Microalbuminuria assessment after thoracic surgery: Early identification of complication risks.

INTRODUCTION: Microalbuminuria (MA) is considered a reflection of systemic capillary leak and an early marker of acute stress reaction to the surgical insult, proportional to the severity of the initiating condition and predictive of the individual response to surgical stress. OBJECTIVES: We conducted a prospective study to assess for the variation of MA within 4 days after thoracic surgery. We correlated observed MA levels with both their respective PaO2 /FiO2 respiratory ratio and the onset of postoperative complications. METHODS: This single-centre study enrolled 255 consecutive patients having an American Society of Anaesthesiologists (ASA) score ≤ 3. The mean age was 62 years with 67% male. All patients were scheduled for elective pulmonary resection. MA was measured in urine samples as the albumin-to-creatinine ratio (A/C), prior to, at and after extubation up to 96 hours. PaO2 /FiO2 was measured at extubation and on the first postoperative day. RESULTS: Overall, preoperative A/C levels resulted normal, with a significant average increase at extubation which peaked 6 hours later (P < 0.001). Larger postoperative A/C increases were observed in patients who developed postoperative complications, compared to those without these complications (P < 0.019). Moreover, patients undergoing major open pulmonary resections had larger postoperative A/C increases, compared to those undergoing minor video-assisted thoracic surgery resections (P < 0.006). At the time of extubation, A/C was inversely related to the PaO2 /FiO2 ratio (r = -0.25; P = 0.038). Peak A/C > 61 mg/g (P = 0.0003) was associated with postoperative cardio-pulmonary complications (OR 3.85; P = 0.003). CONCLUSION: Within 6 hours after extubation, MA assessment may be a rapid and relatively inexpensive method for better predicting perioperative risk in an ASA score ≤ 3 population.

Assessment of a multimodal analgesia protocol to allow the implementation of enhanced recovery after cardiac surgery: Retrospective analysis of patient outcomes.

STUDY OBJECTIVE: To investigate the impact of utilizing a multimodal analgesia protocol to allow the implementation of Enhanced Recovery after Cardiac Surgery (ERACS) in patients requiring cardio-pulmonary bypass. DESIGN: Retrospective analysis of patients treated with the proposed ERACS bundle in comparison to matched controls. SETTING: Single-center study. PATIENTS: A total of 50 patients undergoing elective cardiac surgery limited to on pump coronary artery bypass graft. MEASUREMENTS: Perioperative outcomes of 25 patients that underwent ERACS protocol and 25 controls were measured. In-operating room (OR) extubation, total intubation time, total intra-OP fentanyl given, total post-OP morphine equivalent given, intensive care unit (ICU) length of stay (LOS), hospital LOS and post-OP complications were examined. MAIN RESULTS: The ERACS group and control group were equivalent with regards to age, gender, comorbidities, ASA classification and type of surgery. Mean cardiac bypass time and mean aortic clamp time were similar. Extubation in the OR was achieved for 12 patients in the ERACS group compared to 1 in the control group. Post-operative opioid consumption was lower in ERACS group (27.3 vs. 51.7 morphine equivalents, p = 0.006). Although ICU LOS and hospital LOS were shorter in the ERACS group, this did not reach significance. CONCLUSIONS: The ERACS group showed a significant decrease in opioid use and increased incidence of successful in OR extubation.

An Interprofessional Quality Improvement Initiative to Standardize Pediatric Extubation Readiness Assessment.

OBJECTIVES: Establishing protocols to wean mechanical ventilation and assess readiness for extubation, with the goal of minimizing morbidity associated with extubation failure and prolonged mechanical ventilation, have become increasingly important in contemporary PICUs. The aim of this quality improvement initiative is to establish a respiratory therapist-led daily spontaneous breathing trial protocol to standardize extubation readiness assessment and documentation in our PICU. DESIGN: A quality improvement project. SETTING: Single center, tertiary care Children's Hospital PICU. PATIENTS: All intubated patients admitted to PICU requiring conventional mechanical ventilation between February 2013 and January 2016. INTERVENTIONS: A working group of pediatric intensivists, respiratory therapists, nurses, and information technology specialists established the protocol, standardized documentation via the electronic medical record, and planned education. Daily spontaneous breathing trial protocol implementation began in February 2015. All patients on mechanical ventilation were screened daily at approximately 4 AM by a respiratory therapist to determine daily spontaneous breathing trial eligibility. If all screening criteria were met, patients were placed on continuous positive airway pressure of 5 cm H2O with pressure support of 8 cm H2O for up to 2 hours. If tolerated, patients would be extubated to supplemental oxygen delivered via nasal cannula in the morning, after intensivist approval. Daily audits were done to assess screening compliance and accuracy of documentation. MEASUREMENTS AND MAIN RESULTS: We analyzed data from 398 mechanically ventilated patients during daily spontaneous breathing trial period (February 2015-January 2016), compared with 833 patients from the pre-daily spontaneous breathing trial period (February 2013-January 2015). During the daily spontaneous breathing trial period, daily screening occurred in 92% of patients. Extubation failure decreased from 7.8% in the pre-daily spontaneous breathing trial period to 4.5% in daily spontaneous breathing trial period. The use of high-flow nasal cannula slightly increased during the project, while there was no change in duration of mechanical ventilation or the use of noninvasive ventilation. CONCLUSIONS: An interprofessionally developed respiratory therapist-led extubation readiness protocol can be successfully implemented in a busy tertiary care PICU without adverse events.

An Airway Risk Assessment Score for Unplanned Extubation in Intensive Care Pediatric Patients.

OBJECTIVE: As a result of a workshop to identify common causes of unplanned extubation, Children's Healthcare of Atlanta developed a scoring tool (Risk Assessment Score) to stratify patients into groups of low, moderate, high, and extreme risk. This tool could be used to institute appropriate monitoring or interventions for patients with high risks of unplanned extubation to enhance safety. The objective of this study is to test the hypothesis that the Risk Assessment Score will correlate with the occurrence rate of unplanned extubation in pediatric patients. DESIGN: Retrospective review of 2,811 patients at five ICUs conducted between December 2012 and July 2014. SETTING: Five ICUs at two freestanding pediatric hospitals within a large children's healthcare system in the United States. PATIENTS: All intubated pediatric patients. INTERVENTIONS: Data of intubations and Risk Assessment Score were collected. Extubation outcomes and severity levels were compared across demographic groups and with the maximum Risk Assessment Score of each intubation. MEASUREMENTS AND MAIN RESULTS: Out of 4,566 intubations, 244 were unplanned extubations (5.3%). The occurrence rates of unplanned extubations in those less than 1, 1-6, and more than 6 years old were 6.7%, 3.6%, and 2.7%, respectively, corresponding to a rate of 0.59, 0.53, and 0.58 unplanned extubation every 100 ventilator days. The occurrence rates were 13.6% for patients weighing less than 1 kg (0.59 unplanned extubation per 100 ventilation days) and 3.8% for patients weighing greater than or equal to 1 kg (0.58 unplanned extubation per 100 ventilation days). For intubations with maximum risk score falling in risk categories of low, moderate, high, and extreme, the occurrence rates were 4.7%, 7.7%, 12.0%, and 8.3%, respectively, which corresponded to rates of 0.54, 0.62, 0.95, and 0.92 unplanned extubation per 100 ventilator days. CONCLUSIONS: Higher Risk Assessment Scores are associated with occurrence rates of unplanned extubation.

Assessment of Risk Factors for a Sustainable "On-Table Extubation" Program in Pediatric Congenital Cardiac Surgery: 5-Year Experience.

OBJECTIVE: To delineate risk factors for failure of extubation in the operating room among pediatric cardiac surgery patients. DESIGN: Prospective, observational study. SETTING: Single center, tertiary care, teaching hospital. PARTICIPANTS: The study comprised 448 congenital cardiac surgery patients who were enrolled for intended extubation in the pediatric cardiac operating room over 5 years. INTERVENTIONS: The airways of enrolled patients were extubated in the operating room if predetermined suitability criteria were met. If the criteria were not met, patients were transferred to the intensive care unit with an endotracheal tube in situ. Patients whose airways were extubated successfully were followed up to determine specifically whether reintubation or use of noninvasive ventilation was necessary post-procedure. MEASUREMENTS AND MAIN RESULTS: The airways of 92% (412) patients were extubated in the operating room. Incidence of reintubation in the intensive care unit was 2.4%. There were 4 mortalities in the whole group. A 100% success rate for operating room extubation was achieved for patients in Risk Adjusted Congenital Heart Surgery category 1, and patients undergoing adult congenital cardiac disease surgery and redo sternotomy. The airways of 85% of patients with preoperative pulmonary hypertension were extubated in the operating room. Statistical analysis was applied to identify risk factors present in the group that made extubation in the operating room unachievable. CONCLUSIONS: Extubation in the operating room was successful in a majority of patients undergoing cardiac surgery. Multivariate analysis identified weight<5 kg, age<1 year, cardiopulmonary bypass time>120 minutes, and presence of significant noncardiac structural anomalies as significant factors affecting extubation in the operating room, with an adjusted odds ratio (95% confidence interval) of 10 (2.7-37), 7.2 (2-22), 5.5 (1.7-17.7), and 3.3 (1.2-9.3), respectively. Pulmonary hypertension, redo sternotomy, higher Risk Adjusted Congenital Heart Surgery category, and aortic clamp time>60 minutes did not achieve significance in the multivariate analysis as risk factors for extubation in the operating room.

Preoperative and Intraoperative Predictive Factors of Immediate Extubation After Neonatal Cardiac Surgery.

BACKGROUND: We sought to identify preoperative and intraoperative predictors of immediate extubation (IE) after open heart surgery in neonates. The effect of IE on the postoperative intensive care unit (ICU) length of stay (LOS), cost of postoperative ICU care, operating room turnover, and reintubation rates was assessed. METHODS: Patients younger than 31 days who underwent cardiac surgery with cardiopulmonary bypass (January 2010 to December 2013) at a tertiary-care children's hospital were studied. Immediate extubation was defined as successful extubation before termination of anesthetic care. Data on preoperative and intraoperative variables were compared using descriptive, bivariate, and multivariate statistics to identify the predictors of IE. Propensity scores were used to assess effects of IE on ICU LOS, the cost of ICU care, reintubation rates, and operating room turnover time. RESULTS: One hundred forty-eight procedures done at a median age of 7 days resulted in 45 IEs (30.4%). The IE rate was 22.2% with single-ventricle heart disease. Independent predictors of IE were the absence of the need for preoperative ventilatory assistance, higher gestational age, anesthesiologist, and shorter cardiopulmonary bypass. Immediate extubation was associated with shorter ICU LOS (8.3 versus 12.7 days; p < 0.0001) and lower cost of ICU care (mean postoperative ICU charges, $157,449 versus $198,197; p < 0.0001) with no significant difference in the probability of reintubation (p = 0.7). Immediate extubation was associated with longer operating room turnover time (38.4 versus 46.7 minutes; p = 0.009). CONCLUSIONS: Immediate extubation was accomplished in 30.4% of neonates undergoing open heart surgery involving cardiopulmonary bypass. Immediate extubation was associated with lesser ICU LOS, postoperative ICU costs, and minimal increase in operating room turnover time, but without an increase in reintubation rates. Low gestational age, preoperative ventilatory support requirement, and prolonged cardiopulmonary bypass time were inversely associated with the ability to accomplish IE.

The impact of human rhinovirus infection in pediatric patients undergoing heart surgery.

Human rhinovirus (HRV), the most common cause of upper respiratory infection in children, can present as bronchiolitis, pneumonia, or asthma exacerbations. The impact of HRV in infants and toddlers with congenital heart disease is poorly defined. A case-control study was performed to compare the clinical course for 19 young children with respiratory symptoms who tested positive for rhinovirus after heart surgery with that of 56 matched control subjects. The control subjects were matched by surgical repair, age, weight, and time of the year. Patients with known HRVs before surgery and control subjects with respiratory symptoms or positive test results for viruses were excluded from the study. Human rhinovirus infection was associated with more than a tenfold increase in the odds of noninvasive ventilation after extubation (odds ratio [OR] 11.45; 95 % confidence interval [CI] 3.97-38.67), a 12-fold increase in the probability of extubation failure (OR 12.84; 95 % CI 2.93-56.29), and increased use of pulmonary medications including bronchodilator and nitric oxide (p < 0.001). As a result, the hospital length of stay (HLOS) was two times longer than for the control subjects (p < 0.001), and the cardiac intensive care unit (CICU) length of stay (CICU LOS) was three times longer (p < 0.0001). The intubation time was significantly longer (p < 0.001), and the CICU respiratory charges were significantly greater (p = 0.001) for the infected patients. Human rhinovirus increases resource use and prolongs postoperative recovery after pediatric heart surgery. Surgery timing should be delayed for patients with rhinovirus if possible.

Predicting weaning and extubation outcomes in long-term mechanically ventilated patients using the modified Burns Wean Assessment Program scores.

BACKGROUND AND OBJECTIVE: A number of clinical factors play pivotal roles in weaning and successful extubation of patients requiring long-term mechanical ventilator (LTMV) support. Many patients fail extubation even after passing weaning protocols and spontaneous breathing trials. This study aimed to assess the effectiveness of using a modified Burns Wean Assessment Program (m-BWAP) scoring instrument to predict extubation outcome in patients requiring LTMV. METHODS: All patients with a diagnostic coding for respiratory failure requiring LTMV for longer than 21 days over a 5-year period in a single centre (total 527 patients) were included. Advanced practice nurses trained in the use of the m-BWAP scored the items according to standard definitions. All patients were weaned by pressure support weaning and spontaneous breathing trails. Patients were divided into successful and unsuccessful groups according to the weaning and extubation outcomes. Baseline data, traditional weaning parameters and m-BWAP of the groups were analysed. The sensitivity and specificity of m-BWAP for predicting successful extubation were calculated. RESULTS: Of the 527 patients included, 145 (27.5%) had successful weaning trials. Of the 130 patients extubated, 102 (78.5%) had successful extubation. The m-BWAP score was higher in the patients with successful weaning trials and successful extubation outcome. Using a cut-off value of 60, the sensitivity and specificity of the m-BWAP to predict successful extubation were 81.4% and 82.1%, respectively. This was better than traditional weaning parameters. CONCLUSIONS: The m-BWAP is a good predictor for weaning and extubation outcome in patients requiring LTMV for longer than 21 days.