Mechanical Ventilation Discontinuation Practices in Asia: A Multinational Survey.

Rationale: There are limited data on mechanical discontinuation practices in Asia. Objectives: To document self-reported mechanical discontinuation practices and determine whether there is clinical equipoise regarding protocolized weaning among Asian Intensive Care specialists. Methods: A survey using a validated questionnaire, distributed using a snowball method to Asian Intensive Care specialists. Results: Of the 2,967 invited specialists from 20 territories, 2,074 (69.9%) took part. The majority of respondents (60.5%) were from China. Of the respondents, 42% worked in intensive care units (ICUs) where respiratory therapists were present; 78.9% used a spontaneous breathing trial as the initial weaning step; 44.3% frequently/always used pressure support (PS) alone, 53.4% intermittent spontaneous breathing trials with PS in between, and 19.8% synchronized intermittent mandatory ventilation with PS as a weaning mode. Of the respondents, 56.3% routinely stopped feeds before extubation, 71.5% generally followed a sedation protocol or guideline, and 61.8% worked in an ICU with a weaning protocol. Of these, 78.2% frequently always followed the protocol. A multivariate analysis involving a modified Poisson regression analysis showed that working in an ICU with a weaning protocol and frequently/always following it was positively associated with an upper-middle-income territory, a university-affiliated hospital, or in an ICU that employed respiratory therapists; and negatively with a low-income or lower-middle-income territory or a public hospital. There was no significant association with "in-house" intensivist at night, multidisciplinary ICU, closed ICU, or nurse-patient ratio. There was heterogeneity in agreement/disagreement with the statement, "evidence clearly supports protocolized weaning over nonprotocolized weaning." Conclusions: A substantial minority of Asian Intensive Care specialists do not wean patients in accordance with the best available evidence or current guidelines. There is clinical equipoise regarding the benefit of protocolized weaning.

An Alternate In-Plane Technique of Ultrasound-Guided Internal Jugular Vein Cannulation.

BACKGROUND: Commonly used ultrasound-guided internal jugular vein (IJV) cannulation techniques, short axis out of plane and long axis in-plane, have significantly reduced complications but failed to eliminate them because of technical difficulties. OBJECTIVE: This article describes a new anteroposterior short axis in-plane technique that combines advantage of in-plane technique to track the needle tip and short axis view of visualizing nearby anatomical structures by placing the probe on the side of the neck, oriented anteroposteriorly, perpendicular to the long axis of neck. This view visualizes IJV and its relationship to the carotid artery in short axis. The puncture needle is passed in-plane anteroposteriorly from the anterior aspect of the neck. Visualizing the needle, carotid artery, and IJV in single frame minimizes complications. METHODS: A prospective evaluative clinical trial was conducted in patients who require IJV cannulation for various reasons by performers experienced in ultrasound-guided IJV cannulations. The efficacy of the technique is indicated by 3 primary outcome measures: access time, number of attempts and success rate, and safety by secondary outcome measure, which is the incidence of mechanical complications. RESULTS: Seventy-five patients were enrolled. The average number of attempts was 1.17 (standard deviation 0.44), the access time was 27.12 s (standard deviation 21.47), and the success rate was 100%. This technique had 12% incidence of posterior venous wall punctures and 2.66% misplacements and no other complications. CONCLUSION: Anteroposterior short axis in-plane technique is relatively novel and could be alternatively used safely and effectively in place of existing techniques for IJV cannulation.

Optimum time for intravenous cannulation after induction with sevoflurane, oxygen, and nitrous oxide in children without any premedication.

BACKGROUND: Intravenous cannulation is usually done in children after inhalational induction with volatile anesthetic agents. The optimum time for safe intravenous cannulation after induction with sevoflurane, oxygen, and nitrous oxide has been studied in premedicated children, but there is no information for the optimum time for cannulation with inhalational induction in children without premedication. AIMS: The aim of this study was to determine the optimum time for intravenous cannulation after the induction of anesthesia with sevoflurane, oxygen, and nitrous oxide in children without any premedication. METHODS: This is a prospective, observer-blinded, up-and-down sequential allocation study in unpremedicated ASA grade 1 children aged 2-6 years undergoing elective dental surgery. Intravenous cannulation was attempted after inhalational induction with sevoflurane, oxygen, and nitrous oxide. The timing of cannulation was considered adequate if there was no movement, coughing, or laryngospasm. The cannulation attempt for the first child was set at 4 minutes after the loss of eyelash reflex and the time for intravenous cannulation was determined by the up-and-down method using 15 seconds as step size. Probit test was used to analyze the up-down sequences for the study. RESULTS: The adequate time for effective cannulation after induction with sevoflurane, oxygen, and nitrous oxide in 50% and 95% of patients was 53.02 seconds (95% confidence limits, 20.23-67.76 seconds) and 87.21 seconds (95% confidence limits, 70.77-248.03 seconds), respectively. CONCLUSION: We recommend waiting for 1 minute 45 seconds (105 seconds) after the loss of eyelash reflex before attempting intravenous cannulation in pediatric patients induced with sevoflurane, oxygen, and nitrous oxide without any premedication.