Noninvasive ventilation on reintubation in patients with obesity and hypoxemic respiratory failure following abdominal surgery: a post hoc analysis of a randomized clinical trial.

PURPOSE: Although noninvasive ventilation (NIV) may reduce reintubation in patients with acute hypoxemic respiratory failure following abdominal surgery, this strategy has not been specifically assessed in patients with obesity. METHODS: We conducted a post hoc analysis of a multicenter randomized controlled trial comparing NIV delivered via facial mask to standard oxygen therapy among patients with obesity and acute hypoxemic respiratory failure within 7 days after abdominal surgery. The primary outcome was reintubation within 7 days. Secondary outcomes were invasive ventilation-free days at day 30, intensive care unit (ICU)-acquired pneumonia and 30-day survival. RESULTS: Among 293 patients with hypoxemic respiratory failure following abdominal surgery, 76 (26%) patients had obesity and were included in the intention-to-treat analysis. Reintubation rate was significantly lower with NIV (13/42, 31%) than with standard oxygen therapy (19/34, 56%) within 7 days (absolute difference: - 25%, 95% confidence interval (CI) - 49 to - 1%, p = 0.03). NIV was associated with significantly more invasive ventilation-free days compared with standard oxygen therapy (27.1 ± 8.6 vs 22.7 ± 11.1 days; p = 0.02), while fewer patients developed ICU-acquired pneumonia (1/42, 2% vs 6/34, 18%; p = 0.04). The 30-day survival was 98% in the NIV group (41/42) versus 85% in the standard oxygen therapy (p = 0.08). In patients with body mass index (BMI) < 30 kg/m2, no significant difference was observed between NIV (36/105, 34%) and standard oxygen therapy (47/109, 43%, p = 0.03). An interaction test showed no statistically significant difference between the two subsets (BMI ≥ 30 kg/m2 and BMI < 30 kg/m2). CONCLUSIONS: Among patients with obesity and hypoxemic respiratory failure following abdominal surgery, use of NIV compared with standard oxygen therapy reduced the risk of reintubation within 7 days, contrary to patients without obesity. However, no interaction was found according to the presence of obesity or not, suggesting either a lack of power to conclude in the non-obese subgroup despite existing differences, or that the statistical difference found in the overall sample was driven by a large effect in the obese subsets.

Effect of Noninvasive Ventilation on Tracheal Reintubation Among Patients With Hypoxemic Respiratory Failure Following Abdominal Surgery: A Randomized Clinical Trial.

IMPORTANCE: It has not been established whether noninvasive ventilation (NIV) reduces the need for invasive mechanical ventilation in patients who develop hypoxemic acute respiratory failure after abdominal surgery. OBJECTIVE: To evaluate whether noninvasive ventilation improves outcomes among patients developing hypoxemic acute respiratory failure after abdominal surgery. DESIGN, SETTING, AND PARTICIPANTS: Multicenter, randomized, parallel-group clinical trial conducted between May 2013 and September 2014 in 20 French intensive care units among 293 patients who had undergone abdominal surgery and developed hypoxemic respiratory failure (partial oxygen pressure <60 mm Hg or oxygen saturation [SpO2] ≤90% when breathing room air or <80 mm Hg when breathing 15 L/min of oxygen, plus either [1] a respiratory rate above 30/min or [2] clinical signs suggestive of intense respiratory muscle work and/or labored breathing) if it occurred within 7 days after surgical procedure. INTERVENTIONS: Patients were randomly assigned to receive standard oxygen therapy (up to 15 L/min to maintain SpO2 of 94% or higher) (n = 145) or NIV delivered via facial mask (inspiratory pressure support level, 5-15 cm H2O; positive end-expiratory pressure, 5-10 cm H2O; fraction of inspired oxygen titrated to maintain SpO2 ≥94%) (n = 148). MAIN OUTCOMES AND MEASURES: The primary outcome was tracheal reintubation for any cause within 7 days of randomization. Secondary outcomes were gas exchange, invasive ventilation-free days at day 30, health care-associated infections, and 90-day mortality. RESULTS: Among the 293 patients (mean age, 63.4 [SD, 13.8] years; n=224 men) included in the intention-to-treat analysis, reintubation occurred in 49 of 148 (33.1%) in the NIV group and in 66 of 145 (45.5%) in the standard oxygen therapy group within+ 7 days after randomization (absolute difference, -12.4%; 95% CI, -23.5% to -1.3%; P = .03). Noninvasive ventilation was associated with significantly more invasive ventilation-free days compared with standard oxygen therapy (25.4 vs 23.2 days; absolute difference, -2.2 days; 95% CI, -0.1 to 4.6 days; P = .04), while fewer patients developed health care-associated infections (43/137 [31.4%] vs 63/128 [49.2%]; absolute difference, -17.8%; 95% CI, -30.2% to -5.4%; P = .003). At 90 days, 22 of 148 patients (14.9%) in the NIV group and 31 of 144 (21.5%) in the standard oxygen therapy group had died (absolute difference, -6.5%; 95% CI, -16.0% to 3.0%; P = .15). There were no significant differences in gas exchange. CONCLUSIONS AND RELEVANCE: Among patients with hypoxemic respiratory failure following abdominal surgery, use of NIV compared with standard oxygen therapy reduced the risk of tracheal reintubation within 7 days. These findings support use of NIV in this setting. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01971892.

Left ventricular-right atrial communication with third-degree atrioventricular block after thoracic trauma.

BACKGROUND: Intracardiac shunts are rare but very serious lesions after non-penetrating chest trauma. Their diagnosis is difficult. This pathology often goes unrecognized in the context of multiple trauma. CASE REPORT: We report the case of a 21-year-old man involved in a motor vehicle crash who presented with multiple injuries including myocardial contusion, severe brain injury, multiple pelvic fractures, closed femur fracture, bilateral lung contusion with a right pneumothorax, and intra-abdominal injuries. Three days after the initial event, a new cardiac murmur and complete heart block appeared. Transthoracic echocardiography (echo) followed by transesophageal echo revealed a high-velocity flow communication between the left ventricle and the right atrium. The patient underwent delayed cardiac surgery due to other unstable injuries. The hospital course was prolonged but favorable, and the patient left the hospital 1 month later without any neurologic or cardiologic after-effect. CONCLUSION: This case highlights the potential for cardiac complications to occur in any patient with serious thoracic trauma. Transesophageal echo should be performed on any trauma patient with electrocardiographic abnormalities.

Surgical repair of rupture of the membranous septum after blunt chest trauma.

Rupture of the membranous septum is a very rare complication of blunt chest trauma. In this report, we describe a 22-year-old man who sustained multiple blunt trauma injuries during a motor vehicle accident. Rupture of the membranous septum was diagnosed 48 hours after the initial trauma and the defect was closed with Gore-Tex (W.L. Gore & Assoc, Flagstaff, AZ). However, the operation was complicated by complete atrioventricular block requiring implantation of a permanent DDD pacemaker.

[Epidural hematoma after hemorrhagic shock in a parturient]. / Hématome péridural chez une parturiente au décours d'un choc hémorragique.

PURPOSE: Epidural hematoma is a rare but serious complication of epidural anesthesia. We report a case of epidural hematoma, occurring in an obstetric patient after the epidural catheter had been withdrawn accidentally after an episode of hemorrhagic shock leading to a hypocoagulable state. CLINICAL FEATURES: A patient had the epidural catheter inserted during labour when coagulation was normal. She had a postpartum hemorrhage with alteration of coagulation (platelets 16 x 10(-9) x L(-1), thrombin time: 85 sec. Vital signs returned to normal after a general anesthetic, transfusion of blood products, volume repletion and ligation of hypogastric arteries. It was then noticed that the epidural catheter had been withdrawn inadvertently while the patient was hypocoagulable. The patient then developed neurological signs consistent with spinal cord compression due to an epidural hematoma. A hematoma extending from T3 to L5 was diagnosed by magnetic resonance imaging. Because the cord had minimal compression, no specific action was undertaken, other than clinical and radiological follow-up. There were no long-term sequelae. CONCLUSION: In the presence of an epidural hematoma, surgery for emergency cord decompression is usually required. Another option that receives increasing attention is to monitor neurological function, but the indications for this expectant treatment are not well defined.

Boerhaave's syndrome after postoperative vomiting.

UNLABELLED: Postoperative nausea and vomiting are common after general anesthesia but rarely produce life-threatening conditions. We report a case of postoperative vomiting complicated by esophageal rupture (Boerhaave's syndrome). As this complication is quite rare and can have varied and atypical presentations, anesthesiologists may fail to consider this diagnosis. IMPLICATIONS: We report a case of postoperative vomiting complicated by esophageal rupture (Boerhaave's syndrome). As this complication is quite rare, anesthesiologists may fail to consider this diagnosis.