Ultra-fast track extubation protocol following cardiovascular surgery: Predictors of failure and outcomes.

OBJECTIVES: Identifying independent predictor factors of failure of ultra-fast track (UFT) extubation and to compare in-hospital outcomes with UFT extubation versus fast track (FT) extubation after cardiovascular surgery in adults. MATERIAL AND METHODS: Retrospective analysis of 1498 consecutive patients aged over 18 years-old undergoing cardiovascular surgery at a single institution. Between December 2014 and December 2016, FT extubation was used (N = 713) while, between December 2016 and December 2018, all patients were preoperatively considered suitable for UFT extubation (N = 785). In this instance, a standardized anaesthetic protocol was applied in all cases. The decision to not extubate in the operating room (OR) was based on intraoperative haemodynamic and ventilation. RESULTS: Extubation in the OR was possible in 699 (89%) patients. Significant independent predictors factors of UFT extubation failure were: preoperative NYHA class III-IV, myocardial infarction within two days prior to surgery, preoperative intra-aortic balloon counterpulsation, urgent/emergent surgery, intraoperative transfusion of platelets and intraoperative inotropic and vasopressor support. UFT extubation was associated with lower rates of cardiovascular complications such as congestive cardiac insufficiency (OR: 1,57; 95% CI: 1,13-2,19; p = 0,008) and new-onset postoperatory atrial fibrillation (OR: 1,40; 95% CI: 1,06-1,86; p = 0,020). Patient extubated in the OR presented lower risk of overall complications, shorter intensive care unit stay and higher short-term survival, although, no statistically significance was found when performing the multivariate adjustment. CONCLUSIONS: A routine immediate extubation in the OR following adult cardiovascular surgery is a feasible and safe practice, associated with low cardiovascular morbidity.

National survey on airway and difficult airway management in intensive care units. / Encuesta nacional sobre el manejo de la vía aérea y la vía aérea difícil en las unidades de cuidados intensivos.

OBJECTIVE: To know organization, management and training in airway (AW) in Spanish Intensive Care Units (ICUs), with special interest in difficult airway (DAW). DESIGN: Descriptive cross-sectional study and χ2 subanalysis, conducted through a national survey from november 1th to december 15th, 2016. With the SEMICYUC's support, an online questionnaire of 27 items was sent to 179 ICUs. SETTING: ICUs of public, private centers, and consortia. RESULTS: In total, 101 units responded (56.4%), corresponding to 1,827 beds and almost 95,000 incomes/year. The 85.1% are public hospitals, and 83.2% had residents. Of the responders, 22.8% don't use routinely AW assessment scales, being the most frequently used the Cormack-Mallampati association (35.6%). There's not intubation (IOT) protocol in 77.2%, nor DAW protocol in 75.2%. An 82.2% have a DAW cart. The 48.5% have training in IOT, and in VAD 53.5%. Having a DAW expert is significantly associated with greater training in IOT (60% vs. 39.3%; P=.03), DAW (64.4% vs. 44.6%; P=.04), and more AW protocols (73.4% vs. 37.5%; P=.000). Having an specific guideline for DAW management in UCI is considered necessary in 99%. CONCLUSIONS: There is room for improvement in AW management. It's necessary to identify an expert in DAW in each Unit, and the development of an specific guideline for DAW management in critical care.