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BACKGROUND: Assessment of a patient9s readiness for removal of the endotracheal tube in the ICU is based on respiratory, airway, and neurological measures. However, nearly 20% of patients require reintubation. We created a prediction model for the need for reintubation, which incorporates variables importantly contributing to extubation failure. METHODS: This was a cohort study of 2,007 endotracheally intubated subjects who required ICU admission at a tertiary care center. Data collection included demographic, hemodynamic, respiratory, and neurological variables preceding extubation. Data were compared between subjects extubated successfully and those who required reintubation, using bivariate logistic regression models, with the binary outcome reintubation and the baseline characteristics as predictors. Multivariable logistic regression analysis with robust variance was used to build the prediction model. RESULTS: Of the 2,007 subjects analyzed, 376 (19%) required reintubation. In the bivariate analysis, admission Simplified Acute Physiology Score II, minute ventilation, breathing frequency, oxygenation, number of prior SBTs, rapid shallow breathing index, airway-secretions suctioning frequency and quantity, heart rate, and diastolic blood pressure differed significantly between the extubation success and failure groups. In the multivariable analysis, higher Simplified Acute Physiology Score II and suctioning frequency were associated with failed extubation. The area under the receiver operating characteristic curve was 0.68 for failure at any time, and 0.71 for failure within 24 hours. However, prior failed SBT, minute ventilation, and diastolic blood pressure were additional independent predictors of failure at any time, whereas oxygenation predicted extubation failure within 24 hours. CONCLUSIONS: A small number of independent variables explains a substantial portion of the variability of extubation failure, and can help identify patients at high risk of needing reintubation. These characteristics should be incorporated in the decision-making process of ICU extubation.

Cerebral ischemia plays a major role in the pathophysiology of the injured brain, including traumatic brain injury and subarachnoid hemorrhage, thus improvement in outcome may necessitate monitoring and optimization of cerebral blood flow (CBF). To interpret CBF results in a meaningful way, it may be necessary to quantify cerebral autoregulation as well as cerebral metabolism. This review addresses the recent evidence related to the changes in CBF and its monitoring/management in traumatic brain injury.Recent evidence on the management of patients with traumatic brain injury have focused on the importance of cerebral autoregulation in maintaining perfusion, which necessitates the measurement of CBF. However, adequate CBF measurements alone would not indicate the amount of oxygen delivered to neuronal tissues. Technologic advancements in measurement devices have enabled the assessment of the metabolic state of the cerebral tissue for the purpose of guiding therapy, progress as well as prognostification.Current neurocritical care management strategies are focused on the prevention and limitation of secondary brain injury where neuronal insult continues to evolve during the hours and days after the primary injury. Appropriately chosen multimodal monitoring including CBF and management measures can result in reduction in mortality and morbidity.

Patients with actual or potential spinal cord injury (SCI) are frequently seen at adult trauma centers, and a large number of these patients require operative intervention. All polytrauma patients should be assumed to have an SCI until proven otherwise. Pre-hospital providers should take adequate measures to immobilize the spine for all trauma patients at the site of the accident. Stabilization of the spine facilitates the treatment of other major injuries both in and outside the hospital. The presiding goal of perioperative management is to prevent iatrogenic deterioration of existing injury and limit the development of secondary injury whilst providing overall organ support, which may be adversely affected by the injury. This review article explores the anesthetic implications of the patient with acute SCI. A comprehensive literature search of Medline, Embase, Cochrane database of systematic reviews, conference proceedings and internet sites for relevant literature was performed. Reference lists of relevant published articles were also examined. Searches were carried out in October 2010 and there were no restrictions by study design or country of origin. Publication date of included studies was limited to 1990-2010.

Purpose of review A review of recent updates to trauma anesthesia service requirements in the USA and UK, the evolving role of the trauma anesthesiologist, and opportunities for education and training. Considerations of cost and safety for staffing arrangements are discussed. Recent findings Certifying and specialty organizations have recently escalated the availability requirements and training recommendations for anesthesiology services in trauma centers. Summary There is a growing recognition that trauma anesthesiology represents a distinct area of subspecialty knowledge. Anesthesiology specialty organizations advocate for trauma-specific knowledge and training for trauma anesthesia providers. Requiring the in-house presence of anesthesia providers in level I and level II trauma centers may impose significant costs on medical centers that do not currently provide those services.

Conivaptan is an arginine-vasopressin-receptor antagonist approved for the treatment of hyponatremia. We hypothesized that administration of conivaptan to normonatremic patients with traumatic brain injury (TBI) is safe and could reduce intracranial pressure (ICP).Open-label, randomized, controlled trial enrolling 10 subjects within 24 h of severe TBI to receive a single 20 mg dose of conivaptan (n = 5) or usual care (n = 5). The primary endpoint was the evaluation of the safety profile defined by serum sodium increases averaging1 mEq/h when measured every 4 h and any adverse events. Secondary endpoints were 48-h serum sodium, sodium load, change in ICP, and urine output.Ten patients were included in the intention-to-treat analysis. Three patients (2 conivaptan, 1 usual care group) experienced brief sodium increases averaging1 mEq/h, with no patients achieving Na160 mEq/l. There were no drug-related serious adverse events. At 48 h, the mean sodium was 142 ± 6 mEq/l (conivaptan) and 144 ± 10 mEq/l (usual care, P = 0.71). 48-h sodium load was 819 ± 724 mEq in the conivaptan and 1,137 ± 1,165 mEq in the usual care group (P = 0.62). At 4 h, serum sodium was higher (P = 0.02) and ICP was lower (P = 0.046) in the conivaptan compared with usual care group. 24-h but not 48-h urine output was different between the two groups (P0.01 and P = 0.20, respectively).These data suggest that a single dose conivaptan is safe in non-hyponatremic patients with severe TBI and may reduce ICP. Further studies are needed to establish the effect of conivaptan on clinically relevant endpoints, and its role in the management of intracranial hypertension.

This review will examine the recent literature on anesthesia and monitoring techniques in relation to cerebral autoregulation. We will discuss the effect of physiologic and pharmacological factors on cerebral autoregulation alongside its clinical relevance with the help of new evidence.Intravenous anesthesia, such as combination of propofol and remifentanil, provides best preservation of autoregulation. Among inhaled agents sevoflurane appears to preserve autoregulation at all doses, whereas with other agents autoregulation is impaired in a dose-related manner.Intraoperative cerebral autoregulation monitoring is an important consideration for the patients with neurologic disease. Transcranial Doppler based static autoregulation measurements appears to be the most robust bedside method for this purpose.