Post Extubation Research Articles

Management of Post extubation stridor following Total thyroidectomy due to bilateral recurrent laryngeal nerve damage - a case report

Recurrent laryngeal nerve(RLN) damage during total thyroidectomy is rare and estimated to occur in upto 14% of cases. Damage to RLN may be unilateral or bilateral. Bilateral RLN injury results in dysfunction of both vocal cords ;which remain in midline during inspiration. After extubation ,biphasic stridor ,respiratory distress and aphonia occurs due to unopposed adduction of vocal cords and closure of glottic aperture necessitating immediate intervention and emergency intubation or tracheostomy. Deliberate intraoperative identification and preservation of the recurrent laryngeal nerve minimizes the risk of injury. Post operative visualization of vocal cord movements should also be performed as patients may be asymptomatic at first .Laryngeal electromyography EMG may be useful to distinguish vocal cord paralysis from injury to the cricoarytenoid joint secondary to intubation, and it may yield prognostic information. We report a case of post extubation stridor following total thyroidectomy probably due to accidental bilateral RLN damage and the management of the same after tracheal extubation

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BACKGROUND AND OBJECTIVES: Hemodynamic and cough response to extubation can result in raised heart rate, blood pressures and intracavitary pressures which could be detrimental in highrisk patients. The aim of our study was to estimate the difference in hemodynamic and cough response to orotracheal tube extubation with saline (control group), I.V lignocaine 0.5mg/kg and I.V lignocaine 1mg/kg and to evaluate the comparative efficacy between the groups. METHODS: In our clinical prospective descriptive double blind study 90 patients of either sex scheduled for elective surgical procedures requiring orotracheal intubation, who met inclusion criteria, were considered. They were randomly divided into three groups of 30 each, Group-1 (control-saline), group-2 (lignocaine 0.5mg/kg) and group-3 (lignocaine 1mg/kg). They were administered study drug 2 minutes prior to extubation, following a standard peri operative anesthetic course. Hemodynamic parameters like heart rate, systolic blood pressure, diastolic blood pressure and mean arterial pressure (HR, SBP, DBP and MAP) prior to administration of the study drug and at 1min, 3min, 5min and 10min post extubation were considered for statistical analysis. Post extubation cough graded as per Eshak’s grading (Grade 0, 1, 2 and 3). Data obtained were analyzed using Analysis of variance (ANOVA), Post-hoc Tukey test and Chi-square/Fisher Exact test. Results on continuous measurement were, presented on Mean±SD. Significance was assessed at 5% level of significance. RESULTS: In control group, there was significant rise in HR, SBP and MAP throughout the study period and the incidence of moderate and severs cough was 43.3% and 30% respectively. Diastolic blood pressure and mean arterial pressures attenuation with lignocaine 1mg/kg found to be superior (P<0.001). There was no significant difference in heart rate and systolic blood pressure attenuation between patients who received 0.5mg/kg lignocaine and 1mg/kg lignocaine at 1min (P - 0.101 and P - 0.938 respectively). Post extubation cough suppression was 100% in patients who received lignocaine 1mg/kg. CONCLUSION: Study concludes that lignocaine 1 mg/kg is superior to 0.5 mg/kg in attenuating the hemodynamic responses to tracheal extubation. For post extubation cough suppression (100%) lignocaine 1mg/kg is ideal.

Airway in Thyroid Surgery: To Foresee than to be Ignored

The slow growing nature of thyroid enlargement has made the airway symptoms rarely become the presenting complaints. On the other perspective, acute stridor following extubation after a thyroidectomy is not an uncommon phenomenon. It can ignite an emergency situation which necessitate urgent airway secure failing to do so may lead to fatal outcome. The sufficient re-establishment of the airway may be achieved either by a re-intubation or an emergency tracheostomy. However this condition may be avoided if the possible compromised airway post extubation is foreseen. This is particularly important because emergency procedures will increase morbidity and mortality.

Post anesthesia recovery rate evaluated by using White fast tracking scoring system

Introduction: Postponed recuperation from anesthesia can lead to different complications such as apnoea, aspiration of gastric content whit consequent development of aspiration pneumonia, laryngospasm, bradycardia, and hypoxia. Aim of this research was to determine infl uence of propofol, sevoflurane and isoflurane anesthesia on post anesthesia recovery rate.Methods: This was a prospective study; it included 90 patients hospitalized in period form October 2011 to may 2012 year, all patients included in the study underwent lumbar microdiscectomy surgery. Patients were randomly allocated to one of three groups: group 1: propofol maintained anesthesia, group 2: sevoflurane and group 3: isofl urane maintained anesthesia. Assessments of recovery rate were done 1, 5 and 10 minutes post extubation using White fast tracking scoring system.Results: Significant difference was observed only 1 minute after extubation (p=0,025) finding recovery rate to be superior in propofol group. Propofol group compared to inhaled anesthesia with sevoflurane group, shows significantly faster recovery from anesthesia only one minute after extubation (p=0,046). In comparison of propofol group and isofl urane anesthesia group, statistical significance was noticed one minute following extubation (p=0,008). Comparison of propofol group and inhaled anesthesia groups recovery rates were not significantly different at all times measured. When we were comparing sevoflurane and isoflurane anesthesia, recovery rates shoved no signifi cant statistical difference.Conclusions: Recovery rate evaluated by using White fast tracking scoring system was superior and with fewer complications in propofol maintained in comparison to sevoflurane and isoflurane maintained anesthesia only one minute post extubation, while after fifth and tenth minute difference was lost.

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Introduction: There is controversy regarding the optimal minimal mechanical ventilator support from which to extubate children. While some argue effort of breathing on minimum CPAP best estimates conditions after extubation, others suggest pressure support should be added to overcome perceived resistance from the endotracheal tube. Methods: We conducted a prospective observational trial in endotracheally intubated children in the pediatric and cardiac ICUs at Children’s Hospital Los Angeles. Using esophageal manometry we measured effort of breathing with pressure rate product (PRP = peak-to-trough change in esophageal pressure * respiratory rate) under 4 conditions: Pressure support 10/5 cmH20 (PS), CPAP 5 cmH20 (CPAP), and spontaneous breathing, 5 (5min) and 60 (60min) minutes after extubation. We used repeated measures ANOVA with Scheffe’s test for multiple comparisons to compare PRP, with a log transformation. We used the combination of calibrated Respiratory Inductance Plethysmography (RIP) flow and esophageal pressure to evaluate for inspiratory flow limitation from UAO after extubation. This was used for subgroup analysis to exclude UAO as a confounder. We also stratified by endotracheal tube size ≤ 4.0. Results: One-Hundred and seventy one children were included. Median (IQR) age was 5 (1, 18) months. Median (IQR) PRP for the 4 conditions were: PS 100 (50,200), CPAP 200 (120,325), 5min 300 (170,500), 60min 250 (140,420). PRP was significantly different under these 4 conditions using repeated measures ANOVA (p<0.001); multiple comparisons demonstrated PS was lower than the 3 other values and CPAP was lower than the 5 min value (p<0.001). When limiting to those without UAO (n=128), PRP on PS was significantly lower than the other 3 conditions (p<0.001) with no difference between CPAP and post extubation values (p>0.2): PS 100 (50,180), CPAP 200 (120,300), 5min 250 (150,375), 60min 200 (120,315). When limiting to those without UAO and endotracheal tubes ≤ 4.0 (n=95), PRP on PS was significantly lower than the other 3 conditions (p<0.001) with no difference between CPAP and post extubation values (p>0.2): PS 110 (60,200), CPAP 240 (140,300), 5min 300 (180,400), 60min 230 (130,350). Conclusions: Effort of breathing on CPAP most closely estimates post-extubation effort of breathing, and the addition of pressure support significantly underestimates post-extubation effort. This finding holds even for children with small endotracheal tubes, controlling for post-extubation UAO. Therefore, children should be extubated from CPAP, regardless of endotracheal tube size.

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Introduction: Respiratory failure following extubation causes significant morbidity and increases mortality in the surgical intensive care unit (SICU). However, the causes of respiratory failure following extubation remain poorly understood. Methods: All patients who were extubated in the surgical intensive care unit were enrolled in the study. Our primary endpoint was reintubation within 48 hours and we also examined the use of non-invasive ventilation and tracheostomy as secondary endpoints for respiratory failure. We focused on variables potentially associated with post extubation respiratory failure including preoperative comorbidities, intraoperative factors and postoperative factors. For each variable representing respiratory failure (reintubation within 48 hours, tracheostomy and use of non-invasive ventilation), univariate analysis was used to identify predictors which were then included in a stepwise backward logistic regression model. Results: Of 451 extubations performed in the surgical intensive care unit, there were 34 reintubations within 48 hours (7.5%), 45 (10%) received non-invasive ventilation following extubation and 27 (6%) underwent tracheostomy during their hospital stay. For those patients reintubated within 48 hrs, significant predictors included age (OR 1.03, 95% CI 1.004-1.058), renal failure (OR 1.484, 95% CI 1.112-1.98) and the SPORC score (OR 1.205, 95% CI 1.013-1.434), a recently validated score for predicting postoperative respiratory failure based on preoperative characteristics (1). For patients who received non-invasive ventilation following extubation, significant predictors were age (OR 1.030, 95% CI 1.013-1.048) and renal failure (OR 1.473, 95% CI 1.208-1.796). For patients who underwent tracheostomy, significant predictors were age (OR 1.033, 95% CI 1.006-1.062) and renal failure (OR 1.462, 95% CI 1.089-1.964).

Comparison of Siccoral® spray, Stomatovis® gargle, and Strefen® lozenges on postoperative sore throat

Postoperative sore throat (POST) is a frequent complication caused by mucosal trauma to the pharyngeal, laryngeal, and tracheal airway after endotracheal intubation. We compared the effectiveness of Siccoral, Strefen, and Stomatovis treatments in alleviating POST. This prospective, randomized, single-blinded, controlled trial compares the incidence of POST with Strefen lozenges, Siccoral spray, or Stomatovis gargle. Three hundred and twenty American Society of Anesthesiologists class I-III patients undergoing elective genitourinary surgery under general orotracheal anesthesia were randomly allocated to four groups of 80 patients each. In the postoperative awakening unit and during related services, POST was evaluated by a blinded anesthesiologist at 0, 1, 6, and 24 h post extubation. The highest incidence of POST occured at 0 and 1 h post extubation in all groups (P = 0.002 × 10(-7), P = 0.004 × 10(-6), respectively). A significantly lower incidence of POST was observed in Strefen and Siccoral groups at 0 and 1 h compared to Control group (Strefen: P = 0.004 × 10(-2), P = 0.007 × 10(-4); Siccoral: P = 0.003 × 10(-8), P = 0.007 × 10(-5), respectively). A significantly lower incidence of POST was observed with Siccoral treatment at 0 h post extubation (P = 0.002 vs. Strefen treatment). Although POST incidence was not significantly different between the Stomatovis and Control groups, it was lower in the Stomatovis group at 0 and 1 h (P = 0.026 and 0.013, respectively). The incidence of POST was similar in all groups at 6 and 24 h post extubation (P = 0.141 and 0.426, respectively). Siccoral and Strefen can be effective in relieving POST in the early hours after extubation.

Nurse-led bedside swallowing screening in post extubation patients: an evidence-based project

Nurse-led bedside swallowing screening in post extubation patients: an evidence-based project

Bag Valve Mask Ventilation Versus Controlled Ventilation for Minor Pediatric Surgery.

Introduction: Paediatric anaesthesia deals with Examination under anaesthesia to complicated surgical interventions. Most of the minor surgeries can be performed with Bag Valve Mask Ventilation which avoids complications of endotracheal intubation. Methods: A retrospective randomized control study was undertaken in 654 paediatric surgeries performed at Shree Birendra Hospital, Chhauni (April 2005-March 2010). The children underwent minor general, Ear nose throat and orthopaedic surgery to compare spontaneous Bag Valve Mask ventilation in 503 patients (BVM Group) and controlled ventilation in 151 patients (CV Group). The BVM group was done under spontaneous mask ventilation and CV group under endotracheal intubation. Anaesthesia was induced and maintained with oxygen and halothane, using a Mapleson F system with spontaneous ventilation and a Rendell-Baker face mask. The duration of anaesthesia was less than one hour. Results: In this study we noted the complications like trauma to face and lips, dental trauma, laryngospasm, perforation of tracheaor esophagus, pulmonary aspiration of gastric contents or foreign bodies and post extubation complications. Conclusions: It is concluded that the need of controlled ventilation with endotracheal tube is limited to only a few procedures and many of the paediatric surgeries can be performed with spontaneous mask ventilation. Therefore anaesthesia with oxygen and halothane with spontaneous mask ventilation is a satisfactory method for minor procedures in children. Medical Journal of Shree Birendra Hospital; Jan-June 2012/vol.11/Issue1/17-20 DOI: http://dx.doi.org/10.3126/mjsbh.v11i1.7761

Cormack Lehane Score and Dexamethasone as Predictors of Hoarseness after Bronchocath Extubation

Results: The frequency of hoarseness post-tracheal extubation at two hour intervals was significantly more in group IIa than in group Ia (10% and 2.04%, respectively 0.05). Conclusion: Single preoperative administration of 16 mg Dexamethasone among patients with laryngoscopic Cormack-Lehane score I, IIa and IIb are good predictors of low frequency of hoarseness post bronchocath extubation in subjects scheduled for video assisted thoracoscopic surgery.

Retropharyngeal abscess - A complication of laryngeal mask airway.

Retropharyngeal or parapharyngeal abscesses developing after intubation are rare. This can present as surgical emergency post extubation. We report a case of retropharyngeal abscess that probably occurred as a complication of laryngeal mask insertion.

Non invasive positive pressure ventilation in infants with respiratory failure

To determine whether non-invasive positive pressure ventilation (NIPPV) delivered via nasal prongs can alleviate the need for tracheal intubation and invasive ventilation in infants admitted to the pediatric intensive care unit (PICU) with impending respiratory failure, and to find predictive factors for success or failure with this mode. A single center retrospective cohort study. PICU in a university affiliated hospital. During the 14 months of the study period we recovered 22 NIPPV episodes in 19 infants (median age 65 days) with impending respiratory failure. The patient's respiratory failure etiologies were bronchiolitis (n = 13), pertussis (n = 3), and other respiratory conditions (n = 6). In 64% of the cases, intubation was prevented and the patients were weaned off to spontaneous breathing (Responders group). 36% failed NIPPV and had to be intubated and invasively ventilated (Non-responders group). Apneic episodes were the indication for ventilation in 11 patients (50%) with a 73% success rate in preventing invasive ventilation. Hypoxemic respiratory failure was present in nine patients (41%) and the rate of success was 44%. Two patients with post extubation respiratory distress, improved with NIPPV. Responders and non-responders did not differ with regard to demographics or disease severity prior to initiation of NIPPV. After initiating NIPPV respiratory rate and the need for sedation were lower in the NIPPV responders. In a set group of patient population such as infants with apnea secondary to bronchiolitis NIPPV may be successful to reduce the need for invasive ventilation. Our study failed to detect any physiological or clinical markers which could distinguish between so called "responders" and "non-responders" before initiating NIPPV.

Unsynchronized Nasal Intermittent Positive Pressure Ventilation vs. Head Box Oxygen for Preventing Extubation Failure

Sir, I read the article by Kumar et al. with great interest [1]. However, I would like to point out few issues. First, though the authors have not compared unsynchronized Nasal Intermittent Positive Pressure Ventilation (NIPPV) with the CPAP due to the non-availability of CPAP prongs, ideally unsynchronized NIPPV should also have been given with CPAP nasal prongs rather than the cut endotracheal tube, as short binasal prongs are the best interface available till date [2]. Putting neonates on head box oxygen with the available evidence of CPAP in preventing extubation failure is not justified. Putting neonates on indigenous or bubble CPAP instead of ventilator CPAP or head box oxygen after extubation will be more cost effective intervention in resource poor settings like ours. On one hand this will make the ventilator available for the neonates requiring invasive ventilation and on other hand, it will decrease the extubation failure rate as compared to head box oxygen. Second, nothing has been commented upon the blinding which is an important component of any RCT. Though the intervention can’t be blinded in this case but there is no information whether the persons collecting and analyzing the data were blinded or not to the intervention. Third, the assumption of 45% as the baseline extubation failure rate on head box oxygen for calculating the sample size has not been elaborated by the authors. Fourth, agitation was found to be more in NIPPV group. It would have been good to use some pain scoring system like N-PASS which is a more objective way of assessment rather than just labeling as “agitation” [3]. Agitation per se is subjective in nature and prone for bias. Fifth, the rationale of doing blood gases at least every 12 h in the first 24 h post extubation, then every 24 h for 48 h in all cases in absence of any clinical signs of deterioration is not clear. Despite these limitations, I appreciate the authors for their work.

Prophylactic Effectiveness of Budesonide Inhalation in Reducing Postoperative Throat Complaints

Objective: To evaluate the efficacy of budesonide suspension inhalation in reducing the incidence and severity of postoperative sore throat (POST) and hoarseness induced by tracheal intubation. Methods: 120 patients scheduled for thyroid surgery with general anaesthesia were randomized into 3 groups. Group A received 200 mcg budesonide inhalation suspension (BIS) 10 min prior to the tracheal intubation and received the same treatment 6 h and 24 h after extubation. Group B received 200 mcg BIS 6 h and 24 h after extubation. Control group received the same scheduled treatment as Group A, but the BIS was replaced with 2 ml normal saline. The patients were evaluated for POST and hoarseness 1, 24 and 48h after extubation and the status of laryngopharynx was examined and recorded as well. Results: The incidences of post-operation complaints in three groups were 72.5%, 82.5% and 87.55% for POST, and 37.3%, 52.5% and 75% for hoarseness, respectively. There was no statistically significant difference in the incidence of POST between three groups. However, hoarseness occurred significantly less frequently in Group A in comparison to Group B and control group (P<0.05). One hour post extubation, Group A exhibited significantly less severe POST and hoarseness compared to the other two groups (P<0.05), which disappeared 24 h later. One hour after extubation both VAS scores of POST and hoarseness were significantly lower in Group A than those in the other two groups (P<0.05). The mucositis scores of laryngopharynx at 1,24 and 48 h post extubation were significantly lower in Group A compared to the other two groups (P<0.05). Conclusions: The prophylactic use of inhaled budesonide suspension significantly decreases the incidence and severity of sore throat and hoarseness after tracheal intubation.

Effect of intravenous infusion of dexmedetomidine on perioperative haemodynamic changes and postoperative recovery: A study with entropy analysis

Background:Dexmedetomidine, an α2 agonist, when used as an adjuvant in general anaesthesia attenuates stress response to various noxious stimuli, maintains perioperative haemodynamic stability and provides sedation without significant respiratory depression postoperatively.Methods:Sixty patients were randomly divided into two groups of 30 each. In group A, fentanyl 2 μg/kg and in group B dexmedetomidine were given intravenously as loading dose of 1 μg/kg over 10 min prior to induction. After induction with thiopentone, in group B, dexmedetomidine was given as infusion at a dose of 0.2–0.8 μg/kg. Sevoflurane was used as inhalation agent in both groups. Haemodynamic variables and entropy (response entropy and state entropy) were recorded continuously. Postoperative sedation and recovery were assessed by sedation score and modified Aldrete's score, respectively.Results:Dexmedetomidine significantly attenuates stress response at intubation with lesser increase in heart rate (10% vs. 17%), systolic blood pressure (6% vs. 23%) and diastolic blood pressure (7% vs. 20%) as compared to the control group (P<0.05). Intraoperatively, an average of 8% fall in systolic blood pressure and 8.16% fall in diastolic pressure in the test group as compared to 3.6% rise in systolic and 3.3% in diastolic pressure of the control group was observed. Postoperatively, the test group showed significant sedation at 2 h as compared to the control group (P=0.00) and recovery was better in the control group for the first 2 h post extubation.Conclusion:Dexmedetomidine attenuates various stress responses during surgery and maintains the haemodynamic stability when used as an adjuvant in general anaesthesia. Also, the sedative action of dexmedetomidine delays recovery for the first few hours post extubation.

EXTUBATE: A randomised controlled trial of nasal biphasic positive airway pressure vs. nasal continuous positive airway pressure following extubation in infants less than 30 weeks' gestation: study protocol for a randomised controlled trial

BackgroundRespiratory distress syndrome remains a significant problem among premature infants. Mechanical ventilation through an endotracheal tube remains the mainstay of respiratory support but may be associated with lung injury and the development of chronic lung disease of prematurity. Efforts are needed to reduce the duration of mechanical ventilation in favour of less invasive forms of respiratory support and to improve rates of successful extubation.Non-invasive respiratory support has been demonstrated to be less injurious to the premature lung. Standard practice is to use nasal continuous positive airway pressure (n-CPAP) following extubation to support the baby's breathing. Many clinicians also use nasal biphasic positive airway pressure (n-BiPAP) in efforts to improve rates of successful extubation. However, there is currently no evidence that this confers any advantage over conventional nasal continuous positive airway pressure.MethodsWe propose an unblinded multi-centre randomised trial comparing n-CPAP with n-BiPAP in babies born before 30 weeks' gestation and less than two weeks old. Babies with congenital abnormalities and severe intra-ventricular haemorrhage will be excluded. 540 babies admitted to neonatal centres in England will be randomised at the time of first extubation attempt. The primary aim of this study is to compare the rate of extubation failure within 48 hours following the first attempt at extubation. The secondary aims are to compare the effect of n-BiPAP and n-CPAP on the following outcomes:1. Maintenance of successful extubation for 7 days post extubation2. Oxygen requirement at 28 days of age and at 36 weeks' corrected gestational age3. Total days on ventilator, n-CPAP/n-BiPAP4. Number of ventilator days following first extubation attempt5. pH and partial pressure of carbon dioxide in the first post extubation blood gas6. Duration of hospital stay7. Rate of abdominal distension requiring cessation of feeds8. Rate of apnoea and bradycardia9. The age at transfer back to referral centre in daysThe trial will determine whether n-BiPAP is safe and superior to n-CPAP in preventing extubation failure in babies born before 30 weeks' gestation and less than two weeks old.Trial registration numberISRCTN: ISRCTN18921778

A comparison between the Boussignac™ continuous positive airway pressure mask and the venturi mask in terms of improvement in the PaO2/F i O2 ratio in morbidly obese patients undergoing bariatric surgery: a randomized controlled trial

This study compared the Boussignac™ continuous positive airway pressure (CPAP) mask with the venturi face mask in terms of the postoperative PaO2/F(I)O2 (PF) ratio in morbidly obese patients after bariatric surgery. Following hospital Research Ethics Board approval and written informed consent, morbidly obese (body mass index > 35 kg·m(-2)) patients undergoing bariatric surgery were recruited. The patients were anesthetized and laparoscopic Roux-en-Y gastric bypass was performed. Patients were assigned randomly to receive either the Boussignac (Boussignac Group) or the venturi face mask (Venturi Group) immediately after tracheal extubation. Patients were transported to the postanesthesia care unit, and the respective devices were applied for one hour. The PF ratio was recorded after tracheal intubation and at one hour and two hours post extubation. The percent forced expiratory volume (%FEV1) and the percent forced vital capacity (%FVC) were recorded preoperatively and at one hour and two hours post extubation. Independent Student's t tests were used for continuous variables, and the Chi square test was used for categorical variables. P < 0.05 was considered statistically significant. Eighty-one patients (Group Boussignac, n = 43; Group Venturi, n = 38) completed the study. Mean ages and body mass indices were similar in the two groups. At one hour post extubation, the PF ratio in the Boussignac Group was 361 (170) compared with 279 (91) in the Venturi Group (P = 0.007), and at two hours post extubation, the PF ratio in the Boussignac Group was 371 (162) compared with 323 (127) in the Venturi Group (P = 0.1). The postoperative %FEV(1) and %FVC were comparable in both groups at all time points. Compared with the venturi mask, the Boussignac CPAP mask improves the postoperative PF ratio in morbidly obese patients after bariatric surgery. The postoperative %FEV1 and %FVC are comparable for both groups.

Long-term sedation in intensive care unit: a randomized comparison between inhaled sevoflurane and intravenous propofol or midazolam

To evaluate efficacy and adverse events related to inhaled sevoflurane for long-term sedation compared with standard intravenous (i.v.) sedation with propofol or midazolam. Randomized controlled trial. Sixty intensive care unit (ICU) patients expected to require more than 24 h sedation were randomly assigned to one of three groups: group S, inhaled sevoflurane; group P, i.v. propofol; group M, i.v. midazolam. All patients also received i.v. remifentanil for goal-directed sedation (Ramsay scale and pain score) until extubation or for a maximum of 96 h. Primary end points were wake-up times and extubation delay from termination of sedative administration. Proportion of time within Ramsay score 3-4, i.v. morphine consumption at 24 h post extubation, hallucination episodes after end of sedation, adverse events, inorganic fluoride plasma levels, and ambient sevoflurane concentrations were recorded. Forty-seven patients were analyzed. Wake-up time and extubation delay were significantly (P<0.01) shorter in group S (18.6 ± 11.8 and 33.6 ± 13.1 min) than in group P (91.3 ± 35.2 and 326.11 ± 360.2 min) or M (260.2 ± 150.2 and 599.6 ± 586.6 min). Proportion of time within desired interval of sedation score was comparable between groups. Morphine consumption during the 24 h following extubation was lower in group S than in groups P and M. Four hallucination episodes were reported in group P, five in group M, and none in group S (P=0.04). No hepatic or renal adverse events were reported. Mean plasma fluoride value was 82 μmol l(-1) (range 12-220 μmol l(-1)), and mean ambient sevoflurane concentration was 0.3 ± 0.1 ppm. Long-term inhaled sevoflurane sedation seems to be a safe and effective alternative to i.v. propofol or midazolam. It decreases wake-up and extubation times, and post extubation morphine consumption, and increases awakening quality.

Pulsatile pulmonary perfusion with oxygenated blood ameliorates pulmonary hemodynamic and respiratory indices in low-risk coronary artery bypass patients☆

Acute lung injury still accounts for postoperative mortality after cardiopulmonary bypass (CPB). The safety and the efficacy of pulsatile pulmonary perfusion (PPP) during CPB were analyzed. Preliminary results of the first PPP trial in human beings are reported. Thirty low-risk coronary artery bypass grafting (CABG) patients were prospectively randomized to receive PPP with oxygenated blood during CPB and aortic cross-clamping (15 patients, PPP-group) or to conventional CPB (15 patients, control group). Alveolo-arterial oxygen gradient (A-aDO(2)) was set as the primary end point and collected preoperatively, at intensive care unit (ICU) arrival (T1), 3h postoperatively (T2), and post extubation (T3). Secondary end points were collected at the same time points and consisted of respiratory indices (partial pressure of arterial oxygen/fraction of inspired O(2) (PaO(2)/FiO(2)), lung compliance, mixed-venous partial pressure of oxygen (pO(2))) and hemodynamic pulmonary parameters (indexed pulmonary vascular resistances (PVRI), pulmonary arterial pressure (PAP), pulmonary capillary wedge pressure (PCWP), and cardiac index (CI)). Bronchoalveolar lavage (BAL) fluid was collected preoperatively, at ICU arrival (T1-BAL) and after 4h. There were no PPP-related complications. Patients undergoing PPP showed a better preserved A-aDO(2) (group-p=0.001) throughout the study period (group × time-p = 0.0001). PaO(2)/FiO(2) and lung compliance were better preserved by PPP (group-p and group × time-p ≤ 0.05 for all). Pulmonary hemodynamic status was positively influenced by PPP, as shown by the higher CI (group-p=0.0001, group × time-p = 0.0001), and the lower PVRI, PAP, and PCWP (group-p ≤0.001, group × time-p=0.0001 for all). Postoperative BAL specimens demonstrated a lower absolute count of white blood cells (group-p=0.0001), a higher percentage of monocytes/macrophages (group-p=0.027), and a lower percentage of neutrophils (group-p=0.015) after PPP. Oxygenated blood PPP proved safe and significantly ameliorated pulmonary hemodynamic parameters and respiratory indices in low-risk CABG.

Gentle chest compression relieves extubation laryngospasm in children

Extubation laryngospasm is frequently encountered in children undergoing upper airway surgery. Different drugs and techniques have been used for its treatment. The objective of this study was to examine gentle chest compression as an alternative to standard practice for relief of laryngospasm. This study was conducted over 4 years on all children scheduled for elective tonsillectomy. During the first 2 years, extubation laryngospasm was managed with 100% O₂ with gentle positive pressure ventilation via a tight-fitting face mask (Standard-Practice Group), whereas in the following 2 years; laryngospasm was managed with 100% O₂ and concurrent gentle chest compression (Chest-Compression Group). In both groups, if the spasm was not relieved and oxygen saturation decreased to 85%, IV succinylcholine was administered with subsequent manual ventilation. During the 4-year study period, 1226 children aged 3-12 years were studied. In the chest-compression group, 46/594 children (7.8%) developed laryngospasm compared with 52/632 children (8.2%) in the standard group (P = 0.84). Significantly more children who developed laryngospasm were successfully treated by chest compression 34/46 (73.9%) compared with those managed by the standard method 20/52 (38.4%); (P < 0.001). None of the children in the chest-compression group developed gastric distension compared with 45/52 (86.5%) in the standard group. Gentle chest compression with 100% oxygen is a simple and effective technique for immediate management of post extubation laryngeal spasm in children.