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1.
Crit Care ; 24(1): 86, 2020 Mar 12.
Artigo em Inglês | MEDLINE | ID: mdl-32164739

RESUMO

BACKGROUND: Whereas ICU-acquired weakness may delay extubation in mechanically ventilated patients, its influence on extubation failure is poorly known. This study aimed at assessing the role of ICU-acquired weakness on extubation failure and the relation between limb weakness and cough strength. METHODS: A secondary analysis of two previous prospective studies including patients at high risk of reintubation after a planned extubation, i.e., age greater than 65 years, with underlying cardiac or respiratory disease, or intubated for more than 7 days prior to extubation. Patients intubated less than 24 h and those with a do-not-reintubate order were not included. Limb and cough strength were assessed by a physiotherapist just before extubation. ICU-acquired weakness was clinically diagnosed as limb weakness defined as Medical Research Council (MRC) score < 48 points and severe weakness as MRC sum-score < 36. Cough strength was assessed using a semi-quantitative 5-Likert scale. Extubation failure was defined as reintubation or death within the first 7 days following extubation. RESULTS: Among 344 patients at high risk of reintubation, 16% experienced extubation failure (56/344). They had greater severity and lower MRC sum-score (41 ± 16 vs. 49 ± 13, p < 0.001) and were more likely to have ineffective cough than the others. The prevalence of ICU-acquired weakness at the time of extubation was 38% (130/244). The extubation failure rate was 12% (25/214) in patients with no limb weakness vs. 18% (12/65) and 29% (19/65) in those with moderate and severe limb weakness, respectively (p < 0.01). MRC sum-score and cough strength were weakly but significantly correlated (rho = 0.28, p < .001). After multivariate logistic regression analyses, the lower the MRC sum-score the greater the risk of reintubation; severe limb weakness was independently associated with extubation failure, even after adjustment on cough strength and severity at admission. CONCLUSION: ICU-acquired weakness was diagnosed in 38% in this population of patients at high risk at the time of extubation and was independently associated with extubation failure in the ICU.


Assuntos
Extubação/efeitos adversos , Unidades de Terapia Intensiva , Debilidade Muscular/epidemiologia , Respiração Artificial , Desmame do Respirador , Idoso , Feminino , Humanos , Intubação Intratraqueal/estatística & dados numéricos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Debilidade Muscular/etiologia , Prevalência , Respiração Artificial/estatística & dados numéricos , Resultado do Tratamento , Desmame do Respirador/estatística & dados numéricos
2.
J Surg Res ; 246: 384-394, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31629494

RESUMO

BACKGROUND: Cardiac surgery can be accompanied by postoperative complications, which are associated with increased postoperative morbidity and mortality. Therefore, it is necessary to investigate the effect of prophylactic noninvasive ventilation (NIV) after extubation versus conventional pulmonary care on complications after cardiac surgery. MATERIALS AND METHODS: An electronic search of PubMed, Cochrane Library, Ovid, and EMBASE was conducted to find randomized controlled trials which compared the effect of prophylactic NIV with controlled strategies on complications and which were published before April 2018. RESULTS: Ten studies (1011 patients) were included in the final analysis. The atelectasis rate was 32.6% in the prophylactic-NIV group, which was lower than that in the control group (48.71%). Prophylactic NIV could lower the rate of atelectasis, reintubation, and other respiratory complications (pleural effusion, pneumonia, and hypoxia) (odds ratio = 0.43, 0.33, and 0.45; 95% confidence interval: 0.21-0.88, 0. 13-0.84, 0.27-0.75; P = 0.02, 0.02, and 0.002, respectively). The effect on cardiac and distal organ complications (P = 0.07) and hospital mortality (P = 0.62) might be limited. CONCLUSIONS: Prophylactic NIV is associated with a lower rate of postoperative pulmonary complications. The effect on the other complications and hospital mortality might be limited. Further evidence with randomized controlled trials can discern the benefits.


Assuntos
Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Ventilação não Invasiva , Complicações Pós-Operatórias/prevenção & controle , Atelectasia Pulmonar/prevenção & controle , Extubação/efeitos adversos , Mortalidade Hospitalar , Humanos , Tempo de Internação , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Atelectasia Pulmonar/epidemiologia , Atelectasia Pulmonar/etiologia
3.
World J Pediatr Congenit Heart Surg ; 10(5): 565-571, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31496404

RESUMO

BACKGROUND: Extubation failure rates for critical patients in pediatric intensive care units (ICUs) range from 5% to 29%. Noninvasive (NIV) ventilation has been shown to decrease extubation failure. We compared reintubation rates and outcomes of patients supported with NIV neurally adjusted ventilation assist (NAVA) versus historical controls supported with high-flow nasal cannula (HFNC). METHODS: Case-control study of infants less than three months of age who underwent cardiac surgery and received NIV support after extubation from January 2011 to May 2017. All patients supported with NIV NAVA after it became available in September 2013 were compared to matched patients extubated to HFNC from prior to September 2013. RESULTS: Forty-two patients identified for the NIV NAVA group were matched with 42 historical controls supported with HFNC. Groups had similar baseline characteristics based on rate of acute kidney injury, number of single ventricle patients, Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) category, age, weight, bypass time, and duration of intubation. There was no significant difference in reintubation rates within 72 hours (14.3% in the HFNC group and 16.7% in the NIV NAVA group, P = 1.0). Median duration from extubation to coming off NIV support was longer in the NIV NAVA group (3.6 days vs 0.6 days, P < .001). Median time from extubation to ICU discharge was longer in the NIV NAVA group (10.5 vs 6.8 days, P = .02), as was total postoperative ICU length of stay (LOS; 17.6 vs 12.2, P = .01). CONCLUSIONS: Introduction of NIV NAVA for postextubation support did not reduce reintubation rates compared to HFNC. Further study is needed as adoption of NIV NAVA may prolong LOS.


Assuntos
Cânula , Procedimentos Cirúrgicos Cardíacos , Cardiopatias Congênitas/cirurgia , Suporte Ventilatório Interativo , Ventilação não Invasiva , Cuidados Pós-Operatórios/instrumentação , Extubação/efeitos adversos , Estudos de Casos e Controles , Feminino , Humanos , Lactente , Recém-Nascido , Intubação Intratraqueal , Tempo de Internação , Masculino , Período Pós-Operatório , Estudos Retrospectivos , Resultado do Tratamento
4.
Int J Pediatr Otorhinolaryngol ; 125: 122-127, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31299421

RESUMO

OBJECTIVE: To determine the frequency and risk factors that lead to the development of persistent TCF (tracheocutaneous fistula) formation in children following tracheostomy decannulation at our institution. METHODS: A retrospective chart review of all pediatric patients at Children's Hospital Colorado who underwent tracheostomy decannulation and were being followed between January 1, 2007 and December 31, 2013. TCF was defined as a persistent fistula six months following decannulation. We determined patient demographics, age at tracheotomy, primary indication for tracheotomy, tracheostomy-tube size, medical comorbidities, age at decannulation, date of TCF closure, and method of TCF closure. RESULTS: One hundred twenty-nine patients ranging from 51 days to 19 years of age underwent tracheostomy decannulation. 63 (49%) patients underwent surgical closure of TCF. Compared to those with spontaneous closure by multivariable analysis, those with surgical closure were younger at tracheostomy placement (p = 0.0002), had a tracheostomy for a longer duration (p = 0.0025), and were diagnosed with tracheobronchomalacia (p = 0.0051). The likelihood of spontaneous closure decreased over time. Tracheostomy tube internal diameter correlated with age (R = 0.64, p < 0.0001). CONCLUSIONS: Approximately 50% of pediatric tracheostomy stoma sites will close spontaneously. Development of a persistent TCF was associated with younger age at placement, longer duration of tracheostomy, and the presence of tracheobronchomalacia. These observations may help clinicians anticipate outcomes following tracheostomy decannulation in children.


Assuntos
Extubação/efeitos adversos , Fístula Cutânea/cirurgia , Complicações Pós-Operatórias/cirurgia , Fístula do Sistema Respiratório/cirurgia , Doenças da Traqueia/cirurgia , Traqueostomia/efeitos adversos , Adolescente , Criança , Pré-Escolar , Colorado , Fístula Cutânea/etiologia , Remoção de Dispositivo/efeitos adversos , Feminino , Hospitais Pediátricos , Humanos , Lactente , Masculino , Complicações Pós-Operatórias/etiologia , Fístula do Sistema Respiratório/etiologia , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Doenças da Traqueia/etiologia , Traqueobroncomalácia/cirurgia , Traqueotomia/efeitos adversos , Adulto Jovem
5.
Pediatr Cardiol ; 40(6): 1208-1216, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31230092

RESUMO

Post-operative length of stay (LOS) is an important metric for both healthcare providers and patients and their families. Predicting LOS is a challenge as it is sensitive to multitudinous patient and system factors. All subjects undergoing a Fontan from 1996-2016 who survived to hospital discharge were included. Details about the pre-operative status, operative conduct, and post-operative course of each patient were obtained. The association between patient characteristics and post-Fontan LOS were determined using stepwise multivariable regression models. Of 320 subjects who underwent a Fontan, 314 (98.1%) survived to hospital discharge. Median age at Fontan was 3.3 years (IQR 2.8, 4.0) and the most common underlying diagnosis was hypoplastic left heart syndrome (106, 33.8%). Median post Fontan LOS was 11 days (IQR 8, 17). Univariable risk factors for longer LOS included number of previous surgeries, post-Glenn LOS, cardiopulmonary bypass time, post-operative chylothorax, and failure to extubate in the operating room (all p < 0.05). In multivariable models, number of previous operations, extubation in the operating room, and postoperative complications predicted LOS (R2 = 0.5185 for full model). The proportion of patients discharged on week days (14.7-18.8% per day) was significantly higher than the proportion discharged on weekend days (5.1-9.9% per weekend day). Pre-operative variables have limited use in predicting post-Fontan length of stay. The most important predictors of post-operative LOS are extubation in the operating room and the occurrence of post-operative complications. However, a significant proportion of variability in LOS was not explained by available measurable variables.


Assuntos
Técnica de Fontan/efeitos adversos , Tempo de Internação/estatística & dados numéricos , Extubação/efeitos adversos , Pré-Escolar , Feminino , Humanos , Síndrome do Coração Esquerdo Hipoplásico/cirurgia , Masculino , Análise Multivariada , Complicações Pós-Operatórias/epidemiologia , Período Pós-Operatório , Estudos Retrospectivos , Fatores de Risco
6.
Dimens Crit Care Nurs ; 38(4): 221-227, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31145169

RESUMO

BACKGROUND: Self-extubation is an adverse patient event that can lead to severe complications. Gaps in clinical practice from the lack of nursing awareness and decision making capacity have often resulted in cases of preventable self-extubation. Review of current evidence suggests that initiatives to support nursing clinical decision making can help prevent adverse patient events such as self-extubation. AIMS: The aim of this study was to reduce the incidence of self-extubation by 50% in a cardiology intensive care unit over 1 year. METHODS: A quality improvement project was undertaken with a PEST model of nursing care introduced from January 2017 to December 2017 in the cardiology intensive care unit to guide nursing staff to assess and render appropriate interventions along patient domains such as pain, endotracheal tube securement, sedation, and tie to prevent incidences of self-extubation. RESULTS: Incidences of self-extubation have reduced to 5 cases in 2017, reflecting a 50% improvement from 10 cases in 2016. CONCLUSIONS: Formalizing practice standards into an easy-to-remember mnemonics or framework can improve patient outcomes. Policy makers must be aware that initiatives to facilitate decision making can improve patient safety.


Assuntos
Extubação/efeitos adversos , Extubação/enfermagem , Enfermagem de Cuidados Críticos , Unidades de Terapia Intensiva , Modelos de Enfermagem , Melhoria de Qualidade , Autocuidado/efeitos adversos , Humanos , Singapura
7.
Pediatr Cardiol ; 40(5): 1064-1071, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31065760

RESUMO

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.


Assuntos
Extubação/métodos , Broncodilatadores/administração & dosagem , Técnica de Fontan/efeitos adversos , Óxido Nítrico/administração & dosagem , Cuidados Pós-Operatórios/métodos , Administração por Inalação , Extubação/efeitos adversos , Cânula , Estudos de Casos e Controles , Pré-Escolar , Feminino , Humanos , Masculino , Estudos Retrospectivos
8.
BMC Anesthesiol ; 19(1): 66, 2019 05 04.
Artigo em Inglês | MEDLINE | ID: mdl-31054568

RESUMO

BACKGROUND: Intravenous lidocaine and dexmedetomidine treatments have been proposed as methods for inhibiting cough. We compared the efficacy of intravenous lidocaine and dexmedetomidine treatments on inhibiting cough during the tracheal extubation period after thyroid surgery. METHODS: One hundred eighty patients undergoing thyroid surgeries were randomly allocated to the LIDO group (received lidocaine 1.5 mg/kg loading, 1.5 mg/kg/h infusion), the DEX group (received dexmedetomidine 0.5 µg/kg loading, 0.4 µg/kg/h infusion) and the CON group (received saline), with 60 cases in each group. The primary outcomes of cough were recorded. Secondary outcomes included hemodynamic variables, awareness time, volume of drainage, the postoperative visual analogue scale and adverse effects were recorded. RESULTS: The incidence of cough were significantly lower in the LIDO group (28.3%) and the DEX group (31.7%) than that in the CON group (66.7%) (P = 0.000). Additionally, both moderate and severe cough were significantly lower in the LIDO group (13.3%) and the DEX group (13.4%) than these in the CON group (43.4%) (P < 0.05). Compared with the two treatment groups, both mean arterial blood pressure and heart rate were significantly increased in the CON group during tracheal extubation (P < 0.05). Compared with the CON group, the volume of drainage was significantly reduced in the two treatment groups within 48 h after surgery (P < 0.05). compared with the CON group, the postoperative visual analogue scale was significantly lower in groups LIDO and DEX after surgery(P < 0.05). Compared with the LIDO group and the CON group, the time to awareness was longer in the DEX group (P < 0.05). In the DEX group, bradycardia was noted in 35 patients, while no bradycardia was noted in LIDO group and CON group. CONCLUSION: Compared with intravenous infusions of normal saline, both lidocaine and dexmedetomidine had equal effectiveness in attenuating cough and hemodynamic changes during the tracheal extubation period after thyroid surgery, and both of these treatments were able to reduce the volume of postoperative bleeding and provide better analgesic effect after surgery. But intravenous infusions of dexmedetomidine resulted in bradycardia and delayed the time to awareness when compared with lidocaine and normal saline. TRIAL REGISTRATION: ChiCTR1800017482 . (Prospective registered). Initial registration date was 01/08/2018.


Assuntos
Extubação/tendências , Tosse/tratamento farmacológico , Dexmedetomidina/administração & dosagem , Lidocaína/administração & dosagem , Medição da Dor/efeitos dos fármacos , Glândula Tireoide/cirurgia , Adulto , Extubação/efeitos adversos , Período de Recuperação da Anestesia , Anestésicos Locais/administração & dosagem , Tosse/diagnóstico , Tosse/etiologia , Feminino , Humanos , Hipnóticos e Sedativos/administração & dosagem , Infusões Intravenosas , Masculino , Pessoa de Meia-Idade , Medição da Dor/métodos , Projetos Piloto , Estudos Prospectivos
9.
J Coll Physicians Surg Pak ; 29(5): 474-475, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31036122

RESUMO

Myasthenia Gravis (MG) is an autoimmune disease of the neuromuscular junction which results in generalised weakness. Presentation varies and can often be delayed as the course is waxing and waning. We report the case of an elderly patient who was admitted with severe cholangitis. The patient required a general anaesthesia with intubation for a planned endoscopic retrograde cholangiopancreatogram (ERCP). She was extubated a few hours after the procedure in the intensive care unit (ICU). However, a few hours later, she required re-intubation for tiring out and a raised paCO2 level. When assessed by a diaphragmatic ultrasound, she was found to have severe weakness, and a provisional diagnosis of MG was made after other causes, such as sepsis, were ruled out. As a fast, inexpensive and non-invasive test, ultrasound offers many advantages and can also be used serially to assess recovery of a paralyzed diaphragm as well to achieve successful liberation from mechanical ventilation.


Assuntos
Colangiopancreatografia Retrógrada Endoscópica/efeitos adversos , Diafragma/diagnóstico por imagem , Miastenia Gravis/diagnóstico , Ultrassonografia , Idoso de 80 Anos ou mais , Extubação/efeitos adversos , Anestesia Geral/efeitos adversos , Colangite , Diafragma/fisiopatologia , Feminino , Humanos , Imunoglobulinas Intravenosas , Unidades de Terapia Intensiva , Debilidade Muscular , Miastenia Gravis/complicações , Brometo de Piridostigmina , Respiração Artificial/efeitos adversos , Insuficiência Respiratória/etiologia , Insuficiência Respiratória/terapia
10.
Chest ; 155(4): 740-748, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30955572

RESUMO

BACKGROUND: Nasal high-frequency oscillatory ventilation (NHFOV) has been described as supplying the combined advantages of nasal CPAP (NCPAP) and HFOV. However, its effect on preterm infants needs to be further elucidated. Our objective was to assess whether NHFOV could reduce intubation and Pco2 levels as compared with NCPAP during the postextubation phase in preterm infants. METHODS: This was a single-center, randomized, controlled trial, and it was registered at clinicaltrials.gov (NCT03140891) and conducted between May 2017 and May 2018. Ventilated infants born at less than 37 weeks' gestational age and ready to be extubated were included and randomized to either the NHFOV or NCPAP group. Primary outcomes were the incidence of reintubation within 1 week and the Pco2 level within 6 h. RESULTS: A total of 206 preterm infants were included. Of them, 127 (61.7%) were diagnosed with respiratory distress syndrome, 53 (25.7%) with ARDS, and 26 (12.6%) with both respiratory distress syndrome and ARDS. Comparing with NCPAP, NHFOV significantly reduced the reintubation rate (16:87 vs 35:68; 95% CI, 0.18-0.70; P = .002), especially in the subgroup with a gestational age of ≤ 32 weeks (12:34 vs 25:20; 95% CI, 0.12-0.68; P = .004). The Pco2 level was also significant lower in the NHFOV group (49.6 ± 8.7 vs 56.9 ± 9.9; 95% CI, -9.95 to -4.80; P = < .001). Moreover, NHFOV significantly reduced the reintubation rate in preterm infants with ARDS (10:33 vs 21:15; 95% CI, 0.08-0.57; P = .002). CONCLUSIONS: NHFOV was shown to be superior to NCPAP in avoiding reintubation, especially in very preterm infants and those infants diagnosed with ARDS. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT03140891; URL: www.clinicaltrials.gov.


Assuntos
Extubação/efeitos adversos , Recém-Nascido Prematuro , Ventilação com Pressão Positiva Intermitente/métodos , Síndrome do Desconforto Respiratório do Recém-Nascido/terapia , Insuficiência Respiratória/etiologia , Feminino , Seguimentos , Idade Gestacional , Humanos , Recém-Nascido , Intubação Intratraqueal , Masculino , Estudos Prospectivos , Síndrome do Desconforto Respiratório do Recém-Nascido/fisiopatologia , Fatores de Tempo , Resultado do Tratamento
11.
PLoS One ; 14(4): e0214232, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30946750

RESUMO

OBJECTIVE: To determine whether there is an association between severe intraventricular hemorrhage and early extubation in preterm infants born before 29 weeks of gestational age and intubated at birth. METHODS: This study included 1587 preterm infants from a nationwide French population cohort (EPIPAGE-2). Secondary data on intubated preterm infants were analyzed. After gestational age and propensity score matching (1:1) we built two comparable groups: an early extubation group and a delayed extubation group. Each neonate in one group was paired with a neonate in the other group having the same propensity score and gestational age. Early extubation was defined as extubation within 48 hours of life. Severe intraventricular hemorrhages were defined as grade III or IV hemorrhages according to the Papile classification. RESULTS: After matching, there were 398 neonates in each group. Using a generalized estimating equation model, we found that intraventricular hemorrhage was not associated with early extubation (adjusted OR 0.9, 95%CI 0.6-1.4). This result was supported by sensitivity analyses. CONCLUSION: The practice of early extubation was not associated with an increased proportion of intraventricular hemorrhages. To complete these results, the long-term neurologic outcomes of these infants need to be assessed.


Assuntos
Extubação/efeitos adversos , Hemorragia Cerebral/etiologia , Recém-Nascido Prematuro/fisiologia , Nascimento Prematuro/patologia , Estudos de Coortes , Feminino , Humanos , Gravidez , Pontuação de Propensão , Fatores de Risco
12.
Medicine (Baltimore) ; 98(11): e14841, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30882675

RESUMO

Unplanned extubation (UE) may cause considerable adverse effects in patients receiving mechanical ventilation (MV). Previous literature showed inconsistent prognosis in patients with UE. This study aimed to evaluate the clinical implications and outcomes of UE.The intubated adult patients with MV support in our hospital were enrolled, and they were divided into the UE and non-UE groups. Demographic data, admission unit, MV duration, overall weaning rate, and mortality rates were compared. The outcomes of UE in ordinary ward and intensive care unit (ICU) were also assessed.Totally 9245 intubated adult patients were included. UE occurred in 303 (3.5%) patients, and the UE events were 0.27 times/100 MV days. Old age, nonoperation related MV cause, and admission out of the ICU were significant factors associated with UE events. UE patients showed a trend of better overall weaning rate (71.9% vs 66.7%, P = .054) than non-UE. However, the in-hospital mortality rate (25.7% vs 24.8%, P = .713) were similar between the UE and non-UE patients. The reintubation rate of UE patients was 44.1% (142/322). Successful UEs were associated with patients in weaning process (52.8% vs 38.7%, P = .012), and patients received non-invasive positive pressure ventilation (NIPPV) support after UE (19.4% vs 3.5%, P < .001). Patients with successful UE had significantly shorter MV days, higher overall weaning rate, and lower mortality than those with unsuccessful UE. Outcomes of UE in ordinary ward and in ICU had similar MV duration, reintubation rate, overall weaning rate, and in-hospital mortality rate.The overall weaning rate and in-hospital mortality rates of the UE and non-UE patients were similar. UE occurred in ordinary ward had similar outcomes to those in ICU. Patients receiving MV should be assessed daily for weaning indications to reduce delayed extubation, and therefore, may decrease UE occurrence. Once the UE happened, NIPPV support may reduce the reintubation rate.


Assuntos
Extubação , Unidades de Terapia Intensiva/estatística & dados numéricos , Quartos de Pacientes/estatística & dados numéricos , Respiração Artificial , Retratamento/estatística & dados numéricos , Desmame do Respirador , Idoso , Extubação/efeitos adversos , Extubação/estatística & dados numéricos , Estudos de Casos e Controles , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Cooperação do Paciente , Prognóstico , Respiração Artificial/efeitos adversos , Respiração Artificial/métodos , Respiração Artificial/estatística & dados numéricos , Retratamento/efeitos adversos , Taiwan/epidemiologia , Desmame do Respirador/efeitos adversos , Desmame do Respirador/métodos , Desmame do Respirador/estatística & dados numéricos
13.
Acta Med Okayama ; 73(1): 15-20, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30820050

RESUMO

We compared the reintubation rate in children who received high-flow nasal cannula (HFNC) therapy to the rate in children who received noninvasive ventilation (NIV) therapy for acute respiratory failure (ARF) after cardiac surgery. This was a retrospective analysis of 35 children who received HFNC therapy for ARF after cardiac surgery in 2014-2015 (the HFNC group). We selected 35 children who had received NIV therapy for ARF after cardiac surgery in 2009-2012 as a control group. The matching parameters were body weight and risk adjustment for congenital heart surgery category 1. The reintubation rate within 48 h in the HFNC group tended to be lower than that in the NIV group (3% vs. 17%, p=0.06). The reintubation rate within 28 days was significantly lower in the HFNC group compared to the NIV group (3% vs. 26%, p=0.04). The HFNC group's ICU stays were significantly shorter than those of the NIV group: 10 (IQR: 7-17) days vs. 17 (11-32) days, p=0.009. HFNC therapy might be associated with a reduced reintubation rate in children with ARF after cardiac surgery.


Assuntos
Extubação/efeitos adversos , Cânula , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Ventilação não Invasiva , Insuficiência Respiratória/terapia , Estudos de Casos e Controles , Feminino , Humanos , Lactente , Intubação Intratraqueal , Masculino , Oxigenoterapia , Insuficiência Respiratória/etiologia , Estudos Retrospectivos , Resultado do Tratamento
14.
Anaesthesia ; 74(4): 457-467, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30632138

RESUMO

It is unclear which criteria should be used to define readiness for tracheal extubation in the operating theatre. We studied the effects of desaturation in the operating theatre immediately after tracheal extubation on long-term outcomes. Performing a pre-specified, retrospective analysis of 71,025 cases involving previously independent adults undergoing non-cardiac surgery, we evaluated the association between desaturation events (oxygen saturation < 90%) within 10 min of tracheal extubation and adverse discharge (to a skilled nursing facility or long-term care facility). A total of 404 (12.3%) cases with, and 5035 (7.4%) cases without, early postoperative desaturation had an adverse discharge. Early postoperative desaturation was associated with higher odds of being discharged to a nursing facility (adjusted odds ratio 1.36 (95%CI 1.20-1.54); p < 0.001). Increased duration of desaturation augmented the effect (p for trend < 0.001). Desaturation was associated with a higher risk of respiratory, renal and cardiovascular complications as well as increased duration of hospital stay, postoperative intensive care unit admission frequency and cost. Several modifiable factors were associated with desaturation including: high intra-operative long-acting opioid administration; high neostigmine dose; high intra-operative inspired oxygen concentration; and low oxygen delivery immediately before tracheal extubation. There was substantial provider variability between anaesthetists in the incidence of postoperative desaturation unexplained by patient- and procedure-related factors. Early postoperative desaturation is a potentially preventable complication associated with a higher risk of adverse discharge disposition. Anaesthetists may consider developing guidelines to define tracheal extubation readiness that contain postoperative desaturation as an adverse outcome after tracheal extubation.


Assuntos
Extubação/efeitos adversos , Hipóxia/etiologia , Oxigênio/sangue , Complicações Pós-Operatórias/etiologia , Adulto , Idoso , Feminino , Humanos , Modelos Logísticos , Assistência de Longa Duração , Masculino , Pessoa de Meia-Idade , Salas Cirúrgicas , Alta do Paciente , Estudos Retrospectivos
16.
J Thorac Cardiovasc Surg ; 157(4): 1591-1598, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30665762

RESUMO

OBJECTIVE: Immediate extubation may have outcome benefits when judiciously instituted after neonatal congenital cardiac surgery. We sought to evaluate the outcomes of immediate extubation specifically in neonates undergoing stage 1 Norwood palliation of hypoplastic left heart syndrome. METHODS: Consecutive neonates undergoing stage 1 Norwood (January 2010 to December 2016) for hypoplastic left heart syndrome were retrospectively studied. Immediate extubation was defined as successful extubation before termination of anesthetic care. Preoperative and intraoperative variables were compared between immediate extubation and nonimmediate extubation groups, and bivariate analyses and descriptive methods were used to express the association of outcome variables with immediate extubation. Data were expressed as number and percent for categoric variables, and median and interquartile range for continuous variables. RESULTS: Of 23 patients who underwent stage 1 palliation, 5 had immediate extubation (22%). There were no differences in preoperative or intraoperative factors between patients who did and did not undergo immediate extubation. There were no deaths in the immediate extubation group. In the nonimmediate extubation group, 3 patients died before hospital discharge. One patient who had immediate extubation and 4 patients among those who did not have immediate extubation had to be reintubated in the 96 hours that followed extubation (P = 1). Intensive care unit length of stay was 8 (3-17) and 8 (5-18) (days) for the immediate extubation group and nonimmediate extubation groups, respectively (P = .71). CONCLUSIONS: Immediate extubation strategy was safely accomplished in one-fifth of this cohort of hypoplastic left heart syndrome. A larger cohort may delineate the determinants of immediate extubation and its benefits in infants undergoing stage 1 single ventricle palliation.


Assuntos
Extubação , Síndrome do Coração Esquerdo Hipoplásico/cirurgia , Procedimentos de Norwood , Cuidados Paliativos , Tempo para o Tratamento , Extubação/efeitos adversos , Extubação/mortalidade , Feminino , Mortalidade Hospitalar , Humanos , Síndrome do Coração Esquerdo Hipoplásico/diagnóstico , Síndrome do Coração Esquerdo Hipoplásico/mortalidade , Síndrome do Coração Esquerdo Hipoplásico/fisiopatologia , Recém-Nascido , Intubação Intratraqueal , Masculino , Procedimentos de Norwood/efeitos adversos , Procedimentos de Norwood/mortalidade , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/terapia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
17.
Dysphagia ; 34(4): 475-486, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-30684017

RESUMO

Swallowing disorders and respective consequences (including aspiration-induced pneumonia) are often observed in extubated ICU patients with data indicating that a large number of patients are affected. We recently demonstrated in a large-scale analysis that the incidence of post-extubation dysphagia (PED) is 12.4% in a general ICU population and about 18% in emergency admissions to the ICU. Importantly, PED was mostly sustained until hospital discharge and independently predicted 28- and 90-day mortality. Although oropharyngeal/laryngeal trauma, neuromuscular ICU-acquired weakness, reduced sensation/sensorium, dyssynchronous breathing, and gastrointestinal reflux, are all considered to contribute to PED, little is known about the underlying pathomechanisms and risk factors leading to PED in critically ill patients. Systematic screening of all potential ICU patients for oropharyngeal dysphagia (OD) seems key for early recognition and follow-up, as well as the design and testing of novel therapeutic interventions. Today, screening methods and clinical investigations for dysphagia differ considerably. In the context of a recently proposed pragmatic screening algorithm introduced by us, we provide a concise review on currently available non-instrumental techniques that could potentially serve for non-instrumental OD assessment in critically ill patients. Following systematic literature review, we find that non-instrumental OD assessments were mostly tested in different patient populations with only a minority of studies performed in critically ill patients. Due to little available data on non-instrumental dysphagia assessment in the ICU, future investigations should aim to validate respective approaches in the critically ill against an instrumental (gold) standard, for example, flexible endoscopic evaluation of swallowing. An international expert panel is encouraged to addresses critical illness-related definitions, screening and confirmatory assessment approaches, treatment recommendations, and identifies optimal patient-centered outcome measures for future clinical investigations.


Assuntos
Extubação/efeitos adversos , Transtornos de Deglutição/diagnóstico , Estado Terminal/terapia , Transtornos de Deglutição/etiologia , Humanos
18.
Pediatr Cardiol ; 40(3): 468-476, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30238137

RESUMO

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.


Assuntos
Extubação/métodos , Técnica de Fontan/efeitos adversos , Cardiopatias Congênitas/cirurgia , Salas Cirúrgicas/estatística & dados numéricos , Extubação/efeitos adversos , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Unidades de Terapia Intensiva/estatística & dados numéricos , Intubação Intratraqueal , Masculino , Período Pós-Operatório , Estudos Retrospectivos , Taxa de Sobrevida , Fatores de Tempo
19.
J Pediatr ; 205: 70-76.e2, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30404739

RESUMO

OBJECTIVE: To explore the relation between time to reintubation and death or bronchopulmonary dysplasia (BPD) in extremely preterm infants. STUDY DESIGN: This was a subanalysis from an ongoing multicenter observational study. Infants with birth weight ≤1250 g, requiring mechanical ventilation, and undergoing their first elective extubation were prospectively followed throughout hospitalization. Time to reintubation was defined as the time interval between first elective extubation and reintubation. Univariate and multivariate logistic regression analyses were performed to evaluate associations between time to reintubation, using different observation windows after extubation (24-hour intervals), and death/BPD (primary outcome) or BPD among survivors (secondary outcome). aORs were computed with and without the confounding effects of cumulative mechanical ventilation duration. RESULTS: Of 216 infants included for analysis, 103 (48%) were reintubated at least once after their first elective extubation. Reintubation was associated with lower gestational age/weight and greater morbidities compared with infants never reintubated. After adjusting for confounders, reintubation within observation windows ranging between 24 hours and 3 weeks postextubation was associated with increased odds of death/BPD (but not BPD among survivors), independent of the cumulative mechanical ventilation duration. Reintubation within 48 hours from extubation conferred higher risk-adjusted odds of death/BPD vs other observation windows. CONCLUSIONS: Although reintubation after elective extubation was independently associated with increased likelihood of death/BPD in extremely preterm infants, the greatest risk was attributable to reintubation within the first 48 hours postextubation. Prediction models capable of identifying the highest-risk infants may further improve outcomes.


Assuntos
Extubação/efeitos adversos , Displasia Broncopulmonar/etiologia , Intubação Intratraqueal/efeitos adversos , Respiração Artificial/mortalidade , Extubação/estatística & dados numéricos , Displasia Broncopulmonar/mortalidade , Estudos de Casos e Controles , Feminino , Idade Gestacional , Humanos , Lactente , Lactente Extremamente Prematuro , Recém-Nascido , Recém-Nascido de muito Baixo Peso , Unidades de Terapia Intensiva Neonatal , Masculino , Estudos Prospectivos , Respiração Artificial/efeitos adversos , Respiração Artificial/métodos , Risco Ajustado , Fatores de Tempo
20.
J Perinat Med ; 47(2): 252-257, 2019 Feb 25.
Artigo em Inglês | MEDLINE | ID: mdl-30183667

RESUMO

Background Prematurity and its respective comorbidities may result in longer periods of mechanical ventilation in intensive care units (ICU). A method for the assessment of organic maturity would be useful for this population. Heart rate variability (HRV), as an indicator of homeostasis, is a well-established tool for this approach. The objective of the study was to assess HRV in intubated preterm infants in ICU immediately prior to extubation and correlate HRV with clinical evaluation outcomes. Methods A total of 46 preterm infants, 13 (28.2%) males, were prospectively studied and divided into a group with failed extubation (FEG: n=11) and a group with successful extubation (SEG: n=35). HRV was evaluated in time, frequency and nonlinear domains with a Polar RS800 device. HRV measurements were assessed with Kubios HRV Premium Software and statistically analyzed with the StatsDirect Statistical Software, version 1.9.2015 (2002). P<0.05 values were considered as statistically significant. Results There were no significant differences between heart rate variables of failed and successful extubation when analyzing the total group. However, the analysis of the sub-group of preterm infants weighing less than 1000 g showed a clear differentiation between the groups, when the nonlinear variables (approximate entropy, sample entropy and multiscale entropy 1, 2 and 3) were used, demonstrating that the group with successful extubation shows greater complexity and, therefore, relatively greater autonomic stability. Conclusion HRV was effective in predicting failed extubation in preterm infants when evaluated in a nonlinear domain and in preterm infants weighing less than 1000 g.


Assuntos
Extubação , Frequência Cardíaca/fisiologia , Doenças do Prematuro/terapia , Monitorização Fisiológica/métodos , Respiração Artificial , Extubação/efeitos adversos , Extubação/métodos , Peso ao Nascer , Brasil , Correlação de Dados , Feminino , Idade Gestacional , Humanos , Recém-Nascido , Recém-Nascido Prematuro/fisiologia , Doenças do Prematuro/etiologia , Masculino , Valor Preditivo dos Testes , Estudos Prospectivos , Respiração Artificial/efeitos adversos , Respiração Artificial/métodos
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