Your browser doesn't support javascript.
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 402
Filtrar
1.
Br J Anaesth ; 124(1): 63-72, 2020 01.
Artículo en Inglés | MEDLINE | ID: mdl-31607388

RESUMEN

BACKGROUND: The prospective observational European multicentre cohort study (POPULAR) of postoperative pulmonary complications (NCT01865513) did not demonstrate that adherence to the recommended train-of-four ratio (TOFR) of 0.9 before extubation was associated with better pulmonary outcomes from the first postoperative day up to hospital discharge. We re-analysed the POPULAR data as to whether there existed a better threshold for TOFR recovery before extubation to reduce postoperative pulmonary complications in patients who had quantitative neuromuscular monitoring (87% acceleromyography). METHODS: To identify the optimal TOFR, the complete case cohort of patients with quantitative neuromuscular monitoring (n=3150) was split into several pairs of sub-cohorts related to TOFR values from 0.86 to 0.96; values of 0.97 and higher could not be used as the sub-cohorts were too small. The optimal TOFR was considered to have the lowest P-value from multivariate logistic regression calculated for each of the TOFR values. Data are presented as adjusted absolute risk reduction or median difference with 95% confidence interval. RESULTS: Extubating patients with TOFR >0.95 rather than >0.9 reduced the adjusted risk of postoperative pulmonary complications by 3.5% (0.7-6.0%) from that reported in POPULAR (11.3%). Increasing the recommended TOFR from 0.9 to 0.95 reduced the adjusted risk by 4.9% (1.2-8.5%). Sub-cohorts resulting from 1:1 propensity score matching revealed that sugammadex had been given in higher doses by 0.30 (0.13-0.48) mg kg-1 in the sub-cohort with TOFR > 0.95. CONCLUSIONS: A post hoc analysis of patients receiving quantitative monitoring of neuromuscular function suggests that postoperative pulmonary complications are reduced for TOFR > 0.95 before tracheal extubation compared with TOFR > 0.9. TRIAL REGISTRATION NUMBER: NCT01865513.


Asunto(s)
Extubación Traqueal/métodos , Monitorización Neurofisiológica Intraoperatoria/métodos , Monitoreo Neuromuscular/métodos , Complicaciones Posoperatorias/prevención & control , Adulto , Anciano , Anciano de 80 o más Años , Anestesia , Estudios de Cohortes , Europa (Continente) , Femenino , Humanos , Masculino , Persona de Mediana Edad , Bloqueo Neuromuscular/métodos , Bloqueantes Neuromusculares , Complicaciones Posoperatorias/epidemiología , Puntaje de Propensión , Estudios Prospectivos , Conducta de Reducción del Riesgo , Sugammadex , Adulto Joven
2.
Ann Otol Rhinol Laryngol ; 129(1): 55-62, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31801377

RESUMEN

OBJECTIVE: The purpose of this study was to describe typical anesthesia practices for children with obstructive sleep apnea (OSA). STUDY DESIGN: Online survey. METHOD: A sample of pediatric anesthesiologists received the survey by email. RESULTS: 110 respondents were included. 46.4% worked in a free-standing children's hospital and 32.7% worked in a children's facility within a general hospital. 73.6% taught residents. 44.4% saw at least one child with OSA per week, 25.5% saw them daily. On a 100-mm visual analog scale, respondents rated their comfort with managing these children as 84.94 (SD 17.59). For children with severe OSA, 53.6% gave oral midazolam preoperatively, but 24.5% typically withheld premedication and had the parent present for induction. 68.2% would typically use nitrous oxide for inhalational induction. 68.2% used fentanyl intraoperatively, while 20.0% used morphine. 61.5% reduced their intraop narcotic dose for children with OSA. 98.2% used intraoperative dexamethasone, 58.2% used 0.5 mg/kg for the dose. 98.2% used ondansetron, 62.7% used IV acetaminophen, and 8.2% used IV NSAIDs. 83.6% extubated awake. 27.3% of respondents stated that their institution had standardized guidelines for perioperative management of children with OSA undergoing adenotonsillectomy. People who worked in children's hospitals, who had >10 years of experience, or who saw children with OSA frequently were significantly more comfortable dealing with children with OSA (P < 0.05). CONCLUSION: Apart from using intraoperative dexamethasone and ondansetron, management varied. These children would likely benefit from best practices perioperative management guidelines.


Asunto(s)
Analgésicos/uso terapéutico , Anestesiología , Anestésicos/uso terapéutico , Antieméticos/uso terapéutico , Pediatría , Pautas de la Práctica en Medicina , Apnea Obstructiva del Sueño/cirugía , Tonsilectomía , Acetaminofén/uso terapéutico , Adenoidectomía , Extubación Traqueal/métodos , Antiinflamatorios no Esteroideos/uso terapéutico , Dexametasona/uso terapéutico , Fentanilo/uso terapéutico , Humanos , Midazolam/uso terapéutico , Morfina/uso terapéutico , Óxido Nitroso/uso terapéutico , Ondansetrón/uso terapéutico , Guías de Práctica Clínica como Asunto , Encuestas y Cuestionarios
3.
Medicine (Baltimore) ; 98(40): e17392, 2019 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-31577746

RESUMEN

This study aims to construct a neural network to predict weaning difficulty among planned extubation patients in intensive care units.This observational cohort study was conducted in eight adult ICUs in a medical center about adult patients experiencing planned extubation.The data of 3602 patients with planned extubation in ICUs of Chi-Mei Medical Center (from Dec. 2009 through Dec. 2011) was used to train and test an artificial neural network (ANN) model. The input features contain 47 clinical risk factors and the outputs are classified into three categories: simple, difficult, and prolonged weaning. A deep ANN model with four hidden layers of 30 neurons each was developed. The accuracy is 0.769 and the area under receiver operating characteristic curve for simple weaning, prolonged weaning, and difficult weaning are 0.910, 0.849, and 0.942 respectively.The results revealed that the ANN model achieved a good performance in prediction the weaning difficulty in planned extubation patients. Such a model will be helpful for predicting ICU patients' successful planned extubation.


Asunto(s)
Extubación Traqueal/métodos , Desconexión del Ventilador/métodos , APACHE , Anciano , Anciano de 80 o más Años , Algoritmos , Femenino , Humanos , Unidades de Cuidados Intensivos , Masculino , Persona de Mediana Edad , Curva ROC , Estudios Retrospectivos
4.
Anesthesiology ; 131(4): 801-808, 2019 10.
Artículo en Inglés | MEDLINE | ID: mdl-31343462

RESUMEN

BACKGROUND: Practice patterns surrounding awake extubation of pediatric surgical patients remain largely undocumented. This study assessed the value of commonly used predictors of fitness for extubation to determine which were most salient in predicting successful extubation following emergence from general anesthesia with a volatile anesthetic in young children. METHODS: This prospective, observational study was performed in 600 children from 0 to 7 yr of age. The presence or absence of nine commonly used extubation criteria in children were recorded at the time of extubation including: facial grimace, eye opening, low end-tidal anesthetic concentration, spontaneous tidal volume greater than 5 ml/kg, conjugate gaze, purposeful movement, movement other than coughing, laryngeal stimulation test, and oxygen saturation. Extubations were graded as Successful, Intervention Required, or Major Intervention Required using a standard set of criteria. The Intervention Required and Major Intervention Required outcomes were combined as a single outcome for analysis of predictors of success. RESULTS: Successful extubation occurred in 92.7% (556 of 600) of cases. Facial grimace odds ratio, 1.93 (95% CI, 1.03 to 3.60; P = 0.039), purposeful movement odds ratio, 2.42 (95% CI, 1.14 to 5.12; P = 0.022), conjugate gaze odds ratio, 2.10 (95% CI, 1.14 to 4.01; P = 0.031), eye opening odds ratio, 4.44 (95% CI, 1.06 to 18.64; P= 0.042), and tidal volume greater than 5 ml/kg odds ratio, 2.66 (95% CI, 1.21 to 5.86; P = 0.015) were univariately associated with the Successful group. A stepwise increase in any one, in any order, of these five predictors being present, from one out of five and up to five out of five yielded an increasing positive predictive value for successful extubation of 88.3% (95% CI, 82.4 to 94.3), 88.4% (95% CI, 83.5 to 93.3), 96.3% (95% CI, 93.4 to 99.2), 97.4% (95% CI, 94.4 to 100), and 100% (95% CI, 90 to 100). CONCLUSIONS: Conjugate gaze, facial grimace, eye opening, purposeful movement, and tidal volume greater than 5 ml/kg were each individually associated with extubation success in pediatric surgical patients after volatile anesthetic. Further, the use of a multifactorial approach using these predictors, may lead to a more rational and robust approach to successful awake extubation.


Asunto(s)
Extubación Traqueal/métodos , Toma de Decisiones Clínicas/métodos , Vigilia , Niño , Preescolar , Humanos , Lactante , Guías de Práctica Clínica como Asunto , Estudios Prospectivos
5.
Emerg Med Clin North Am ; 37(3): 557-568, 2019 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-31262421

RESUMEN

A subset of intubated patients can safely be extubated in the emergency department (ED). The emergency medicine provider should be prepared for both common and life-threatening complications if considering ED extubation. Patients selected for extubation in the ED should have a low or near zero risk of reintubation or extubation failure. Intensive nursing care, close monitoring, and the ability to reintubate are minimum requirements for EDs considering ED extubation. This article provides a framework for determining appropriate patients for extubation and a practical approach on how to safely perform the procedure.


Asunto(s)
Extubación Traqueal/métodos , Servicio de Urgencia en Hospital , Presión Sanguínea , Delirio/complicaciones , Frecuencia Cardíaca , Hemodinámica , Humanos , Hipoxia/etiología , Hipoxia/prevención & control , Examen Neurológico , Oxígeno/sangre , Cuidados Paliativos , Selección de Paciente , Agitación Psicomotora/complicaciones , Frecuencia Respiratoria , Ruidos Respiratorios , Medición de Riesgo , Desconexión del Ventilador
6.
Interact Cardiovasc Thorac Surg ; 29(1): 85-92, 2019 07 01.
Artículo en Inglés | MEDLINE | ID: mdl-31220277

RESUMEN

OBJECTIVES: The aim of this study was to investigate the impact of an early extubation strategy on the outcome following extracardiac total cavopulmonary connection. METHODS: From 1999 through 2017, 458 patients underwent extracardiac total cavopulmonary connection; 257 (56%) patients were managed with an early extubation strategy adopted in 2009 (group A). Their outcome was compared with those of 201 (44%) patients treated before 2009 (group B). In group A, the outcome of unstable patients, defined as >75th percentile for volume administered and inotrope scores, was compared with those of stable patients. RESULTS: Ventilation time (median: 4 h vs 16 h, P < 0.001), fluid volume administered during the first 24 h (mean: 110 ml/kg vs 164 ml/kg, P = 0.003), chest tube duration (median: 3 days vs 4 days, P = 0.028) and length of intensive care unit stay (median: 6 days vs 7 days, P = 0.001) were less in group A than in group B. The reintubation rate (7% vs 6%, P = 0.547) and early mortality (0.8% vs 1.5%, P = 0.465) were similar between groups. The 80 unstable group A patients received more inotropic support (P < 0.001) and fluid volume (P < 0.001) than stable patients, but the ventilation time (6 h vs 5 h, P = 0.220), the reintubation rate (10% vs 6%, P = 0.283) and the length of intensive care unit stay (7 days vs 6 days, P = 0.590) were similar. In unstable patients, mean arterial pressure before extubation was significantly lower than stable patients (P = 0.001). However, mean arterial pressure in unstable patients increased significantly (P < 0.001) soon after extubation, and became similar to the value in stable patients. CONCLUSIONS: Early extubation following extracardiac total cavopulmonary connection improves postoperative haemodynamics and recovery regardless of the initial haemodynamic status.


Asunto(s)
Extubación Traqueal/métodos , Procedimiento de Fontan/métodos , Cardiopatías Congénitas/cirugía , Hemodinámica/fisiología , Arteria Pulmonar/cirugía , Preescolar , Femenino , Estudios de Seguimiento , Cardiopatías Congénitas/fisiopatología , Humanos , Lactante , Unidades de Cuidados Intensivos , Tiempo de Internación/tendencias , Masculino , Periodo Posoperatorio , Estudios Retrospectivos , Factores de Tiempo , Resultado del Tratamiento
7.
Ann Thorac Surg ; 108(2): 432-442, 2019 08.
Artículo en Inglés | MEDLINE | ID: mdl-31082359

RESUMEN

BACKGROUND: The frequency and safety of overnight extubation (OE) after cardiac surgery across intensive care units (ICUs) is unknown. METHODS: We performed a retrospective study of adults (≥ 18 years) in US ICUs after coronary artery bypass grafting (CABG) or aortic valve replacement (AVR) or both, using The Society of Thoracic Surgery Adult Cardiac Surgery Database (July 2014 to June 2017); our primary cohort was elective CABGs. We assessed OE (7:00 pm to 6:59 am) frequency and used multilevel regression modelling to identify factors associated with OE. Within mechanical ventilation (MV) duration strata, we used propensity score matching to evaluate associations of OE with reintubations (primary outcome), mortality, and complications. RESULTS: Among 142,225 patients with elective CABG, 42.2% had OEs. MV duration, cardiopulmonary bypass time, distal anastomosis number, and hospital of admission (median odds ratio [OR] 1.82, 95% confidence interval [CI]: 1.76 to 1.89) were independently associated with OE. After propensity matching, OE was associated with increased reintubation for patients with MV duration of 6 to 8 hours (2.2% vs 1.7%, OR 1.27, 95% CI: 1.04 to 1.56) and decreased reintubation for patients with MV duration of 15 to 17 hours (3.0% vs 4.2%, OR 0.70, 95% CI: 0.50 to 0.97) and 18 to 20 hours (2.3% vs 5.7%, OR 0.39, 95% CI: 0.21 to 0.72); OE was associated with increased ICU length of stay for patients with MV duration of 6 to 8 hours, but reduced length of stay for patients with MV duration of 9 to 20 hours. OE was not associated with increased mortality (hospital, 30-day). Other groups had similar OE rates (nonelective CABGs, 47.6%; elective AVR, 36.0%; elective CABG + AVRs, 51.0%) and outcomes. CONCLUSIONS: OE is prevalent after cardiac surgery. OE is associated with little risk and reduces ICU length of stay for patients who require MV for more than 8 hours.


Asunto(s)
Extubación Traqueal/métodos , Procedimientos Quirúrgicos Cardíacos , Unidades de Cuidados Intensivos , Cuidados Posoperatorios/métodos , Complicaciones Posoperatorias/prevención & control , Respiración Artificial/métodos , Anciano , Femenino , Mortalidad Hospitalaria/tendencias , Humanos , Incidencia , Tiempo de Internación/tendencias , Masculino , Complicaciones Posoperatorias/epidemiología , Estudios Retrospectivos , Tasa de Supervivencia/tendencias , Estados Unidos/epidemiología
8.
Pediatr Cardiol ; 40(5): 1064-1071, 2019 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-31065760

RESUMEN

In 2014, our hospital introduced inhaled nitric oxide (iNO) therapy combined with high-flow nasal cannula (HFNC) oxygen therapy after extubation following the Fontan procedure in patients with unstable hemodynamics. We report the benefits of HFNC-iNO therapy in these patients. This was a single-center, retrospective review of 38 patients who underwent the Fontan procedure between January 2010 and June 2016, and required iNO therapy before extubation. The patients were divided into two groups: patients in Epoch 1 (n = 24) were treated between January 2010 and December 2013, receiving only iNO therapy; patients in Epoch 2 (n = 14) were treated between January 2014 and June 2016, receiving iNO therapy and additional HFNC-iNO therapy after extubation. There were no significant differences between Epoch 1 and 2 regarding preoperative cardiac function, age at surgery, body weight, initial diagnosis (hypoplastic left heart syndrome, 4 vs. 2; total anomalous pulmonary venous return, 5 vs. 4; heterotaxy, 7 vs. 8), intraoperative fluid balance, or central venous pressure upon admission to the intensive care unit. Epoch 2 had a significantly shorter duration of postoperative intubation [7.2 (3.7-49) vs. 3.5 (3.0-4.6) hours, p = 0.033], pleural drainage [23 (13-34) vs. 9.5 (8.3-18) days, p = 0.007], and postoperative hospitalization [36 (29-49) vs. 27 (22-36) days, p = 0.017]. Two patients in Epoch 1 (8.3%), but none in Epoch 2, required re-intubation. Our results suggest that HFNC-iNO therapy reduces the duration of postoperative intubation, pleural drainage, and hospitalization.


Asunto(s)
Extubación Traqueal/métodos , Broncodilatadores/administración & dosificación , Procedimiento de Fontan/efectos adversos , Óxido Nítrico/administración & dosificación , Cuidados Posoperatorios/métodos , Administración por Inhalación , Extubación Traqueal/efectos adversos , Cánula , Estudios de Casos y Controles , Preescolar , Femenino , Humanos , Masculino , Estudios Retrospectivos
9.
Rev Bras Ter Intensiva ; 31(2): 180-185, 2019 May 23.
Artículo en Español, Inglés | MEDLINE | ID: mdl-31141083

RESUMEN

OBJECTIVE: To examine the usual practice of airway management during the extubation procedure through an online survey to professionals working in intensive care units in the Autonomous City of Buenos Aires and in the Province of Buenos Aires, Argentina. METHODS: A cross-sectional descriptive study online survey was conducted from February 11 to March 11, 2013. A database was generated, and a voluntary and anonymous invitation to access the survey was sent by email to 500 participants. RESULTS: Out of a total of 500 participants, 217 (44%) responded to the survey, of whom 59.4% were physical therapists. One hundred ninety-five (89.9%) professionals were working in adult care. Regarding the cuff deflation procedure and extubation, 203 (93.5%) performe endotracheal suctioning, and 27 (12.5%) use positive pressure. Approximately 53.5% of participants reported having experienced immediate complications with this procedure in the last three months. In all, 163 complications were reported, and stridor was the most prevalent (52.7%). CONCLUSION: Most professionals working in intensive care units in the Autonomous City of Buenos Aires and in the Province of Buenos Aires, Argentina, use endotracheal suctioning without applying positive pressure during extubation.


Asunto(s)
Extubación Traqueal/métodos , Manejo de la Vía Aérea/métodos , Cuidados Críticos/métodos , Personal de Salud/estadística & datos numéricos , Extubación Traqueal/estadística & datos numéricos , Argentina , Cuidados Críticos/estadística & datos numéricos , Estudios Transversales , Encuestas de Atención de la Salud , Humanos , Unidades de Cuidados Intensivos , Prevalencia , Succión
10.
Crit Care ; 23(1): 180, 2019 05 17.
Artículo en Inglés | MEDLINE | ID: mdl-31101127

RESUMEN

BACKGROUND: The effect of high-flow nasal cannula (HFNC) therapy in patients after planned extubation remains inconclusive. We aimed to perform a rigorous and comprehensive systematic meta-analysis to robustly quantify the benefits of HFNC for patients after planned extubation by investigating postextubation respiratory failure and other outcomes. METHOD: We searched MEDLINE, EMBASE, Web of Science, and the Cochrane Library from inception to August 2018. Two researchers screened studies and collected the data independently. Randomized controlled trials (RCTs) and crossover studies were included. The main outcome was postextubation respiratory failure. RESULTS: Ten studies (seven RCTs and three crossover studies; HFNC group: 856 patients; Conventional oxygen therapy (COT) group: 852 patients) were included. Compared with COT, HFNC may significantly reduce postextubation respiratory failure (RR, 0.61; 95% CI, 0.41, 0.92; z = 2.38; P = 0.02) and respiratory rates (standardized mean differences (SMD), - 0.70; 95% CI, - 1.16, - 0.25; z = 3.03; P = 0.002) and increase PaO2 (SMD, 0.30; 95% CI, 0.04, 0.56; z = 2.23; P = 0.03). There were no significant differences in reintubation rate, length of ICU and hospital stay, comfort score, PaCO2, mortality in ICU and hospital, and severe adverse events between HFNC and COT group. CONCLUSIONS: Our meta-analysis demonstrated that compared with COT, HFNC may significantly reduce postextubation respiratory failure and respiratory rates, increase PaO2, and be safely administered in patients after planned extubation. Further large-scale, multicenter studies are needed to confirm our results.


Asunto(s)
Cánula/normas , Terapia por Inhalación de Oxígeno/instrumentación , Oxígeno/administración & dosificación , Extubación Traqueal/métodos , Humanos , Ventilación no Invasiva/instrumentación , Ventilación no Invasiva/métodos , Ventilación no Invasiva/normas , Oxígeno/uso terapéutico , Terapia por Inhalación de Oxígeno/métodos , Recurrencia , Desconexión del Ventilador/métodos
11.
Pan Afr Med J ; 32: 55, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-31143360

RESUMEN

In recent years, low-dose, short-acting anesthetic agents, which replaced the former high-dose opioid regimens, offer a faster postoperative recovery and decrease the need for mechanical ventilatory support. In this study, the aim was to determine the success rate of fast-track approach in surgical procedures for congenital heart disease. There is some evidence, mostly from retrospective analyses, that fast tracking can be beneficial. Ninety-one cases with moderate complex cardiac malformations were operated with fast-track protocol during cardiothoracic charitable missions. The essential aspects of early extubation in our cohort included: selected patients with good preoperative status, good surgical result with hemodynamic stability in low dose of inotropic drugs at the end of bypass, no active bleeding. In this setting a carefull choice and dosing of anesthetic agents, alongside a good postoperative analgesia are mandatory. The authors found that an early extubation (< 4 hours) can be both effective and safe as it reduces intubation and ventilator times without increasing post-operative complications in pediatric congenital heart disease. This study supports a wider use of fast-track extubation protocols in paediatric patients submitted for congenital cardiac surgery in developing countries.


Asunto(s)
Extubación Traqueal/métodos , Anestésicos/administración & dosificación , Procedimientos Quirúrgicos Cardíacos/métodos , Cardiopatías Congénitas/cirugía , Adolescente , Niño , Preescolar , Estudios de Cohortes , Países en Desarrollo , Femenino , Humanos , Lactante , Intubación Intratraqueal/métodos , Masculino , Misiones Médicas , Selección de Paciente , Complicaciones Posoperatorias/epidemiología , Factores de Tiempo
12.
Res Nurs Health ; 42(3): 217-225, 2019 06.
Artículo en Inglés | MEDLINE | ID: mdl-30887549

RESUMEN

High flow nasal cannula (HFNC) has been shown to improve extubation outcomes in patients with hypoxemia, but the role of HFNC in weaning patients with chronic obstructive pulmonary disease (COPD) with hypercapnia from invasive ventilation is unclear. We compared the effects of HFNC to noninvasive ventilation (NIV) on postextubation vital signs and arterial blood gases (ABGs) among patients with COPD. Other outcomes included comfort scores, need for bronchoscopy, use of pulmonary medications, and chest physiotherapy. Forty-two COPD patients who had persistent hypercapnia at extubation were assigned randomly to receive HFNC (22) or NIV (20). Twenty patients in each group were enrolled for per-protocol analysis with regard to primary outcomes. Vital signs and ABGs before extubation were similar between groups. At 3 hr after extubation, pH in the NIV group was lower than HFNC group (7.42 ± 0.06 vs. 7.45 ± 0.05, p = 0.01). At 24 hr after extubation, patients' mean arterial pressure (82.97 ± 9.04 vs. 92.06 ± 11.11 mmHg, p = 0.05) and pH (7.42 ± 0.05 vs. 7.46 ± 0.03, p = 0.05) in the NIV group were lower than in the HFNC group. No significant differences were found at 48 hr after extubation. In the HFNC group, comfort scores were better (3.55 ± 2.01 vs. 5.15 ± 2.28, p = 0.02) and fewer patients needed bronchoscopy for secretion management within 48 hr after extubation (2/22 vs. 9/20, p = 0.03). HFNC is a potential alternative to NIV to wean hypercapnic COPD patients with regard to vital signs and ABGs, HFNC improved patients' comfort and secretion clearance.


Asunto(s)
Ventilación de Alta Frecuencia/métodos , Ventilación no Invasiva/métodos , Terapia por Inhalación de Oxígeno/métodos , Oxígeno/administración & dosificación , Enfermedad Pulmonar Obstructiva Crónica/terapia , Insuficiencia Respiratoria/prevención & control , Anciano , Anciano de 80 o más Años , Extubación Traqueal/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Factores de Riesgo , Resultado del Tratamiento
13.
Am J Surg ; 217(6): 1072-1075, 2019 06.
Artículo en Inglés | MEDLINE | ID: mdl-30890263

RESUMEN

BACKGROUND: Failed extubation has been shown to increase ICU stay, transfers to rehabilitation facilities, and mortality. The purpose of this study was to assess the differences in rates of failed extubation before and after implementation of an extubation checklist. METHODS: We performed a retrospective study from January 2013-April 2017 on adult trauma patients (age 18-89) who were admitted to the ICU and required mechanical ventilation. Patients were grouped before and after implementation of an extubation checklist and compared. RESULTS: A total of 993 patients were included in this study. After checklist implementation, significantly fewer patients required reintubation compared to those prior to checklist (7% vs 3%, p = 0.005). There was no difference in mortality (20% vs 21%, p = 0.54) or hospital length of stay between the two groups (16 days vs 15 days, p = 0.16). CONCLUSION: Our study reveals that implementing an extubation checklist is associated with fewer failed extubations.


Asunto(s)
Extubación Traqueal/normas , Lista de Verificación , Desconexión del Ventilador/normas , Heridas y Traumatismos/terapia , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Extubación Traqueal/métodos , Extubación Traqueal/mortalidad , Extubación Traqueal/estadística & datos numéricos , Femenino , Humanos , Unidades de Cuidados Intensivos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del Tratamiento , Desconexión del Ventilador/métodos , Desconexión del Ventilador/mortalidad , Desconexión del Ventilador/estadística & datos numéricos , Heridas y Traumatismos/mortalidad , Adulto Joven
14.
Medicine (Baltimore) ; 98(5): e14348, 2019 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-30702622

RESUMEN

RATIONALE: Ventilator-associated complications comprise important fatal aetiologies during heart transplantation. Ultra-fast anesthesia might provide the most effective measure to prevent this type of complication. Immediate extubation after heart transplantation (IEAHT) has recently been reported in adult patients. However, IEAHT in children is much more challenging due to limitations in anesthesia protocols. Recently, we managed to perform an ultra-fast anesthesia protocol combined with IEAHT during a heart transplant operation in a child, who had an excellent postoperative outcome. PATIENT CONCERNS: A 13-year-old girl had been diagnosed with dilated cardiomyopathy 5 years before this case, due to intractable dyspnoea and cough. She received multiple medical treatments after diagnosis, with minimal effects. Physical examination findings included a bulge in her left chest and pitting edema over both legs. Moist rales could be heard in the lung. Echocardiography revealed very large heart chambers, with an ejection fraction of 17%. DIAGNOSIS: The patient was diagnosed with dilated cardiomyopathy and scheduled to undergo an emergent operation for heart transplantation. INTERVENTIONS: The patient underwent an ultra-fast anesthesia protocol and ultra-fast reversal during heart transplantation. General anesthesia was induced with etomidate, fentanyl, and vecuronium; it was then maintained with remifentanil-based total intravenous anesthesia. OUTCOMES: Immediately after the end of the operation, the patient was brought to consciousness with stable breathing and haemodynamics. The patient was successfully extubated on the operating table and transferred to the intensive care unit with spontaneous breathing, without postoperative mechanical ventilation. The recovery period was uneventful and the patient was discharged 1 month later without complications. LESSONS: Our experience, in this case, revealed that IEAHT in children is achievable if the ultra-fast protocol is performed properly and carefully, in order to prevent ventilator-associated complications.


Asunto(s)
Extubación Traqueal/métodos , Analgésicos Opioides/uso terapéutico , Anestesia General/métodos , Cardiomiopatía Dilatada/cirugía , Trasplante de Corazón , Remifentanilo/uso terapéutico , Adolescente , Femenino , Humanos
15.
BMC Anesthesiol ; 19(1): 14, 2019 01 17.
Artículo en Inglés | MEDLINE | ID: mdl-30654750

RESUMEN

BACKGROUND: The asleep-awake-asleep (AAA) technique and laryngeal mask airway (LMA) is a common general anesthesia technique for deep brain stimulation (DBS) surgery. However, the LMA is not always the ideal artificial airway. In this report, we presented our experiences with nasotracheal intubation-extubation-intubation (IEI) and AAA techniques in DBS surgery for Parkinson's disease (PD) patients to meet the needs of surgery and ensure patients' safety and comfort. CASE PRESENTATION: Three PD patients scheduled for DBS surgery had to receive general anesthesia for various reasons. For the first asleep stage, general anesthesia and nasotracheal intubation was completed with routine methods. During the awake stage, we pulled the nasotracheal tube back right above the epiglottis under fiberoptic bronchoscope (FOB) guidance for microelectrode recording (MER), macrostimulation testing and verbal communication. Once monitoring is completed, we induced anesthesia with rapid sequence induction and utilized the FOB to advance the nasotracheal tube into the trachea again. To minimize airway irritations during the process, we sprayed the airway with lidocaine before any manipulation. The neurophysiologists completed neuromoinitroing successfully and all three patients were satisfied with the anesthesia provided at follow-up. CONCLUSION: Nasotracheal IEI and AAA anesthetic techniques should be considered as a viable option during DBS surgery.


Asunto(s)
Extubación Traqueal/métodos , Estimulación Encefálica Profunda/métodos , Intubación Intratraqueal/métodos , Enfermedad de Parkinson/terapia , Anestesia General/métodos , Broncoscopía/métodos , Femenino , Tecnología de Fibra Óptica , Estudios de Seguimiento , Humanos , Lidocaína/administración & dosificación , Masculino , Persona de Mediana Edad , Vigilia
16.
Medicine (Baltimore) ; 98(2): e14098, 2019 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-30633221

RESUMEN

Fast-track anesthesia (FTA) is difficult to achieve in neonates due to immature organ function and high rates of perioperative events. As a high-risk population, neonates require prolonged postoperative mechanical ventilation, which may lead to contradictions in cases where neonatal intensive care unit resources and ventilator facilities are limited. The choice of anesthesia strategy and anesthetic can help achieve rapid postoperative rehabilitation and save hospitalization costs. The authors describe their experience with maintaining spontaneous breathing in neonates undergoing anoplasty without opioids or muscle relaxants.This retrospective chart review included neonates who underwent anoplasty in the authors' institution. Twelve neonates who underwent the procedure with atomized 5% lidocaine topical anesthesia around the glottis, combined with sevoflurane sedation and caudal anesthesia facilitating tracheal intubation without opioid and muscle relaxant comprised the FTA group. Ten neonates who underwent the intervention with routine anesthesia techniques in the same period comprised the control group (group C).The surgical success rate in the FTA group was 91.7%. There were no severe complications related to lidocaine administered around the glottis. Extubation time was significantly shorter in the FTA group than in group C (4 [2.5, 5.2] vs 81.5 [60.6, 96.8], respectively; P < .01). The duration of stay in the surgical intensive care unit (SICU) was longer in group C than in the FTA group (2 [2.0, 2.6] vs 1 [0.9, 2.0], respectively; P = .006,). A statistically significant lower rate of extubation-cough was noted after endotracheal tube removal in the FTA group compared with group C (18% vs 90%, respectively; P < .001). There was no difference in the duration of anesthesia or hospitalization costs between the 2 groups. No neonates required re-intubation after extubation.On-table extubation via 5% atomized lidocaine topical anesthesia around the glottis for tracheal intubation combined with sevoflurane sedation and caudal anesthesia without opioid and muscle relaxant was feasible in neonates undergoing anoplasty. This reduced time to extubation, length of SICU stay and saved resources. A similar trend in cost savings was also found; nevertheless, more studies are needed to confirm these results.


Asunto(s)
Extubación Traqueal/métodos , Canal Anal/cirugía , Anestesia/métodos , Intubación Intratraqueal/métodos , Extubación Traqueal/economía , Anestesia/economía , Anestesia Caudal/métodos , Anestésicos por Inhalación/administración & dosificación , Anestésicos Locales/administración & dosificación , China , Femenino , Costos de Hospital/estadística & datos numéricos , Humanos , Recién Nacido , Tiempo de Internación/economía , Tiempo de Internación/estadística & datos numéricos , Lidocaína/administración & dosificación , Masculino , Proyectos Piloto , Estudios Retrospectivos , Sevoflurano/administración & dosificación , Factores de Tiempo
17.
Rev Bras Anestesiol ; 69(2): 222-226, 2019.
Artículo en Portugués | MEDLINE | ID: mdl-30591273

RESUMEN

BACKGROUND AND OBJECTIVES: Negative pressure pulmonary edema occurs by increased intrathoracic negative pressure following inspiration against obstructed upper airway. The pressure generated is transmitted to the pulmonary capillaries and exceeds the pressure of hydrostatic equilibrium, causing fluid extravasation into the pulmonary parenchyma and alveoli. In anesthesiology, common situations such as laryngospasm and upper airway obstruction can trigger this complication, which presents considerable morbidity and requires immediate diagnosis and propaedeutics. Upper airway patency, noninvasive ventilation with positive pressure, supplemental oxygen and, if necessary, reintubation with mechanical ventilation are the basis of therapy. CASE REPORT: Case 1: Male, 52 years old, undergoing appendectomy under general anesthesia with orotracheal intubation, non-depolarizing neuromuscular blocker, reversed with anticholinesterase, presented with laryngospasm after extubation, followed by pulmonary edema. Case 2: Female, 23 years old, undergoing breast reduction under general anesthesia with orotracheal intubation, non-depolarizing neuromuscular blocker, reversed with anticholinesterase, presented with inspiration against closed glottis after extubation, was treated with non-invasive ventilation with positive pressure; after 1 hour, she had pulmonary edema. Case 3: Male, 44 years old, undergoing ureterolithotripsy under general anesthesia, without neuromuscular blocker, presented with laryngospasm after laryngeal mask removal evolving with pulmonary edema. Case 4: Male, 7 years old, undergoing crude fracture reduction under general anesthesia with orotracheal intubation, non-depolarizing neuromuscular blocker, presented with laryngospasm reversed with non-invasive ventilation with positive pressure after extubation, followed by pulmonary edema. CONCLUSIONS: The anesthesiologists should prevent the patient from perform a forced inspiration against closed glottis, in addition to being able to recognize and treat cases of negative pressure pulmonary edema.


Asunto(s)
Obstrucción de las Vías Aéreas/complicaciones , Laringismo/complicaciones , Edema Pulmonar/etiología , Adulto , Extubación Traqueal/métodos , Anestesia General/métodos , Niño , Femenino , Humanos , Intubación Intratraqueal/métodos , Máscaras Laríngeas , Masculino , Persona de Mediana Edad , Ventilación no Invasiva/métodos , Adulto Joven
18.
Intensive Care Med ; 45(1): 62-71, 2019 01.
Artículo en Inglés | MEDLINE | ID: mdl-30535516

RESUMEN

PURPOSE: Noninvasive ventilation (NIV) may facilitate withdrawal of invasive mechanical ventilation (i-MV) and shorten intensive care unit (ICU) length of stay (LOS) in hypercapnic patients, while data are lacking on hypoxemic patients. We aim to determine whether NIV after early extubation reduces the duration of i-MV and ICU LOS in patients recovering from hypoxemic acute respiratory failure. METHODS: Highly selected non-hypercapnic hypoxemic patients were randomly assigned to receive NIV after early or standard extubation. Co-primary end points were duration of i-MV and ICU LOS. Secondary end points were treatment failure, severe events (hemorrhagic, septic, cardiac, renal or neurologic episodes, pneumothorax or pulmonary embolism), ventilator-associated pneumonia (VAP) or tracheobronchitis (VAT), tracheotomy, percent of patients receiving sedation after study enrollment, hospital LOS, and ICU and hospital mortality. RESULTS: We enrolled 130 consecutive patients, 65 treatments and 65 controls. Duration of i-MV was shorter in the treatment group than for controls [4.0 (3.0-7.0) vs. 5.5 (4.0-9.0) days, respectively, p = 0.004], while ICU LOS was not significantly different [8.0 (6.0-12.0) vs. 9.0 (6.5-12.5) days, respectively (p = 0.259)]. Incidence of VAT or VAP (9% vs. 25%, p = 0.019), rate of patients requiring infusion of sedatives after enrollment (57% vs. 85%, p = 0.001), and hospital LOS, 20 (13-32) vs. 27(18-39) days (p = 0.043) were all significantly reduced in the treatment group compared with controls. There were no significant differences in ICU and hospital mortality or in the number of treatment failures, severe events, and tracheostomies. CONCLUSIONS: In highly selected hypoxemic patients, early extubation followed by immediate NIV application reduced the days spent on invasive ventilation without affecting ICU LOS.


Asunto(s)
Extubación Traqueal/normas , Hipoxia/terapia , Ventilación no Invasiva/normas , Factores de Tiempo , Anciano , Extubación Traqueal/métodos , Extubación Traqueal/estadística & datos numéricos , Análisis de los Gases de la Sangre/métodos , Distribución de Chi-Cuadrado , Femenino , Humanos , Unidades de Cuidados Intensivos/organización & administración , Unidades de Cuidados Intensivos/estadística & datos numéricos , Italia , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Ventilación no Invasiva/métodos , Ventilación no Invasiva/estadística & datos numéricos , Respiración Artificial/métodos , Respiración Artificial/estadística & datos numéricos , Desconexión del Ventilador/métodos
19.
Pediatr Cardiol ; 40(3): 468-476, 2019 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-30238137

RESUMEN

Early extubation appears to have beneficial effects on the Fontan circulation. The goal of this study was to assess the impact of extubation on the operating table in comparison with extubation during the first hours after Fontan operation (FO) on the early postoperative course. Between 2013 and 2016, 114 children with a single ventricle heart malformations (mean age, 3.8 ± 2.3 years) underwent FO: 60 patients were extubated in the operating room (ORE) and 54 in the intensive care unit (ICUE) in the median time of 195 min (range 30-515 min) after procedure. Pre-, peri-, and postoperative records were retrospectively analyzed. The hospital survival rate was 100%. One patient from the ORE group needed an immediate reintubation because of laryngospasm. The ORE group showed lower heart rate (106.5 vs. 120.3 bpm; p < 0.001) and lower central venous pressure (10.4 vs. 11.4 mmHg; p = 0.001) than patients in the ICUE group within the first 24 h after FO, as well as higher systolic blood pressure within 7 h after operation (88.6 ± 2.5 vs. 85.6 ± 2.6 mmHg; p = 0.036). The ORE children manifested significantly less pleural effusions during 48 h after FO (38.0 vs. 49.5 ml/kg; p = 0.004), received less intravenous fluid administration within 24 h after FO (54.1 vs. 73.8 ml/kg; p = 0.019), less inotropic support (9.8 vs. 12.8 h of dopamine; p = 0.033), and less antibiotics (4.7 vs. 5.8 days; p = 0.037). ICUE children manifested metabolic acidosis more frequently than the ORE group 3-4 h after FO (p < 0.05). Immediate extubation after FO in comparison with extubation in the ICU appears to be associated with improved hemodynamics and reduced application of therapeutic interventions in the postoperative course.


Asunto(s)
Extubación Traqueal/métodos , Procedimiento de Fontan/efectos adversos , Cardiopatías Congénitas/cirugía , Quirófanos/estadística & datos numéricos , Extubación Traqueal/efectos adversos , Niño , Preescolar , Femenino , Humanos , Lactante , Unidades de Cuidados Intensivos/estadística & datos numéricos , Intubación Intratraqueal , Masculino , Periodo Posoperatorio , Estudios Retrospectivos , Tasa de Supervivencia , Factores de Tiempo
20.
Ann Thorac Surg ; 107(2): 453-459, 2019 02.
Artículo en Inglés | MEDLINE | ID: mdl-30395853

RESUMEN

BACKGROUND: Previous reports of early extubation after cardiac surgical procedures vary in the definition of "early" and may limit findings to patients with less preoperative risk. This study sought to determine whether an eight-tier multidisciplinary early extubation protocol with the goal of extubating within 6 hours postoperatively would be successful without increasing adverse events in patients with increased preoperative risk. METHODS: Postoperative adult cardiac surgical patients in a tertiary care intensive care unit (n = 459) were analyzed 6 months before and 6 months after implementation of the protocol. The Society of Thoracic Surgeons (STS) risk scores were used as surrogate markers of risk. Patients with STS scores (n = 333) were stratified into four equal groups from lowest to highest score. A composite of acute renal failure, reintubation, stroke, and mortality was the primary outcome. Secondary outcomes included intensive care unit and hospital lengths of stay, reoperation, and sternal wound infection. RESULTS: In all patients, ventilation times were significantly decreased from a median of 7.4 hours to 5.7 hours after protocol implementation. When stratified by STS scores, higher-risk patients (groups 3 and 4) had the largest reduction in ventilation times from a median of 9.2 hours to 5.7 hours (p < 0.0001) without a significant increase in adverse events. The highest-risk patients (STS score >40%; n = 14) all had extubation times shorter than 6 hours after the protocol with no significant increase found in adverse events (p = 0.138). CONCLUSIONS: A prudent and diligent multifaceted early extubation protocol may be successful in high-risk cardiac surgical patients without an increase in adverse outcomes. A larger study is needed in the future to confirm the finding.


Asunto(s)
Extubación Traqueal/métodos , Procedimientos Quirúrgicos Cardíacos , Complicaciones Posoperatorias/prevención & control , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Unidades de Cuidados Intensivos , Kansas/epidemiología , Tiempo de Internación/tendencias , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Periodo Posoperatorio , Respiración Artificial/métodos , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Desconexión del Ventilador/métodos
SELECCIÓN DE REFERENCIAS
DETALLE DE LA BÚSQUEDA