Critical Events Leading to Endotracheal Reintubation in the Postanesthesia Care Unit: A Retrospective Inquiry of Contributory Factors.

The tracheal reintubation of a surgical patient in the postanesthesia care unit (PACU) is a critical event that increases patient morbidity and mortality, cost, and staff demands. We performed a descriptive retrospective cohort study to identify the incidence of reintubation after planned extubation (RAP) in the PACU from 2010 to 2017. The incidence of RAP was 0.00083% (89/107,845) for the entire study period, an incidence range from 0.00014% to 0.00172% (1/7,407 to 26/15,139) with a steady decline from 2011 to 2017. A post hoc application of published prediction tools demonstrated that most RAP cases could be predicted preoperatively when the RAP predictive risk index (described in 2013) was applied to patients over the age of 64 years. Preoperative attention to increased risk of RAP decreases the incidence of RAP. Neuromuscular blockade (NMB) must be monitored, and reversal must be ensured. Attempting to reverse moderate to deep NMB with increased dosing of neostigmine should be avoided, and NMB reversal with sugammadex should be used in these cases and when residual weakness is observed. Hypothermia must be avoided, and a multimodal pain management regimen must be adopted.

The ECLIPSE trials: comparative studies of clevidipine to nitroglycerin, sodium nitroprusside, and nicardipine for acute hypertension treatment in cardiac surgery patients.

BACKGROUND: Acute hypertension during cardiac surgery can be difficult to manage and may adversely affect patient outcomes. Clevidipine is a novel, rapidly acting dihydropyridine L-type calcium channel blocker with an ultrashort half-life that decreases arterial blood pressure (BP). The Evaluation of CLevidipine In the Perioperative Treatment of Hypertension Assessing Safety Events trial (ECLIPSE) was performed to compare the safety and efficacy of clevidipine (CLV) with nitroglycerin (NTG), sodium nitroprusside (SNP), and nicardipine (NIC) in the treatment of perioperative acute hypertension in patients undergoing cardiac surgery. METHODS: We analyzed data from three prospective, randomized, open-label, parallel comparison studies of CLV to NTG or SNP perioperatively, or NIC postoperatively in patients undergoing cardiac surgery at 61 medical centers. Of the 1964 patients enrolled, 1512 met postrandomization inclusion criteria of requiring acute treatment of hypertension based on clinical criteria. The patients were randomized 1:1 for each of the three parallel comparator treatment groups. The primary outcome was the incidence of death, myocardial infarction, stroke or renal dysfunction at 30 days. Adequacy and precision of BP control was evaluated and is reported as a secondary outcome. RESULTS: There was no difference in the incidence of myocardial infarction, stroke or renal dysfunction for CLV-treated patients compared with the other treatment groups. There was no difference in mortality rates between the CLV, NTG or NIC groups. Mortality was significantly higher, though, for SNP-treated patients compared with CLV-treated patients (P=0.04). CLV was more effective compared with NTG (P=0.0006) or SNP (P=0.003) in maintaining BP within the prespecified BP range. CLV was equivalent to NIC in keeping patients within a prespecified BP range; however, when BP range was narrowed, CLV was associated with fewer BP excursions beyond these BP limits compared with NIC. CONCLUSIONS: CLV is a safe and effective treatment for acute hypertension in patients undergoing cardiac surgery.

A phase II, double-blind, placebo-controlled, ascending-dose study of Eritoran (E5564), a lipid A antagonist, in patients undergoing cardiac surgery with cardiopulmonary bypass.

BACKGROUND: Lipid A, the toxic moiety of endotoxin, is linked to multiple complications after cardiac surgery, including fever, vasodilation, and pulmonary and renal dysfunction. The lipid A antagonist eritoran (or E5564) prevents endotoxin-induced systemic inflammation in animals and humans. In this study we assessed the safety of eritoran administration in patients undergoing cardiac surgery and obtained preliminary efficacy data for the prophylaxis of endotoxin-mediated surgical complications. METHODS: A double-blind, randomized, ascending-dose, placebo-controlled study was conducted at nine hospitals. Patients undergoing coronary artery bypass graft and/or cardiac valvular surgery with cardiopulmonary bypass were enrolled. Patients received a 4-h infusion of placebo (n = 78) vs 2 mg (n = 24), 12 mg (n = 26), or 28 mg (n = 24) of eritoran initiated approximately 1 h before cardiopulmonary bypass. RESULTS: No significant safety concerns were identified with continuous safety monitoring, and enrollment continued to the highest prespecified dose (28 mg). No statistically significant differences were observed in most variables related to systemic inflammation or organ dysfunction/injury. CONCLUSIONS: This Phase II safety study suggests that the administration of the novel lipid A antagonist, eritoran, is not associated with overt toxicity in cardiac surgical patients. Blocking lipid A with eritoran does not appear to confer any clear benefit to elective cardiac surgical patients.

No bacterial growth found in spiked intravenous fluids over an 8-hour period.

Protocol changes prompted by the Joint Commission mandating intravenous (IV) fluid bags to be used within 1 hour of spiking because of possible bacterial contamination have sparked clinical and economic concerns. This study investigated the degree of bacterial growth in which samples were obtained from spiked IV fluid bags at the time of spiking and 1, 2, 4, and 8 hours after spiking. No bacterial growth occurred in any of the 80 bags of Lactated Ringer's (LR) IV solutions sampled. This study demonstrated that LR IV bags do not support any bacterial growth for up to 8 hours after spiking.