Factors associated with extubation failure in an intensive care unit: a case-control study / Fatores associados à falha de extubação em unidade de terapia intensiva: estudo de caso-controle / Factores asociados al fracaso de la extubación en unidad de cuidados intensivos: estudio de caso y control

Abstract Objective: to investigate the factors associated with extubation failure of patients in the intensive care unit. Method: unpaired, longitudinal, retrospective and quantitative case-control with the participation of 480 patients through clinical parameters for ventilator weaning. Data were analyzed by: Fisher's exact test or the chi-square test; unpaired two-tailed Student's t test; and Mann-Whitney test. Significant P values lower than or equal to 0.05 were admitted. Results: of the patients, 415 (86.5%) were successful and 65 (13.5%) failed. Success group: the most negative fluid balance, APACHE II in 20 (14-25), weak cough in 58 (13.9%). Failure group: the most positive fluid balance, APACHE II in 23 (19-29), weak cough in 31 (47.7%), abundant amount of pulmonary secretions in 47.7%. Conclusion: positive fluid balance and the presence of inefficient cough or inability to clear the airway were predictors of extubation failure.

Resumo Objetivo: investigar os fatores associados à falha de extubação de pacientes na unidade de terapia intensiva. Método: caso-controle não pareado, longitudinal, retrospectivo e quantitativo com a participação de 480 pacientes por meio de parâmetros clínicos para desmame ventilatório. Dados analisados por: Teste Exato de Fisher ou o teste Qui-quadrado; teste t de Student bicaudal não pareado; e teste de Mann-Whitney. Admitiram-se significantes valores de P menores ou iguais a 0,05. Resultados: dos pacientes, 415 (86,5%) tiveram sucesso e 65 (13,5%) falharam. Grupo sucesso: balanço hídrico mais negativo, APACHE II em 20 (14-25), tosse fraca em 58 (13,9%). Grupo falha: balanço hídrico mais positivo, APACHE II em 23 (19-29), tosse fraca em 31 (47,7 %), quantidade abundante de secreção pulmonar em 47,7 %. Conclusão: o balanço hídrico positivo e a presença de tosse ineficiente ou incapacidade de higienizar a via aérea foram preditores de falhas de extubação.

Resumen Objetivo: investigar los factores asociados al fracaso de la extubación de pacientes en la unidad de cuidados intensivos. Método: caso y control no apareado, longitudinal, retrospectivo y cuantitativo con la participación de 480 pacientes mediante parámetros clínicos para el destete de la ventilación. Datos analizados por: Prueba Exacta de Fisher o prueba de Chi-cuadrado; prueba t de Student de dos colas para datos no apareados; y prueba de Mann-Whitney. Se admitieron valores de P significativos menores o iguales a 0,05. Resultados: de los pacientes, 415 (86,5%) tuvieron éxito y 65 (13,5%) fracasaron. Grupo de éxito: balance hídrico más negativo, APACHE II en 20 (14-25), tos débil en 58 (13,9%). Grupo de fracaso: balance de líquidos más positivo, APACHE II en 23 (19-29), tos débil en 31 (47,7%), abundante cantidad de secreciones pulmonares en 47,7%. Conclusión: el balance hídrico positivo y la presencia de tos ineficaz o incapacidad para higienizar la vía aérea fueron predictores de fracaso de la extubación.

Efficacy of a single dose of esmolol to prevent extubation-related complications during emergence from anesthesia: a randomized, double-blind, placebo-controlled trial

Abstract Background Few trials have examined the efficacy of esmolol to attenuate hemodynamic and respiratory responses during extubation. However, the most appropriate dose of esmolol and an optimal protocol for administering this beta-blocker are uncertain. Methods Ninety patients ASA physical status I, II, and III (aged 18-60 years) scheduled to procedures with general anesthesia and tracheal extubation were selected. Patients were randomized into esmolol and placebo group to evaluate the efficacy and safety of a single bolus dose of esmolol (2 mg.kg-1) on cardiorespiratory responses during the peri-extubation period. The primary outcome was the rate of tachycardia during extubation. Results The rate of tachycardia was significantly lower in esmolol-treated patients compared to placebo-treated patients (2.2% vs. 48.9%, relative risk (RR): 0.04, 95% confidence interval (95% CI) = 0.01 to 0.32, p= 0.002). The rate of hypertension was also significantly lower in the esmolol group (4.4% vs. 31.1%, RR: 0.14, 95% CI 0.03 to 0.6, p= 0.004). Esmolol-treated patients were associated with higher extubation quality compared to patients who received placebo (p< 0.001), with an approximately two-fold increase in the rate of patients without cough (91.1%) in the esmolol group compared to the placebo group (46.7%). The rate of bucking was approximately 5-fold lower in the esmolol group (8.9% vs. 44.5%, respectively, RR: 0.20 (95% CI, 0.1 to 0.5, p= 0.002, with an NNT of 2.8). Conclusion A single bolus dose of esmolol is an effective and safe therapeutic strategy to attenuate cardiorespiratory responses during the peri-extubation period.

Deglución post extubación de pacientes críticos con y sin diagnóstico de COVID-19 durante la pandemia / Post extubation swallowing in critical patients with and without COVID-19 during the pandemic

Estudios previos han caracterizado la disfagia en pacientes críticos hospitalizados que requieren intubación y ventilación mecánica invasiva. A raíz de la pandemia COVID-19 es necesario conocer las características deglutorias de pacientes diagnosticados con la enfermedad para su manejo. El objetivo de este estudio es analizar las características deglutorias de pacientes críticos extubados con y sin diagnóstico de COVID-19. Se llevó a cabo un estudio de cohorte retrospectivo con una muestra a conveniencia de 43 sujetos mayores de 15 años, ingresados al Hospital San Juan de Dios (Santiago, Chile) entre el 01 de junio y el 31 de agosto de 2020, intubados con o sin diagnóstico de COVID-19. Del total de sujetos, 22 padecieron de COVID-19 quienes estuvieron significativamente más días intubados que aquellos sin la patología (p=0,002). Inmediatamente posterior a la extubación orotraqueal, más del 90% de la muestra presentó disfagia. No hubo diferencia significativa en el nivel FILS ni asociación significativa en el grado de severidad de la disfagia entre sujetos con y sin COVID-19. Tampoco hubo diferencia significativa en el nivel FILS entre los grupos a los 10 días post-extubación. El nivel FILS a los 10 días aumentó significativamente en aquellos sujetos con COVID-19 (p=0,016) y sin COVID-19 (p=0,004). En la muestra, el nivel FILS y grado de severidad de la disfagia de los pacientes con y sin COVID-19 no mostraron diferencias estadísticas, siendo alto el porcentaje de disfagia en ambos grupos, lo que se podría asociar a la intubación orotraqueal y al tubo orotraqueal. Es necesaria la incorporación del fonoaudiólogo dentro de los equipos de Unidades de Pacientes Críticos para el manejo de los pacientes con COVID-19 y disfagia. Además, se recomienda continuar con más estudios en el área.

Previous research have described the deglutition disorders in critical hospitalised patients who required intubation and mechanical ventilation. In the pandemic context, it is mandatory to study both level and grade of dysphagia in patients suffering from COVID-19. The aim of this study is to analyse the deglutition features of extubated critical patients with and without COVID-19. A retrospective cohort study was performed, considering a convenience sample of 43 patients from 15 years old hospitalised at 'Hospital San Juan de Dios' between June 1st and August 31th 2020, who were intubated, with and without the diagnosis of COVID-19. 22of out 43 patients were diagnosed with COVID-19 who were intubated for significantly more days in comparison with those without COVID-19 (p=.002). After the intratracheal extubation, 90% of the sample was diagnosed with dysphagia. There was no significant difference in the FILS score nor significant association in dysphagia severity between patients with and without COVID-19. After 10 days post extubation, there was no significant difference in the FILS score between both groups. The FILS score increased significantly in the COVID-19 (p=.016) and non-COVID-19 (p=.004) patients after 10 days post extubation. Post extubation, there are no statistical differences in the FILS score and dysphagia severity in critical ill patients with and without COVID-19, with a high percentage of dysphagia in both groups which could be associated with intratracheal intubation and endotracheal tubes. The incorporation of speech and language therapists in Critical Care Units is mandatory. Furthermore, it is recommended to perform extra research in the area.

Adverse events related to mechanical ventilation in a pediatric intensive care unit / Eventos adversos relacionados à ventilação mecânica em uma unidade de terapia intensiva pediátrica

ABSTRACT Objective: To identify the prevalence and factors associated with adverse events (AE) related to invasive mechanical ventilation in patients admitted to the Pediatric Intensive Care Unit (PICU) of a tertiary public hospital. Methods: This is a cross-sectional study from July 2016 to June 2018, with data collected throughout patients' routine care in the unit by the care team. Demographic, clinical and ventilatory characteristics and adverse events were analysed. The logistic regression model was used for multivariate analysis regarding the factors associated with AE. Results: Three hundred and six patients were included, with a total ventilation time of 2,155 days. Adverse events occurred in 66 patients (21.6%), and in 11 of those (16.7%) two AE occurred, totalling 77 events (36 AE per 1000 days of ventilation). The most common AE was post-extubation stridor (25.9%), followed by unplanned extubation (16.9%). Episodes occurred predominantly in the afternoon shift (49.3%) and associated with mild damage (54.6%). Multivariate analysis showed a higher occurrence of AE associated with length of stay of 7 days or more (Odds Ratio [OR]=2.6; 95% confidence interval [95%CI] 1.49-4.66; p=0.001). Conclusions: The results of the present study show a significant number of preventable adverse events, especially stridor after extubation and accidental extubation. The higher frequency of these events is associated with longer hospitalization.

RESUMO Objetivo: Identificar a prevalência e os fatores associados a eventos adversos (EA) relacionados à ventilação mecânica (VM) invasiva em pacientes internados na Unidade de Terapia Intensiva Pediátrica (UTIP) de hospital público terciário. Métodos: Trata-se de estudo transversal realizado entre julho de 2016 e junho de 2018, com dados coletados ao longo da rotina de atendimento dos pacientes na unidade pela equipe assistencial. Neste estudo, foram analisados características demográficas, clínicas, ventilatórias e os EA ocorridos. O modelo de regressão logística foi utilizado para análise multivariada quanto aos fatores associados aos EA. Resultados: Neste estudo, foram incluídos 306 pacientes, com tempo de ventilação total de 2.155 dias. Ocorreram EA em 66 pacientes (21,6%), dos quais 11 (16,7%) sofreram dois EA, totalizando 77 eventos (36 EA por mil dias de ventilação). O EA mais comum foi o estridor pós-extubação (25,9%), seguido da extubação não planejada (16,9%). Os episódios ocorreram predominantemente no turno da tarde (49,3%) e associados a grau de dano leve (54,6%). Na análise multivariada, observou-se maior ocorrência de EA associado a tempo de internação igual ou superior a sete dias (Odds Ratio [OR]=2,6, intervalo de confiança de 95% [IC95%)]1,49-4,66, p=0,001). Conclusões: Evidenciou-se número significativo de EA que podem ser prevenidos, destacando-se o estridor pós-extubação e a extubação acidental, com ocorrência mais frequentemente associada ao maior tempo de internação.

Asociación de factores de riesgo independientes con fracaso posextubación en pacientes desconectados de la ventilación mecánica / Association of independent risk factors with post-extubation failure in patients undergoing mechanical ventilation weaning

Resumen Introducción: Aun con adecuado protocolo de desconexión de la ventilación mecánica (DVM), el procedimiento falla en 15 a 30 % de los casos. Objetivo: Evaluar la asociación entre factores de riesgo independientes y fracaso posextubación en pacientes con DVM en una unidad de cuidados intensivos. Método: Estudio de cohorte, longitudinal, prospectivo, analítico, que incluyó pacientes sometidos a ventilación mecánica por más de 24 horas y que fueron extubados. Se obtuvieron reportes preextubación de hemoglobina, albúmina, fósforo, índice cintura-cadera y puntuación SOFA. Se definió como fracaso de extubación al reinicio de la ventilación mecánica en 48 horas o menos. Resultados: Se extubaron 123 pacientes, 74 hombres (60 %); la edad promedio fue de 50 ± 18 años. Ocurrió fracaso de extubación en 37 (30 %). Como factores de riesgo independentes se asoció hipoalbuminemia en 29 (23.8 %, RR = 1.43, IC 95 % = 1.11-1.85) e hipofosfatemia en 18 (14.6 %, RR = 2.98, IC 95 % = 1.66-5.35); se observaron dos o más factores de riesgo independientes en 22.7 % (RR = 1.51, IC 95 % = 1.14-2.00). Conclusiones: Identificar los factores de riesgo independentes antes de la DVM puede ayudar a reducir el fracaso de la extubación y la morbimortalidad asociada.

Abstract Introduction: Even with an adequate mechanical ventilation weaning (MVW) protocol, the procedure fails in 15 to 30 % of cases. Objective: To assess the association between independent risk factors (IRFs) and post-extubation failure in patients undergoing MVW in an intensive care unit. Method: Longitudinal, prospective, analytical cohort study in patients on mechanical ventilation for more than 24 hours and who were extubated. Pre-extubation reports of hemoglobin, albumin, phosphorus, waist-hip ratio and SOFA score were obtained. Extubation failure was defined as resumption of mechanical ventilation within 48 hours or less. Results: 123 patients were extubated, out of whom 74 were males (60 %); average age was 50 ± 18 years. Extubation failure occurred in 37 (30 %). Hypoalbuminemia was associated as an independent risk factor in 29 (23.8 %, RR = 1.43, 95 % CI = 1.11-1.85) and hypophosphatemia was in 18 (14.6 %, RR = 2.98, 95 % CI = 1.66-5.35); two or more IRFs were observed in 22.7 % (RR = 1.51, 95 % CI = 1.14-2.00). Conclusions: Identifying independent risk factors prior to MVW can help reduce the risk of extubation failure and associated morbidity and mortality.

Idade avançada e sexo são fatores de risco para falha na extubação em UTI adulto / Advanced age and gender are risk factors for extubation failure in adult ICU

Introdução: A falha no processo de retirada da ventilação mecânica invasiva (VMI) está associada a desfechos adversos, como alta mortalidade hospitalar e custos elevados. Objetivo: Conhecer os fatores de risco para falha na extubação em adultos internados em UTI submetidos à VMI. Secundariamente, conhecer a taxa de reintubação orotraqueal (Re-TOT). Métodos: Estudo prospectivo, observacional, realizado em prontuários eletrônicos em um período de 11 meses em uma UTI adulto. Os testes Qui-quadrado ou Exato de Fischer compararam a Re-TOT, sexo e faixas etárias. Resultados: Prontuários de 224 adultos foram analisados, com média de idade 61,9±16,9 anos e 48,2% do sexo masculino. O principal motivo de internação foi por insuficiência respiratória aguda (33%). Mulheres foram susceptíveis à falha na extubação comparadas aos homens (21,5% vs. 10%, p= 0,019; respectivamente), e idade avançada. A Re-TOT foi de 31,5%. Conclusão: Sexo feminino e idade avançada foram fatores de risco para falha na extubação. A Re-TOT foi mais elevada que outros índices da literatura

Falha de extubação em unidade de terapia intensiva pediátrica: estudo de coorte retrospectivo / Fracaso de la extubación en una unidad de cuidados intensivos pediátrica: un estudio de cohorte retrospectivo / Extubation failure in pediatric intensive care unit: a retrospective cohort study

RESUMO Na unidade de terapia intensiva (UTI) pediátrica, a falha de extubação pode aumentar o risco de mortalidade. Este estudo objetivou: (1) verificar a taxa de falha de extubação na UTI pediátrica de um hospital público do município de Bauru (São Paulo, Brasil); (2) identificar a principal causa atribuída à falha de extubação; (3) avaliar se características como a idade e o tempo de ventilação mecânica invasiva (VMI) estão associadas à falha de extubação; (4) avaliar se o tempo de permanência na UTI e hospital é maior entre os pacientes que apresentaram falha de extubação. Foi realizado estudo de coorte retrospectivo com 89 pacientes internados de maio de 2017 até julho de 2018. Os resultados mostraram taxa de falha de extubação correspondente a 16%. A principal causa atribuída à falha de extubação foi o estridor laríngeo, totalizando 57% dos casos. A comparação intergrupos (sucesso vs. falha de extubação) não mostrou diferenças em relação à idade (p=0,294) e ao tempo de VMI (p=0,228). No entanto, observamos que o grupo falha de extubação apresentou maior tempo de UTI (p=0,000) e hospital (p=0,010). Desta forma, concluímos que a taxa de extubação está de acordo com a observada em outros estudos. O estridor laríngeo foi responsável por mais da metade dos casos de falha de extubação. Embora a idade e o tempo de VMI não tenham sido características associadas à falha de extubação, esta contribuiu para o maior período de permanência na UTI e no hospital.

RESUMEN En la unidad de cuidados intensivos (UCI) pediátrica, el fracaso de la extubación puede aumentar el riesgo de mortalidad. Este estudio tuvo el objetivo de: (1) verificar el índice de fracaso de la extubación en la UCI pediátrica de un hospital público en el municipio de Bauru (São Paulo, Brasil); (2) identificar la causa principal atribuida al fracaso de la extubación; (3) evaluar si las características edad y tiempo de ventilación mecánica invasiva (VMI) están asociadas al fracaso de la extubación; (4) evaluar si la duración en la UCI y el hospital es mayor entre los pacientes que experimentaron este fracaso. Se realizó un estudio de cohorte retrospectivo con 89 pacientes hospitalizados desde mayo de 2017 hasta julio de 2018. Los índices del fracaso de la extubación fueron del 16%. El estridor laríngeo fue la causa principal atribuida al fracaso de la extubación, lo que totaliza el 57% de los casos. La comparación intergrupal (éxito versus fracaso de la extubación) no presentó diferencias en relación con la edad (p=0,294) y el tiempo VMI (p=0,228). Se observó que el grupo fracaso de la extubación estuvo más tiempo en la UCI (p=0,000) y el hospital (p=0,010). Se concluye que el índice de extubación está en consonancia con lo observado en otros estudios. El estridor laríngeo fue el responsable de más de la mitad de los casos de fracaso de la extubación. Las características edad y el tiempo de VMI no estuvieron asociadas al fracaso de la extubación, pero esta contribuyó a un período más prolongado en la UCI y en el hospital.

ABSTRACT In the pediatric intensive care unit (ICU), extubation failure may increase mortality risk. This study aimed: (1) to verify the rate of extubation failure in the pediatric ICU of a public hospital located in the city of Bauru (São Paulo, Brazil); (2) to identify the main cause attributed to extubation failure; (3) to evaluate whether age and time of invasive mechanical ventilation (IMV) are characteristics associated to extubation failure; (4) to evaluate whether the length of stay in the ICU/hospital is longer among patients who presented extubation failure. A retrospective study was performed with 89 hospitalized patients from May 2017 to July 2018. Results showed an extubation failure rate corresponding to 16%. The main cause attributed to extubation failure was laryngeal stridor, totaling 57% of the cases. Intergroup comparison (success vs. failure of extubation) showed no differences in relation to age (p=0.294) and IMV time (p=0.228). However, we observed that the extubation failure group had longer ICU (p=0.000) and hospital time (p=0.010). In this way, we conclude that the rate of extubation failure is in agreement with other studies. Laryngeal stridor was responsible for more than half of cases of extubation failure. Although IMV time and age were not associated with the extubation failure, they contributed to a longer stay in the ICU and in the hospital.

Timing of Tracheostomy in Intensive Care Unit Patients

Abstract Introduction The ideal timing of tracheostomy in intensive care units (ICUs) for critically ill patients undergoing prolonged mechanical ventilation (MV) is still a controversial issue. Objectives To determine the proper timing of tracheostomy and its impact on various clinical outcomes of adult patients in ICUs undergoing prolonged MV. Methods The present study consisted of a sample of 67 ICU adult patients who were submitted to open surgical tracheostomy and divided into two groups: 30 patients in the early tracheostomy (ET) group (within 1-10 days post intubation), and 37 patients in the late tracheostomy (LT) group (within 11-21 days post intubation). The correlation between the timing of tracheostomy of each group and various associated ICU clinical parameters were analyzed. Results The sample consisted of 61.19% male and 38.81% female patients, with a mean age of 47.263 ± 7.581 years. The mean MV duration in days was 7.91 ± 4.937 standard deviation (SD) in the ET group, and 15.32 ± 7.472 SD in the LT group (p= 0.001), with a mean sedation time of 6.13 ± 4.647 SD in the ET group, and of 11.98 ± 6.596 SD in the LT group (p= 0.001). The duration of the weaning process duration had a mean of 2.75 ± 2.586 SD days in the ET group, and of 5.39 ± 5.817 SD days in the LT group (p= 0.025), with a weaning failure rate of 28.57% in the ET group and 71.42% in the LT group (p= 0.01). The Mean ICU stay was 26.18 ± 4.732 SD in the ET group, and 11.98 ± 6.596 SD in the LT group (p= 0.879), and the incidence of ventilator-associated pneumonia (VAP) of 23.33% in the ET group and of 27.02% in the LT group (p= 0.15). Conclusion Early tracheostomy had a notable benefit in shortening the duration of the MV, lessening the sedation time and minimizing the risks of weaning failure, but it had no significant impact on both the overall duration of ICU stay and VAP incidence.

Low dose propofol vs. lidocaine for relief of resistant post-extubation laryngospasm in the obstetric patient / Dose baixa de propofol versus lidocaína para alívio de laringoespasmo resistente pós-extubação em paciente obstétrica

Abstract Background Post-extubation laryngospasm is a dangerous complication that should be managed promptly. Standard measures were described for its management. We aimed to compare the efficacy of propofol (0.5 mg.kg-1) vs. lidocaine (1.5 mg.kg-1) for treatment of resistant post-extubation laryngospasm in the obstetric patients, after failure of the standard measures. Method This study was conducted over 2 years on all obstetric patients scheduled for cesarean delivery. Post-extubation laryngospasm was initially managed with a standard protocol (removal of offending stimulus, jaw thrust, positive pressure ventilation with 100% oxygen). When this protocol failed, the tested drug was the second line (lidocaine in the first year and propofol in the second year). Lastly, succinylcholine was used when the tested drug failed. Results In lidocaine group, 5% of parturients developed post-extubation laryngospasm, 31.9% of them were successfully treated via standard protocol, and 68.1% required lidocaine treatment. Among these, 65.6% of patients treated with lidocaine responded successfully and 34.4% required succinylcholine to relieve laryngospasm. In propofol group, 4.7% of parturients developed post-extubation laryngospasm, 30.1% of them were successfully treated via standard protocol, and 69.9% required propofol treatment. Among these, 82.8% of patients treated with propofol responded successfully and 17.2% required succinylcholine to relieve laryngospasm. Conclusion Small dose of propofol (0.5 mg.kg-1) is marginally more effective than lidocaine (1.5 mg.kg-1) for the treatment of resistant post-extubation laryngospasm in obstetric patients, after failure of standard measures and before the use of muscle relaxants.

Resumo Justificativa O laringoespasmo pós-extubação é uma complicação perigosa que deve ser prontamente tratada. Medidas padrão para o seu manejo foram descritas. O nosso objetivo foi comparar a eficácia de propofol (0,5 mg.kg-1) versus lidocaína (1,5 mg.kg-1) no tratamento de laringoespasmo resistente pós-extubação em pacientes obstétricas após falha das medidas padrão. Método Este estudo foi conduzido ao longo de dois anos em todas as pacientes obstétricas programadas para cesariana. O laringoespasmo pós-extubação foi inicialmente tratado com um protocolo padrão (remoção do estímulo ofensivo, protrusão mandibular, ventilação com pressão positiva com oxigênio a 100%). Ao constatar a falha desse protocolo, o fármaco testado foi a segunda opção (lidocaína no primeiro ano e propofol no segundo ano). Por fim, succinilcolina foi usada quando houve falha do fármaco testado. Resultados No grupo lidocaína, 5% das parturientes desenvolveram laringoespasmo pós-extubação, 31,9% delas foram tratadas com sucesso via protocolo padrão e 68,1% precisaram de tratamento com lidocaína, das quais, 65,6% responderam com sucesso ao tratamento com lidocaína e 34,4% precisaram de succinilcolina para alívio do laringoespasmo. No grupo propofol, 4,7% das parturientes desenvolveram laringoespasmo pós-extubação, 30,1% delas foram tratadas com sucesso via protocolo padrão e 69,9% precisaram de tratamento com propofol, das quais, 82,8% responderam com sucesso ao tratamento com propofol e 17,2% precisaram de succinilcolina para alívio do laringoespasmo. Conclusão Uma pequena dose de propofol (0,5 mg.kg-1) é marginalmente mais eficaz do que lidocaína (1,5 mg.kg-1) no tratamento de laringoespasmo resistente pós-extubação em pacientes obstétricas, após falha das medidas padrão e antes do uso de relaxantes musculares.

Manejo del fracaso de la extubación en la unidad de terapia intensiva pediátrica / Management of extubation failure in the pediatric intensive care unit / Gestão de falha de extubação na Unidade de Terapia Intensiva Pediátrica

El fracaso de la extubación es la incapacidad de tolerar el retiro del tubo endotraqueal con necesidad de reintubación. Puede ser causada por la obstrucción de la vía aérea superior y por la aspiración o la incapacidad de manejar las secreciones, factores que se evidencian al retirar el tubo. La reintubación por fracaso respiratorio post-extubación debe ser evitada en lo posible, ya que aumenta el riesgo de neumonía asociada al respirador, la estancia hospitalaria y en terapia intensiva, y la morbimortalidad. Describimos el manejo del fracaso de la extubación de causa laríngea en la Unidad de Terapia Intensiva de un hospital pediátrico.

Extubation failure is the inability to tolerate removal of the endotracheal tube with subsequent reintubation. It can be caused by obstruction of the upper airway and aspiration or inadequate clearance of airway secretion, factors that become evident when removing the tube. Reintubation due to postextubation respiratory failure should be avoided if possible because it increases the risk of ventilator associated pneumonia, hospital and intensive care unit stay, and morbidity and mortality. We describe the management of failed extubation due to laryngeal cause in the Intensive Care Unit of a pediatric hospital.

Falha de extubação é a incapacidade de tolerar a remoção do tubo endotraqueal na necessidade de reintubação. Ela pode ser causada por obstrução das vias aéreas superiores e aspiração ou incapacidade para lidar com secreções, factores que são evidentes para remover o tubo. Reintubação devido a insuficiência respiratória pós-extubação deve ser evitada, se possível, porque aumenta o risco de pneumonia associada à ventilação mecânica, permanência hospitalar e terapia, morbidade e mortalidade. Nós descrevemos a gestão de extubação falhou devido à causa da laringe na Unidade de Terapia Intensiva de um hospital pediátrico.

Inappropriate fixation of an endotracheal tube causing cuff malfunction resulting in difficult extubation / Fixação inadequada de tubo endotraqueal, resultando em mau funcionamento do manguito e extubação difícil

Abstract We discuss a case of difficult extubation, due to inadequate deflation of the tracheal tube cuff, despite collapse of the pilot balloon, on its aspiration. This was caused by inadvertent kinking of the pilot balloon tubing due to inappropriate tape fixation of the endotracheal tube.

Resumo Relatamos o caso de extubação difícil devido à desinsuflação inadequada do cuff do tubo traqueal, a despeito do colapso do balão piloto, em sua aspiração. Isso foi causado pela torção inadvertida do tubo com balão piloto devido à fixação inadequado do tubo endotraqueal com fita adesiva.

Clinical efficacy of high-flow nasal cannula compared to noninvasive ventilation in patients with post-extubation respiratory failure

BACKGROUND/AIMS: Post-extubation respiratory failure (PERF) is associated with poor clinica l outcomes. High-f low nasa l cannula (HF NC) ox ygen therapy has been used in patients with respiratory failure, but the clinical benefit in patients with PERF remains unclear. The aim of this study was to evaluate the clinical efficacy of HFNC compared to noninvasive ventilation (NIV) in patients with PERF. METHODS: A historic retrospective cohort analysis was performed in 28 beds in the medical Intensive Care Unit (ICU) at a single medical center in South Korea. In total, 73 patients with PERF were enrolled: 39 patients who underwent NIV from April 2007 to March 2009 and 34 patients who received HFNC from April 2009 to May 2011. RESULTS: The rate of avoidance of reintubation was not different between the HFNC group (79.4%) and NIV group (66.7%, p = 0.22). All patients with HFNC tolerated the device, whereas five of those with NIV did not tolerate treatment (p = 0.057). The mean duration of ICU stay was significantly shorter in the HFNC group than in the NIV group (13.4 days vs. 20.6 days, p = 0.015). There was no difference in ICU or in-hospital mortality rate. CONCLUSIONS: HFNC is likely to be as effective as, and better tolerated than, NIV for treatment of PERF.

Post extubation negative pressure pulmonary edema due to posterior mediastinal cyst in an infant.

A 3‑month‑old male child underwent uneventful inguinal herniotomy under general anesthesia. After extubation, airway obstruction followed by pulmonary edema appeared for which the baby was reintubated and ventilated. The baby made a complete recovery and extubated after about 2 h. A post‑operative computed tomography scan revealed a posterior mediastinal cystic mass abutting the tracheal bifurcation. Presumably, extrinsic compression by the mass on the tracheal bifurcation led to the development of negative pressure pulmonary edema.

Impacto de um protocolo de desmame de ventilação mecânica na taxa de falha de extubação em pacientes de difícil desmame / Impact of a mechanical ventilation weaning protocol on the extubation failure rate in difficult-to-wean patients

OBJETIVO: Determinar se a acurácia preditiva do julgamento clínico isolado pode ser melhorada com o uso suplementar de um protocolo de desmame objetivo como ferramenta de suporte para a tomada de decisão. MÉTODOS: Estudo prospectivo multicêntrico de coorte realizado em três UTIs clínicas/cirúrgicas. Foram incluídos no estudo todos os pacientes de difícil desmame (falha no primeiro teste de ventilação espontânea [TVE]), sob ventilação mecânica (VM) por mais de 48 h, admitidos em uma das UTIs entre janeiro de 2002 e dezembro de 2005. Os pacientes do grupo protocolo (GP) foram extubados após teste de tubo T de acordo com um protocolo de desmame e comparados com o grupo de pacientes extubados sem o uso do protocolo (GNP). O desfecho primário foi a taxa de reintubação em até 48 h após a extubação. RESULTADOS: Foram incluídos 731 pacientes - 533 (72,9%) no GP e 198 (27,1%) no GNP. A taxa global de reintubação foi de 17,9%. As taxas de sucesso da extubação no GP e no GNP foram 86,7% e 69,6%, respectivamente (p < 0,001). Não houve diferenças significativas entre os grupos quanto a idade, gênero, escore de gravidade e tempo de VM antes da inclusão. Entretanto, DPOC foi mais frequente no GNP que no GP (44,4% vs. 17,6%; p < 0,001), ao passo que pacientes sépticos e em pós-operatório foram mais comuns no GP (23,8% vs. 11,6% e 42,4% vs. 26,4%, respectivamente; p < 0,001 para ambos). O tempo de VM após a falha no primeiro TVE foi maior no GP que no GNP (9 ± 5 dias vs. 7 ± 2 dias; p < 0,001). CONCLUSÕES: Nesta amostra de pacientes de difícil desmame, o uso de um protocolo de desmame melhorou o processo decisório, reduzindo a possibilidade de falha na extubação.

OBJECTIVE: To determine whether the predictive accuracy of clinical judgment alone can be improved by supplementing it with an objective weaning protocol as a decision support tool. METHODS: This was a multicenter prospective cohort study carried out at three medical/surgical ICUs. The study involved all consecutive difficult-to-wean ICU patients (failure in the first spontaneous breathing trial [SBT]), on mechanical ventilation (MV) for more than 48 h, admitted between January of 2002 and December of 2005. The patients in the protocol group (PG) were extubated after a T-piece weaning trial and were compared with patients who were otherwise extubated (non-protocol group, NPG). The primary outcome measure was reintubation within 48 h after extubation. RESULTS: We included 731 patients-533 (72.9%) and 198 (27.1%) in the PG and NPG, respectively. The overall reintubation rate was 17.9%. The extubation success rates in the PG and NPG were 86.7% and 69.6%, respectively (p < 0.001). There were no significant differences between the groups in terms of age, gender, severity score, or pre-inclusion time on MV. However, COPD was more common in the NPG than in the PG (44.4% vs. 17.6%; p < 0.001), whereas sepsis and being a post-operative patient were more common in the PG (23.8% vs. 11.6% and 42.4% vs. 26.4%, respectively; p < 0.001 for both). The time on MV after the failure in the first SBT was higher in the PG than in the NPG (9 ± 5 days vs. 7 ± 2 days; p < 0.001). CONCLUSIONS: In this sample of difficult-to-wean patients, the use of a weaning protocol improved the decision-making process, decreasing the possibility of extubation failure.

Implications of extubation failure and prolonged mechanical ventilation in the postoperative period following elective intracranial surgery

Patients undergoing neurosurgery are predisposed to a variety of complications related to mechanical ventilation (MV). There is an increased incidence of extubation failure, pneumonia, and prolonged MV among such patients. The aim of the present study was to assess the influence of extubation failure and prolonged MV on the following variables: postoperative pulmonary complications (PPC), mortality, reoperation, tracheostomy, and duration of postoperative hospitalization following elective intra-cranial surgery. The study involved a prospective observational cohort of 317 patients submitted to elective intracranial surgery for tumors, aneurysms and arteriovenous malformation. Preoperative assessment was performed and patients were followed up for the determination of extubation failure and prolonged MV (>48 h) until discharge from the hospital or death. The occurrence of PPC, incidence of death, the need for reoperation and tracheostomy, and the length of hospitalization were assessed during the postoperative period. Twenty-six patients (8.2 percent) experienced extubation failure and 30 (9.5 percent) needed prolonged MV after surgery. Multivariate analysis showed that extubation failure was significant for the occurrence of death (OR = 8.05 [1.88; 34.36]), PPC (OR = 11.18 [2.27; 55.02]) and tracheostomy (OR = 7.8 [1.12; 55.07]). Prolonged MV was significant only for the occurrence of PPC (OR = 4.87 [1.3; 18.18]). Elective intracranial surgery patients who experienced extubation failure or required prolonged MV had a higher incidence of PPC, reoperation and tracheostomy and required a longer period of time in the ICU. Level of consciousness and extubation failure were associated with death and PPC. Patients who required prolonged MV had a higher incidence of extubation failure.

Uso de VNI en una unidad de cuidados intensivos cardiovasculares pediátricos. Factores de riesgo asociados al fracaso / Use of NIV in a pediatric cardiovascular intensive care unit. Risk factors associated with failure

Objetivo: Describir el uso de Ventilación No Invasiva (VNI) en pacientes internados en una Unidad de Cuidados Intensivos (UCI) cardiovascular (CCV) pediátrica e identificar factores de riesgo que lleven al fracaso, definido como requerimiento de ARM a las 72 hs. Diseño: Estudio observacional analítico, de cohorte retrospectiva. Material y Método: Se estudiaron 340 niños internados en UCI 35 del Hospital Garrahan durante el período 2005-2008 con indicación de VNI por insuficiencia cardiaca (IC), como rescate en el fallo post-extubación y como destete de ARM: se registraron datos demográficos, período pre (PREQ) o postquirúrgico (POP), tipo de interfase, la presencia de atelectasias (ATL), paresia diafragmática (PD), hipertensión pulmonar (HTP), infecciones, defecto residual quirúrgico (DR), lesiones cutáneas (LC), disfunción ventricular (DV), síndromes genéticos (SG), y obstrucción de vías aéreas superiores (VAS), tiempo de exposición a la VNI y fracaso de la VNI. Se utilizó fuente de datos primarios, las variables continuas fueron tratadas con Test de Student o Wilcoxon de acuerdo a su distribución, las variables categóricas con Chi2, se realizó análisis de regresión logística univariado (ARLU) con Wald Test y para el control simultáneo de confundidores, análisis de regresión logística multivariado (ARLM). En todos los casos se tomó como punto de corte 0,05 para asociación estadísticamente significativa (AES). Resultados: Se estudiaron 182 niñas y 158 varones, edad mediana 4,2 meses (r 0,5-216), peso mediana 4,7 kilos(r 2- 64). En el período prequirúrgico (PREQ) 20 y 320 en post quirúrgico(POP). La indicación más frecuente: destete en un 86,76%, la interfase más utilizada fue la cánula nasal (CN) 99,71%, el tiempo de VNI fue de 1 a 11 días con una mediana de 2 días. Se presentaron lesiones cutáneas en un 5,29% y se consideró fracaso en un 17,65%. En el modelo de regresión logística multivariado (MRLM), fueron identificadas como factores de riesgo de fracaso: ATL OR: 2,99 (IC 95%1,23-7,25); edad<=6meses OR: 3,50 (IC95% 1,59-7,73); infecciones OR: 6,93 (IC95% 1,77-27,14); DV, OR: 10,88 (IC 95% 4,44-26,68); el tener obstrucción de VAS OR: 11,66 (IC 95% 4,47-26,68) Conclusiones: Los factores de riesgo que explicaron el fracaso de la VNI en el MRLM fueron la presencia de atelectasia, la edad menor o igual a seis meses, las comorbilidades infecciosas, así como la disfunción ventricular y la obstrucción de VAS. Si bien faltan aún estudios controlados en pediatría, la consideramos una alternativa terapéutica de soporte respiratorio útil y en expansión tanto en el periodo pre como en el post quirúrgico de CCV pediátrica y neonatal (AU)

Objective: To assess the use of non-invasive ventilation (NIV) in patients in the pediatric cardiovascular intensive care unit (ICU) and to identify risk factors that lead to failure, defined as need for mechanical respiratory assistance within 72 hours. Study design: An observational analytical retrospective cohort study. Material and Methods: We studied 340 children with heart failure hospitalized in the ICU 35 of the Garrahan Hospital between 2005 and 2008 who needed NIV as rescue therapy for post-extubation failure and weaning from mechanical respiration. Demographic data, pre- or postsurgical period, type of interface, presence of atelectasis, diaphragmatic paresis, pulmonary hypertension, infections, residual defect, skin lesions, ventricular dysfunction, genetic syndromes, and upper respiratory tract obstruction, time of NIV exposure and NIV failure were recorded. A primary data source was used. According to their distribution, the continuous variables were analyzed uzing the Student's t test or the Wilcoxon test and for categorical variables the Chi-square test was used. Univariate logistic regression analysis was performed using the Wald Test and multivariate logistic regression analysis was done to simultaneously control for confounding factors. In all cases, p< 0.05 was considered as statistically significant. Results: 182 girls and 158 boys with a mean age of 4.2 months (r 0.5-216) and a mean weight of 4.7 kg (r 2- 64) were studied. The period was presurgical in 10 and postsurgical in 320. The most frequent indication was weaning (86.76%), the most-frequently used interface was a nasal tube (99.71%), and time on NIV was between 1 and 11 days with a median of 2 days. Skin lesion were observed in 5.29% and NIV was considered a failure in 17.65%. In the model of multivariate logistic regression the following risk factors were identified: atelectasis, OR: 2.99 (95% CI 1.23-7.25); age ≤ 6 months OR: 3.50 (95% CI 1.59- 7.73); infections, OR: 6.93 (95% CI 1.77-27.14); ventricular dysfunction, OR: 10.88 (95% CI 4.44-26.68); upper respiratory tract obstruction, OR: 11,66 (95% CI 4.47-26.68). Conclusions: Risk factors for NIV failure found with the multivariate logistic regression model were the presence of atelectasis, age ≤ 6 months, infectious comorbidities, as well as ventricular dysfunction and upper respiratory tract obstruction. Although controlled trials are lacking in the pediatric population, we consider NIV to be a useful therapeutic alternative for respiratory support both pre- and postsurgically in pediatric and neonatal cardiovascular disease (AU)

Rotura de tráquea / Tracheal fracture

En este trabajo se presenta un caso de rotura traqueal posextubación orotraqueal ocurrido durante una cirugía laparoscópica habitual. La rotura o laceración traqueal se produce por un aumento de la presión en la vía aérea, el uso de mandriles, la exposición a gases anestésicos o sobreinsuflación en el manguito del tubo endotraqueal, o por praxis no anestésicas (cirugía de esófago, broncoscopías, etc.) Es detectada en el posoperatorio inmediato (quirófano, sala de recuperación posanestésica o primeras horas en sala), y aunque es una patología de muy baja incidencia, el anestesiólogo debe estar involucrado activamente en su diagnóstico porque las posibilidades de morbimortalidad son elevadas. El objetivo de esta presentación es señalar las causas del evento para tratar de evitar su ocurrencia, describir los primeros signos y síntomas para ayudar a su diagnóstico precoz y realizar una recopilación de los tratamientos reconocidos. Recordemos que por su baja incidencia no se conocen trabajos randomizados sobre la adopción a tiempo de medidas clínicas y quirúrgicas, incluidas la del tratamiento expectante, que es la conducta más aceptada, rápida y con menores o ninguna secuela para resolver la rotura traqueal posextubación.

This paper presents a case of tracheal fracture after endotracheal extubation following a routine laparoscopic surgery. Tracheal fracture or laceration may be caused by an increase of pressure in the airway, the use of mandrels, exposure to anesthetic gases or excessive insufflation in the cuff of the endotracheal tube, or due to non-anesthetic practices (esophageal surgery, bronchoscopy, etc.) It was detected in the immediate postoperative period (operating theater, post-anesthesia recovery room or first hours in the ward), and although it is a rare occurrence, the anesthesiologist must be actively involved in its diagnosis because of the high possibilities of morbi-mortality. The purpose of this presentation is to point out the causes of this occurrence so as to attempt to avoid it, to describe the first signs and symptoms for early diagnosis and to compile renowned treatment. Bear in mind that due to its low incidence there are no known randomized papers on timely adoption of clinical and surgical measures, including the expectant treatment, which is the most accepted and fastest one, with the least or no consequences to solve the post-extubation tracheal fracture.

Neste trabalho é apresentado um caso de ruptura traqueal pós-extubação orotraqueal durante uma cirurgia laparoscópica habitual. A ruptura ou laceração traqueal ocorre por aumento da pressão na via aérea, uso de mandris, exposição a gases anestésicos, superinsuflação no manguito do tubo endotraqueal, ou por práticas não anestésicas (cirurgia de esôfago, broncoscopias, etc.). É detectada no pós-operatório imediato - na sala de operações, na sala de recuperação pós-anestésica ou nas primeiras horas na sala- e apesar de ser uma patologia de incidência muito baixa, é necessário que o anestesiologista se envolva ativamente em seu diagnóstico, já que as possibilidades de morbimortalidade são elevadas. O objetivo desta apresentação é apontar as causas do evento a fim de evitar sua ocorrência, descrever os primeiros sinais e sintomas que facilitem o diagnóstico precoce e realizar uma recopilação dos tratamentos reconhecidos. É importante lembrar que por sua reduzida incidência não se conhecem trabalhos randomizados sobre adoção de medidas clínicas e cirúrgicas em tempo adequado, entre as quais se inclui o tratamento expectante, a conduta mais aceita, rápida e com menores ou nenhuma sequela para resolver a ruptura traqueal pós-extubação.