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1.
J Laryngol Otol ; 134(1): 63-67, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31910909

RESUMO

BACKGROUND: Determining prognostic factors for the probability of tracheostomy decannulation is key to an adequate therapeutic plan. METHODS: A retrospective cohort study of 160 paediatric patients undergoing tracheostomy was conducted. Associations between different parameters and eventual tracheostomy decannulation were assessed. RESULTS: Mean follow-up duration was 27.8 months (interquartile range = 25.5-30.2 months). Median age at tracheostomy was 6.96 months (interquartile range = 3.37-29.42 months), with median tracheostomy maintenance of 14.5 months (interquartile range = 3.7-21.5 months). The overall tracheostomy decannulation rate was 22.5 per cent. Factors associated with a higher probability of tracheostomy decannulation included age at tracheostomy (hazard ratio = 1.11, 95 per cent confidence interval = 1.03-1.18) and post-intubation laryngitis as an indication for tracheostomy (hazard ratio = 2.25, 95 per cent confidence interval = 1.09-4.62). Neurological (hazard ratio = 0.30, 95 per cent confidence interval = 0.12-0.80) and pulmonary (hazard ratio = 0.41, 95 per cent confidence interval = 0.18-0.91) co-morbidities were negatively associated with tracheostomy decannulation. The probability of tracheostomy decannulation decreased significantly with increasing numbers of co-morbidities (p < 0.001). CONCLUSION: Age, post-intubation laryngitis, and number and type of co-morbidities influence tracheostomy decannulation rate in the paediatric population.


Assuntos
Extubação/estatística & dados numéricos , Laringite/etiologia , Traqueostomia/instrumentação , Extubação/métodos , Pré-Escolar , Estudos de Coortes , Feminino , Humanos , Lactente , Masculino , Estudos Retrospectivos , Medição de Risco , Traqueostomia/efeitos adversos
2.
Physiother Res Int ; 24(4): e1793, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31237395

RESUMO

OBJECTIVE: Most patients requiring intubation and mechanical ventilation are extubated successfully at the first attempt; however, a minority experience extubation failure, which is associated with increased risk of ventilator-associated pneumonia, prolonged intensive care unit (ICU) length of stay and mortality. Physiotherapists have expertise to assess cough strength, work of breathing, respiratory muscle strength, and respiratory secretion load, which are important factors in the outcome of extubation. Accurate prediction of extubation outcome could help to inform management plans pre-extubation and postextubation. The primary objective of this service evaluation was to report the accuracy of physiotherapists' prediction of extubation outcome in the adult ICU. METHODS: A single-centre case note review was undertaken. All subjects who received a physiotherapy assessment of extubation suitability prior to extubation between January and March 2016 in the adult ICU of a large teaching hospital in the United Kingdom were included. Assessment, by both specialist and nonspecialist physiotherapists-which included risk stratification of extubation failure as "high," "moderate," or "low"-was undertaken prior to extubation. Logistic regression analysis was performed to determine which pre-extubation factors were predictive of extubation outcome. RESULTS: During the evaluation period, 68 subjects were extubated following a physiotherapy assessment. Physiotherapy risk stratification as "high risk" (OR 4; 95% confidence interval, CI, [1.312]; p=0.009) and "inappropriate" neurological status (OR 3.3; 95% CI [1.0410]; p=0.037) were the only pre-extubation factors significantly associated with extubation failure. Assessment by specialist physiotherapists demonstrated greater sensitivity (100% vs. 22%) but lower specificity (68% vs. 95%) to detect extubation failure compared with the assessment performed by nonspecialist physiotherapists. CONCLUSION: Patients classified as "high risk" of extubation failure by a physiotherapist are significantly more likely to fail extubation. Specialist physiotherapists should be involved in the decision to extubate patients in the adult ICU.


Assuntos
Extubação/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Índice de Gravidade de Doença , Desmame do Respirador/estatística & dados numéricos , Adulto , Feminino , Humanos , Unidades de Terapia Intensiva , Intubação Intratraqueal/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Modalidades de Fisioterapia , Respiração Artificial/estatística & dados numéricos , Reino Unido
3.
Rev Bras Ter Intensiva ; 31(2): 180-185, 2019 May 23.
Artigo em Espanhol, Inglês | MEDLINE | ID: mdl-31141083

RESUMO

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.


Assuntos
Extubação/métodos , Manuseio das Vias Aéreas/métodos , Cuidados Críticos/métodos , Pessoal de Saúde/estatística & dados numéricos , Extubação/estatística & dados numéricos , Argentina , Cuidados Críticos/estatística & dados numéricos , Estudos Transversais , Pesquisas sobre Serviços de Saúde , Humanos , Unidades de Terapia Intensiva , Prevalência , Sucção
4.
Crit Care ; 23(1): 161, 2019 05 07.
Artigo em Inglês | MEDLINE | ID: mdl-31064406

RESUMO

BACKGROUND: The optimal securement method of endotracheal tubes is unknown but should prevent dislodgement while minimizing complications. The use of an endotracheal tube fastener might reduce complications among critically ill adults undergoing endotracheal intubation. METHODS: In this pragmatic, single-center, randomized trial, critically ill adults admitted to the medical intensive care unit (MICU) and expected to require invasive mechanical ventilation for greater than 24 h were randomized to adhesive tape or endotracheal tube fastener at the time of intubation. The primary endpoint was a composite of any of the following: presence of lip ulcer, endotracheal tube dislodgement (defined as moving at least 2 cm), ventilator-associated pneumonia, or facial skin tears anytime between randomization and the earlier of death or 48 h after extubation. Secondary endpoints included duration of mechanical ventilation and ICU and in-hospital mortality. RESULTS: Of 500 patients randomized over a 12-month period, 162 had a duration of mechanical ventilation less than 24 h and 40 had missing outcome data, leaving 153 evaluable patients randomized to tube fastener and 145 evaluable patients randomized to adhesive tape. Baseline characteristics were similar between the groups. The primary endpoint occurred 13 times in 12 (7.8%) patients in the tube fastener group and 30 times in 25 (17.2%) patients in the adhesive tape group (p = 0.014) for an overall incidence of 22.0 versus 52.6 per 1000 ventilator days, respectively (p = 0.020). Lip ulcers occurred in 4 (2.6%) versus 11 (7.3%) patients, or an incidence rate of 6.5 versus 19.5 per 1000 patient ventilator days (p = 0.053) in the fastener and tape groups, respectively. The endotracheal tube was dislodged 7 times in 6 (3.9%) patients in the tube fastener group and 16 times in 15 (10.3%) patients in the tape group (p = 0.03), reflecting incidences of 11.9 and 28.1 per 1000 ventilator days, respectively. Facial skin tears were similar between the groups. Mechanical ventilation duration and ICU and hospital mortality did not differ. CONCLUSION: The use of the endotracheal tube fastener to secure the endotracheal tubes reduces the rate of a composite outcome that included lip ulcers, facial skin tears, or endotracheal tube dislodgement compared to adhesive tape. TRIAL REGISTRATION: ClinicalTrials.gov NCT03760510. Retrospectively registered on November 30, 2018.


Assuntos
Intubação Intratraqueal/instrumentação , Fita Cirúrgica/efeitos adversos , Adulto , Idoso , Extubação/estatística & dados numéricos , Distribuição de Qui-Quadrado , Estado Terminal/epidemiologia , Estado Terminal/terapia , Feminino , Humanos , Unidades de Terapia Intensiva/organização & administração , Unidades de Terapia Intensiva/estatística & dados numéricos , Intubação Intratraqueal/métodos , Intubação Intratraqueal/normas , Masculino , Pessoa de Meia-Idade , Lesão por Pressão/epidemiologia , Lesão por Pressão/etiologia , Respiração Artificial/instrumentação , Respiração Artificial/métodos , Respiração Artificial/normas , Estudos Retrospectivos , Estatísticas não Paramétricas , Fita Cirúrgica/estatística & dados numéricos
5.
Rev Bras Ter Intensiva ; 31(1): 79-85, 2019 Mar.
Artigo em Português, Inglês | MEDLINE | ID: mdl-30970094

RESUMO

OBJECTIVE: We aimed to determine the incidence, risk factors, and outcomes of unplanned extubation among adult patients. METHODS: We conducted a prospective cohort study of adult intubated patients admitted to the charity wards of a government tertiary teaching hospital in the Philippines. Patients managed in both intensive care and nonintensive care settings were included. Patients were followed-up until discharge or until seven days postextubation. RESULTS: The outcomes of the 191 included patients were planned extubation (35%), unplanned extubation (19%), death (39%), and discharge against advice (7%). Competing risk regression showed that male sex (Crude OR: 2.25, 95%CI: 1.10 - 4.63) and age (Crude OR 0.976, 95%CI: 0.957 - 0.996) were significant baseline factors. The night shift (Crude OR: 24.6, 95%CI: 2.87 - 211) was also consistently associated with more unplanned extubations. Among postextubation outcomes, reintubation (unplanned extubation: 61.1% versus planned extubation: 25.4%), acute respiratory failure (unplanned extubation: 38.9% versus planned extubation: 17.5%), and cardiovascular events (unplanned extubation: 8.33% versus planned extubation: 1.49%) occurred significantly more often among the unplanned extubation patients. Admission in an intensive care unit was not associated with a lower risk of unplanned extubation (Crude OR 1.15, 95%CI: 0.594 - 2.21). CONCLUSION: Many intubated patients had unplanned extubation. Patients admitted in nonintensive care unit settings did not have significantly higher odds of unplanned extubation.


Assuntos
Extubação/estatística & dados numéricos , Unidades de Terapia Intensiva/estatística & dados numéricos , Intubação Intratraqueal/estatística & dados numéricos , Respiração Artificial/estatística & dados numéricos , Adulto , Idoso , Estudos de Coortes , Feminino , Seguimentos , Hospitais de Ensino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Filipinas , Estudos Prospectivos , Fatores de Risco , Centros de Atenção Terciária
6.
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
7.
Am J Surg ; 217(6): 1072-1075, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30890263

RESUMO

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.


Assuntos
Extubação/normas , Lista de Checagem , Desmame do Respirador/normas , Ferimentos e Lesões/terapia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Extubação/métodos , Extubação/mortalidade , Extubação/estatística & dados numéricos , Feminino , Humanos , Unidades de Terapia Intensiva , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , Desmame do Respirador/métodos , Desmame do Respirador/mortalidade , Desmame do Respirador/estatística & dados numéricos , Ferimentos e Lesões/mortalidade , Adulto Jovem
8.
J Cardiothorac Vasc Anesth ; 33(2): 406-415, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30115517

RESUMO

OBJECTIVE: To describe global practices for on-table extubation (OTE) in pediatric cardiac anesthesia in European and non-European countries. DESIGN: Multiple-choice, web-based survey with 34 questions addressing organizational data, existence of OTE programs, inclusion and exclusion criteria for OTE, and intraoperative and immediate postoperative management. SETTING: Online survey endorsed by the European Association of Cardiothoracic Anesthesiologists. PARTICIPANTS: Anesthesiologists departments in European and non-European pediatric cardiac surgical centers. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The survey was sent to 144 pediatric cardiac surgical centers in 29 countries as a web-based questionnaire. Addressees were pediatric cardiac anesthesiologists who were members of European Association of Cardiothoracic Anesthesiologists or were known to the authors. The response rate was 63%. Fifty percent of the respondents were practicing in university hospitals. The survey demonstrated that 76% of the respondents practiced OTE, with 50% of the pediatric cardiac anesthesiologists regularly performing OTE in different proportions, ranging from 1 to 51% of on-pump pediatric cardiac surgeries. Seventy-seven percent of respondents made their decision to perform OTE on an individual case-by-case basis. Seventy-eight percent of the congenital cardiac lesions deemed eligible for OTE fell into Risk Adjustment for Congenital Heart Surgery-1 categories 1 and 2. In patients for whom OTE was planned, anesthesia primarily was maintained using a combined inhalational and intravenous technique. The main reasons not to perform OTE were that it was deemed to provide no major advantage (45%), to be dangerous (9%), or to decrease operating room efficiency by increasing operating room turnover time (36%). CONCLUSION: The survey demonstrated that the majority of the approached pediatric cardiac anesthesiologists practice OTE regularly in pediatric cardiac surgery. Frequency of OTE and inclusion criteria vary widely. The observations made in this survey should prompt appropriately powered, randomized controlled clinical trials to examine the effect of OTE on various effectiveness and safety outcomes.


Assuntos
Extubação/estatística & dados numéricos , Anestesia/métodos , Anestesiologistas/estatística & dados numéricos , Competência Clínica , Tomada de Decisões , Cardiopatias Congênitas/cirurgia , Inquéritos e Questionários , Procedimentos Cirúrgicos Cardíacos , Criança , Estudos Transversais , Seguimentos , Humanos , Mesas Cirúrgicas , Cuidados Pós-Operatórios/normas , Estudos Retrospectivos
9.
Intensive Care Med ; 45(1): 62-71, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30535516

RESUMO

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.


Assuntos
Extubação/normas , Hipóxia/terapia , Ventilação não Invasiva/normas , Fatores de Tempo , Idoso , Extubação/métodos , Extubação/estatística & dados numéricos , Gasometria/métodos , Distribuição de Qui-Quadrado , Feminino , Humanos , Unidades de Terapia Intensiva/organização & administração , Unidades de Terapia Intensiva/estatística & dados numéricos , Itália , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Ventilação não Invasiva/métodos , Ventilação não Invasiva/estatística & dados numéricos , Respiração Artificial/métodos , Respiração Artificial/estatística & dados numéricos , Desmame do Respirador/métodos
10.
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
11.
J Clin Anesth ; 54: 76-80, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30412813

RESUMO

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


Assuntos
Analgesia/métodos , Ponte de Artéria Coronária/efeitos adversos , Dor Pós-Operatória/prevenção & controle , Avaliação de Resultados da Assistência ao Paciente , Cuidados Pós-Operatórios/métodos , Idoso , Extubação/estatística & dados numéricos , Ponte Cardiopulmonar/efeitos adversos , Protocolos Clínicos , Ponte de Artéria Coronária/métodos , Feminino , Implementação de Plano de Saúde , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Salas Cirúrgicas/estatística & dados numéricos , Manejo da Dor/métodos , Dor Pós-Operatória/tratamento farmacológico , Assistência Perioperatória/métodos , Estudos Retrospectivos , Fatores de Tempo
12.
Acta Biomed ; 89(7-S): 25-31, 2018 12 07.
Artigo em Inglês | MEDLINE | ID: mdl-30539936

RESUMO

BACKGROUND AND AIM: Unplanned extubation (UE) in Intensive Care Units (ICU) is an indicator of quality and safety of care. UEs are classified in: accidental extubations, if involuntarily caused during nursing care or medical procedures; self-extubation, if determined by the patient him/herself.  In scientific literature, the cumulative incidence of UEs varies from 0.3% to 35.8%. The aim of this study is to explore the incidence of UEs in an Italian university general ICU adopting a well-established protocol of tracheal tube nursing management and fixation. METHODS: retrospective observational study. We enrolled all patients undergone to invasive mechanical ventilation from 1st January 2008 to 31st December 2016. RESULTS: in the studied period 3422 patients underwent to endotracheal intubation. The UEs were 35: 33 self extubations (94%) and 2 accidental extubations (6%). The incidence of UEs calculated on 1497 patients intubated for more than 24 hours was 2.34%. Instead, it was 1.02%, if we consider the whole number of intubated patients. Only in 9 (26%) cases out of 35 UEs the patient was re-intubated. No deaths consequent to UE were recorded. CONCLUSIONS: The incidence of UEs in this study showed rates according to the minimal values reported in scientific literature. A standardized program of endotracheal tube management (based on an effective and comfortable fixing system) seems to be a safe and a valid foundation in order to maintain the UE episodes at minimum rates.


Assuntos
Acidentes/estatística & dados numéricos , Extubação/enfermagem , Unidades de Terapia Intensiva , Prevenção de Acidentes , Idoso , Extubação/estatística & dados numéricos , Feminino , Humanos , Incidência , Intubação Intratraqueal/enfermagem , Masculino , Pessoa de Meia-Idade , Cooperação do Paciente/estatística & dados numéricos , Indicadores de Qualidade em Assistência à Saúde , Respiração Artificial/enfermagem , Estudos Retrospectivos , Fatores de Risco , Comportamento Autodestrutivo/epidemiologia , Comportamento Autodestrutivo/enfermagem , Comportamento Autodestrutivo/prevenção & controle
13.
Isr Med Assoc J ; 20(12): 737-740, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30550001

RESUMO

BACKGROUND: Pneumonia is a major cause of morbidity and mortality in burn patients with inhalation injuries. An increased risk of pneumonia has been demonstrated in trauma and burn patients urgently intubated in the field vs. emergency departments (EDs). OBJECTIVES: To compare intubation setting (field vs. ED) and subsequent development of pneumonia in burn patients and to evaluate the indication for urgent intubation outside the hospital setting. METHODS: A retrospective medical records review was conducted on all intubated patients presenting with thermal (study group, 118 patients) or trauma (control group A, 74 patients) injuries and admitted to the intensive care unit of a level I trauma and burn center at a single institution during a 15 year period. Control group B (50 patients) included non-intubated facial burn patients hospitalized in the plastic surgery department. RESULTS: Field intubation was less frequent (37% field vs. 63% ED), although it was more frequent in larger burns (total body surface area > 50%; 43% field vs. 27% ED). More field intubated patients developed pneumonia during hospitalization (65% field vs. 36% ED [burns]; 81% field vs. 45% ED [multi-trauma]; 2% non-intubated, P < 0.05), with a significantly higher all-cause mortality (49% field vs. 24% ED, P < 0.05) and dramatically lower rates of extubation within 3 days (7% field vs. 27% ED, P < 0.05). CONCLUSIONS: Field intubation is associated with a higher risk of subsequent development of pneumonia in burn and multi-trauma patients and should be applied with caution, only when airway patency is at immediate risk.


Assuntos
Queimaduras/terapia , Serviços Médicos de Emergência/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Intubação Intratraqueal/métodos , Pneumonia/epidemiologia , Adulto , Extubação/estatística & dados numéricos , Queimaduras/mortalidade , Feminino , Hospitalização , Humanos , Masculino , Pneumonia/etiologia , Estudos Retrospectivos , Fatores de Risco , Índices de Gravidade do Trauma
14.
Can Respir J ; 2018: 3654251, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30510604

RESUMO

Unexpected reintubation may occur, even if the risk factors are considered and a spontaneous breathing trial is successful. Reintubation is thought to be caused by various factors. Several studies have investigated the risk factors of reintubation, but most did not classify reintubation by cause. We retrospectively classified patients undergoing reintubation at intensive care unit by cause (respiratory insufficiency vs. nonrespiratory insufficiency) to examine the cause-specific risk factors of reintubation. A total of 262 patients were included; reintubation within 48 hours after extubation was performed in 12 patients (reintubation rate, 4.5%). After classification by cause of reintubation, the pressure of arterial oxygen to fractional inspired oxygen concentration (P/F) ratio exhibited a significant association with reintubation only in the respiratory insufficiency group (odds ratio (OR) 0.989, 95% confidence interval (CI) 0.980 to 0.999, p=0.036, and OR 0.989, 95% CI 0.979 to 0.999, p=0.026, in the univariate and multivariate analyses, respectively). In the propensity score analysis, a P/F ratio ≤ 200 may be a risk factor for reintubation in the respiratory insufficiency group (OR 7.811, 95% CI 1.345 to 45.367, p=0.022). In the nonrespiratory insufficiency group, intubation duration was significantly related to reintubation (OR 1.165, 95% CI 1.012 to 1.342, p=0.033, and OR 1.163, 95% CI 1.004 to 1.348, p=0.044, in the univariate and multivariate analyses, respectively). In conclusion, a low P/F ratio at extubation may be a risk factor for reintubation due to respiratory insufficiency. In the nonrespiratory insufficiency group, intubation duration may be significantly related to reintubation. The risk factors for reintubation may differ by the cause of reintubation. Further large-scale randomized controlled trials are required.


Assuntos
Extubação/estatística & dados numéricos , Intubação Intratraqueal/estatística & dados numéricos , Insuficiência Respiratória/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco
15.
Clin Respir J ; 12(11): 2613-2621, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30264933

RESUMO

BACKGROUND: Extubation failure can lead to a longer intensive care unit (ICU) stay, higher mortality rate, and higher risk of requiring tracheostomy. Chest physiotherapy (CPT) can help patients in reducing the accumulation of airway secretion, preventing collapsed lung, improving lung compliance, and reducing comorbidities. Much research has investigated the correlation between CPT and respiratory system clearance. However, few studies have investigated the correlation between CPT and failed ventilator extubation. Therefore, this study aimed to investigate the use of CPT for reducing the rate of failed removal from mechanical ventilators. METHODS: This study was an intervention study with mechanical control. Subjects were divided into two groups. The control group, which received routine nursing chest care, was selected from a retrospective chart review. The intervention group was prospectively taken into the chest physiotherapy program. The chest physiotherapy treatment protocol consisted of inspiratory muscle training, manual hyperinflation, chest wall mobilization, secretion removal, cough function training, and early mobilization. RESULTS: A total of 439 subjects were enrolled in the intervention and control groups, with a mean age of 69 years. APACHE II score (P = .09) and GCS scores (P = .54) were similar between the two groups. Compared to the control group, patients in the intervention group had a significantly lower reintubation rate (8% vs 16%; P = .01). CONCLUSIONS: The results indicate that intensive chest physiotherapy could decrease extubation failure in mechanically ventilated patients in the ICU. In addition, chest physiotherapy could also significantly improve the rapid shallow breathing index score.


Assuntos
Estado Terminal/enfermagem , Deambulação Precoce/efeitos adversos , Unidades de Terapia Intensiva/estatística & dados numéricos , Intubação Intratraqueal/efeitos adversos , Terapia Respiratória/efeitos adversos , APACHE , Idoso , Idoso de 80 Anos ou mais , Extubação/estatística & dados numéricos , Extubação/tendências , Estado Terminal/epidemiologia , Estado Terminal/terapia , Deambulação Precoce/métodos , Feminino , Humanos , Intubação Intratraqueal/mortalidade , Intubação Intratraqueal/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Mortalidade/tendências , Modalidades de Fisioterapia/classificação , Estudos Prospectivos , Terapia Respiratória/métodos , Estudos Retrospectivos , Traqueostomia/normas , Traqueostomia/estatística & dados numéricos , Desmame do Respirador/métodos , Ventiladores Mecânicos/estatística & dados numéricos , Ventiladores Mecânicos/tendências
16.
World J Pediatr Congenit Heart Surg ; 9(5): 529-536, 2018 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-30157739

RESUMO

OBJECTIVES: The objectives were to assess the incidence of immediate tracheal extubation in the operating room after pediatric cardiac surgery and to investigate predictors for subsequent reintubation. METHODS: This is a single institutional retrospective study including all patients who had a cardiac operation with cardiopulmonary bypass from 2011 to 2016. Patients who required preoperative ventilator support, postoperative open chest, or mechanical support were excluded. Predictors for reintubation after immediate extubation were analyzed only for patients with stage II palliation for single ventricle physiology. RESULTS: Nine hundred nine qualifying operations were identified. Immediate extubation was performed in 590 (64.9%) operations. A multivariable logistic regression model showed that the identities of anesthesiologist ( P = .0003), year of the operation performed ( P < .001), cardiopulmonary bypass time ( P < .001), and type of operations ( P < .001) were significantly associated with immediate extubation. Reintubation was significantly less frequent in patients with immediate extubation compared to those without (6.1% vs 15.0%; P < .001). A subgroup analysis for stage II palliation showed that reintubation after immediate extubation was significant for younger age (0.42 vs 0.54 years, P = .044), lower Po2/Fio2 and Po2 at the last blood gas analysis (66 vs 98 mm Hg, P = .032 and 39 vs 47 mm Hg, P = .008), and higher inotropic score (2 vs 0, P = .034). A multivariable logistic regression model showed that only inotropic score was significantly associated with reintubation ( P = .018). CONCLUSIONS: Immediate extubation in the operating room after pediatric cardiac surgery can be performed in most patients. Inotropic score is a predictor for reintubation in stage II palliation.


Assuntos
Extubação/estatística & dados numéricos , Procedimentos Cirúrgicos Cardíacos , Intubação Intratraqueal/estatística & dados numéricos , Cuidados Pós-Operatórios/métodos , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Incidência , Lactente , Masculino , Estudos Retrospectivos , Fatores de Tempo
17.
Physiol Meas ; 39(7): 075005, 2018 07 16.
Artigo em Inglês | MEDLINE | ID: mdl-29932430

RESUMO

OBJECTIVE: Predictive analytics monitoring that informs clinicians of the risk for failed extubation would help minimize both the duration of mechanical ventilation and the risk of emergency re-intubation in ICU patients. We hypothesized that dynamic monitoring of cardiorespiratory data, vital signs, and lab test results would add information to standard clinical risk factors. METHODS: We report model development in a retrospective observational cohort admitted to either the medical or surgical/trauma ICU that were intubated during their ICU stay and had available physiologic monitoring data (n = 1202). The primary outcome was removal of endotracheal intubation (i.e. extubation) followed within 48 h by reintubation or death (i.e. failed extubation). We developed a standard risk marker model based on demographic and clinical data. We also developed a novel risk marker model using dynamic data elements-continuous cardiorespiratory monitoring, vital signs, and lab values. RESULTS: Risk estimates from multivariate predictive models in the 24 h preceding extubation were significantly higher for patients that failed. Combined standard and novel risk markers demonstrated good predictive performance in leave-one-out validation: AUC of 0.64 (95% CI: 0.57-0.69) and 1.6 alerts per week to identify 32% of extubations that will fail. Novel risk factors added significantly to the standard model. CONCLUSION: Predictive analytics monitoring models can detect changes in vital signs, continuous cardiorespiratory monitoring, and laboratory measurements in both the hours preceding and following extubation for those patients destined for extubation failure.


Assuntos
Extubação/estatística & dados numéricos , Unidades de Terapia Intensiva/estatística & dados numéricos , Idoso , Fenômenos Fisiológicos Cardiovasculares , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Respiração , Respiração Artificial , Estudos Retrospectivos
18.
Medicine (Baltimore) ; 97(25): e11190, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-29924038

RESUMO

BACKGROUND: It is very rare but challenging to perform emergency airway management for accidental extubation in a patient whose head and neck are fixed in the prone position when urgently turning the patient to the supine position would be unsafe. The authors hypothesized that tracheal intubation with a videolaryngoscope would allow effective airway rescue in this situation compared with a supraglottic airway device and designed a randomized crossover manikin study to test this hypothesis. METHODS: The authors compared airway rescue performances of the 3 devices-the ProSeal laryngeal mask airway (PLMA; Teleflex Medical, Westmeath, Ireland) as a reference; the Pentax AWS (AWS; Nihon Kohden, Tokyo, Japan) as a channeled blade-type videolaryngoscope; and the McGRATH videolaryngoscope (McGRATH; Medtronic, Minneapolis, MN) as a nonchanneled blade type in a manikin fixed to the operating table in the prone position. Twenty-one anesthesiologists performed airway management on the prone manikin with the 3 devices, and the time required for intubation/ventilation and the success rates were recorded. RESULTS: The median (range) intubation/ventilation times with the PLMA, AWS, and McGRATH were 24.5 (13.5-89.5) s, 29.9 (17.1-79.8) s, and 46.7 (21.9-211.7) s, respectively. There was no significant difference in intubation/ventilation times between the PLMA and AWS. The AWS permitted significantly faster tracheal intubation than did the McGRATH (P = 0.006). The success rates with the PLMA (100%) and AWS (100%) were significantly greater than that with the McGRATH (71.4%). Airway management performance of the PLMA and AWS was comparable between devices and better than that of the McGRATH in the prone position. CONCLUSIONS: Considering that tracheal intubation can provide a more secure airway and more stable ventilation than the PLMA, re-intubation with a channeled blade-type videolaryngoscope such as the AWS may be a useful method of airway rescue for accidental extubation in patients in the prone position.


Assuntos
Extubação/efeitos adversos , Manuseio das Vias Aéreas/instrumentação , Laringoscópios/normas , Decúbito Ventral/fisiologia , Extubação/estatística & dados numéricos , Manuseio das Vias Aéreas/métodos , Anestesiologia/educação , Competência Clínica , Humanos , Intubação Intratraqueal/instrumentação , Intubação Intratraqueal/estatística & dados numéricos , Máscaras Laríngeas/normas , Laringoscópios/tendências , Laringoscopia/métodos , Manequins , Fatores de Tempo , Ventilação/instrumentação , Ventilação/estatística & dados numéricos
19.
Eur J Cardiothorac Surg ; 54(6): 1128-1133, 2018 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-29800126

RESUMO

OBJECTIVES: We introduced an extubation strategy for emphysema patients after bilateral lung transplantation. Patients who met the extubation criteria were extubated in the operating room (OR) followed by non-invasive ventilation, and the other patients were extubated in the intensive care unit (ICU). The primary objective was to determine the extubation rate. The secondary outcomes were to determine the factors allowing for extubation in the OR and the postoperative course. METHODS: This study is a single-centre retrospective database analysis of 96 patients. Anaesthesia was performed using automated titration of total intravenous anaesthesia combined with thoracic epidural analgesia. Extubation criteria included arterial partial pressure oxygen (PaO2)/fraction of inspired oxygen (FiO2) ratio, chest radiograph, oedema and haemodynamic stability. Data were compared using non-parametric tests and expressed as median (interquartile ranges) or number (%). RESULTS: Fifty-three (55%) patients were extubated in the OR (the OR group) with 1 requiring reintubation and 43 (45%) patients were extubated in the ICU (the ICU group). Preoperative pulmonary hypertension, the requirement for intraoperative extracorporeal membrane oxygenation (ECMO), bleeding and ex vivo lung reconditioning donors were lower in the OR group. At the end of the procedure, the PaO2/FiO2 ratio was better [352 (289-437) vs 206 (144-357), P = 0.004), and the need for postoperative ECMO, mechanical ventilation duration, length of stay in the ICU [5 (4-7) vs 12 (8-20) days, P < 0.0001], Grade 3 primary graft dysfunction at 72 h [1 (2%) vs 10 (24%), P = 0.002] and 1-year mortality [5 (9%) vs 11 (26%) patients, P = 0.014] were lower in the OR group than in the ICU group. CONCLUSIONS: Half of patients were extubated in the OR, and this strategy does not require additional ICU resources.


Assuntos
Extubação , Enfisema/cirurgia , Transplante de Pulmão , Adulto , Extubação/efeitos adversos , Extubação/mortalidade , Extubação/estatística & dados numéricos , Estudos de Viabilidade , Feminino , Humanos , Estimativa de Kaplan-Meier , Transplante de Pulmão/métodos , Transplante de Pulmão/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/mortalidade
20.
BMC Anesthesiol ; 18(1): 43, 2018 04 20.
Artigo em Inglês | MEDLINE | ID: mdl-29678147

RESUMO

BACKGROUND: Despite risks, complications and negative impact to quality of life, tracheostomy is widely used to bypass upper airway obstruction after major oral cancer surgery (MOCS). Decision to tracheostomy is frequently based on clinical scoring systems which mainly have not been validated by different cohorts. Delayed extubation in the Intensive Care Unit (ICU) may be a suitable alternative in selected cases. We hypothesize that delayed routine ICU extubation after MOCS instead of scoring system based tracheostomy is safe, feasible and leads to lower tracheostomy rates. METHODS: We retrospectively analyzed our clinical protocol which provides routine extubation of patients after MOCS in the ICU. The primary outcome measure was a composite of early reintubation within 24 h or secondary tracheostomy. Secondary outcome measures included airway obstruction related morbidity and mortality. Predictor variables included tumor localisation, surgical procedure and reconstruction method, length of operation and pre-existing morbidity. Furthermore we assessed the ability of four clinical scoring systems to identify patients requiring secondary tracheostomy. Statistical processing includes basic descriptive statistics, Chi-squared test and multivariate logistic regression analysis. RESULTS: Two hundred thirty four cases were enclosed to this retrospective study. Fourteen patients (6%) required secondary tracheostomy, Ten patients (4%) required reintubation within 24 h after extubation. No airway obstruction associated mortality, morbidity and cannot intubate cannot ventilate situation was observed. Seventy five percent of the patients were extubated within 17 h after ICU admission. All evaluated scores showed a poor positive predictive value (0.08 to 0.18) with a sensitivity ranged from 0.13 to 0.63 and specificity ranged from 0.5 to 0.93. CONCLUSIONS: Our data demonstrate that common clinical scoring systems fail to prevent tracheostomy in patients after MOCS. Application of scoring systems may lead to a higher number of unnecessary tracheostomies. Delayed routine extubation in the ICU after MOCS seems an appropriate and safe approach to avoid tracheostomy and the related morbidity.


Assuntos
Extubação/métodos , Tomada de Decisão Clínica/métodos , Protocolos Clínicos , Neoplasias Bucais , Traqueostomia/estatística & dados numéricos , Idoso , Extubação/estatística & dados numéricos , Estudos de Coortes , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Estudos Retrospectivos , Fatores de Tempo
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