Reintubation Rate Research Articles

135: ENHANCED RECOVERY AFTER CARDIAC SURGERY (ERACS): A PILOT STUDY

Introduction: Surgery is known to cause extreme insults to the body such as increasing oxygen demand, end organ ischemia, and depletion of energy stores. Enhanced Recovery After Surgery (ERAS) is an evidence-based improvement process for surgical procedures. This study aims to evaluate the current policy and procedure used in patients undergoing open heart surgery with the ERACS treatment algorithm developed by the team of intensivists and surgeons at AdventHealth Celebration. Methods: This was a retrospective chart review of patients who underwent a physician approved Enhanced Recovery After Cardiac Surgery protocol at AdventHealth celebration. Patients were enrolled into the protocol-based inclusion criteria. Data was obtained from January 2021 through September 2021. The primary outcome sought to evaluate time to extubation from mechanical ventilation post-operatively. Secondary outcomes include time to reintubation if applicable, intensive care unit length of stay, post-operative length of stay, and 30-day mortality. Outcomes were compared to the historical cohort which was the population prior to implementation between July 2019 through December 2020. Results: A total of 50 patients were included in the study population who received the ERACS protocol compared 241 in the historical cohort. The ERACS cohort had a 100% successful extubation within less than six hours compared to 84.2% in the historical cohort (p < 0.05). Re-intubation post-operatively was 0% compared to 4.35% in the ERACS compared to historical cohort respectively (p < 0.05). ICU length of stay was significantly shorter than in the ERACS compared to historical cohort 24 compared to 53.28 hours (p < 0.05). No statistical difference was detected between both groups for post-op length of stay being 141.6 compared to 144 hours in the ERACS vs historical cohort respectively (p=0.24). No statistical difference noted between 30-day all-cause mortality 0% compared to 2.5% in the ERACS compared to historical cohort respectively (p=0.11). Conclusions: Statistical and clinical significance was observed with respect to the cohorts. This was most notably seen with the primary outcome, time to extubation, a nationally measured Society of Thoracic Surgery metric. Differences were also noted in re-intubation rates post-operatively and ICU length of stay.

Early Use of High-Flow Nasal Cannula in Postextubation Period: Can It Reduce Reintubation Rate? Authors' Reply.

Early Use of High-Flow Nasal Cannula in Postextubation Period: Can It Reduce Reintubation Rate? Authors' Reply.

Early Use of High Flow Nasal Cannula in Postextubation Period: Can It Reduce Reintubation Rate?

See the letter "Early Use of High-Flow Nasal Cannula in Postextubation Period: Can It Reduce Reintubation Rate? Authors’ Reply" on page 65.

Operating Room Versus Intensive Care Unit Extubation Within 6 Hours After On-Pump Cardiac Surgery: Early Results and Hospital Costs

Time-directed extubation (fast-track) protocols may decrease length of stay and cost but data on operating room (OR) extubation is limited. The objective of this study was to compare the outcomes of extubation in the OR versus fast-track extubation within 6 hours of leaving the operating room. Patients undergoing nonemergent STS index cases (2011-2021) who were extubated within 6 hours were identified from a regional STS quality collaborative. Patients were stratified by extubation in the OR versus fast track. Propensity score matching (1:n) was performed to balance baseline differences. Of the 24,962 patients, 498 were extubated in the OR. After matching, 487 OR extubation cases and 899 fast track cases were well balanced. The rate of reintubation was higher for patients extubated in the OR [21/487 (4.3%) vs 16/899 (1.8%), P = 0.008] as was the incidence of reoperation for bleeding [12/487 (2.5%) vs 8/899 (0.9%), P = 0.03]. There was no significant difference in the rate of any reoperation [16/487 (3.3%) vs 15/899 (1.6%), P = 0.06] or operative mortality [4/487 (0.8%) vs 6/899 (0.6%), P = 0.7]. OR extubation was associated with shorter hospital length of stay (5.6 vs 6.2 days, P < 0.001) and lower total cost of admission ($29,602 vs $31,565 P < 0.001). OR extubation is associated with a higher postoperative risk of reintubation and reoperation due to bleeding, but lower resource utilization.Future research exploring predictors of extubation readiness may be required prior to widespread adoption of this practice.

Association Between Pressure Support During Extubation Readiness Testing and Time to First Extubation in Children With Congenital Heart Disease.

Extubation readiness testing (ERT) is often performed in children with congenital heart disease prior to liberation from mechanical ventilation. The ideal ERT method in this population is unknown. We recently changed our ERT method from variable (10, 8, or 6 cm H2O, depending on endotracheal tube size) to fixed (5 cm H2O) pressure support (PS). Our study assessed the association between this change and time to first extubation and need for re-intubation. We studied 2 temporally distinct cohorts, one where ERT was conducted with variable PS and another using PS fixed at 5 cm H2O. Data were prospectively collected as part of a quality improvement project. The primary outcome was time to first extubation. Secondary outcomes were need for re-intubation and percentage of successful ERTs. We performed Poisson regression or logistic regression for the association between PS during ERT and time to first extubation or re-intubation, respectively. We included 320 subjects, 186 in the variable PS group and 152 in fixed PS group. In unadjusted analysis, median time to first extubation was longer in the fixed PS group compared to the variable PS group (4.1 [2.0-7.1] d vs 3.1 [1.1-5.9] d, P = .02), and there was no difference in re-intubation rate (11% vs 8%, P = .34). Subjects in the fixed PS group were significantly more likely to be mechanically ventilated after cardiac arrest, have a Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) category of 4 or 5, be extubated on day shift, receive enteral feeds at extubation, have higher respiratory support at extubation, and higher dead-space-to-tidal-volume ratio. After controlling for these variables in multivariable regression, we found no association between the choice of PS and time to first extubation or re-intubation. The use of a fixed PS of 5 cm H2O instead of variable PS during ERT was not associated with longer time to first extubation or extubation failure.

Mid- and Long-Term Surgical Outcomes Due to Infective Endocarditis in Elderly Patients: A Retrospective Cohort Study.

Infective endocarditis (IE) is one of the true remaining dreaded situations in cardiovascular medicine. Current international guidelines do not include specific recommendations for treatment options of infective endocarditis (conventional vs. surgical) based on the patient's age, functional status or comorbidities. Elderly patients have less invasive and often delayed surgeries compared to younger patients due to their shorter long-term survival probabilities. In the setting of IE, this might not be the right treatment, as surgery is the only curative option in up to 50% of all endocarditis patients. The aim of our study was to evaluate the mid- and long-term surgical outcomes due to infective endocarditis of patients aged ≥70 years. Between 2002 and 2020, a retrospective study with 137 patients aged 70 years and older and 276 patients aged below 70 years was conducted. Altogether, 413 consecutive patients who received surgery due to infective native or prosthetic valve endocarditis were assigned to either the elderly (E)-Group or the control (C)-Group. Primary endpoints were short- and long-term MACCEs (Major Adverse Cardiac and Cerebrovascular Events) as a composite of death or major adverse events, and secondary endpoints were intraoperative variables and postoperative course. Preoperative risk factors differed significantly. Elderly patients had more arterial hypertension, atrial fibrillation, diabetes, chronic renal insufficiency and coronary heart disease. Fewer of them were in a state of emergency. Time from diagnosis to OR, antibiotic pretreatment, length of surgery and cardiopulmonary bypass time were significantly longer in the E-Group. Furthermore, 44.5% of patients in the E-Group had prosthesis endocarditis as opposed to 29.7% in the C-group. During postoperative follow-up, new onset of hemodialysis, duration of ventilation, delirium, reintubation and tracheotomy rates were significantly higher in the E-Group. There were significant differences in 7- and 30-day mortality. One- year survival was 62% for the E-Group and 79% for the C-Group. Five-year survival was 47% for the E-Group and 67% for the C-Group. This study demonstrates that surgery for infective endocarditis is a high-risk procedure, especially for elderly people. Nevertheless, as it is more or less the only concept to increase long-term survival, it should be offered generously to all patients who are still able to take care of themselves.

Abstract 14448: On-Table Extubation Associated With Lower Resource Utilization and Non-Inferior Outcomes After Coronary Bypass

Introduction: Minimizing the duration of postoperative ventilation facilitates early discharge from the intensive care unit (ICU) thus promoting enhanced recovery after cardiac surgery (ERAS). Hence, we sought to investigate the impact of on-table extubation on outcomes and resource utilization after coronary artery bypass graft (CABG) surgery. Methods: We performed a retrospective review of a prospectively collected local database, including all patients undergoing CABG surgery at a large academic center from January 2020 to December 2021. Patients were stratified into two groups, on-table (before leaving the operating room) extubation versus early (&lt; 6 hours after procedure) extubation. In-hospital mortality and postoperative complications were compared using univariate analyses. Length of stay (LOS), 30-day readmission and high resource utilization (HRU), a binary outcome defined as direct procedure cost of the highest quartile, were investigated. Results: A total of 691 patients were included in our analysis, 267 (38.6%) of which were extubated on-table. The two groups had similar median age and preoperative ejection fractions. However, on-table extubation patients were more likely to be males (86.9% vs 76.6%, p&lt;0.001) with smaller BMIs (27.7% vs 28.5%, p=0.002), lower STS risk scores (0.75% vs 0.95%, p=0.022) and lower cerebrovascular disease prevalence (8.2% vs 14.2%, p=0.017). Compared to early extubation, on-table extubation patients had similar rates of in-hospital mortality (0 % vs 1.4 %, p=0.051), postoperative blood transfusion (7.5% vs 9.0%, p=0.494), reintubation (2.6% vs 3.5%, p=0.499) and pneumonia (1.9% vs 3.3%, p=0.263). As hypothesized, on-table extubation patients had shorter ICU LOS (32hrs vs 39hrs, p=0.02), shorter postoperative LOS (4.9 days vs 5.9 days, p=0.003), and lower incidence of high resource utilization (18.0% vs 29.5%, p&lt;0.001). ICU readmission (3.8% vs 3.5%, p=0.887) and 30-day readmission (5.2% vs 7.3%, p=0.277) were similar in the two groups. Conclusions: On-table extubation is a safe and effective ERAS practice, that is associated with lower ICU LOS, postoperative LOS, and resource utilization, without affecting rates of reintubation, ICU readmission, 30-day readmission or operative mortality.

Increased diaphragm echodensity correlates with postoperative pulmonary complications in patients after major abdominal surgery: a prospective observational study

BackgroundAssociated with increased morbidity and mortality, postoperative pulmonary complications (PPCs) often occur after major abdominal surgery. Diaphragmatic dysfunction is suggested to play an important role in the development of PPCs and diaphragm echodensity can be used as an indicator of diaphragm function. This study aimed to determine whether diaphragm echodensity could predict the occurrence of PPCs in patients after major abdominal surgery.MethodsDiaphragm ultrasound images of patients after major abdominal surgery were collected during spontaneous breathing trials. Echodensity was quantified based on the right-skewed distribution of grayscale values (50th percentile, ED50; 85th percentile, ED85; mean, EDmean). Intra- and inter-analyzer measurement reproducibility was determined. Outcomes including occurrence of PPCs, reintubation rate, duration of ventilation, and length of ICU stay were recorded.ResultsDiaphragm echodensity was measured serially in 117 patients. Patients who developed PPCs exhibited a higher ED50 (35.00 vs. 26.00, p < 0.001), higher ED85 (64.00 vs. 55.00, p < 0.001) and higher EDmean (39.32 vs. 33.98, p < 0.001). In ROC curve analysis, the area under the curve of ED50 for predicting PPCs was 0.611. The optimal ED50 cutoff value for predicting the occurrence of PPCs was 36. According to this optimal ED50 cutoff value, patients were further divided into a high-risk group (ED50 > 36, n = 35) and low-risk group (ED50 ≤ 36, n = 82). Compared with the low-risk group, the high-risk group had a higher incidence of PPCs (unadjusted p = 0.003; multivariate-adjusted p < 0.001).ConclusionDiaphragm echodensity can be feasibly and reproducibly measured in mechanically ventilated patients. The increase in diaphragm echodensity during spontaneous breathing trials was related to an increased risk of PPCs in patients after major abdominal surgery.

Pre-existing pulmonary fibrosis is associated with adverse outcomes after lung resection

IntroductionPulmonary fibrosis is a risk factor for the development of lung cancer. However, the low incidence of the pathology means that it is not well represented in thoracic surgery risk scoring systems. We aimed to assess whether short and long-term outcomes after lung resection for primary lung cancer were worse in patients with pre-existing pulmonary fibrosis. MethodsA total of 5029 consecutive patients undergoing lung resection for primary lung cancer between 2012 and 2018 in two UK centres were included. Primary outcomes were 90-day & 1-year mortality, post-operative complications and overall survival. Univariable analyses were used to compare outcomes between patients with and without pre-existing pulmonary fibrosis. ResultsIn total, 0.7% (n = 33) of patients had a pre-existing diagnosis of pulmonary fibrosis (idiopathic pulmonary fibrosis 48.5%, non-specific interstitial pneumonia 6.1%, unknown 45.5%). Overall, 90-day and 1-year mortality were all significantly higher amongst patients with fibrosis (90-day: 18.2% vs 3.6%, p < 0.001; 1-year: 36.4% vs 10.7%, p < 0.001). The rate of reintubation was significantly higher for patients with fibrosis (9.1% vs 2.9%, p = 0.038) yet there was no difference in post-operative length of stay between groups (fibrosis: 6 days [IQR 4–9 days] vs non-fibrosis: 5 days [IQR 4–8 days], p = 0.675). Overall survival was also significantly reduced for patients with pulmonary fibrosis (log-rank analysis, p < 0.001). ConclusionsDespite its small size, this study suggests that short and long-term outcomes after lung resection are worse for patients with pre-existing pulmonary fibrosis. Segmental resections could be considered in these patients where oncologically appropriate to minimise peri-operative risk.

Value of high-flow oxygen therapy after weaning for successful extubation of critical ill patients with mechanical ventilation

To investigate the value of high-flow oxygen therapy after weaning in successful extubation of critically ill patients with mechanical ventilation. A retrospective study was conducted. The weaned patients who were older than 18 years old and underwent mechanical ventilation for the first time due to cerebrovascular accidents, surgical operations, cardiovascular diseases, and pneumonia admitted to the department of critical care medicine of Zhejiang Hospital from January 2018 to June 2020 were enrolled. Among the patients, 40 cases received high-flow oxygen therapy after weaning, and 37 cases received Venturi combined with the humidifier. The patient's gender, age, primary disease, severity score, duration of mechanical ventilation before weaning, heart rate (HR), blood pressure, pulse oxygen saturation (SpO2) at 0, 6, 12, 18, and 24 hours after weaning, and pH value, arterial partial pressure of oxygen (PaO2), arterial partial pressure of carbon dioxide (PaCO2) at 6, 12, 18, and 24 hours after weaning, the rate of performing mechanical ventilation after weaning, extubation time after weaning, and the rate of reintubation after extubation for 72 hours were collected. There was no significant difference in baseline data such as gender, age, primary disease, severity score, and duration of mechanical ventilation before weaning between the two groups. After weaning, the vital signs of the two groups were stable, and there was no significant difference in HR, systolic blood pressure (SBP), diastolic blood pressure (DBP) or SpO2 at each time point between the two groups. After weaning, the pH of arterial blood gas analysis in the two groups and the fluctuations of PaO2 and PaCO2 in the high-flow group were not obvious. In the Venturi group, PaO2 gradually decreased after weaning, PaCO2 increased significantly at 12 hours, and slowly decreased after 12 hours. The PaO2 from 6 hours and PaCO2 from 12 hours in the high-flow group were significantly lower than those in the Venturi group, and continued to 24 hours [PaO2 (mmHg, 1 mmHg ≈ 0.133 kPa): 112.34±38.25 vs. 156.76±68.44 at 6 hours, 110.92±38.66 vs. 150.64±59.07 at 12 hours, 111.12±36.77 vs. 141.30±39.05 at 18 hours, 110.82±39.37 vs. 139.65±41.50 at 24 hours; PaCO2 (mmHg): 41.30±7.51 vs. 47.42±7.54 at 12 hours, 40.97±6.98 vs. 45.83±8.63 at 18 hours, 40.10±7.06 vs. 46.14±9.15 at 24 hours, all P < 0.01]. The rate of performed mechanical ventilation after weaning and the rate of reintubation after extubation for 72 hours in the high-flow group were significantly lower than those in the Venturi group [17.5% (7/40) vs. 40.5% (15/37), 6.2% (2/32) vs. 31.8% (7/22), both P < 0.05], and the extubation time after weaning was significantly shorter than that in the Venturi group (hours: 22.43±11.72 vs. 28.07±10.42, P < 0.05). Using high-flow oxygen therapy to the extubation process of critically ill mechanical ventilation patients can reduce the incidence of carbon dioxide retention and the rate of performed mechanical ventilation after weaning, shorten the extubation time after weaning, and reduce the rate of reintubation after extubation for 72 hours.

Role of Early Extubation in Decreasing Morbidity and Mortality in Liver Transplantation

BackgroundEarly extubation is a fundamental element integrated into enhanced recovery protocols in orthotopic liver transplantation (OLT). The aim is to evaluate whether early extubation influences short- and medium-term postoperative morbidity and mortality. MethodsA cohort of 209 patients who underwent OLT in a tertiary hospital in a period from January 2016 to December 2018 were retrospectively analyzed. Patients were divided into 2 groups: group 1: early extubation in the intensive care unit and group 2: delayed extubation. Mortality is compared between both groups in the first month and first and third year. Postoperative morbidity was also compared. ResultsPatients in group 1 (n = 165, 79.9%) presented, with statistical significance, lower mortality at 1 month, 1 year, and 3 years; shorter duration of admission to the critical care unit and of hospital stay; lower incidence of surgical reoperation and retransplant; lower rate of transfusion of blood products; fewer pulmonary, digestive, neurologic, cardiologic, hemodynamic, kidney, surgical, infectious, metabolic, thrombotic, vascular, and graft complications; less need for kidney replacement therapy; less refractory ascites; and greater infectious risk. However, no statistically significant differences were found in the need for hospital readmission; in biliary, endocrine, nutritional, hematologic, thrombotic, and hematologic complications; or in graft rejection.In group 1, 6.6% of patients required reintubation. In group 2, 97% of patients could be extubated during the first week; 7.8% required noninvasive mechanical ventilation type bilevel positive airway pressure and 8.1% high flow. Only 2.8% of patients required tracheotomy. ConclusionsThe role of early extubation seems key to improve outcomes in OLT because it reduces the incidence of multiple complications and mortality, with low reintubation rates. It is a feasible and safe procedure.

Protocol for a randomised controlled trial: reducing reintubation among high-risk cardiac surgery patients with high-flow nasal cannula (I-CAN)

IntroductionHeated, humidified, high-flow nasal cannula oxygen therapy has been used as a therapy for hypoxic respiratory failure in numerous clinical settings. To date, limited data exist to guide appropriate use...

16 RAM cannula versus Infant Flow Driver systems for post-extubation non-invasive ventilation support in extremely preterm infants - A retrospective cohort study

Abstract Background Non-invasive ventilation (NIV) delivered by RAM cannula is being used for post-extubation support of preterm infants in some centers for its potential benefits of ease of setup and less nasal trauma. Objectives To assess characteristics and clinical outcomes for infants extubated to NIV support delivered via RAM cannula, as compared to those extubated to Vyaire Infant Flow Driver (IFD) systems. Design/Methods Retrospective cohort study. All infants born at 25 to 27 + 6 weeks of gestation during a 3-year period (2016-2018) and admitted to a regional Level-3 NICU, were eligible if: 1) they were ventilated for RDS within 48 hours of birth, and 2) extubated to NIV support using RAM cannula or IFD systems (using Viasys or FabianTM devices). Primary outcome was the failure of the primary mode of NIV support within the first 72 hours post-extubation (defined as need for reintubation or change of initial NIV mode to prevent reintubation). We adjusted for antenatal steroid use and delivery route. Data was stratified for gestational age (GA) &amp;lt;26 wks/&amp;gt;=26 wks. Sensitivity analysis were performed on additional parameters, e.g., inborn status, duration of initial ventilation restricted to &amp;lt;4 days. Logistic and linear regression models were built for the categorical and continuous outcomes. Results 150 infants were enrolled, RAM cannula (n = 62) and IFD devices (n = 88). The majority of patients in both groups were on conventional ventilation, received one dose of surfactant, and were on FiO2 &amp;lt;0.3 prior to extubation. RAM cannula group had significantly longer duration of intubation prior to first extubation (median duration 99 hrs vs 19 hrs). There was no difference in the primary outcome between the groups [(RAM 51.6% and IFD 45.5%; adjOR 1.25(95% CIs: 0.65 – 2.4)]. However, RAM cannula group had higher rates of reintubation within &amp;lt;=7 days after extubation (89.5% vs 68.5%; adjOR 3.87(95% CIs: 1.18, 12.73), p-value=0.026] and higher incidence of IVH [62.9% vs 38.6%; 2.77(95% CIs: 1.39, 5.53), p-value 0.004], with lesser infants weaned to room air prior to discharge [58.1% vs 76.1.6%; adjOR 0.42(95% CIs: 0.21, 0.85), p-value 0.016]. In the stratified analyses by GA, these differences were noted to be restricted to those born at &amp;gt;=26 weeks, with an additional risk for increased BPD36 (adjORs 2.76 (95% CIs: 1.16, 6.57), p-value 0.022] associated with the RAM cannula use in this stratum. Conclusion Post-extubation NIV support via RAM cannula, as compared to IFD systems, was associated with higher rates of reintubation in &amp;lt;=7 days, IVH, with a greater number of infants discharged home on supplemental oxygen.

Outcomes of COVID-19 Patients with Severe Hypoxemic Acute Respiratory Failure: Non-Invasive Ventilation vs. Straight Intubation-A Propensity Score-Matched Multicenter Cohort Study.

The best timing for endotracheal intubation in patients with coronavirus disease 2019 (COVID-19) hypoxemic acute respiratory failure (hARF) remains debated. Aim of this study is to compare the outcomes of COVID-19 patients with hARF receiving either a trial of non-invasive ventilation (NIV) or intubated with no prior attempt of NIV (“straight intubation”). All consecutive patients admitted to the 25 participating ICUs were included and divided in two groups: the “straight intubation” group and the “NIV” group. A propensity score matching was performed to correct for biases associated with the choice of the respiratory support. Primary outcome was in-hospital mortality. Secondary outcomes were length of mechanical ventilation, hospital stay and reintubation rate. A total of 704 COVID-19 patients were admitted to ICUs during the study period. After matching, 141 patients were included in each group. No clinically relevant difference at ICU admission was found between groups. In-hospital mortality was significantly lower in the NIV group (22.0% vs. 36.2%), with no significant difference in secondary endpoints. There was no significant mortality difference between patients who received straight intubation and those intubated after NIV failure. In COVID-19 patients with hARF it is worth and safe attempting a trial of NIV prior to intubation.

Bivalirudin vs. Enoxaparin in Intubated COVID-19 Patients: A Pilot Multicenter Randomized Controlled Trial.

(1) Background: In COVID-19 patients, the occurrence of thromboembolic complications contributes to disease progression and mortality. In patients at increased risk for thrombotic complications, therapeutic enoxaparin should be considered. However, critically ill COVID-19 patients could develop resistance to enoxaparin. Bivalirudin, a thrombin inhibitor, may be an alternative. This pilot multicenter randomized controlled trial aims to ascertain if bivalirudin may reduce the time spent under invasive mechanical ventilation, as compared to enoxaparin. (2) Methods: Intubated COVID-19 patients at risk for thrombo-embolic complications were randomized to receive therapeutic doses of enoxaparin or bivalirudin. We ascertained the time spent under invasive mechanical ventilation during the first 28 days from Intensive Care Unit (ICU) admission. A standardized weaning protocol was implemented in all centers. In addition, we assessed the occurrence of thromboembolic complications, the number of patients requiring percutaneous tracheostomy, the gas exchange, the reintubation rate, the ICU length of stay, the ICU and 28-days mortalities. (3) Results: We enrolled 58 consecutive patients. Bivalirudin did not reduce the time spent under invasive mechanical ventilation as compared to enoxaparin (12 [8; 13] vs. 13 [10; 15] days, respectively; p = 0.078). Thrombotic (p = 0.056) and embolic (p = 0.423) complications, need for tracheostomy (p = 0.423) or reintubation (p = 0.999), the ICU length of stay (p = 0.076) and mortality (p = 0.777) were also similar between treatments. Patients randomized to bivalirudin showed a higher oxygenation at day 7 and 15 after randomization, when compared to enoxaparin group. (4) Conclusions: In intubated COVID-19 patients at increased risk for thromboembolic complications, bivalirudin did not reduce the time spent under invasive mechanical ventilation, nor improved any other clinical outcomes.

One-year experience after adoption of an on-table extubation protocol following pediatric cardiac surgery.

To report our initial experience with on-table extubation following cardiac surgery for congenital heart disease, assessing its efficacy and safety, and the potential for fast-tracking these patients through the intensive care unit (ICU). We decided to implement a multidisciplinary protocol aiming toward on-table extubation following congenital cardiac surgery at our hospital. Between December 2018 and January 2020, 376 patients underwent congenital cardiac surgery. The management strategy involved choosing the patients preoperatively, a specific anesthetic technique, application of a standard extubation protocol, multidisciplinary team approach, and perioperative echocardiogram for assessment of surgical repair. Relevant data were collected and analyzed. Out of the 376 patients who underwent congenital cardiac surgery during the study period, 44 patients were extubated on-table. Although a majority of these patients belonged to Risk Adjustment for Congenital Heart Surgery-1 score (RACHS-1) 1 and 2 categories, 18% of the patients who were extubated on-table were of RACHS-3 category. This included a wide spectrum of anatomical substrates such as endocardial cushion defects, pulmonary venous anomalies, single ventricle physiology, valvular defects, and others such as cor triatriatum and sinus of Valsalva aneurysm. There was no in-hospital mortality related to on-table extubation. Only one patient was reintubated following on-table extubation resulting in a reintubation rate of 2.27% among those patients extubated on-table. The patients extubated on-table had a shorter ICU stay (25.89 ± 7.20 h) compared with those patients who underwent delayed extubation (59.30 ± 6.80 h). The duration of the hospital stay was also significantly reduced in these patients (91.09 ± 20.40 h) leading to an earlier discharge compared with those patients who underwent delayed extubation (134.40 ± 16.20 h). On-table extubation is an attractive alternative in limited-resource environments to enhance recovery in patients following congenital cardiac malformations. Owing to the lack of significant comorbidities such as Chronic Obstructive Pulmonary Disease (COPD) in this patient population, corrective surgery for cardiac malformation usually optimizes the cardiorespiratory status. This results in more chances of successful extubation immediately following surgery. However, this requires proper perioperative planning, a careful discussion about the choice of patients, adoption of an extubation protocol, and most importantly, a multidisciplinary team approach. It is associated with low morbidity and mortality, with reduced length of stay in the ICU and hospital. This preliminary study demonstrated that on-table extubation is feasible following congenital cardiac surgery at our center and greatly reduces the intensive care requirements. This article focuses mainly on the decision-making process which determines the ideal candidates for on-table extubation and the anesthetic protocol implemented in a low-resource environment to enable the same.

Safety and feasibility of immediate tracheal extubation of small pediatric patients after living donor liver transplantation.

Immediate extubation is integral constituent of enhance recovery protocols. Purpose of this study was to examine success rates and safety of protocolized immediate extubation in pediatric living donor liver transplant recipients and to find out factors associated with non-immediate extubation in operation room. We performed retrospective analysis for data of small (≤20 kg) pediatric patients transplanted between 2017 and 2019 (protocolized duration) and compared with data of transplants done between 2014 and 2016 (non-protocolized duration). Further, we compared data during each time duration between immediate extubation and non-immediate extubation group to find risk factors in that particular duration. Immediate extubation rates were significantly higher during protocolized duration compared with non-protocolized duration (85.52% vs. 48.29%, p < .001). Reintubation rates decreased during protocolized duration (10.9% vs. 4.6%). Hospital stays (20.47 ± 7.06 vs. 27.8 ± 6.2 days, p < .001) and mortality (13.2% vs. 28%, p=.04) were significantly decreased in protocolized duration. Higher age (OR: 2.85, 95% CI 1.22-6.67, p=.02), weight > 10 (OR: 4.37, 95% CI 1.16-16.46, p=.029) and high vasopressor support (OR: 32, 95% CI 6.4-160.13, p < .001) found as significant predictors of non-immediate extubation however only high vasopressor support found to be independent predictor during protocolized duration. Outcomes in pediatric transplants can be optimized by immediate extubation in majority of cases when protocolized as part of policy.

Clinical Characteristics and Mortality-Associated Factors in COVID-19 Critical Patients in a Portuguese ICU.

Severe COVID-19 is associated with serious complications and poor outcomes. Older age and underlying comorbidities are known risk factors for severe COVID-19, but a better understanding of baseline characteristics and outcomes of patients with severe COVID-19 is urgently needed. This study was a retrospective case series of 227 consecutive patients with laboratory-confirmed COVID-19 admitted to the intensive care unit (ICU) at our institution between March 2020 and December 2021. Demographic and clinical data were collected. The median age of patients was 65 years, and 180 (79.3%)were male. Cardiovascular comorbidities were frequent and included hypertension (n=148; 65.2%), dyslipidemia (n=116; 51.1%), obesity (n=114; 50.2%), and diabetes mellitus (n=80; 35.2%). About 20% of the patients had the chronic respiratory disease, with sleep apnea being the most common. Immunosuppression was identified in 13% of the patients, with autoimmunity, post-transplantation, and neoplasms being the most represented causes. Most patients were admitted to the ICU at six to 15 days after symptom onset, corresponding to stages IIb (pulmonary involvement/hypoxia) and III (hyperinflammatory). All patients received systemic steroids, with an average treatment duration of 22 days. Several ventilatory support strategies were used; 80 patients were supported entirely noninvasively with high flow nasal oxygenation and noninvasive ventilation, while 164 patients were invasively ventilated. Most intubations (65%) occurred in the first 24 hours after admission, and the mean duration of mechanical ventilation was 14 days. The reintubation rate was 10%, occurring on average two to three days after planned extubation. Thirty-two tracheostomies were performed. Bacterial co-infection was treated in 75% of patients, and Aspergillus co-infection complicating COVID-19 pneumonia was diagnosed in eight patients. Median ICU and hospital stays were 15 and 25 days, respectively, and the 28-day mortality rate was 38%. Patients over 75 years experienced a higher mortality rate (56%). Increased age and multimorbidity, particularly comprising cardiovascular disease and associated risk factors, were significantly more common in patients who died within 28 days after ICU admission. A large proportion of critically ill COVID-19 patients required prolonged mechanical ventilation. ICU/hospital stay and mortality were particularly elevated in older patients and patients with cardiovascular risk factors. Considerable discrepancy existed between the proportion of patients with microbiological documentation of bacterial infections and those receiving antimicrobials. Improved methods for adequate microbiological diagnosis are needed and stewardship programs should be reinforced.

Reducing duration of invasive mechanical ventilation for preterm infants

Mechanical ventilation contributes to bronchopulmonary dysplasia in preterm infants. We aimed to reduce the duration of ventilation by weaning ventilator settings within 1 h of “weanable” blood gases and extubating within 1 h of a “weanable” blood gas on “extubatable” ventilator settings. Infants born at < 32 weeks/< 1500 g were included. “Weanable” blood gases and “extubatable” ventilator settings were defined. Interventions included: a multidisciplinary BPD prevention team, extubation criteria, NICU education, a process for rapid notification of medical staff about all blood gas results, and monthly data dissemination. Extubations within 1 h of criteria increased from 64% to 88% after the dissemination of guidelines and education. The time to extubation decreased from 325 to 49 min, and the duration of intubation decreased from 8 to 3 days. However, the time for ventilator weaning did not change. Re-intubation rates did not change. Standardization of extubation led to decreased duration of mechanical ventilation.

Postoperative Alanine Aminotransferase Levels Are Associated with Outcomes in Pediatric Patients Undergoing Total Cavopulmonary Connection

Background: This single-center, retrospective study aims to determine the association between alanine aminotransferase (ALT) and outcomes in pediatric patients undergoing total cavopulmonary connection (TCPC). Methods: In total, 256 pediatric patients undergoing TCPC were included and divided into a normal-ALT group and a high-ALT group. Clinical data were collected for comparisons between groups, and risk factors of high postoperative ALT were identified by univariate and multivariate analysis. A ROC analysis of the predictive value of postoperative ALT was conducted. Results: Compared to the normal-ALT group, the members of the high-ALT group were 1.6 years older and had significantly higher preoperative creatinine and direct bilirubin levels. The high-ALT group had increased fluid overload, higher vasoactive inotropic drug scores, and inferior central venous pressure. The short-term outcomes in the high-ALT group were markedly worse: they suffered a longer duration of mechanical ventilation (MV), had a higher ICU and hospital length of stay (LOS), and higher rates of mortality, infection, and reintubation. Prolonged ICU and hospital LOS, longer MV, and reintubation were identified as independent risk factors for high postoperative ALT. Postoperative ALT was of high value in predicting reintubation, MV, ICU LOS, and mortality. Conclusions: Elevated postoperative ALT levels are associated with poor short-term outcomes in pediatric patients undergoing TCPC.