A 2-minute pre-extubation protocol for ventilated intensive care unit patients.

BACKGROUND: Clinicians often are challenged with safely predicting the optimal time of extubation for ventilated patients. Commonly used weaning parameters have poor positive predictive value for successful extubation. METHODS: A total of 213 intubated patients in our 20-bed surgical intensive care unit were enrolled in a trial to test a prospective, observational, 2-minute extubation protocol (TMEP). Daily measurements were obtained on all intubated patients who met criteria, which included adequate oxygenation, systolic blood pressure, heart rate, hemoglobin, Glasgow Coma Score greater than 10t, absence of significant metabolic/respiratory acidosis, and absence of therapeutic or neurologic paralysis. During TMEP, endotracheally intubated patients were physically disconnected from the ventilator for a 2-minute period of observation while spontaneously breathing room air. Patients were extubated if they tolerated the trial without clinically significant desaturation or alteration of vital signs or mental status. RESULTS: The TMEP reliably predicted successful extubations in 203 of 213 patients (95.3%). Patients who required reintubation had a longer intensive care unit stay and a longer hospital stay. CONCLUSIONS: TMEP is a simple and reliable method of predicting successful extubation.

Laparotomy for visceral ischemia and gangrene.

In the six centuries since mesenteric ischemia was first described, multiple factors have been investigated as predictors of bowel viability with little consensus. We retrospectively examined all cases of exploratory laparotomy for suspected bowel ischemia over an 8.5-year period. Patients were grouped into those who had a "positive laparotomy" with findings of bowel ischemia, bowel gangrene, or both (PL) and those who had a "negative laparotomy" with no evidence of compromised bowel (NL). Of the 114 patients, 86 (75%) were in the PL group and 28 (25%) in the NL group. The significant differences between the two groups were the higher prevalence of females in the PL group versus the NL group [71% vs. 50% (P = 0.04)] and the younger age in the NL group versus the PL group [64 +/- 19 vs. 76 +/- 14 (P = 0.0002)]. The groups did not significantly differ with respect to preoperative comorbidities and results of laboratory studies. Two patients in NL group had pneumatosis intestinalis on abdominal CT. One patient in PL group had a negative visceral angiogram. There was no difference in mortality between the groups. No single preoperative study reliably predicted positive findings at laparotomy in our series.