Post Extubation Research Articles

Ultrasound guided pediatric caudal dose: a two-center randomized controlled trial

BackgroundThe drug volume to be used in caudal in pediatric patients has remained an unmet issue since long. We determined the minimum drug volume required to reach T10 level in pediatric patients using ultrasonography and compared it with the already established volume by Armitage formula.AimTo determine the minimum effective caudal local anesthetic dose using ultrasound guidance.MethodsStudy was performed at two centres and at each centre, 50 pediatric patients (Total 100 patients), aged 1 to 3 years, undergoing below umbilical surgeries were included and randomised into two groups of 25 each (Total 50) to receive ultrasound guided drug volume vs. Armitage formula based volume. The volume required to reach T10 level was assessed with ultrasound in one group. Also, maximum height achieved, cutaneous level achieved after 15 min, FLACC scores 30 min post extubation and parental satisfaction scores were noted.ResultsThe mean drug volume required to reach T10 level in Group U was 0.755 ± 0.053 ml/kg with a P value < 0.001. (Compared to the drug volume of 1 ml/kg using one sample t test). The highest level achieved in both groups were calculated as the mode value of T8 and T7 in Group U and Group A respectively. The highest cutaneous level achieved after 15 min was also calculated as the mode value of T4 in both groups. FLACC scores at 30 min were also comparable. Satisfaction scores were comparable in both groups.ConclusionA volume of 0.7 ml/kg of local anaesthetic in pediatric caudal block is sufficient to achieve a target of T10 level for infraumblical surgeries.

Clinical effects of perineural dexmedetomidine or magnesium sulphate as adjuvants to ropivacaine in dogs undergoing tibial plateau leveling osteotomy

The study aimed to compare the quality of perioperative analgesia, the motor block duration, and the effects on main cardiovascular parameters of dexmedetomidine (1 μg/kg/nerve block) or magnesium sulphate (2 mg/kg/nerve block) as adjuvants to 0.3% ropivacaine for sciatic and saphenous nerves block in dogs undergoing tibial plateau leveling osteotomy (TPLO). Dogs randomly received perineural dexmedetomidine-ropivacaine (D group), magnesium sulphate-ropivacaine (M group), or ropivacaine (C group). Fentanyl was administered in case of intraoperative nociception. Postoperative pain was assessed using the Short Form-Glasgow Composite Measure Pain Scale (SF-GCMPS) and VAS scale. The duration of motor blockade and intra- and postoperative cardiovascular parameters were also recorded. Group M required significantly more fentanyl than D group (p = 0.04). Group M had a significantly higher SF-GCMPS score than group C at 4 (p = 0.002) and 5 h after extubation (p = 0.01), and a significantly higher VAS score than group D at 3 h after extubation (p = 0.03), and at 4 h if compared to group C (p = 0.009). No significant differences regarding the duration of motor blockade were detected between groups (p = 0.07). The heart rate was significantly lower in group D than in M and C groups intraoperatively and during the first 1.5 h post extubation. The addition of dexmedetomidine or magnesium sulphate as adjuvants to perineural ropivacaine did not improve the quality of perioperative analgesia and did not prolong the motor blockade in dogs undergoing sciatic and saphenous nerves block for TPLO surgery.

Noninvasive High Frequency Ventilation as a Post-extubation Respiratory Support in Preterm Neonates

Abstract Background Noninvasive mechanical ventilation aims to provide respiratory support without the pulmonary and non-pulmonary complications associated with invasivemechanical ventilation including infection, subglottic stenosis, air leak syndrome and bronchopulmonary dysplasia (BPD). There is a notable increase in use of various types of noninvasive respiratory support post extubation to ensure the sucesss of extubation and avoid re-intubation. Noninvasive high frequency ventilation (NHFOV) is a new mode of noninvasive ventilation which is achieved through the use of noninvasive continuous flow with superimposed oscillations combining the benefits of high frequency oscillatory ventilaltion and noninvasive ventilation. Aim of Work The primary aim of the study is to compare re-ventilation rate between noninvasive positive pressure ventilation (NIPPV) and NHFOV when used as post extubation respiratory support. Secondary aim was to compare workof breathing, chest X-ray grade, incidence of pneumothorax and duration to reach full enteral intake between the 2 groups. Methodology Sixty preterm neonates with respiratory distress syndrome (RDS) who received invasive mechanical ventilation for more than 48 hours were included in this randomized controlled trial. Patients were randomly allocated post-extubation toNIPPV or NHFOV. The 2 groups were matched regarding weight, gestational age and comorbidities during invasive ventilation. Patients were compared regarding re-ventilation rate, work of breathing assessed by Downes score, chest X-ray grade, incidence of pneumothorax and duration to reach full enteral intake. Results Lower re-ventilation rate was found in NHFOV group (23.3%) compared to NIPPV group (30.0%). Median duration to reach full intake was shorter in NHFOV group (8 days) compared to NIPPV group (9.5 days) however, theseresults didn’t reach statistically significant difference (P value = 0.559 value and0.299 respectively). No difference was found between studied groups regarding work of breathing assessed by Downes’ score (P value = 0.634) nor regarding chest X-ray grades (p value= 0.902). Incidence of pneumothorax was equal in NHFOV group compared to NIPPV group with p value of 0.313. Conclusion NHFOV is a promising safe noninvasive mode for neonates post-extubation.

Screening of Palatopharyngeal Incoordination in Mechanically Ventilated Critically Ill Infants

Abstract Background Palatopharyngeal incoordination is a common phenomenon in patients requiring endotracheal intubation for mechanical ventilation. Understanding the underlying mechanism of palatopharyngeal incoordination may help as a screening tool that improves rates of early recognition and diagnosis and the ability to take preventive measures essential to alleviate related morbidity and complications. Objective The aim of this study is to screen palatopharyngeal incoordination in infants who needed mechanical ventilation and to elicit palatopharyngeal incoordination secondary to mechanical ventilation. Material and Methods This study included 51 patients at the Pediatric Intensive Care Unit, Faculty of Medicine, Ain Shams University, The study was conducted during the period from February 2021 to February 2022. patients were classified according to a Fiberoptic Flexible Endoscopic Evaluation of Swallowing (FEES) early post intubation, FEES early post extubation, Videofluoroscopic Swallow Study (VFSS) post extubation and dye study into five groups: group (1) the not affected group, group (2) the palatopharyngeal incoordination group, group (3) The palatopharyngeal incoordination with gastro esophageal reflux group, group (4) The reflux group, group (5) The congenital upper air way anomalies group in which patients were ventilated due to respiratory distress. Follow up FEES and VFSS were done after three months for palatopharyngeal incoordination patients. Results Palatopharyngeal incoordination was detected in 16 patients (31.3%), congenital upper airway anomalies were found in 12 patients (23.5%), and gastroesophageal reflux was only detected in 10 patients (19.6%). Performing VFSS and FEES after three months showed 92.3 % of palatopharyngeal incoordination patients had resolved palatopharyngeal incoordination and 7.7 % of palatopharyngeal incoordination patients had silent aspiration. Conclusion The prevalence of palatopharyngeal incoordination is 31.3 % and there was no palatopharyngeal incoordination secondary to mechanical ventilation.

Cuffed versus uncuffed endotracheal tubes in neonates undergoing noncardiac surgeries: A randomized controlled trial.

The efficacy and safety of cuffed endotracheal tubes (ETTs) in neonates are still unclear, this study aimed to assess the efficacy of cuffed versus uncuffed ETTs in neonate undergoing noncardiac surgeries. Neonates scheduled for noncardiac surgeries were randomized into two groups according to the type of airway device during general anesthesia: cuffed ETT group (n = 60) and the uncuffed ETT group (n = 60). The primary outcome was the incidence of ETT exchange to find the appropriate ETT. Other outcomes included: duration of intubation, lung ultrasound score, and incidence of postoperative complications (croup, wheezes, hypoxia, etc.). The frequency of ETT exchange was lower in the cuffed ETT group compared to the uncuffed one {1 (1.7%) vs. 28 (46.7%), p = .0001; relative risk [95% confidence interval]: 0.54 [0.43-0.69]}. Postoperative adverse events were comparable between both groups except for significantly higher post extubation croup in the uncuffed ETT group compared to the cuffed ETT {10 (16.7%) vs. 3(5%), p value = .04, relative risk (95% confidence interval): 1.14 (1-1.29)}. In full term neonates undergoing noncardiac surgeries, the use of cuffed ETT was associated with less need to tracheal tube exchange and less incidence of postoperative croup, without increasing the postoperative respiratory complications compared to uncuffed ETT.

Clinical assessment of recovery from neuromuscular blockers, is it a safe practise - An observational study

The incidence of residual neuromuscular paralysis (RNMB) with Train of four ratio&amp;#60;0.9 remains as high as 16% in PACU even after administration of reversal when neuromuscular monitoring is not done. Reversal with standard dose of neostigmine and extubation are done based on the clinical signs. We observed the clinical signs of neuromuscular recovery and correlated with neuromuscular monitoring to assess the degree of residual blockade in the post-operative period.100 Patients posted for surgery under general anaesthesia with endotracheal tube intubation and controlled ventilation were enrolled for the study after obtaining human ethical approval. Standard anaesthesia technique using morphine, propofol, vecuronium, isoflurane with low flow anaesthesia were administered for all patients. TOF was noted at the end of surgical procedure when patient resumed spontaneous respiration, during extubation, and at 15 minutes interval for one hour in the postoperative period. Hemodynamics were observed including respiratory rate. Overall 32 percent of patients had residual paralysis. 27% at 15 min, 26% at 30min, 6% at 45min and 3% at one hour in the postoperative period showed RNMB. Subgroup analysis showed that at the time administration of reversal 72 patients had (TOFR&amp;#62;0.4) and 28 had (TOFR&amp;#60;.0.4), showed significant difference in improvement in TOFR between 2 subgroups before reversal, immediate extubation and 15 min post extubation (p=0.00,0.001,0.003,) respectively. Clinical findings of neuromuscular reversal is not foolproof for complete recovery and standard dose neostigmine given during shallow block will accentuate the residual neuromuscular paralysis.

Combination of neuromuscular block monitoring and hand grip strength assessment for patients undergoing emergency abdominal surgery

Relevance. The hand grip strength measurement together with neuromuscular block monitoring played an important role during surgery. They both helped in losing less time during surgery and also facilitate the task of the surgeon. The aim of this study was to reduce time on intubation, facilitate the task of the surgeon and to limit post-surgical pain. In rehabilitation, hand grip strength helps in determining further recuperation measures after asurgery. There are three fundamental principles for an anesthesiologist to ensure that the patient after combined endotracheal anesthesia can be extubated, the first one is to ask the patient to move his head forward, the second one is to ask the patient whether the intubation tube is disturbing him in his mouth and the third most important one is to make the patient hold his wrist very firmly. Materials and Methods. Monitoring of muscle relaxant on induction, intra and post-surgery is carried out using aTOF Watch SX in coordination with handgrip strength measurement on 46 patients aged from 18 to 60 years of BMI of 18-30 kg/m² 15min before endotracheal intubation and 15min, 45min and 210min post extubation by using adynamometer “MEGEON 34090” to help us understand whether after extubation muscle strength changes and to what extent. Also, pre-anesthesiology protocol, combined endotracheal protocol, Microsoft excel advanced, monitoring of hemodynamics, ECG, PEEP, PCO2, PO2, respiratory volume using Drager Fabius. Results and Discussion. The results showed that to reach deep muscle relaxation both atracurium benzilate (FKP Kursk Biofabric company, Kursk, Russia) at TOF 0 took 258.5± 83.5 secs and Cisatracurium benzilate (ZAO Obninsk Chemical pharmaceutical company, Obninsk, Russia) at TOF0-252.4±100.1 secs in emergency patients and basically hand grip strength also was lesser as compared to planned cholecystectomy patients. Conclusion. Rehabilitation was necessary for patients undergoing massive abdominal emergency surgeries underlying the fact that on apain scale 10/10 post surgery, further treatments should be implemented to reduce pain, reduce residual neuromuscular block and muscle weakness after extubation at TOF 90-95%.

Abstract 222: Immediate post thrombectomy extubation is associated with improved clinical outcomes

Introduction Recent findings suggest that general anesthesia with endotracheal intubation (GA) in patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO) who receive mechanical thrombectomy (MT) is associated with similar outcomes to conscious sedation (CS). [1][2] However, these trials involved stroke specific GA protocols in which immediate, post‐operative extubation was emphasized. In this study, we investigated outcomes of MT in AIS due to LVO as a function of the timing of extubation and explored variables that could delay extubation. Methods We performed a retrospective analysis of collected data gathered during a 5‐year period (2018‐2022) for all our patients with AIS due to LVO who received MT. We analyzed the stroke outcomes and complications between patients who had received GA and those who had received CS. We also investigated the relationships between associated pulmonary risk factors, timing of extubation, and tracheostomy, on the outcomes of stroke. Results A total of 242 patients were included in our study. 83 patients received GA and 159 patients received CS. Our study shows CS in MT had a 2.74 (95% CI = 1.21‐6.22) higher odds of having a final TICI rating of 0‐2a compared to those who had GA. A logistic regression model was fitted that included NIHSS prior to MT; in this analysis, patients who received GA had 2.71 times higher odds of reaching TICI 2b or higher (OR = 2.71, 95% CI = 1.19‐6.17). NIHSS was not a significant predictor of recanalization in our patients. Patients extubated in the IR suite vs. elsewhere (excluding patients who were not extubated in hospital) had 3.82 (95% CI = 1.03‐14.18) times higher odds of having an excellent mRS at 90 days (n=65). Those extubated late had higher odds of transitioning to comfort care (OR=4.50, 95% CI = 1.52‐13.31, p=0.004), and 90‐day mortality (OR=5.49, 95% CI = 1.71‐17.65, p=0.002). Those who were extubated early had a lower NIHSS post MT (mean = 10.89 vs 19.18), t=‐5.79, p&lt;0.001), and a lower NIHSS at discharge (mean = 9.20 vs 17.11), t=‐5.79, p&lt;0.001). There were no significant correlations between history of COPD or the BMI and the timing of extubation or the outcomes of MT. In addition, COPD was not associated with any significant changes in discharge or 90 days mRS. Conclusion Administration of GA to patients who receive MT for AIS was associated with better outcomes in our cohort. Immediate extubation was associated with better outcomes than delayed extubation in the GA group. A history of COPD or high BMI should not affect the decision to provide with GA for MT.

A randomised, prospective, double blind study of intraperitoneal instillation of 0.25% bupivacaine with clonidine versus 0.25% bupivacaine with dexmedetomidine for post-operative analgesia in patients undergoing laparoscopic cholecystectomy

Laparoscopic cholecystectomy is the standard and most accepted technique for Cholecystectomies due to lesser postop pain and short recovery time.The origin of abdominal and shoulder pain after laparoscopic procedures has led to the use of intra peritoneal instillation of local anaesthetic agent to reduce postoperative pain. To assess the efficacy and quality of postoperative analgesia between the study groups using Visual Analogue Scale (VAS) score at various time intervals along with side effects if any.: 60 patients belonging to ASA 1 and 11 categories posted for Laparoscopic Cholecystectomy were given General Anaesthesia. After completion of surgery, before removing the trocar, anaesthetic study solution was sprayed on the surface of liver, gall bladder bed, right sub-diaphragmatic space, and port sites in Trendelenburg position. Volume and dilution of two drugs were same in both groups. Bupivacaine (0.25%) 50 mL; Dexmedetomidine (1 µg/kg) (BD) or Clonidine (1 µg/kg) (BC) was used. VAS score, Heart rate and BP measured at various time intervals and the time of first rescue analgesia noted.: VAS of BD group was 5.27 ± 0.64 to 3.70 ± 0.837 from 1 hour to 6 hour post extubation, when compared to BC group of 6.03 ± 0.669 in 1 hour reduced to 4.17 ± 0.699 at 6 hour post extubation. Dexmedetomidine combination significantly reduced the total dose of rescue analgesic required in 24 hours as compared to Clonidine combination.

Speech pathology assessment of dysphagia post endotracheal extubation: A service-model evaluation

BackgroundAs postextubation dysphagia (PED) is correlated with pneumonia, feeding-tube placement, and in-hospital mortality, early identification is paramount. Endotracheal intubation duration of ≥48 h is independently predictive for PED. Therefore, a blanket intensive care unit (ICU) referral protocol was implemented to conduct PED assessment of patients intubated for ≥48 h. ObjectivesThe objective of this study was to review outcomes of an established blanket referral model for PED assessment in patients intubated for ≥48 h. Outcomes of the model were examined over a 2-year period (June 2015–June 2017) for (i) numbers and clinical characteristics of patients meeting criteria and referred for speech pathology (SP) assessment; (ii) frequency identified with PED on clinical swallow examination; (iii) severity and duration of PED; and (iv) SP management within the ICU. ResultsThere was 96% adherence to the pathway with 108 participants (68% male) assessed. Median intubation duration was 142 h (mode = 61; interquartile range [IQR] = 131.75), and median ICU admission was 9 days (mode = 8; IQR = 6.75). SP referral occurred at a median of 19.5 h (mode = 4; IQR = 18.75) after extubation. Dysphagia assessment occurred at a median of 22 h (mode = 4; IQR = 19), with 34% assessed on the same day and 77% within 24 h of extubation. PED was observed in 89%, with 26% exhibiting profound PED. Dysphagia recovery occurred at a median of 7 days (mode = 2; IQR = 11). Dysphagia severity was associated with duration to swallow recovery (p = 0.001). A median of two occasions of service and 90 min clinical time was spent by the speech pathologist in the ICU. ConclusionThe blanket referral model enabled timely triage and assessment of dysphagia in a patient cohort at high risk of PED in our facility.

Comparison between the effect of ketamine-dexmedetomidine versus ketamine-propofol on emergence agitation in pediatrics undergoing adenotonsillectomy by sevoflurane anesthesia

Background Pediatric Emergence Agitation (PEA) Emergence agitation (EA) is a state of anxiety, irritability, non-purposeful movement, thrashing, and disorientation during early recovery from general anesthesia. it can be harmful for the children and their family, causing bleeding at the surgical site, parental unhappiness, and anxiety. Aim To decrease the incidence of emergence agitation (EA) in pediatrics undergoing adenotonsillectomy under sevoflurane anesthesia, by using ketamine-dexmedetomidine (KD) or ketamine-propofol (KP). Patients and methods In this prospective randomised controlled clinical trial, 63 children were randomly assigned to one of three groups of similar size: group C (Control group) (n=21), who received a single intravenous bolus of 10 ml 0.9% normal saline; group KD (n=21), who received 0.15 mg/kg ketamine and 0.3 μg/kg dexmedetomidine; 10 min before the end of surgery, and group KP (n=21), who received 0.15 mg/kg ketamine and 0.5 mg/kg propofol, 10 min before the end of surgery. The primary outcome was the post anesthesia EA which was evaluated using the pediatric anesthesia emergence agitation scale (PAED) score out come was assessment of OPS and complications. Results There were significant difference between the groups regarding the heart rate which was faster in the control group immediately, 5, 10, and 15 min post extubation. In the KD group the extubation time was the longest compared with the KP group and the control group. The PAED scores were significantly different among the three studied groups at 10, 20, 25, 30, 35, 40, 45, 50, 55, and 60 min. Conclusion The combination of ketamine (0.15 mg/kg) and dexmedetomidine (0.3 μg/kg) given 10 min before the completion of surgery was more effective in preventing emerging agitation than ketofol.

Comparing intravenous clonidine and nalbuphine for attenuating hemodynamic response to laryngoscopy and improving perioperative outcomes in laparoscopic surgeries

The Department of Anaesthesia at SPMC Bikaner approved the trial and it was carried out during laparoscopic surgery OT with proper informed written permission. The study was a double-blind, randomised, prospective interventional trial. The study comprised 60 (ASA) Classes I and II patients between the ages of 18 and 60 who were scheduled for elective laparoscopic cholecystectomy. Using a computer-generated random number sequence, patients were divided into two groups of 30 each: Group A received 1.5 mg/kg of clonidine, whereas Group B received.2 mg/kg of nalbuphine in a 50 ml NS solution. Prior to administering the study drug, five minutes after premedication, hemodynamic parameters were recorded. Double-blind administration of the study medication occurred more than 10 minutes before anaesthesia onset. Hemodynamic parameters were recorded following the administration of the study medication, 1 and 5 minutes after intubation, prior to pneumoperitoneum, 5 minutes, 10 minutes, 20 minutes, 30 minutes, and 40 minutes after pneumoperitoneum, and finally following extubation. following 1 minute and 5 minutes after intubation (and following pneumoperitoneum at 5 minutes, 10 minutes, 20 minutes, and post extubation), it was discovered that there was a substantial difference in heart rate, SBP, DBP, and MAP between Group A and Group B. In our investigation, hemodynamics related to heart rate were improved with clonidine. Based on the results of our study and other earlier research conducted by different authors, we came to the conclusion that both clonidine and nalbuphine, when administered 5 minutes prior to intubation in patients undergoing laparoscopic surgery, attenuated the hemodynamic response to intubation and pneumoperitoneum during the surgery. The difference in heart rate, systolic and diastolic blood pressure, and mean arterial pressure is much less with clonidine than with nalbuphine, which leads us to the conclusion that clonidine produced greater hemodynamic response than nalbuphine.

Comparing intravenous clonidine and nalbuphine for attenuating hemodynamic response to laryngoscopy and improving perioperative outcomes in laparoscopic surgeries

The Department of Anaesthesia at SPMC Bikaner approved the trial and it was carried out during laparoscopic surgery OT with proper informed written permission. The study was a double-blind, randomised, prospective interventional trial. The study comprised 60 (ASA) Classes I and II patients between the ages of 18 and 60 who were scheduled for elective laparoscopic cholecystectomy. Using a computer-generated random number sequence, patients were divided into two groups of 30 each: Group A received 1.5 mg/kg of clonidine, whereas Group B received.2 mg/kg of nalbuphine in a 50 ml NS solution. Prior to administering the study drug, five minutes after premedication, hemodynamic parameters were recorded. Double-blind administration of the study medication occurred more than 10 minutes before anaesthesia onset. Hemodynamic parameters were recorded following the administration of the study medication, 1 and 5 minutes after intubation, prior to pneumoperitoneum, 5 minutes, 10 minutes, 20 minutes, 30 minutes, and 40 minutes after pneumoperitoneum, and finally following extubation. following 1 minute and 5 minutes after intubation (and following pneumoperitoneum at 5 minutes, 10 minutes, 20 minutes, and post extubation), it was discovered that there was a substantial difference in heart rate, SBP, DBP, and MAP between Group A and Group B. In our investigation, hemodynamics related to heart rate were improved with clonidine. Based on the results of our study and other earlier research conducted by different authors, we came to the conclusion that both clonidine and nalbuphine, when administered 5 minutes prior to intubation in patients undergoing laparoscopic surgery, attenuated the hemodynamic response to intubation and pneumoperitoneum during the surgery. The difference in heart rate, systolic and diastolic blood pressure, and mean arterial pressure is much less with clonidine than with nalbuphine, which leads us to the conclusion that clonidine produced greater hemodynamic response than nalbuphine.

A new index, Respiratory Insufficiency index and Modified Early Warning Scores predict extubation failure.

Extubation failure occurs in 5%-20% of patients and is associated with poor clinical outcomes. The primary aim of this project was to determine the predictive ability of the Respiratory Insufficiency (RI) index, Respiratory Oxygenation (ROX) index and Modified Early Warning Score (MEWS) in identifying extubation failure. This was a secondary analysis of a prior cross-sectional retrospective study conducted from February 2018 through December 2018 among adult subjects who received mechanical ventilation for more than 24 h. Extubation failure was defined as the need for reintubation or rescue non-invasive ventilation (NIV) within 48 h after planned extubation. Univariate analysis and logistic regression were used to identify the predictors and final model was validated using 10-fold cross validation. Nomogram was constructed based on the final model. Of 216 enrolled subjects, 46 (21.3%) experienced extubation failure. The median RI index 1-h post extubation was 20 [interquartile range [IQR] 16.33-24.24] for success group and 27.02 [IQR 22.42-33.83] for the failure group (P<0.001). The median ROX index 1-h post extubation was 16.66 [IQR 12.57-19.84] for success group and 11.11 [IQR 8.09-14.67] for failure group (P<0.001). The median MEWS 1-h post extubation was 2 [IQR 1-3] for the success group and 4 [IQR 3-5] for the failure group (P<0.001). In multivariable analysis, age >60 years [OR 3.89 (95% CI 1.56-9.73); P=0.004], MEWS >4 [OR 4.01 (95% CI (1.59-10.14); P=0.003] and, RI index >20 [OR 4.50 (95% CI 1.43-14.21); P=0.010] were independently associated with extubation failure. In the present study, RI index and MEWS were independently associated with predicting extubation failure within 1 h of extubation. A prospective validation study is warranted to establish the role of these indices in predicting extubation outcome.

AB090. SOH23ABS_218. An audit on post operative extubation practices among non-consultant hospital doctors in Ireland

AB090. SOH23ABS_218. An audit on post operative extubation practices among non-consultant hospital doctors in Ireland

Effort and work-of-breathing parameters strongly correlate with increased resistance in an animal model.

Effort of Breathing (EOB) calculations may be a reliable alternative to Work of Breathing (WOB) calculations in which Respiratory Inductance Plethysmography (RIP) replaces spirometry. We sought to compare EOB and WOB measurements in a nonhuman primate model of increasing extrathoracic inspiratory resistance simulating upper airway obstruction (UAO). RIP, spirometry, and esophageal manometry were measured in spontaneously breathing, intubated Rhesus monkeys utilizing 11 calibrated resistors randomly applied for 2-min. EOB was calculated breath-by-breath as Pressure Rate Product (PRP) and Pressure Time Product (PTP). WOB was calculated from the Pressure-Volume curve based on spirometry (WOBSPIR) or RIP flow (WOBRIP). WOB, PRP and PTP showed similar linear increases when exposed to higher levels of resistive loads. When comparing WOBSPIR to WOBRIP, a similar strong correlation was seen for both signals as resistance increased and there were no statistically significant differences. EOB and WOB parameters utilizing esophageal manometry and RIP, independent of spirometry, showed a strong correlation as a function of increasing inspiratory resistance in nonhuman primates. This allows several potential monitoring possibilities for non-invasively ventilated patients or situations where spirometry is not available. EOB and WOB parameters showed a strong correlation as a function of increasing inspiratory resistance in nonhuman primates. There was a strong correlation between spirometry-based WOB versus RIP-based WOB. To date, it has remained untested as to whether EOB is a reliable alternative for WOB and if RIP can replace spirometry in these measurements. Our results enable additional potential monitoring possibilities for non-invasively ventilated patients or situations where spirometry is not available. Where spirometry is not available, there is no need to apply a facemask post extubation to a spontaneously breathing, non-intubated infant to make objective EOB measurements.

A randomized controlled trial to compare the success rates and efficacy of high flow nasal cannulae versus nasal continuous positive airway pressure in post extubation period in neonates

Background: Nasal continuous positive airway pressure (nCPAP) is the mainstay for non-invasive respiratory support for all respiratory distress neonates. Recent advances in Heated humidified high flow nasal cannula (HHHFNC) usage with enhanced humidity, and improved comfort factors have led to its widespread use, at times replacing nCPAP in many neonatal settings. The present study was to assess the efficacy and safety of HHHFNC compared with nCPAP for non-invasive respiratory support in post-extubation period. Methods: A hospital based randomized controlled trial was conducted in neonatal intensive care unit (NICU) of S. Nijalingappa Medical College and HSK Hospital, Bagalkot from January 2019 to June 2020. 140 post-extubated neonates were enrolled for the study after obtaining informed consent from parents, and those who were directly extubated to no support and with major congenital anomalies were excluded from the study. Randomization was done by computer generated random number allocation method. Results: Of the140 babies, 60% were males and 40% were females. Out of 84 male neonates, 47 (67.1%) were on nCPAP and 37 (32.9%) on HHHFNC and out of 56 female neonates 23 (32.9%) were on nCPAP and 33 (47.1%) on HFNC. In this study, 4 babies on nCPAP required re-intubation within 72 hours. 5 babies on HHHFNC, 3 babies required re-intubation within 72 hours and 2 babies within 5 days. The incidence of nasal trauma, hospital stay and duration of NIV support were less in HHHFNC group as compared to nCPAP group. Conclusions: HHHFNC therapy is as effective as nCPAP therapy for the facilitation of extubation in neonates.

The development and implementation of an evidence-based risk reduction algorithm for post-extubation dysphagia in intensive care

Intubation and mechanical ventilation are often required to support critically ill patients. These are life-sustaining measures and when they are no longer necessary, patients need to be carefully transitioned back to breathing, eating, and talking on their own. Post-extubation dysphagia is defined as swallowing difficulty following extubation. This condition can affect up to 87% of critically ill patients and can cause serious health complications such as aspiration pneumonia, which could require re-intubation, prolonged intensive care stays and increased in-hospital mortality. Currently, many extubated patients are trialed with oral intake without dysphagia screening or kept with nothing by mouth pending speech language pathology evaluation. This is not only a source of discomfort and distress for patients, families, and staff but can lead to malnutrition and dehydration, and puts patients at risk for aspiration. Systematically screening extubated patients for dysphagia is an opportunity to improve practice by enabling nurses to advocate for the safe and timely resumption of oral intake. A novel, evidence-based algorithm, called SAPE (Swallowing Algorithm Post-Extubation) was developed by an interdisciplinary critical care team to assist nurses to identify risk factors for post extubation dysphagia and help make evidence-informed decisions regarding referral to speech-language pathology and initiation of per os intake in the absence of a water swallow test. SAPE was implemented in four tertiary-level medical and/or surgical intensive care units. Process and outcome measures of a quality improvement initiative are discussed, and future directions proposed.

Comparison of intravenous lignocaine versus combination of lignocaine with diltiazem on attenuation of haemodynamic responses to tracheal extubation in patients undergoing abdominal surgeries under general anaesthesia: A randomized double blind interventi

Background: Tracheal intubation is frequently associated with cardiovascular stress response characterized by hypertension, tachycardia and increased serum concentration of catecholamines and similar phenomenon is also seen during extubation. During Endotracheal extubation increase in sympathoadrenergic activity is caused by epipharyngeal and laryngopharyngeal stimulation. Objective: The aim and objectives of this study are to compare the effect of combination of intravenous (i.v.) diltiazem 0.1 mg/kg and i.v lignocaine 1.0 mg/kg vs intravenous lignocaine alone to attenuate haemodynamic extubation responses and airway reflexes during extubation. Material and method: This study was undertaken with 72 patients belonging to the age group 20–60 years with physical status ASA Classes I and II of either sex. Group A received injection diltiazem 0.1 mg/kg and lignocaine 1 mg/kg. Group B received injection lignocaine 1 mg/kg with normal saline. In this study, the drug dosage was fixed based on the previous studies. Result: The baseline values of heart rate,systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial pressure (MAP) were statistically comparable between the two groups. The heart rate, SBP, DBP, and MAP was significantly high in group A (lignocaine) as compared to group B (diltiazem with lignocaine) at extubation and till 1 min, 3 min, 5 min, and 10 min post extubation (pvalue &lt; 0.05). Conclusion: Combined diltiazem and lignocaine provides more effective prophylaxis than lignocaine alone for attenuating the cardiovascular responses to tracheal extubation

In this Issue of CCR

Point of View: A four-step model to aid teaching, clinical assessment and communication of circulatory disorders amongst junior clinicians Editorial: Midodrine – why don't you just work better? Review: Midodrine Use in Critically Ill Patients – A Narrative Review Original Articles: Study protocol and statistical analysis plan for the 20% Human Albumin Solution Fluid Bolus Administration Therapy in Patients after Cardiac Surgery-II (HAS FLAIR-II) trial Early sedation in traumatic brain injury: a multicentre international observational study The association between vital signs abnormalities during post-anaesthesia care unit stay and deterioration in the general ward following major abdominal cancer surgery assessed by continuous wireless monitoring Mortality associated with Acute Respiratory Distress Syndrome 2009-2019: A systematic review and meta-analysis The prevalence of post extubation dysphagia in critically ill adults: An Australian data linkage study ANTIPORT: adaptation of a transfusion prediction score to an Australian cardiac surgery population