Post Extubation Research Articles

Focused airway ultrasound: an armamentarium in future airway management

Point-of-care ultrasound (POCUS) has gained the upper hand for being simple, non-invasive and portable. Traditional beliefs that ultrasound is futile in the imaging of air-filled structures has been refuted. Upper airway ultrasound is applicable to patients with distorted anatomy, not easily discernable by traditional methods, besides serving as a useful adjunct peri-intubation; as a pre-intubation screening tool for difficult laryngoscopy, selection of endotracheal tube (ETT) size and confirmation of ETT placement and depth, and to detect laryngeal mask airway (LMA) malrotation. Airway ultrasound also assists in procedural guidance for percutaneous cricothyroidotomy, percutaneous dilatational tracheostomy (PDT) and airway nerve blocks by improving success rate with fewer attempts and safety. In the critical care unit, sonographic parameters of the airway provide means to predict post extubation stridor hence successful extubation, in addition to identifying upper airway pathologies. The feasibility of focused airway ultrasound also lies in its shallow learning curve and the relative ease of mastering the skill with appropriate training. The integration of upper airway ultrasound into POCUS examination may be a prelude to a bigger picture in future airway management. Increasing awareness of the practicality of this tool, availability in critical areas and improving technological advancements will encourage more usage resulting in its incorporation into routine clinical practice.

Cardiorespiratory behavior of preterm infants receiving continuous positive airway pressure and high flow nasal cannula post extubation: randomized crossover study.

BackgroundNasal continuous positive airway pressure (NCPAP) and high flow nasal cannula (HFNC) are modes of non-invasive respiratory support commonly used after extubation in extremely preterm infants. However, the cardiorespiratory physiology of these infants on each mode is unknown.MethodsProspective, randomized crossover study in infants with birth weight ≤1250 g undergoing their first extubation attempt. NCPAP and HFNC were applied randomly for 45 min each, while ribcage and abdominal movements, electrocardiogram, oxygen saturation, and fraction of inspired oxygen (FiO2) were recorded. Respiratory signals were analyzed using an automated method, and differences between NCPAP and HFNC features and changes in FiO2 were analyzed.ResultsA total of 30 infants with median [interquartile range] gestational age of 27 weeks [25.7, 27.9] and birth weight of 930 g [780, 1090] were studied. Infants were extubated at 5 days [2, 13] of life with 973 g [880, 1170] and three failed (10%). No differences in cardiorespiratory behavior were noted, except for longer respiratory pauses (9.2 s [5.0, 11.5] vs. 7.3 s [4.6, 9.3]; p = 0.04) and higher FiO2 levels (p = 0.02) during HFNC compared to NCPAP.ConclusionsIn extremely preterm infants studied shortly after extubation, the use of HFNC was associated with longer respiratory pauses and higher FiO2 requirements.

Status quo and influencing factors of thirst in patients receiving cardiopulmonary bypass

Objective To explore the status quo of thirst in patients receiving cardiopulmonary bypass (CPB) during fasting and water deprivation after extubation and to analyze its influencing factors. Methods Totally 120 patients undergoing CPB in a Class Ⅲ Grade A hospital in Nanjing from December 2017 to May 2018 were selected in this prospective study. The general information questionnaire was used to collect the data, and the patients' thirst score and unstimulated salivary flow rate (USF) were measured. SPSS 22.0 was used to analyze the factors affecting postoperative thirst in the patients. Results The incidence rate of thirst in the CPB patients 6 h post extubation was 100%, and their thirst score was (6.20±1.90) ; and the patients' thirst intensified over time. Univariate analysis showed that the patients' postoperative thirst was positively correlated with postoperative body temperature, respiratory rate, serum sodium concentration and urinary volume (r=0.172, 0.105, 0.209, 0.258; P<0.05) , and negatively correlated with postoperative fluid balance volume and USF (r=-0.222, -0.565; P<0.05) . Multivariate analysis showed that USF and fluid balance volume were the main influencing factors to thirst in the patients (P<0.05) . Conclusions The incidence rate of thirst in CPB patients is relatively high and it is associated with multiple factors. Nurses should pay attention to the patients' thirst and take targeted measures to ameliorate their thirst to improve their comfort in nursing practice. Key words: Cardiac surgery; Cardiopulmonary bypass; Thirst; Unstimulated salivary flow rate; Fluid balance volume

A randomized prospective study comparing characteristics of Desflurane with Isoflurane under low flow anaesthesia using equilibration time

Introduction: Equilibration point of an inhalational agent is the transition point when ratio of expired (Fe) to inspired (Fi) concentration of inhalational anaesthetic agent (Fe/Fi) reaches 0.8 or when uptake of volatile agent reaches 80%. It helps in reducing the duration of initial high gas flows before switching over to low flows. Aim: To compare Desflurane with Isoflurane for equilibration time, intraoperative hemodynamic parameters and post extubation recovery parameters. Materials and Methods: Depending on the volatile anesthetic agent being used patients were randomly allocated into two groups. Group I (n =25) received Desflurane and Group II (n=25) received Isoflurane as inhalational anesthetic agent. In all patients low flow anaesthesia was given after achieving equilibration time and that time was noted. Other parameters measured were intraoperative heart rate, mean blood pressure, mean EtN2O, mean EtFe (End tidal volatile anesthetic agent concentration), recovery parameters (recovery time, recovery score and vitals) and any complications if any. Statistics: Analysis was performed on SPSS (Statistical package for social sciences) version 17.0 Statistical Analysis Software. Result: The equilibration point for group I was achieved in 2.18 ± 0.84 min and for group II was achieved in 10.08 ± 2.36 min and this difference was statistically significant. The intraoperative heart rate and MAP did not differ significantly (p>0.05) between the two groups at all time periods. On comparing, post extubation vitals i.e. HR (8.1%) and recovery time (69.9%) they were found significantly (p Conclusion: Desflurane use results in shorter equilibrium time and earlier reduction of FGF with early and better recovery than Isoflurane. Keywords: Desflurane, Isoflurane, Low flow Anaesthesia, Equilibration time.

Magnetic Resonance Imaging Procedure for Ventilated Intensive Care Patient in the International Islamic University Malaysia Medical Centre: Issues and Challenges

Managing a ventilated patient in the Intensive Care Unit (ICU) for Magnetic Resonance Imaging (MRI) procedure requires precise planning. Vigilant anesthetist with adequate MRI compatible monitoring of a critically ill patient and in preparation of any crisis event during transport to MRI suite, during MRI and return journey to ICU is essential. Problems in transporting ICU patient are usually equipment related, deterioration in gas exchange and increased rate of ventilator associated pneumonia. Preparation includes clinical reassessment for swift and systematic transport, airway management, optimum sedation and record keeping close to the patient. This is a case report of a 64 year-old gentleman who presented to International Islamic University Malaysia Medical Centre with right sided headache for one week associated with high intracranial pressure symptoms. His initial Glasgow Coma Scale (GCS) was 15/15 and Computed Tomography (CT) scan of his brain showed bilateral acute-on-chronic subdural haemorrhage, uncal herniation and minimal midline shift. His GCS dropped to 6/15 (E1V1M4) in the ward and proceeded with right craniectomy, evacuation of clot and duraplasty. Post operatively, his GCS improved to 15/15 in ICU and was extubated. On Day 2 post extubation, his GCS dropped to 6/15 (E1V1M4) and intubation was performed. Repeat CT Brain in ICU showed no evidence of new bleeding or mass effect. MRI was performed and it showed acute infarctions at right pons and right occipital region. Tracheostomy was done and the patient was sent to the general ward on fixed performance mask.

Comparison between bupivacaine\u2013dexmedetomidine mixture and bupivacaine\u2013magnesium mixture when used for wound infiltration before skin incision in surgeries for hernia repair regarding their intraoperative and postoperative analgesic effects

BackgroundWound infiltration with local anesthetics was developed to provide intraoperative and postoperative analgesia and to reduce opioid consumption and its side effects.MethodsThis is a prospective randomized, double-blinded study. A total of 45 patients, American Society of Anesthesiologists physical status I–II, aged from 18 to 60 years scheduled for open abdominal surgeries were randomly assigned to one of the following groups to receive wound infiltration 2 min prior to skin incision: group I: bupivacaine 0.25% alone (20 ml) (n = 15), group II: bupivacaine 0.25% + magnesium sulfate (1 g) (20 ml) (n = 15), and group III: bupivacaine 0.25% + dexmedetomidine (70 μg) (20 ml) (n = 15). Induction and maintenance were done according to our hospital protocol. Heart rate (HR) and systolic blood pressure (SBP) at baseline and every 15 min till the end of surgery, the need for supplemental fentanyl, and the concentration of inhalational anesthetic were assessed. Postoperatively, Ramsay sedation scale was assessed 10 min post extubation and every 30 min for 6 h; visual analog scale was assessed at rest and every 30 min for 6 h postoperatively; time to the first request of analgesia and the cumulative analgesic consumption were recorded; HR and SBP were recorded for 6 h.ResultsThe concentration of inhalational isoflurane and the need for supplemental fentanyl intraoperatively were significantly lower in group III than in groups I and II. Postoperatively in group III, HR and SBP and visual analog scale scores were significantly lower compared with groups I and II. Ramsay sedation score was significantly higher in group III up to 2 h after recovery in comparison to groups I and II. Group III showed longer time for the first request of analgesia and a lower need for postoperative opioids in comparison to groups I and II.ConclusionsWound infiltration with dexmedetomidine–bupivacaine mixture before skin incision decreases the anesthetic requirements, provides prolonged analgesia, and decreases the need for rescue analgesics in patients undergoing open abdominal surgeries.

EFFICACY OF OVERNIGHT INTUBATION IN ORAL ONCOLOGICAL SURGERIES A RETROSPECTIVE STUDY

In the post-operative period of maxillofacial oncological operations, tracheostomy is the most commonly used method for securing the airway. These untoward complications made practitioners choose alternative modalities like submental intubation, but literature support on alternatives to tracheostomy for oral oncologic cases is limited. The aim of this observational study is to ascertain whether the use of overnight intubation is a safer and cost-effective practice and if it can be considered an alternative to tracheostomy. Material and methods. 30 patients, 23 males and 7 females in the age group of 34–80 years who underwent treatment for head and neck cancer with major intraoral resection and a unilateral or bilateral neck dissection were included in the study. The following variables were recorded: age, sex, site of tumour, type of neck dissection, use of mandibulotomy/ mandibulectomy, type of reconstruction, duration of stay in ICU, mean hospital stay and Mallampati classification. Postoperative complications, associated with the airway, if any, were recorded simultaneously. Results. None of the 30 patients required re-intubation nor did they develop any respiratory distress post extubation. Conclusion. The purpose of this study is to raise the conscience of every surgeon to cogitate his/her choice of procedure for his/her patients and advocate the use of overnight intubation, as it is a virtuous alternative to tracheostomy.

Implementing a thoracic enhanced recovery with ambulation after surgery program: key aspects and challenges.

Enhanced recovery after surgery (ERAS) protocols aim to improve operative outcomes by focusing on perioperative care, including early mobilization, limitation of narcotics, and maintenance of fluid balance. We implemented a T-ERAAS (Thoracic-Early Recovery with Ambulation After Surgery) protocol which focused on early ambulation, with the rationale that a patient's mobility may be a reproducible and measurable metric for their overall status-pain control, respiratory function, cardiac function, and patient satisfaction. We set a benchmark distance of 250 feet for our early ambulation goal and redefined "early" as within the first hour post extubation. We describe some of the major aspects to our program as well as some of the challenges and successes during our 8-year experience following the implementation of this program.

HIGH FLOW NASAL CANNULA OXYGEN USE IN OCTOGENARIAN AND NONAGENARIAN PATIENTS: A RETROSPECTIVE ANALYSIS AMONG MICU PATIENTS

SESSION TITLE: Critical Respiratory Care SESSION TYPE: Original Investigations PRESENTED ON: 10/08/2018 07:30 AM - 08:30 AM PURPOSE: High flow nasal cannula (HFNC) oxygen(O2) therapy delivers heated and humidified gas with flow rates up to 60 L/min. It also provides a small PEEP effect, reduces anatomical dead space, and provides a constant fraction of inspired oxygen(FiO2). It has been extensively studied in pediatric population and has lately gained popularity in adult patient population although evidence for use in critically ill adults still remains poor. Additionally, to our knowledge, evidence of its use in patients 80 years of age and above has not been assessed. We attempt to study the indications and effects of HFNC use in patients 80 years of age and above in the medical intensive care unit (MICU) of a tertiary care hospital. METHODS: 40 patients 80 years of age and above who required HFNC O2 in the MICU for more than 12 hours between 01/01/2016 and 08/01/2017 were identified. Retrospective chart review was performed and data related to HFNC O2 use was obtained. Data included age, diagnosis, indication for HFNC, duration of HFNC use, initial FiO2 and flow rate, modality of oxygenation used before and after HFNC, disposition and code status. The data was charted on a spreadsheet and analyzed by calculating percentage associated with various variables. RESULTS: Mean age of the patients was 89.025 years. Mean duration of HFNC O2 use was 5 days. Mean initial FiO2 was 45.625%. Mean initial flow rate was 42.75 L/min. Most common indication for HFNC use was hypoxemia post extubation. Most common diagnosis was sepsis due to pneumonia. 52.5%(21/40) patients were transitioned to HFNC O2 post extubation. 47.5%(19/40) were transitioned from nasal cannula(NC) or bilevel positive airway pressure ventilation (BPAP). 15%(6/40) had to be intubated and mechanically ventilated after HFNC O2 use whereas 85%(34/40) were downscaled to regular NC O2. Of the 6 intubations, 3 were re-intubations. 12.5%(5/40) patients expired whereas 87.5%(35/40) patients were discharged from the hospital. Code status for 4 patients was changed to comfort care with do not intubate(DNI) after extubation to HFNC, 2/4 were discharged and the other 2 expired. CONCLUSIONS: This study revealed a positive outcome with respect to use of HFNC O2 in patients 80 years of age and above. Majority (87.5%) of the patients were discharged from the hospital. Intubation(15%) and re-intubation rates were low after use of HFNC O2. Patients who opted for comfort care (DNR/DNI) but could not maintain optimum oxyhemoglobin saturation with NC O2 and found BPAP uncomfortable, benefitted from HFNC with respect to comfort and compliance per chart review. CLINICAL IMPLICATIONS: Elderly patients might benefit from HFNC O2 especially after liberation from mechanical ventilation. Elderly patients with hypoxemic respiratory failure who opt for comfort care but cannot maintain optimum oxyhemoglobin saturation with NC O2 and find BPAP uncomfortable could also benefit from HFNC O2 use. DISCLOSURES: No relevant relationships by Prarthna Chandar, source=Web Response No relevant relationships by Yizhak Kupfer, source=Web Response No relevant relationships by Anand Rai, source=Web Response No relevant relationships by Arjun Saradna, source=Web Response No relevant relationships by Ben Shamian, source=Web Response No relevant relationships by Shyam Shankar, source=Web Response

BISOPROLOL VERSUS ENALAPRIL ON HEMODYNAMICS UNDER GENERAL ANESTHESIA

Background: Systemic arterial hypertension is a common disease in patients undergoing surgery. Bisoprolol and Enalapril are anti-hypertensive drugs that affect the perioperative hemodynamics (blood pressure and pulse rate) in different manners. Objectives: The aim of the present study was to compare the effect of general anesthesia on the hemodynamics of hypertensive patients undergoing elective surgery and controlled on Enalapril versus Bisoprolol as a primary outcome, and criteria of discharge from recovery room, postoperative pain assessment, and adverse effects as a secondary outcome. Patients and Methods: In this comparative clinical randomized study, thirty hypertensive patients of both sexes, aged from 40 to 60 years, according to the American Society of Anesthiologists (ASA) physical status class II, undergoing elective surgery under general anesthesia of less than two hours duration (Abdominal and upper limb surgery), and controlled on antihypertensive medication regularly administered for at least six months duration (Enalapril versus Bisoprolol) were enrolled in the study. The study started from January, 2016 to February, 2018. Patients were randomly allocated into equal two groups, group (A) hypertensive patients controlled on Enalapril 10 mg and group (B) hypertensive patients controlled on Bisoprolol 5 mg. To evaluate intraoperative arterial blood pressure:( systolic arterial blood pressure, diastolic arterial blood pressure and mean arterial blood pressure) and Heart rate as follow: preoperative basal arterial blood pressure and pulse rate reading (0), immediately after induction, (1), every 5 minutes for 20 minutes and every 15 minutes till the end of the operation. Results: Hypertensive patients controlled on Enalapril (group E) had more statistically significant decrease in blood pressure (systolic-diastolic-mean) after induction of general anesthesia and more hypotensive episodes in the first 30 minutes after induction than patients treated with Bisoprolol 5 mg (group B) while, group A had more increase in blood pressure post-intubation, post-extubation and on exposure to noxious stimuli. When comparing heart rate changes between both studied groups the results showed that hypertensive patients controlled on Bisoprolol (group B) had more statistically significant heart rate control (decrease) all over the operation especially at periods of intraoperative stress as post-intubation, 1st 30 minutes of operation and post extubation than hypertensive patients controlled on Enalapril (group A). The remaining intraoperative periods of the operation are nearly comparable between both studied groups (A and B) as regard blood pressure and heart rate. Patients of both groups (A and B) had no statistically significant difference as regard criteria of discharge from recovery room, postoperative pain assessment and adverse effects. Conclusion: Bisoprolol as a beta blocking antihypertensive drug was associated with effective control of pulse rate and blood pressure and attenuation of pressor response to all stressful events all over the operation especially after laryngoscopy, intubation, extubation and the first 30 minutes of operation ensuring more hemodynamic stability under general anesthesia when compared to hypertensive patients controlled on Enalapril. Recommendation: Beta blockers (Bisoprolol) are recommended before surgery even for those who do not use them when exposed to anesthesia unless there are contraindications.

AN UNUSUAL PRESENTATION OF TRACHEAL STENOSIS FOLLOWING 22 HOURS OF ENDOTRACHEAL INTUBATION IN A COCAINE ABUSER

SESSION TITLE: Critical Care 5 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Tracheal stenosis following intubation is a relatively rare but a serious problem. Thermal airway injury from cocaine inhalation resulting in tracheal stenosis has been rarely reported. We present an unusual case of tracheal stenosis in a cocaine abuser which developed following twenty two hours of endotracheal intubation. CASE PRESENTATION: An 18 year old female with history of depression was brought to the hospital due to acute encephalopathy secondary to suspected Benzodiazepine (BDZ) overdose. She was found unresponsive and was intubated for airway protection. This was her first intubation. She was also getting treatment for aspiration pneumonia. Urine toxicology tested positive for BDZ and cocaine. She was extubated the next day after her mentation improved. After 4 days, she went into respiratory distress associated with significant stridor. The possibility of bronchial asthma or allergic reaction to medication was sought. Emergency intubation was done to secure the airway but there was no apparent tongue swelling, vocal cord edema or paralysis. Because of persistent stridor despite of aggressive bronchodilator treatment, flexible bronchoscopy was done. It showed endotracheal circumferential growth (4-5 cm above carina) which narrowed 50% of the lumen. Biopsy from the growth was negative for viral, fungal and bacterial etiology. Tissue pathology showed fragments of fibrin, acute inflammatory changes suggestive of tracheal stenosis. Patient was transferred to higher level of care. She underwent cryotherapy and dilation of stenosis and was successfully extubated. DISCUSSION: Recent endotracheal intubation and history of cocaine inhalation are important risk factors for tracheal stenosis in our patient. It seems unlikely that trauma at the time of intubation induced tracheal stenosis. Another important risk factor is cocaine inhalation, which can cause thermal injury, mucosal damage to trachea and consequent tracheal stenosis. Thermal airway injury secondary to cocaine smoking may result from either (a) inhalation injury from chemical byproducts transported in the smoke, or (b) intratracheal combustion of highly inflammable solvents used in the production process. We think that cocaine inhalation initiated injury to mucosa and recent intubation aggravated development of tracheal stenosis. CONCLUSIONS: Tracheal stenosis should be kept in a differential diagnosis in patient with post extubation stridor who has history of cocaine abuse despite of short duration of intubation. Treatment options include cryotherapy, balloon tracheoplasty, laser therapy and surgery. Reference #1: Carlos S. Restrepo, MD, Jorge A. Carrillo, MD, Santiago Martínez, MD, Paulina Ojeda, MD, Aura L. Rivera, MD, and Ami Hatta, MD Pulmonary Complications from Cocaine and Cocaine-based Substances: Imaging Manifestations Reference #2: Post intubation tracheal stenosis, Sajal De and Sarmishtha De Reference #3: Taylor, RF and Bernard, GR. Airway complications from freebasing cocaine. Chest. 1989; 95: 476–477 DISCLOSURES: No relevant relationships by Muhammad Habib, source=Web Response No relevant relationships by Mohammad Islam, source=Web Response No relevant relationships by Manish Patel, source=Web Response No relevant relationships by Thien Vo, source=Web Response

Role of Pulmonary Sonography in Evaluation of Artificially Ventilated Neonates

AbstractBackground: Several neonatal chest conditions require Invasive mechanical ventilation, which is lifesaving for the critically ill neonates. Limiting the duration of airway intuba-tion and mechanical ventilator support is crucial. Weaning from mechanical ventilation induces significant changes in lung aeration which can be easily detected by lung sonography.Aim of the Work: Is to identify the role of pulmonary sonography in evaluation of the artificially ventilated neonates.Patients and Methods: The study included 40 neonates suffering from peripheral diseases requiring mechanical ventilation. All patients had chest ultrasound studies after clinical assessment. Chest ultrasound was performed during the different modes of mechanical ventilation including Assisted Controlled Ventilation (AC), Synchronized Intermit-tent Mechanical Ventilation (SIMV) and before extubation, follow-up the patients for 48 hours postextubation to assess if its failure occurred. Lung ultrasound was done using a standardized evaluation of lung aeration, i.e. Lung Ultrasound Score (LUS). Other traditional investigations including blood gases and chest X-ray were performed as well.Results: LUS was significantly higher in the 10 patients with post extubation failure. A cut off value of LUS of >13 was highly sensitive and specific for failure of switching from AC to SIMV mode and >6 prior to extubation was indicative of post extubation failure.Conclusion: Chest ultrasound provides a rapid, non inva-sive, objective and reliable tool for guiding the mechanical ventilation weaning process in neonates through the LUS with high confidence even when compared to other traditional indices as blood gases and respiratory mechanics. A cut off value of LUS of >13 was highly sensitive and specific for failure of switching from AC to SIMV mode and >6 prior to extubation was indicative of post extubation failure.

Abstract P-615: POST-EXTUBATION USE OF NON-INVASIVE VENTILATION IN CHILDREN- A RANDOMIZED CONTROLLED TRIAL

Aims & Objectives: The present investigation was to study the effect of elective use NIV on reintubation, length of stay (LOS) in PICU and hospital and mortality after extubation. Methods Over 12 months all patients on invasive mechanical ventilation (IMV) for >48 hrs were enrolled after successful weaning. Patients were randomized immediately before extubation to receive NIV or O2 therapy. All cases were monitored for increased work of breathing and blood gases were obtained at 2, 6 and 24 hours post extubation. Results 97 patients were randomized, 46 received NIV (BIPAP mode, Drager Evita) and 51 received O2 by simple mask. SpO2 was maintained>92%. The primary disease, PRISM scores at 12 (8.4 ± 7.2 vs 8.9 ± 6.9, p value 0.6) and 24 (9.3 ± 8 vs 8.8 ± 7, p value 0.9) hrs and duration of MV prior to extubation (4.5 ± 3.7 vs 4.3 ± 3.4 days, p value 0.7) were not significantly different in two study groups. Out of 97 patients, 19 (19.7%) patients were re-intubated within 48 hours of extubation, 13(25%) patients belonged to O2 group and 6(13%) were in NIV group (p value- 0.12). The post extubation durations of PICU (4.18 ± 2.9 vs 3.67 ± 2.5 days, p value 0.4) and hospital stay (18 ± 9 vs 17.2 ± 12.3 days, p value 0.3) were not significantly different in two study groups. There were two deaths, one in each study group. Conclusions NIV did not show benefits over oxygen therapy in immediate post extubation state in children.

An Exploratory Reanalysis of the Randomized Trial on Efficacy of Corticosteroids as Rescue Therapy for the Late Phase of Acute Respiratory Distress Syndrome.

In the Acute Respiratory Distress Syndrome Network randomized controlled trial, methylprednisolone treatment was associated with increased return to mechanical ventilation with partial loss of early improvements. We hypothesize a causal relationship between protocol-driven rapid discontinuation of methylprednisolone post extubation and return to mechanical ventilation. To explore this possibility, we investigated the timing that events occurred in each treatment arm during active treatment intervention (efficacy) and after stopping therapy. Retrospective intention-to-treat analysis of multicenter randomized controlled trial. Patients were randomized to methylprednisolone (2 mg/kg/d) or placebo (89 vs 91). The target sample size was reduced post hoc and provided 80% power for an optimistic 50% mortality reduction. Findings are reported as methylprednisolone versus placebo. By day 28, fewer patients died before achieving extubation (15.7% vs 25.3% and risk ratio, 0.62; 95% CI, 0.34-1.13), more achieved successful extubation (71.9% vs 49.5% and risk ratio, 1.45; CI, 1.14-1.85), time to successful extubation was shorter (hazard ratio, 2.05; CI, 1.42-2.96), and more were discharged alive from the ICU (65.2% vs 48.3%; risk ratio, 1.35; CI, 1.04-1.75). After treatment discontinuation, more methylprednisolone-treated patients returned to mechanical ventilation (26.6% vs 6.7%; risk ratio, 3.98; CI, 1.24-12.79)-consistent with reconstituted systemic inflammation in the presence of adrenal suppression. Participants returning to mechanical ventilation without reinstitution of methylprednisolone had increased risk of ventilator dependence and mortality. Despite loss of early benefits, methylprednisolone was associated with sizable and significant improvements in all secondary outcomes and reduction in serious complications (shock and severe infections). During active intervention, methylprednisolone was safe and effective in achieving disease resolution. Our findings support rapid glucocorticoid discontinuation post extubation as likely cause of disease relapse. Gradual tapering might be necessary to preserve the significant improvements achieved during methylprednisolone administration.

Abstract P-600: PREDICTORS OF SUCCESS OF HIGH FLOW NASAL CANNULA (HFNC) THERAPY IN CHILDREN PRESENTING WITH RESPIRATORY DISTRESS

Aims & Objectives: To identify the clinical and laboratory variables that predict HFNC success in children presenting to PICU with respiratory distress of varied etiology. Methods Prospective observational study. from May 2016 to April 2017.All children between 1 month and 5 years presenting with moderate/severe respiratory distress of varied etiology were included and treated with HFNC. Children with general contraindictions for NIV were excluded.Clinical and laboratory variables were monitored.The participants were categorised as responders and non responders. Results 114 children between 1month and 5 years participated in our study. 59 children had pneumonia, 14 WALRI, 13 bronchiolitis, 12 post extubation respiratory distress, 8 dengue fever with respiratory distress, 4 had upper air way obstruction,7 had distress due to other causes .99 were responders and 15 were non responders.Baseline characteristics of the two groups were comparable. Decreas in heart rate and respiratory rate at the end of 1 hour and 6 hours strongly correlated with response to therapy (heart rate p=0.017) (Respiratory rate p=0.001).Respiratory distress due to pneumonia(N=13) as underlying etiology was another predictor of failure of HFNC(p=0.005).Nonresponders had lower PaO2 compared to responders at the initiation and did not show improvement in the mean PaO2 by the end of 1 hour.No differences were noted between these two groups for pH,PCO2,SpO2 at 0,1 and 6 hours of HFNC therapy. Conclusions Improving HR,RR and Pao2 are the predictors of response to HFNC.Proper patient selection and close monitoring of the vital signs and distress while on therapy are the key to success.

Abstract PD-051: ROLE OF STEROIDS IN PREVENTION OF POST EXTUBATION STRIDOR

Aims & Objectives: Primary-To study the effect of prophylactic steroids on occurance of post extubation stridor (PES) in ventilated children. Secondary-To compare the severity of PES in ventilated children receiving prophylactic steroids or placebo. Methods Setting- PICU of Lok Nayak Hospital, Delhi in 2014 - 2015 Patients-Children aged 2 months to 12 years, ventilated for at least 48 hours and planned for extubation in next 6–12 hours.Children ventilated through tracheostomy, receiving steroids within 7 days before extubation, having unplanned self extubation, and previously failed extubation were excluded. Intervention-Group A received dexamethasone 0.15 mg/kg 6 hourly for 6 doses at extubation while group B received placebo (normal saline). Stridor scoring was done using Westley stridor score. Results Group A comprised of 42 children while group B had 38 children. PES occurred in total 48.7% children with 42.8% in dexamethasone group and 55.2% in placebo group (p=0.26). The median age of children with PES was 6 months and without PES was 18 months (p=0.05). Stridor score >4 was present in 28.5% of dexamethasone group vs 47.3% of placebo group (p=0.08). Median stridor scores were same in both groups (score 2 in each group). 38% patients in group A compared to 47.3% in Group B required adrenaline nebulization (p=0.40). There was no difference in the incidence of PES with the duration of ventilation (p=0.38). There were no significant adverse effects of steroids. Conclusions We didn’t find significant difference in the incidence of PES and severity of stridor in ventilated patients receiving dexamethasone or placebo.

Oral flurbiprofen spray for postoperative sore throat and hoarseness: a prospective, randomized, double-blind, placebo-controlled study.

Sore throat and hoarseness are common complications after surgery. Flurbiprofen spray has been successfully used for treatment of oral inflammations, but its effects on postoperative sore throat and hoarseness are unknown. We conducted this study to evaluate the effectiveness of flurbiprofen spray on postoperative sore throat and hoarseness, by comparing it with benzydamine hydrochloride spray and placebo. One hundred fifty patients who were scheduled to undergo elective ear surgery were enrolled. Patients were randomized to three groups of 50 patients each; flurbiprofen oral spray, benzydamine hydrochloride oral spray and placebo spray groups. Patients received sprays just before intubation, and the incidence and severity of postoperative sore throat and hoarseness were evaluated by a blinded investigator at 0, 1, 6 and 24-hour post extubation. Patients were also questioned for possible side effects at all time points. The sore throat severity scores were significantly lower in treatment groups when compared to placebo group at all time points (P=0.003/108). Similarly, the incidence of sore throat was significantly lower in both of the treatment groups (P=0.007/104). The incidence of hoarseness and hoarseness scores were significantly lower in treatment groups when compared to placebo group (P=0.006/105 and P=0.005/104, respectively). While none of the patients complained of any adverse effects in flurbiprofen group, only two patients in benzydamine hydrochloride group experienced numbness. Both oral flurbiprofen and benzydamine hydrochloride sprays were found to be more effective than placebo in decreasing the incidence and severity of postoperative sore throat and hoarseness, with no adverse effects.

Comparison of intracuff dexamethasone, lignocaine and normal saline on post extubation response - A prospective study

Comparison of intracuff dexamethasone, lignocaine and normal saline on post extubation response - A prospective study

Predictors of success of high flow nasal cannula (HFNC) therapy in children with respiratory distress in pediatric intensive care unit

Objective: To identify clinical and laboratory variables that predict success of High Flow Nasal Canula (HFNC) therapy in children presenting to Pediatric Intensive Care Unit (PICU) with respiratory distress of varied etiology. Methods: This was a prospective observational study conducted in PICU of St John’s medical college, Bengaluru over a period of one year from May 2016 to April 2017. All children 1 month to 2 years presenting with moderate/severe respiratory distress of varied etiology were included for the study. The standard exclusion criteria of noninvasive ventilation were used. They were started on HFNC and clinical and laboratory variables were monitored at regular intervals. The participants were categorized as responders and non-responders (defined by need for escalation of respiratory support to invasive ventilation while on HFNC therapy). Results: One hundred fourteen childrens participated in the study, 99 of them responded and 15 were non-responders. Fifty nine had pneumonia(51.7%), 14 had WALRI (12.2%),13 had bronchiolitis (11.4%), 12 had post extubation respiratory distress(10.5%), 8 had fluid overload with respiratory distress(7%), 4 had upper air way obstruction (1.7% ), 4 had respiratory distress due to other causes. No differences were noted between these two groups for age, sex, weight, comorbid conditions. Decreasing heart rate, decrease in the mean respiratory rate and improving distress score at the end of 1 hour and 6 hours strongly correlated with response to therapy. The PRISM III scores were significantly higher (p =0.004) in non-responders. Respiratory distress due to pneumonia as underlying etiology was another predictor of failure of HFNC (p=0.009). No differences were noted in arterial blood gas parameters between these two groups, however paO2 among responders was significantly higher compared to non-responders at the initiation of HFNC and at 1 hour. Conclusion: Improving trends of clinical vital signs like heart rate, respiratory rate and RDS while on HFNC therapy are the key to success. Majority of children who failed HFNC had pneumonia as the underlying etiology of respiratory distress.

Conservative Management of Synchronous Intrauterine Molar Pregnancy and Cervical Ectopic Pregnancy : A case Report

Background: Systemic arterial hypertension is a common disease in patients undergoing surgery. Bisoprolol and Enalapril are anti-hypertensive drugs that affect the perioperative hemodynamics (blood pressure and pulse rate) in different manners. Objectives: The aim of the present study was to compare the effect of general anesthesia on the hemodynamics of hypertensive patients undergoing elective surgery and controlled on Enalapril versus Bisoprolol as a primary outcome, and criteria of discharge from recovery room, postoperative pain assessment, and adverse effects as a secondary outcome. Patients and Methods: In this comparative clinical randomized study, thirty hypertensive patients of both sexes, aged from 40 to 60 years, according to the American Society of Anesthiologists (ASA) physical status class II, undergoing elective surgery under general anesthesia of less than two hours duration (Abdominal and upper limb surgery), and controlled on antihypertensive medication regularly administered for at least six months duration (Enalapril versus Bisoprolol) were enrolled in the study. The study started from January, 2016 to February, 2018. Patients were randomly allocated into equal two groups, group (A) hypertensive patients controlled on Enalapril 10 mg and group (B) hypertensive patients controlled on Bisoprolol 5 mg. To evaluate intraoperative arterial blood pressure:( systolic arterial blood pressure, diastolic arterial blood pressure and mean arterial blood pressure) and Heart rate as follow: preoperative basal arterial blood pressure and pulse rate reading (0), immediately after induction, (1), every 5 minutes for 20 minutes and every 15 minutes till the end of the operation. Results: Hypertensive patients controlled on Enalapril (group E) had more statistically significant decrease in blood pressure (systolic-diastolic-mean) after induction of general anesthesia and more hypotensive episodes in the first 30 minutes after induction than patients treated with Bisoprolol 5 mg (group B) while, group A had more increase in blood pressure post-intubation, post-extubation and on exposure to noxious stimuli. When comparing heart rate changes between both studied groups the results showed that hypertensive patients controlled on Bisoprolol (group B) had more statistically significant heart rate control (decrease) all over the operation especially at periods of intraoperative stress as post-intubation, 1st 30 minutes of operation and post extubation than hypertensive patients controlled on Enalapril (group A). The remaining intraoperative periods of the operation are nearly comparable between both studied groups (A and B) as regard blood pressure and heart rate. Patients of both groups (A and B) had no statistically significant difference as regard criteria of discharge from recovery room, postoperative pain assessment and adverse effects. Conclusion: Bisoprolol as a beta blocking antihypertensive drug was associated with effective control of pulse rate and blood pressure and attenuation of pressor response to all stressful events all over the operation especially after laryngoscopy, intubation, extubation and the first 30 minutes of operation ensuring more hemodynamic stability under general anesthesia when compared to hypertensive patients controlled on Enalapril. Recommendation: Beta blockers (Bisoprolol) are recommended before surgery even for those who do not use them when exposed to anesthesia unless there are contraindications.