during anesthesia. Despite the generally safe track record of this anesthetic regimen in the past, these findings demonstrate the value of high inspiratory O2 concentrations and the necessity of constant vigilance and caution. In order to avoid hypoxemia, we emphasize the importance of late extubation or at least maintenance of mask ventilation on O2 until anesthetic‐induced respiratory depression is resolved. In this regard, whether for planned or emergency application, we also describe a simple, easily employed intubation technique with the Casper “zalophoscope” for sea lions.

Factors Influencing Fast Track Extubation Following Liver Transplant Surgery: A 3 Year Mayo Clinic Experience

SESSION TITLE: Critical Care SESSION TYPE: Original Investigation Slide PRESENTED ON: Sunday, April 17, 2016 at 02:15 PM - 03:45 PM PURPOSE: Liver transplantation (LT) is a complex surgery with potential for a number of short term peri and post operative complications including bleeding, vascular compromise and hemodynamic instability. Most transplant centers utilize some kind of formal or informal approach to assess readiness for early extubation after LT. What is currently lacking in the literature is a risk predictor tool to determine which patients would be a candidate for rapid extubation. The goal of this study was to identify pre and intra-operative factors that could help identify factors associated with successful early extubation post LT. METHODS: Retrospective analysis of all patients who underwent LT from Jan 1st 2012 to December 31th, 2014. A total of 313 patients (including pediatric subjects) comprised the study cohort. A total of 154 patients remained intubated longer than six hours (late extubation group) and 159 patients were extubated within first 6 hours post LT surgery (early extubation group). We compared the demographics, preoperative and intraoperative clinical and laboratory markers between the two groups RESULTS: Baseline characteristics such as age, gender, MELD, MELD-Na, BMI and length of the surgery were no different between two groups (P > 0.05). On univariate analysis; coagulation parameters obtained at the end of surgery including higher INR (p= 0.03), lower platelets (p= 0.006) and lower fibrinogen (p= 0.003) were all associated with delayed extubation. Similarly intraoperative transfusion volume of RBC, platelets, FFP, autologous PRBC, cryoprecipitate, crystalloids, volume of ascitic fluid removed and low urine output were all significantly associated with delayed extubation (P <0.001). On multivariate analysis the only variable that was associated with delayed extubation was the transfusion of more than 6 units in OR (P=0.02). CONCLUSIONS: Our data suggest that several important intra-operative variables including last intraoperative coagulation labs, intraoperative transfusion requirements, lower urine output, large volume ascitic fluid removed and amount of crystalloid infused are associated with prolonged time to extubation. However on multivariate modelling only FFP transfusion of more than 6 units was associated with prolonged extubation time CLINICAL IMPLICATIONS: With identification of factors associated with early extubation in patient post liver transplant surgery, our hope is to ultimately develop risk predictor tool to determine which patients would be a candidate for rapid extubation. DISCLOSURE: The following authors have nothing to disclose: Devang Sanghavi, Kumar Sarvottam, Rahul Kashyap, Bibek Pannu, Julie Heimbach, Vivek Iyer No Product/Research Disclosure Information

A comparative study of early and late extubation following transoral odontoidectomy and posterior fixation.

Background and Aims:Elective ventilation is the usual practice after transoral odontoidectomy (TOO) and posterior fixation. This practice of elective ventilation is not based on any evidence. The primary objective of our study was to find out the difference in oxygenation and ventilation in patients extubated early compared to those extubated late after TOO and posterior fixation. The secondary objectives were to compare the length of Intensive Care Unit (ICU)/hospital stay and pulmonary complications between the two groups.Material and Methods:After TOO and posterior fixation, patients were either extubated in the operating room (Group E) or extubated next day (Group D). The oxygenation (PaO2:FiO2 ratio) and ventilation (PaCO2) of the two groups before surgery, at 30 min and at 6/12/24 and 48 h after extubation were compared. Complications, durations of ICU and hospital stay were noted.Results:The base-line PaO2:FiO2 and PaCO2 was comparable between the groups. No significant change in the PaO2:FiO2 was noted in the postoperative period in either group as compared to the preoperative values. Except for at 12 h after surgery, there was no significant difference between the two groups at various time intervals. No significant change in the PaCO2 level was seen during the study period in either group. PaCO2 measured at 30 min after surgery was more in Group E (37.5 ± 3.2 mmHg in Group E vs. 34.6 ± 2.9 mmHg in Group D), otherwise there was no significant difference between the two groups at various time intervals. One patient in Group E (7.1%) and two patients in Group D (13%) developed postoperative respiratory complication, but the difference was not statistically significant. The mean ICU stay (Group D = 42 ± 25 h vs. Group E = 25.1 ± 16.9 h) and mean hospital stay (Group D = 9.9 ± 4 days vs. Group E = 7.6 ± 2.2 days) were longer in Group D patients.Conclusion:Ventilation and oxygenation in the postoperative period in patients undergoing TOO and posterior fixation are not different between the two groups. However, the duration of ICU and hospital stay was prolonged in group D.

Early versus late extubation after surfactant replacement therapy for respiratory distress syndrome

Patients and methodsNinety patients treated by surfactant replacement therapy were included in the study. Patients were divided into 2 groups; group A consists of patients who were extubated early within 24h after surfactant administration and group B consists of patients who were extubated after 24h from surfactant administration. Results59 patients were extubated early (within 24h after surfactant administration) while 31 patients were extubated late (after 24h from surfactant administration). Patients in group B (late extubation group) had a longer duration of CPAP (41.53+9.74h in group B versus 17.30+4.03h in group A), a longer duration of total oxygen administration (73.41+11.24h in group B versus 45.33+5.22h in group A) and a longer duration of hospital stay (171.88+75.74h in group B versus 106.82+52.79h in group A) than patients in group A (early extubation group). 41 (69.50%) Patients who were extubated early received surfactants at or before the age of 6h while 22 (70.97%) patients who were extubated late received surfactants after the age of 6h. Regarding complications, 6 patients had transient bradycardia (6.7%), 4 patients had pneumothorax (4.4%) and 4 patients had pulmonary hemorrhage (4.4%). ConclusionEarly administration of surfactants is associated with early extubation. Patients who were extubated early (most of them had an early administration of surfactants) had a lower chance for re-intubation, less duration of total oxygen administration and less hospital stay.

Ultra fast-track extubation in heart transplant surgery patients.

Background:Heart transplant surgeries using cardiopulmonary bypass (CPB) typically requires mechanical ventilation in intensive care units (ICU) in post-operation period. Ultra fast-track extubation (UFE) have been described in patients undergoing various cardiac surgeries.Aim:To determine the possibility of ultra-fast-track extubation instead of late extubation in post heart transplant patients.Materials and Methods:Patients randomly assigned into two groups; Ultra fast-track extubation (UFE) group was defined by extubation inside operating room right after surgery. Late extubation group was defined by patients who were not extubated in operating room and transferred to post operation cardiac care unit (CCU) to extubate.Results:The mean cardiopulmonary bypass time was 136.8 ± 25.7 minutes in ultra-fast extubation and 145.3 ± 29.8 minutes in late extubation patients (P > 0.05). Mechanical ventilation duration (days) was 0 days in ultra-fast and 2.31 ± 1.8 days in late extubation. Length of ICU stay was significantly higher in late extubation group (4.2 ± 1.2 days) than the UFE group (1.72 ± 1.5 days) (P = 0.02). In survival analysis there was no significant difference between ultra-fast and late extubation groups (Log-rank test, P = 0.9).Conclusions:Patients undergoing cardiac transplant could be managed with “ultra-fast-track extubation”, without increased morbidity and mortality.

ACHIEVING RECOMMENDED ENDOTRACHEAL TUBE INTRACUFF PRESSURE: A RANDOMIZED CONTROL STUDY COMPARING LOSS OF RESISTANCE SYRINGE TO PILOT BALLOON PALPATION (THE LOR-ICP TRIAL, NCT02294422)

It has been agreed that the safe endotracheal tube intracuff pressures ranges from 20cmH2O to 30cmH2O with pressures above that range being dangerous to the patient even for a short time. While there are many different methods of inflation, the cuff manometer is considered the standard. However, its applicability in clinical practice is marred with numerous hindrances. Without the cuff manometer, anaesthesia providers employ a varied range of subjective methods to inflate and estimate optimal ETT cuff pressure. The most common method used is the palpation of the pilot balloon. This method has been shown to administer high ETT cuff pressures which are associated with both early and late post extubation airway symptoms.