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Abstract Objective: To evaluate the success rate of high-flow nasal cannula (HFNC) therapy using an adapted obsolete mechanical ventilator (MV), Optiflow™ and Vapotherm™ in newborns (NBs). Method: This was a retrospective observational study conducted in the neonatal intensive care unit (NICU). The sample comprised NBs who underwent HFNC therapy due to ventilatory dysfunction, for weaning from non-invasive ventilation (NIV), or post-extubation. The three groups, stratified according to gestational age (GA) and birth weight, and corrected GA and weight at the beginning of HFNC use, were as follows: Optiflow ™, Vapotherm ™, and obsolete Mechanical Ventilator (MV) adapted for high flow therapy. Subsequently, the NBs were divided into a success group (SG) and a failure group (FG). HFNC success was defined as a therapy duration exceeding 72 h. Results: A total of 209 NBs were evaluated, with 31.1 % using HFNC due to ventilatory dysfunction, 2.4 % after extubation, and 66.5 % after NIV weaning. HFNC success rate was observed in 90.9 % of the NBs, with no difference between equipment types (Vapotherm ™, Optiflow ™, and adapted VM). Conclusion: Different types of HFNC equipment are equally effective when used in neonatology for respiratory dysfunction, as a method of weaning from NIV and post-extubation. Adapted obsolete MV can be an alternative for HFCN therapy in resource-constrained settings.
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ObjectiveTo investigate risk factors for postoperative sore throat in patients with double-lumen endotracheal intubation. MethodsThe data used in this post-hoc analysis were prospectively collected from a randomized， controlled trial. Age from 18 to 65 years old， ASAI-Ⅲ patients undergoing general anesthesia with a double-lumen endotracheal tube were enrolled. The perioperative data collected retrospectively were as follows： gender， age， smoking history， endotracheal tube diameter， duration of endotracheal tube， dose of Sufentanil， use of Flurbiprofen Axetil， cough after extubation， etc..Dynamometer was applied to assess extubation force. According to occurrence of postoperative sore throat， patients were divided into two groups： those who experienced sore throats and those who did not. Comparative analysis and multivariate logistic regression analysis were performed to screen the risk factors. ROC curve was used for predicting the predictive value of risk factors. ResultsAmong the 163 patients ， 74 （45.4%） had postoperative sore throat vs 89 （54.6%） not had. Multivariate logistic regression showed female ［OR95%CI=3.83（1.73， 8.50）， P=0.000 1］ and extubation force ［OR95%CI=1.78（1.45， 2.17）， P＜0.001］ were independent risk factors for postoperative sore throat. AUC value showed the extubation force was 0.773［95%CI（0.701， 0.846）， P＜0.001］. Youden index was 0.447， and the cut-off valve of extubation force was 13N. ConclusionFemale and extubation force were risk factors for sore throat in patients with double lumen endotracheal intubation.
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Abstract Difficult airway management represents a major challenge, requiring a careful approach, advanced technical expertise, and accurate protocols. The task force of the Brazilian Society of Anesthesiology (SBA) presents a report with updated recommendations for the management of difficult airway in adults. These recommendations were developed based on the consensus of a group of expert anesthesiologists, aiming to provide strategies for managing difficulties during tracheal intubation. They are based on evidence published in international guidelines and opinions of experts. The report underlines the essential steps for proper difficult airway management, encompassing assessment, preparation, positioning, pre-oxygenation, minimizing trauma, and maintaining arterial oxygenation. Additional strategies for using advanced tools, such as video laryngoscopy, flexible bronchoscopy, and supraglottic devices, are discussed. The report considers recent advances in understanding crisis management, and the implementation seeks to further patient safety and improve clinical outcomes. The recommendations are outlined to be uncomplicated and easy to implement. The report underscores the importance of ongoing education, training in realistic simulations, and familiarity with the latest technologies available.
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Abstract Background: Respiratory responses to extubation can cause serious postoperative complications. Beta-blockers, such as metoprolol, can interfere with the cough pathway. However, whether metoprolol can effectively control respiratory reflexes during extubation remains unclear. The objective of this study is to evaluate the efficacy of intravenous metoprolol in attenuating respiratory responses to tracheal extubation. Methods: Randomized, double-blinded, placebo-controlled trial. Setting: Tertiary referral center located in Brasília, Brazil. Recruitment: June 2021 to December 2021. Sample: 222 patients of both sexes with an American Society of Anesthesiologists (ASA) physical status I-III aged 18-80 years. Patients were randomly assigned to receive intravenous metoprolol 5 mg IV or placebo at the end of surgery. The primary outcome was the proportion of patients who developed bucking secondary to endotracheal tube stimulation of the tracheal mucosa during extubation. Secondary outcomes included coughing, bronchospasm, laryngospasm, Mean Blood Pressure (MAP), and Heart Rate (HR) levels. Results: Two hundred and seven participants were included in the final analysis: 102 in the metoprolol group and 105 in the placebo group. Patients who received metoprolol had a significantly lower risk of bucking (43.1% vs. 64.8%, Relative Risk [RR = 0.66], 95% Confidence Interval [95% CI 0.51-0.87], p = 0.003). In the metoprolol group, 6 (5.9%) patients had moderate/severe coughing compared with 33 (31.4%) in the placebo group (RR = 0.19; 95% CI 0.08-0.43, p < 0.001). Conclusion: Metoprolol reduced the risk of bucking at extubation in patients undergoing general anesthesia compared to placebo.
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ABSTRACT Objective: To evaluate the association of biomarkers with successful ventilatory weaning in COVID-19 patients. Methods: An observational, retrospective, and single-center study was conducted between March 2020 and April 2021. C-reactive protein, total lymphocytes, and the neutrophil/lymphocyte ratio were evaluated during attrition and extubation, and the variation in these biomarker values was measured. The primary outcome was successful extubation. ROC curves were drawn to find the best cutoff points for the biomarkers based on sensitivity and specificity. Statistical analysis was performed using logistic regression. Results: Of the 2,377 patients admitted to the intensive care unit, 458 were included in the analysis, 356 in the Successful Weaning Group and 102 in the Failure Group. The cutoff points found from the ROC curves were −62.4% for C-reactive protein, +45.7% for total lymphocytes, and −32.9% for neutrophil/lymphocyte ratio. These points were significantly associated with greater extubation success. In the multivariate analysis, only C-reactive protein variation remained statistically significant (OR 2.6; 95%CI 1.51 - 4.5; p < 0.001). Conclusion: In this study, a decrease in C-reactive protein levels was associated with successful extubation in COVID-19 patients. Total lymphocytes and the neutrophil/lymphocyte ratio did not maintain the association after multivariate analysis. However, a decrease in C-reactive protein levels should not be used as a sole variable to identify COVID-19 patients suitable for weaning; as in our study, the area under the ROC curve demonstrated poor accuracy in discriminating extubation outcomes, with low sensitivity and specificity.
RESUMO Objetivo: Avaliar a associação de biomarcadores com o sucesso do desmame ventilatório em pacientes com COVID-19. Métodos: Trata-se de estudo observacional, retrospectivo e de centro único realizado entre março de 2020 e abril de 2021. Foram avaliados a proteína C-reativa, os linfócitos totais e a relação neutrófilos/linfócitos durante o atrito e a extubação; mediu-se a variação desses valores de biomarcadores. O desfecho primário foi o sucesso da extubação. As curvas ROC foram desenhadas para encontrar os melhores pontos de corte dos biomarcadores segundo a sensibilidade e a especificidade. A análise estatística foi realizada por meio de regressão logística. Resultados: Dos 2.377 pacientes admitidos na unidade de terapia intensiva, 458 foram incluídos na análise, 356 no Grupo Sucesso do desmame e 102 no Grupo Fracasso do desmame. Os pontos de corte encontrados nas curvas ROC foram −62,4% para proteína C-reativa, +45,7% para linfócitos totais e −32,9% para relação neutrófilo/linfócito. Esses pontos foram significativamente associados ao maior sucesso da extubação. Na análise multivariada, apenas a variação da proteína C-reativa permaneceu estatisticamente significativa (RC 2,6; IC95% 1,51 - 4,5; p < 0,001). Conclusão: Neste estudo, uma diminuição nos níveis de proteína C-reativa foi associada ao sucesso da extubação em pacientes com COVID-19. Os linfócitos totais e a relação neutrófilos/linfócitos não mantiveram a associação após a análise multivariada. No entanto, uma diminuição nos níveis de proteína C-reativa não deve ser usada como única variável para identificar pacientes com COVID-19 adequados para o desmame; como em nosso estudo, a área sob a curva ROC demonstrou baixa precisão na discriminação dos resultados de extubação, com baixas sensibilidade e especificidade.
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Abstract Introduction The criteria for the removal of the tracheostomy tube (decannulation) vary from center to center. Some perform an endoscopic evaluation under anesthesia or computed tomography, which adds to the cost and discomfort. We use a simple two-part protocol to determine the eligibility and carry out the decannulation: part I consists of airway and swallowing assessment through an office-based flexible laryngotracheoscopy, and part II involves a tracheostomy capping trial. Objective The primary objective was to determine the safety and efficacy of the simplified decannulation protocol followed at our center among the patients who were weaned off the mechanical ventilator and exhibited good swallowing function clinically. Methods Of the patients considered for decannulation between November 1st, 2018, and October 31st, 2020, those who had undergone tracheostomy for prolonged mechanical ventilation were included. The efficacy to predict successful decannulation was calculated by the decannulation rate among patients who had been deemed eligible for decannulation in part I of the protocol, and the safety profile was defined by the protocol's ability to correctly predict the chances of risk-free decannulation among those submitted to part II of the protocol. Results Among the 48 patients included (mean age: 46.5 years; male-to-female ratio: 3:1), the efficacy of our protocol in predicting the successful decannulation was of 87.5%, and it was was safe or reliable in 95.45%. Also, in our cohort, the decannulation success and the duration of tracheotomy dependence were significantly affected by the neurological status of the patients. Conclusion The decannulation protocol consisting of office-based flexible laryngotracheoscopy and capping trial of the tracheostomy tube can safely and effectively aid the decannulation process.
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ABSTRACT Introduction: Obese patients are at risk of complications after cardiac surgery. The aim of this study is to investigate safety and efficacy of a minimally invasive approach via upper sternotomy in this setting. Methods: We retrospectively reviewed 203 obese patients who underwent isolated, elective aortic valve replacement between January 2014 and January 2023 - 106 with minimally invasive aortic valve replacement (MIAVR) and 97 with conventional aortic valve replacement (CAVR). To account for baseline differences, a propensity-matching analysis was performed obtaining two balanced groups of 91 patients each. Results: The 30-day mortality rate was comparable between groups (1.1% MIAVR vs. 0% CAVR, P=0.99). MIAVR patients had faster extubation than CAVR patients (6 ± 2 vs. 9 ± 2 hours, P<0.01). Continuous positive airway pressure therapy was less common in the MIAVR than in the CAVR group (3.3% vs. 13.2%, P=0.03). Other postoperative complications did not differ significantly. Intensive care unit stay (1.8 ± 1.2 vs. 3.2 ± 1.4 days, P<0.01), but not hospital stay (6.7 ± 2.1 vs. 7.2 ± 1.9 days, P=0.09), was shorter for MIAVR than for CAVR patients. Follow-up survival was comparable (logrank P-value = 0.58). Conclusion: MIAVR via upper sternotomy has been shown to be a safe and effective option for obese patients. Respiratory outcome was promising with shorter mechanical ventilation time and reduced need for post-extubation support. The length of stay in the intensive care unit was reduced. These advantages might be important for the obese patient to whom minimally invasive surgery should not be denied.
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ABSTRACT Introduction: Inflammatory and immunological factors play pivotal roles in the prognosis of acute type A aortic dissection. We aimed to evaluate the prognostic values of immune-inflammatory parameters in acute type A aortic dissection patients after surgery. Methods: A total of 127 acute type A aortic dissection patients were included. Perioperative clinical data were collected through the hospital's information system. The outcomes studied were delayed extubation, reintubation, and 30-day mortality. Multivariate logistic regression analysis and receiver operating characteristic analysis were used to screen the risk factors of poor prognosis. Results: Of all participants, 94 were male, and mean age was 51.95±11.89 years. The postoperative prognostic nutritional indexes were lower in delayed extubation patients, reintubation patients, and patients who died within 30 days. After multivariate regression analysis, the postoperative prognostic nutritional index was a protective parameter of poor prognosis. The odds ratios (95% confidence interval) of postoperative prognostic nutritional index were 0.898 (0.815, 0.989) for delayed extubation and 0.792 (0.696, 0.901) for 30-day mortality. Low postoperative fibrinogen could also well predict poor clinical outcomes. The odds ratios (95% confidence interval) of postoperative fibrinogen were 0.487 (0.291, 0.813) for delayed extubation, 0.292 (0.124, 0.687) for reintubation, and 0.249 (0.093, 0.669) for 30-day mortality. Conclusion: Postoperative prognostic nutritional index and postoperative fibrinogen could be two promising markers to identify poor prognosis of acute type A aortic dissection patients after surgery.
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INTRODUCCIÓN: El creciente aumento de la incidencia del soporte ventilatorio mecánico ha impulsado el interés y desarrollo de estudios para mejorar la conducción de este proceso, sin embargo, conocer las experiencias que han vivido los profesionales de enfermería durante la extubación, puede contribuir a mejorar las prácticas de cuidado para hacer el proceso más humanizado y hacer de la UCI un lugar más ameno para la recuperación. OBJETIVO: Describir la percepción de profesionales de enfermería sobre los cuidados durante el proceso de weaning sustentado en los principios teóricos de Kristen Swanson. MÉTODOS: Estudio descriptivo, en base a un diseño fenomenológico según Husserl. La recogida de datos se realizó a través de una entrevista realizada por Google Meet, grabada en audio y luego transcrita a texto. El proceso de análisis formal estuvo orientado por los 9 pasos de Colaizzi. Para aumentar la credibilidad y precisión de la investigación se utilizaron los criterios de rigor propuestos por Lincoln y Guba. RESULTADOS: Emergieron 15 temas relacionados a los procesos de cuidado de Swanson. Se encontraron hallazgos en relación a cuidados integrales en contexto de extubación; encontrar significado al proceso de destete como experiencia de vida y la relación profesional-paciente en la extubación. CONCLUSIÓN: La experiencia al entregar cuidados durante el proceso de extubación deja en evidencia la importancia que otorgan no solo a aspectos hemodinámicos, fisiológicos y parámetros ventilatorios, sino que también a favorecer que la experiencia del destete sea realizada en un contexto de integralidad, seguridad, calidad, humanismo y respeto por sus derechos.
INTRODUCTION: The increasing incidence of mechanical ventilatory support has prompted an interest in and development of studies to improve the process, and knowing the experiences of nursing professionals during extubation can contribute to the improvement of care practices to make it more humanized as well as make the ICU a more pleasant place for recovery. OBJECTIVE: To describe nursing professionals' perception of care during the weaning process based on Kristen Swanson's theoretical principles. METHODS: Descriptive study, based on a phenomenological design according to Husserl. Data collection was done through an interview conducted by Google Meet, audio-recorded and then transcribed to text. The formal analysis process was guided by Colaizzi's 9 steps. To increase the credibility and accuracy of the research, the rigor criteria proposed by Lincoln and Guba were used. RESULTS: Fifteen themes related to Swanson's care processes emerged. Findings related to comprehensive care in the context of extubation were found, including finding meaning in the weaning process as a life experience, and the professional-patient relationship in extubation. CONCLUSION: The experience of providing care during the extubation process shows the importance they attach not only to hemodynamic, physiological and ventilatory parameters, but also to ensuring that the weaning experience is carried out in a context of integrality, safety, quality, humanism and respect for their rights.
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Resumen: Introducción: uno de los principales efectos de la ventilación mecánica invasiva es la lesión de los músculos respiratorios, específicamente, sobre el diafragma en el que pueden ocurrir alteraciones estructurales y funcionales que modifican parcial o totalmente su función. Durante la ventilación mecánica se produce un proceso de atrofia por desuso de dicho músculo. Por ello la utilidad clínica de la medición de la fuerza muscular diafragmática es importante para conocer si el paciente tiene la capacidad de activar los mecanismos protectores de la vía aérea para lograr la extubación exitosa y el retiro del ventilador mecánico en el menor tiempo posible. Objetivos: describir la medición de la fuerza muscular como predictor de la extubación en las unidades de cuidados intensivos. Material y métodos: se realizó una revisión de la literatura, entre 2011 y 2022. Resultados: los pacientes que son sometidos a ventilación mecánica invasiva prolongada generalmente desarrollan una afección muscular diafragmática, lo que se convierte en una problemática para el proceso de extubación temprana, por lo cual es vital conocer los métodos de medición de fuerza muscular como predictor de extubación.
Abstract: Introduction: one of the main effects of invasive mechanical ventilation is injury to the respiratory muscles, specifically the diaphragm. In which structural and functional alterations can occur that partially or totally modify its function. During mechanical ventilation, a process of disuse atrophy of said muscle occurs. Therefore, the clinical utility of measuring diaphragmatic muscle strength is important to know if the patient has the ability to activate the protective mechanisms of the airway to achieve successful extubation and removal of the mechanical ventilator in the shortest time possible. Objective: describe the measurement of muscle strength as a predictor of extubation in intensive care units. Material and methods: a literature review was carried out, carried out between 2011 and 2022. Results: patients who are subjected to prolonged mechanical ventilation generally develop a diaphragmatic muscle disorder, becoming a problem for the weaning, for it is important know the methods of measuring muscle strength.
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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.
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Humanos , Pacientes , Respiración Artificial/efectos adversos , Estudios de Casos y Controles , Distribución de Chi-Cuadrado , APACHE , Secreciones Corporales , Extubación Traqueal/efectos adversos , Unidades de Cuidados IntensivosRESUMEN
Background: Airway management of patients with tracheal stenosis is highly challenging and even establishing a surgical airway may be difficult in these patients. Case: A 24 year old female developed pinhole tracheal restenosis after undergoing tracheal web resection and reconstruction. After other modes of ventilation had failed, we used the Manual jet ventilator endotracheal tube assembly as a rescue device and performed intermittent low-frequency jet ventilation until a definitive surgical airway could be established. Conclusion: Central airway obstruction in severe tracheal stenosis can cause life-threatening hypoxia. Jet ventilation through the pin hole opening buys some time for the surgeon to secure the airway.
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Resumen: Introducción: La tos es una respuesta fisiológica de protección de la vía aérea, produce aerosoles que se identifican por imagen y alcanza una velocidad de hasta ocho metros por segundo. La extubación produce tos, hipertensión, taquicardia, apnea y laringoespasmo, existen métodos para minimizar su aparición. Debido a la pandemia de COVID-19 se han utilizado como profilaxis del reflejo tusígeno, la lidocaína intravenosa y el bloqueo del nervio laríngeo superior. El objetivo fue compararlos en la inhibición de la tos. Material y métodos: Se seleccionaron pacientes entre 18-60 años, cirugía electiva con anestesia general balanceada, ASA 1-3, con intubación menor a tres horas. Se aleatorizó un total de 90 pacientes, 45 en cada grupo, se eliminó un total de 10 pacientes por presentar inestabilidad hemodinámica al final de la cirugía o por no administrar dosis intravenosa de lidocaína en el tiempo establecido. Resultados: No hubo diferencia estadísticamente significativa en el número de pacientes que presentaron tos en ambos grupos (13 vs 10, p = 0.4684), de éstos se obtuvo una diferencia estadísticamente significativa en el número de decibeles a favor del grupo de bloqueo (75.6 vs 67, p < 0.001). Conclusiones: El bloqueo (selectivo) presenta menos aerolización que la lidocaína intravenosa en la extubación.
Abstract: Introduction: Coughing is a physiological response to protect the airway, it produces aerosols that are identified by imaging reaching a speed of up to 8 meters per second. Extubation produces cough, hypertension, tachycardia, apnea and laryngospasm, there are methods to minimize its occurrence. Due to the COVID-19 pandemic, intravenous lidocaine and superior laryngeal nerve block have been used as cough reflex prophylaxis. The aim was to compare them in cough inhibition. Material and methods: Patients aged 18-60 years, elective surgery with balanced general anesthesia, ASA 1-3, with intubation less than 3 hours, were selected. A total of 90 patients were randomized, 45 in each group. A total of 10 patients were eliminated because they presented hemodynamic instability at the end of surgery, and because the intravenous dose of lidocaine was not administered within the established time. Results: There was no statistically significant difference in the number of patients who presented cough in both groups (13 vs 10, p = 0.4684), of these there was a statistically significant difference in the number of decibels in favor of the block group (75.6 vs 67, p < 0.001). Conclusions: Block presents less aerolization than intravenous lidocaine in extubation.
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Introduction Acute respiratory failure remains one of the three leading causes of admission to the intensive care unit (ICU). Self-extubation is an adverse outcome requiring reintubation in 50% of cases. Objective To assess for determinants (risk factors) of self-extubation and mortality in the ICU by using a generalized estimation equation model (GEE). Methods The data was collected from a retrospective cohort study from 2017-2020 including all patients admitted to the ICU with mechanical ventilation. Univariate and bivariate analyses were performed. Then, a GEE model was conducted to predict the risk of self-extubation and mortality. Results A total of 857 subjects were included, with a mean age of 60.5 +/- 17 years-old. Most of the subjects were males (55.2%). An 8.99-fold risk (95%CI 3.83-21.1, p<0.0i) of self-extubation was identified in patients with agitation. Exposure to infusion of neuromuscular blockade was also found to increase the risk of self-extubation 3.37 times (95%CI 1.31-8.68, p=0.01). No associations were identified between immobilization and self-extubation (OR 1.38 95%CI 0.76-2.51, p=0.29). Finally, light sedation according to the Richmond Sedation Scale (RASS) between 0 to -2 rather than moderate (RASS-3) reduces the risk of mortality (OR 0.57, 95%CI 0.38-0.83, p<0.01). Conclusions The main factors resulting in self-extubation were: agitation, delirium, and infusion of neuromuscular blocking agents. An association was found between light sedation and a lower risk of mortality. No association was found between the use of physical restraint and the desired outcome.
Introducción: La insuficiencia respiratoria aguda continúa siendo una de las tres causas principales de ingreso a la unidad de cuidado intensivo (UCI). La auto-extubación es un desenlace adverso que requiere re-intubación en un 50% de los casos. Objetivo: Evaluar los determinantes (factores de riesgo) de la auto-extubación y la mortalidad en UCI mediante el uso de un modelo de ecuaciones de estimación generalizadas (EEG). Métodos: Estudio de una cohorte retrospectiva realizada durante el periodo 2017-2020 incluyendo a todos los pacientes ingresados a UCI con ventilación mecánica invasiva. Se realizaron análisis univariado y bivariado. Adicionalmente, se utilizó un modelo EEG para predecir el riesgo de auto-extubación y mortalidad. Resultados: Se analizó un total de 857 pacientes con un promedio de edad entre 60,5 +/-17 años, siendo hombres en su mayoría (55,2%). Se encontró un riesgo 8,99 veces mayor (IC95% 3,83-21,1, p<0,01) de auto-extubación en los pacientes con agitación. La infusión de relajación muscular incrementó el riesgo de auto-extubación en 3,37 veces (IC95% 1,318,68, p=0,01). No se encontró asociación entre inmovilización y auto-extubación (OR 1,38 IC95% 0,76-2,51, p=0,29). Finalmente, una sedación ligera según la Escala de Sedación de Richmond (RASS) entre 0 a -2 en lugar de moderada (RASS-3) redujo el riesgo de mortalidad (OR 0,5 IC95% 0,38-0,83, p<0.01). Conclusiones: Los principales factores asociados a auto-extubación fueron agitación, delirium e infusión de relajantes musculares. Se encontró asociación entre una sedación ligera y menor riesgo de mortalidad. No se encontró asociación entre el uso de la restricción física y el desenlace de interés.
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Purpose: Emergency delirium (ED), a common postoperative neurologic complication, causes behavioral disturbances leading to self?traumas and also has long?term adverse effects in children. Our aim was to investigate the efficacy of a single?bolus dose of dexmedetomidine in reducing the incidence of ED. Additionally, pain relief, number of patients who needed rescue analgesia, hemodynamic parameters, and adverse events were assessed. Methods: One hundred and one patients were randomly allocated into two groups: 50 patients received 15 mL of dexmedetomidine 0.4 ?g/kg (group D) and 51 patients received volume?matched normal saline (group C). Hemodynamic parameters such as heart rate (HR), systolic blood pressure (SBP), and diastolic blood pressure (DBP) were monitored regularly throughout the procedure. ED was assessed with Pediatric Anesthesia Emergence Delirium Scale (PAEDS), and pain was measured using the modified Objective Pain Score (MOPS). Results: The incidences of ED and pain were higher in group C than group D (P < 0.0001 and P < 0.0001, respectively). Group D showed significant decrease in MOPS and PAEDS values at 5, 10, 15, and 20 min (P < 0.05), HR at 5 min (P < 0.0243), and SBP at 15 min (P < 0.0127). There was no significant difference in DBP between the two groups at any time point. The mean blood pressure (MBP) at 10 min was significantly less in group D than group C (P < 0.001). Conclusion: Dexmedetomidine 0.4 ?g/kg as a single bolus over 10 min immediately after intubation is effective for the prevention of ED and significantly reduces the need of rescue analgesia without compromising the hemodynamic parameters in children undergoing ophthalmic surgery.
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Resumen Antecedentes: En la unidad de cuidados intensivos neonatales el 47% de prematuros requieren ventilación mecánica (VM), cuyo uso prolongado se asocia con secuelas a largo plazo. Objetivo: Identificar los factores de riesgo para falla en la extubación en prematuros. Material y métodos: Estudio de casos y controles; se tomó como casos las extubaciones fallidas (EF) y como controles las extubaciones exitosas (EE). El fracaso de la extubación se definió como la reintubación dentro de las primeras 72 horas. Resultados: El 46% de prematuros ingresados requirió VM. Se presentaron 12 EF y 27 EE. La proporción de EF fue del 31%. La VM más de 7 días fue del 17% en los casos y del 11% en los controles (OR: 0.6; IC 95%: 0.09-4.32; p = 0.634). La principal causa de reintubación fue por apnea (50%). Conclusiones: Los parámetros establecidos para este estudio no se determinaron como factores de riesgo para extubación fallida. Debido a los números de casos en este estudio, no podemos identificar un buen valor de corte para los factores de riesgo y predictores. Se requieren más estudios a gran escala para confirmar nuestros hallazgos y determinar los valores de corte.
Abstract Background: In the neonatal intensive care unit, 47% of premature infants require mechanical ventilation (MV); its prolonged use is associated with long-term sequelae. Objective: To identify the risk factors for extubation failure in premature infants. Material and methods: Case-control study, taking failed extubations (FE) as cases and successful extubations (SE) as controls. Extubation failure was defined as reintubation within the first 72 hours. Results: 46% of hospitalized premature infants required MV; twelve FE and 27 SE were presented. The proportion of FE was 31%. MV over 7 days was 17% in cases and 11% in controls (OR: 0.6; 95% CI: 0.09-4.32; p = 0.634). The main cause of reintubation was apnea (50%). Conclusions: The parameters established for this study were not determined as risk factors for failed extubation. Due to the case numbers in this study, we are unable to identify a good cut-off value for risk factors and predictors. More large-scale studies are required to confirm our findings and determine cut-off values.
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ABSTRACT Objective: To compare the diagnostic performance of maximal expiratory pressure with maximal expiratory pressure during induced cough for predicting extubation failure within 72 hours in patients who completed a spontaneous breathing trial (SBT). Methods: The study was conducted between October 2018 and September 2019. All patients aged over 18 years admitted to the intensive care unit who required invasive mechanical ventilation for over 48 hours and successfully completed a spontaneous breathing trial were included. The maximal expiratory pressure was assessed with a unidirectional valve for 40 seconds, and verbal encouragement was given. The maximal expiratory pressure during induced cough was measured with slow instillation of 2mL of a 0.9% saline solution. The primary outcome variable was extubation failure. Results: Eighty patients were included, of which 43 (54%) were male. Twenty-two patients [27.5% (95%CI 18.9 - 38.1)] failed extubation within 72 hours. Differences were observed in the maximal expiratory pressure during induced cough between the group who failed extubation, with a median of 0cmH2O (P25-75: 0 - 90), and the group without extubation failure, with a median of 120cmH2O (P25-75: 73 - 120); p < 0.001. Conclusion: In patients who completed a spontaneous breathing trial, the maximal expiratory pressure during induced cough had a higher diagnostic performance for predicting extubation failure within 72 hours. Clinicaltrials.gov Registry:NCT04356625
RESUMO Objetivo: Comparar o desempenho diagnóstico da pressão expiratória máxima com a pressão expiratória máxima durante a tosse induzida para prever a falha na extubação em 72 horas em pacientes que completaram o teste de respiração espontânea. Métodos: O estudo foi realizado entre outubro de 2018 e setembro de 2019. Foram incluídos todos os pacientes com mais de 18 anos admitidos à unidade de terapia intensiva que necessitavam de ventilação mecânica invasiva durante mais de 48 horas e completaram com sucesso o teste de respiração espontânea. A pressão expiratória máxima foi avaliada com uma válvula unidirecional durante 40 segundos, e foi dado encorajamento verbal. A pressão expiratória máxima durante a tosse induzida foi medida com instilação lenta de 2mL de solução salina a 0,9%. A variável do desfecho primário foi a falha na extubação. Resultados: Foram incluídos 80 pacientes, dos quais 43 (54%) eram do sexo masculino. Verificou-se falha na extubação de 22 pacientes [27,5% (IC95% 18,9 - 38,1)] em 72 horas. Observou-se diferença entre a pressão expiratória máxima durante a tosse induzida do grupo com falha na extubação, com mediana de 0cmH2O (P25-75 de 0 - 90) e do grupo sem falha na extubação, com mediana de 120cmH2O (P25-75 de 73 - 120), com p < 0,001. Conclusão: Em pacientes que completaram o teste de respiração espontânea, a pressão expiratória máxima durante a tosse induzida apresentou melhor desempenho diagnóstico para prever falha na extubação em 72 horas. Registro Cliniclatrials.gov:NCT04356625
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ABSTRACT Objective: To evaluate whether a model of a daily fitness checklist for spontaneous breathing tests is able to identify predictive variables of extubation failure in pediatric patients admitted to a Brazilian intensive care unit. Methods: This was a single-center, cross-sectional study with prospective data collection. The checklist model comprised 20 items and was applied to assess the ability to perform spontaneous breathing tests. Results: The sample consisted of 126 pediatric patients (85 males (67.5%)) on invasive mechanical ventilation, for whom 1,217 daily assessments were applied at the bedside. The weighted total score of the prediction model showed the highest discriminatory power for the spontaneous breathing test, with sensitivity and specificity indices for fitness failure of 89.7% or success of 84.6%. The cutoff point suggested by the checklist was 8, with a probability of extubation failure less than 5%. Failure increased progressively with increasing score, with a maximum probability of predicting extubation failure of 85%. Conclusion: The extubation failure rate with the use of this model was within what is acceptable in the literature. The daily checklist model for the spontaneous breathing test was able to identify predictive variables of failure in the extubation process in pediatric patients.
RESUMO Objetivo: Avaliar se um modelo de checklist diário de aptidão para o teste de respiração espontânea é capaz de identificar variáveis preditivas de falha no processo de extubação em pacientes pediátricos internados em uma unidade de terapia intensiva brasileira. Métodos: Estudo unicêntricotransversal, com coleta prospectiva de dados. O modelo de checklist foi elaborado com 20 itens e aplicado para avaliação de aptidão para o teste de respiração espontânea. Resultados: A amostra foi composta de 126 pacientes pediátricos em ventilação mecânica invasiva, 85 do sexo masculino (67,5%), para os quais foram aplicadas 1.217 avaliações diárias à beira do leito. A pontuação total ponderada do modelo de predição apresentou o maior poder de discriminação para a realização do teste de respiração espontânea, com índices de sensibilidade e especificidade para a falha de aptidão de 89,7% ou sucesso de 84,6%. O ponto de corte sugerido pelo checklist foi 8, com probabilidade de falha de extubação inferior a 5%. Observou-se que a falha aumentou progressivamente com o aumento da pontuação obtida, com probabilidade máxima de predição de falha de extubação de 85%. Conclusão: A taxa de falha de extubação com a utilização desse modelo ficou dentro do que é aceitável na literatura. O modelo de checklist diário para aptidão do teste de respiração espontânea foi capaz de identificar variáveis preditivas de falha no processo de extubação em pacientes pediátricos.
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ABSTRACT Objective: To investigate whether protocol-directed weaning in neurocritical patients would reduce the rate of extubation failure (as a primary outcome) and the associated complications (as a secondary outcome) compared with conventional weaning. Methods: A quasi-experimental study was conducted in a medical-surgical intensive care unit from January 2016 to December 2018. Patients aged 18 years or older with an acute neurological disease who were on mechanical ventilation > 24 hours were included. All patients included in the study were ready to wean, with no or minimal sedation, Glasgow coma score ≥ 9, spontaneous ventilatory stimulus, noradrenaline ≤ 0.2μgr/kg/ minute, fraction of inspired oxygen ≤ 0.5, positive end-expiratory pressure ≤ 5cmH2O, maximal inspiratory pressure < -20cmH2O, and occlusion pressure < 6cmH2O. Results: Ninety-four of 314 patients admitted to the intensive care unit were included (50 in the Intervention Group and 44 in the Control Group). There was no significant difference in spontaneous breathing trial failure (18% in the Intervention Group versus 34% in the Control Group, p = 0.12). More patients in the Intervention Group were extubated than in the Control Group (100% versus 79%, p = 0.01). The rate of extubation failure was not signifiantly diffrent between the groups (18% in the Intervention Group versus 17% in the Control Group; relative risk 1.02; 95%CI 0.64 - 1.61; p = 1.00). The reintubation rate was lower in the Control Group (16% in the Intervention Group versus 11% in the Control Group; relative risk 1.15; 95%CI 0.74 - 1.82; p = 0.75). The need for tracheotomy was lower in the Intervention Group [4 (8%) versus 11 (25%) in the Control Group; relative risk 0.32; 95%CI 0.11 - 0.93; p = 0.04]. At Day 28, the patients in the Intervention Group had more ventilator-free days than those in the Control Group [28 (26 - 28) days versus 26 (19 - 28) days; p = 0.01]. The total duration of mechanical ventilation was shorter in the Intervention Group than in the Control Group [5 (2 - 13) days versus 9 (3 - 22) days; p = 0.01]. There were no diffrences in the length of intensive care unit stay, 28-day free from mechanical ventilation, hospital stay or 90-day mortality. Conclusion: Considering the limitations of our study, the application of a weaning protocol for neurocritical patients led to a high percentage of extubation, a reduced need for tracheotomy and a shortened duration of mechanical ventilation. However, there was no reduction in extubation failure or the 28-day free of from mechanical ventilation compared with the Control Group. ClinicalTrials.gov Registry:NCT03128086
RESUMO Objetivo: Investigar se o desmame por protocolo em pacientes neurocríticos reduz a taxa de falha de extubação (desfecho primário) e as complicações associadas (desfecho secundário) em comparação com o desmame convencional. Métodos: Realizou-se um estudo quase experimental em uma unidade de terapia intensiva médico-cirúrgica de janeiro de 2016 a dezembro de 2018. Foram incluídos pacientes com 18 anos de idade ou mais, com doença neurológica aguda e em ventilação mecânica > 24 horas. Todos os pacientes incluídos no estudo estavam prontos para o desmame, com nenhuma ou mínima sedação, escala de coma de Glasgow ≥ 9, estímulo ventilatório espontâneo, noradrenalina ≤ 0,2μgr/kg/minuto, fração inspirada de oxigênio ≤ 0,5, pressão expiratória positiva final ≤ 5cmH2O, pressão inspiratória máxima < -20cmH2O e pressão de oclusão < 6cmH2O. Resultados: Foram incluídos 94 dos 314 pacientes admitidos à unidade de terapia intensiva, sendo 50 no Grupo Intervenção e 44 no Grupo Controle. Não houve diferença significativa na falha do ensaio respiratório espontâneo (18% no Grupo Intervenção versus 34% no Grupo Controle, p = 0,12). Foram extubados mais pacientes no Grupo Intervenção do que no Controle (100% versus 79%; p = 0,01). A taxa de falha de extubação não foi significativamente diferente entre os grupos (18% no Grupo Intervenção versus 17% no Grupo Controle, risco relativo de 1,02; IC95% 0,64 - 1,61; p = 1,00). A taxa de reintubação foi menor no Grupo Controle (16% no Grupo Intervenção versus 11% no Grupo Controle; risco relativo de 1,15; IC95% 0,74 -1,82; p = 0,75). A necessidade de traqueotomia foi menor no Grupo Intervenção [4 (8%) versus 11 (25%) no Grupo Controle; risco relativo de 0,32; IC95% 0,11 - 0,93; p = 0,04]. Aos 28 dias, os pacientes do Grupo Intervenção tinham mais dias sem ventilador do que os do Grupo Controle [28 (26 - 28) dias versus 26 (19 - 28) dias; p = 0,01]. A duração total da ventilação mecânica foi menor no Grupo Intervenção do que no Controle [5 (2 - 13) dias versus 9 (3 - 22) dias; p = 0,01]. Não houve diferenças no tempo de internação na unidade de terapia intensiva, 28 dias sem ventilação mecânica, internação hospitalar ou mortalidade em 90 dias. Conclusão: Considerando as limitações de nosso estudo, a aplicação de um protocolo de desmame em pacientes neurocríticos levou à maior proporção de extubação, à menor necessidade de traqueotomia e à menor duração da ventilação mecânica. Entretanto, não houve redução na falha de extubação ou 28 dias sem ventilação mecânica em comparação com o Grupo de Controle. Registro ClinicalTrials.gov:NCT03128086