Nasal/orotracheal tube switch to reduce length of mechanical ventilation in neurocritical patients: A propensity score matched analysis.

INTRODUCTION AND OBJECTIVES: Nasotracheal intubation was advocated to increase patients comfort and tube tolerance, but no study showed a clear benefit of nasotracheal intubation over orotracheal intubation. Neurocritically ill patients are a fragile group with specific requirements regarding ventilation and sedation. The aim of this study was to evaluate whether nasotracheal intubation might reduce length of mechanical ventilation in neurocritically ill patients. MATERIALS AND METHODS: We conducted a retrospective cohort study with propensity matched analysis including all patients who underwent prolonged mechanical ventilation in the neurocritical Intensive Care Unit. RESULTS: A total of 4030 patients were admitted during the period of interest and 312 entered the final analysis. Propensity score analysis identified 74 matched couples. Length of mechanical ventilation in patients who underwent early nasotracheal intubation resulted to be statistically significantly shorter than patients who underwent orotracheal intubation. Accordingly, length of sedation was significantly lower in patients with nasotracheal intubation, while no difference in complications occurred with similar length of stay. CONCLUSIONS: In critical care units using nasotracheal intubation in the standard management of patients, the nasotracheal route was associated with lesser need for sedatives leading to shorter mechanical ventilation in neurocritical patients. However, causality has to be proven by future randomized controlled trials.

Sustitución del tubo nasal/orotraqueal para reducir la duración de la ventilación mecánica en pacientes neurocríticos: análisis de emparejamiento por puntuación de propensión / Nasal/orotracheal tube switch to reduce length of mechanical ventilation in neurocritical patients: A propensity score matched analysis

Introducción y objetivos: Se ha aducido que la intubación nasotraqueal incrementa la comodidad y la tolerancia al tubo por parte del paciente, aunque ningún estudio ha demostrado un beneficio claro de la intubación nasotraqueal con respecto a la intubación orotraqueal. Los pacientes neurocríticos constituyen un grupo frágil con necesidades específicas, en cuanto a ventilación y sedación. El objetivo de este estudio fue evaluar si la intubación nasotraqueal podría reducir la duración de la ventilación mecánica en los pacientes neurocríticos. Materiales y métodos: Realizamos un estudio prospectivo de cohorte con análisis pareado de propensión, incluyendo a todos los pacientes que recibieron ventilación mecánica en la Unidad de Cuidados Intensivos neurocríticos. Resultados: Se ingresó a un total de 4.030 pacientes durante el periodo de interés, incluyendo a 312 de ellos en el análisis final. El análisis de la puntuación de propensión identificó a 74 parejas pareadas. La duración de la ventilación mecánica de los pacientes que recibieron intubación nasotraqueal temprana resultó ser significativamente inferior a la de los pacientes que recibieron intubación orotraqueal. Por tanto, la duración de la sedación fue considerablemente inferior en los pacientes con intubación nasotraqueal y no existió diferencia en cuanto a las complicaciones que se producen con las estancias de duración similar. Conclusiones: En las unidades de cuidados críticos que utiliza intubación nasotraqueal en el manejo estándar de los pacientes, la vía nasotraqueal estuvo asociada a una menor necesidad de sedantes, lo cual conllevó una ventilación mecánica más breve en los pacientes neurocríticos. Sin embargo, los ensayos controlados aleatorizados deberán probar la causalidad.(AU)

Introduction and objectives: Nasotracheal intubation was advocated to increase patients comfort and tube tolerance, but no study showed a clear benefit of nasotracheal intubation over orotracheal intubation. Neurocritically ill patients are a fragile group with specific requirements regarding ventilation and sedation. The aim of this study was to evaluate whether nasotracheal intubation might reduce length of mechanical ventilation in neurocritically ill patients. Materials and methods: We conducted a retrospective cohort study with propensity matched analysis including all patients who underwent prolonged mechanical ventilation in the neurocritical Intensive Care Unit. Results: A total of 4030 patients were admitted during the period of interest and 312 entered the final analysis. Propensity score analysis identified 74 matched couples. Length of mechanical ventilation in patients who underwent early nasotracheal intubation resulted to be statistically significantly shorter than patients who underwent orotracheal intubation. Accordingly, length of sedation was significantly lower in patients with nasotracheal intubation, while no difference in complications occurred with similar length of stay. Conclusions: In critical care units using nasotracheal intubation in the standard management of patients, the nasotracheal route was associated with lesser need for sedatives leading to shorter mechanical ventilation in neurocritical patients. However, causality has to be proven by future randomized controlled trials.(AU)

Impact on grafted kidney function of rocuronium-sugammadex vs cisatracurium-neostigmine strategy for neuromuscular block management. An Italian single-center, 2014-2017 retrospective cohort case-control study.

BACKGROUND: The impact of sugammadex in patients with end-stage renal disease undergoing kidney transplantation is still far from being defined. The aim of the study is to compare sugammadex to neostigmine for reversal of rocuronium- and cisatracurium-induced neuromuscular block (NMB), respectively, in patients undergoing kidney transplantation. METHODS: A single-center, 2014-2017 retrospective cohort case-control study was performed. A total of 350 patients undergoing kidney transplantation, equally divided between a sugammadex group (175 patients) and a neostigmine group (175 patients), were considered. Postoperative kidney function, evaluated by monitoring of serum creatinine and urea and estimated glomerular filtration rate (eGFR), was the endpoint. Other endpoints were anesthetic and surgical times, post-anesthesia care unit length of stay, postoperative intensive care unit admission, and recurrent NMB or complications. RESULTS: No significant differences in patient or, with the exception of drugs involved in NMB management, anesthetic, and surgical characteristics, were observed between the two groups. Serum creatinine (median [interquartile range]: 596.0 [478.0-749.0] vs 639.0 [527.7-870.0] µmol/L, p = 0.0128) and serum urea (14.9 [10.8-21.6] vs 17.1 [13.1-22.0] mmol/L, p = 0.0486) were lower, while eGFR (8.0 [6.0-11.0] vs 8.0 [6.0-10.0], p = 0.0473) was higher in the sugammadex group than in the neostigmine group after surgery. The sugammadex group showed significantly lower incidence of postoperative severe hypoxemia (0.6% vs 6.3%, p = 0.006), shorter PACU stay (70 [60-90] min vs 90 [60-105] min, p < 0.001), and reduced ICU admissions (0.6% vs 8.0%, p = 0.001). CONCLUSIONS: Compared to cisatracurium-neostigmine, the rocuronium-sugammadex strategy for reversal of NMB showed a better recovery profile in patients undergoing kidney transplantation.