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Despite neweffective medications, patients with spinal muscular atrophy types 1-3 can continue to have inadequate cough flows to prevent episodes of acute respiratory failure. Ventilator unweanable intubated patients are thought to require tracheostomy tubes. As a result, potentially beneficial medications may be discontinued and patients die despite receiving these medications. Three cases are presented of medically treated, physically strengthening children, with spinal muscular atrophy type 1. All three subsequently died or underwent tracheotomy. However, there is no evidence of extubation attempts to noninvasive ventilatory support settings or optimal mechanical insufflation-exsufflation despite this option being described to be over 98% successful for extubating unweanable medically untreated children with spinal muscular atrophy 1. [ABSTRACT FROM AUTHOR]

Background: Palliative extubation (PE) is the cessation of mechanical ventilation (MV) during terminal illness. Although PE is widely practiced in many countries, it remains illegal in others. Attitudes toward PE of patients at the highest risk for MV were scarcely explored before. Objective: To assess the attitudes of patients with advanced chronic illnesses (ACI) toward PE and other end-of-life decisions in a country where PE is illegal. Design: A prospective observational study using questionnaire-based interviews. Setting/Subjects: Patients with ACI hospitalized between 2021 and 2022 in a large tertiary center. Attitudes toward PE and mechanical ventilation were evaluated. Predictors for favoring/opposing PE were analyzed using multivariate logistical regression models. Results: A total of 152 (40% female, 75 ± 11 years) patients were included. The most common ACIs were advanced heart failure (32%), metastatic malignancy (32%), and chronic obstructive pulmonary disease (22%). Around 132 patients (87%) supported the legalization of PE, and their main reason was to avoid pain and suffering (87%). Legalization of PE would change the decision to avoid mechanical intubation in 34% of the cases. Most patients thought that the decision to perform PE should be made by the patient's physician and primary caregiver collaboratively (64%). Religious observance was an independent predictor for opposing PE (adjusted odds ratio 0.18; 95% confidence interval 0.06–0.59; p < 0.01), whereas the type of ACI was not. Conclusion: Most admitted patients with ACIs support the legalization of PE. Such policy change could have major impact on patients' end-of-life preferences. At-risk patients should be the focus of future studies in this area. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To evaluate the association between the pre-extubation sum of eye and motor components of the Glasgow Coma Score (GCS-EM) and odds of extubation failure in patients with acute brain injury being liberated from mechanical ventilation. DESIGN: Secondary analysis of a prospective, multicenter observational study (ClinicalTrials.gov identifier NCT03400904). SETTING: Sixty-three hospital sites worldwide, with patient recruitment from January 2018 to November 2020. PATIENTS: One thousand one hundred fifty-two critically ill patients with acute brain injury, with a median age of 54 years, of whom 783 (68.0%) were male, 559 (48.5%) had traumatic brain injury, and 905 (78.6%) had a GCS-EM greater than 8 before extubation (scores range from 2 to 10). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: GCS-EM was computed in intubated patients on the day of extubation. The main outcome was extubation failure, defined as unplanned reintubation within 5 days of extubation. Analyses used multilevel logistic regression with adjustment for patient characteristics and a random intercept for hospital site. In the primary analysis, GCS-EM was not associated with extubation failure (odds ratio, 1.07 per additional point; 95% CI, 0.87-1.31). Findings were consistent in sensitivity analyses that: 1) used different adjustment covariates, 2) included a verbal estimate to derive an overall GCS, 3) accounted for missing data, 4) considered a 2-day time interval to define extubation failure, 5) accounted for competing risks, and 6) used a propensity score-based model. There was no association between GCS-EM and extubation outcome in sub-groups defined by brain injury diagnosis or age. CONCLUSIONS: In this large, contemporary, multicenter cohort of patients with acute brain injury, we found no association between the GCS-EM and odds of extubation failure. However, few patients had a pre-extubation GCS-EM less than or equal to 8, and the possibility of a true prognostic association in patients with low scores is not excluded. [ABSTRACT FROM AUTHOR]

Objective Nasal high-frequency oscillatory ventilation (nHFOV) and synchronized nasal intermittent positive pressure ventilation (sNIPPV) were the new modes of noninvasive ventilation. This study's aim was to clarify as to which of the nHFOV and sNIPPV modes was superior in preventing postextubation failure or reintubation in neonates. Study Design An open-label parallel randomized study was performed. Extubated preterm and term neonates were randomly allocated into nHFOV or sNIPPV modes; the reintubation rate was evaluated within 7 days after extubation between the two modes. Subgroup analyses were performed for preterm (gestational age <37 weeks) and very preterm (gestational age <32 weeks) neonates. The sample calculation was 1,050 neonates; however, this trial was stopped early as enrollment was too slow. Results From July 2020 to June 2022, 202 neonates were assessed for eligibility and 69 neonates were excluded. Finally, 133 neonates were randomly allocated to the study interventions (nHFOV = 67, sNIPPV = 66). The median gestational age and birth weight were 33 (30–37) weeks and 1,910 (1,355–2,836) g, respectively. The reintubation rate within 7 days did not significantly differ between the groups (nHFOV [5/67, 7%] vs. sNIPPV [4/66, 6%]); risk difference [95% confidence interval] = 0.01 [−0.08 to 0.11]; p = 0.99), including preterm (nHFOV [4/55, 7%] vs. sNIPPV [3/44, 7%]) and very preterm (nHFOV [3/25, 12%] vs. sNIPPV [3/25, 12%]) neonates. Conclusion After neonatal extubation, there was no significant difference of reintubation rates within 7 days between nHFOV and sNIPPV. This trial has been registered in the ClinicalTrials.gov database (https://clinicaltrials.gov/ct2/show/NCT04323397). First posted registration on March 26, 2020. Key Points There was no significant difference of reintubation rates between nHFOV and sNIPPV. During nHFOV support, one neonate developed pneumomediastinum. During sNIPPV support, one neonate developed pulmonary hemorrhage. [ABSTRACT FROM AUTHOR]

Objective Nasal high-frequency oscillatory ventilation (nHFOV) and synchronized nasal intermittent positive pressure ventilation (sNIPPV) yield a lower partial pressure of carbon dioxide (pCO 2) after extubation than nasal continuous positive airway pressure. Our aim was to clarify which of the two was superior. Study Design We performed a crossover randomized study to evaluate pCO 2 level among 102 participants from July 2020 to June 2022. Intubated preterm and term neonates with arterial lines were randomly allocated to nHFOV–sNIPPV or sNIPPV–nHFOV sequences; their pCO 2 levels were measured after 2 hours in each mode. Subgroup analyses were performed for preterm (gestational age <37 weeks) and very preterm (gestational age <32 weeks) neonates. Results The mean gestational age (nHFOV–sNIPPV, 32.8 vs. sNIPPV–nHFOV, 33.5 weeks) and median birth weight (1,850 vs. 1,930 g) did not differ between the sequences. The mean ± standard deviation pCO 2 level after nHFOV (38.7 ± 8.8 mm Hg) was significantly higher than that after sNIPPV (36.8 ± 10.2 mm Hg; mean difference: 1.9 mm Hg; 95% confidence interval: 0.3–3.4 mm Hg; treatment effect [ p = 0.007] but no sequence [ p = 0.92], period [ p = 0.53], or carryover [ p = 0.94] effects). However, the difference in pCO 2 level between the sequences was not statistically significant in the subgroup analyses of preterm and very preterm neonates. Conclusion After neonatal extubation, the sNIPPV mode was associated with a lower pCO 2 level than the nHFOV mode with no significant difference in preterm and very preterm neonates. Key Points Full noninvasive ventilation support is suggested in neonatal ventilation. pCO 2 level in sNIPPV was lower than in nHFOV. No differences in pCO 2 levels were observed in either preterm or very preterm neonates. [ABSTRACT FROM AUTHOR]

Emergence and extubation are critical transitional phases in the perioperative period. Evidence has shown that complications occur more at extubation than intubation and induction. A comprehensive understanding of the various factors influencing emergence and extubation, potential complications, essential steps and different techniques employed can maximize patient outcomes and satisfaction. Vigilant monitoring and assessment of the patient's readiness for extubation are required at emergence. Reasons for delay and delirium in emergence must be screened and investigated so that corresponding treatment can be pursued. Haemodynamic stability, continued oxygen delivery, adequate analgesia and anti-emesis are the general objectives. Extubation is an elective procedure with the potential for unanticipated challenges and mortalities. Should extubation be determined appropriate, individualized planning and methodical preparation must precede the performance of extubation to avoid complications and failures. Risk stratification, airway assessment and optimization of physiological parameters are some of the necessary processes. Different extubation techniques are selected and performed to address specific physiological consequences and airway concerns. Guidelines and systematic approaches regarding emergence and extubation should be followed. [ABSTRACT FROM AUTHOR]

Copyright of Balikesir Health Sciences Journal / Balıkesir Sağlık Bilimleri Dergisi is the property of Balikesir Health Sciences Journal (BAUN Health Sci J) and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Journal of Clinical Nursing in Practice is the property of Journal of Clinical Nursing in Practice (Editorial Board, Shanghai Jiao Tong University Press) and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Journal of Clinical Nursing in Practice is the property of Journal of Clinical Nursing in Practice (Editorial Board, Shanghai Jiao Tong University Press) and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Purpose: We investigated the association between the time to first post-extubation oral intake, barriers to oral intake, and the rate of activities of daily living (ADL) independence at discharge (Barthel Index score <70). Method: Consecutive patients admitted to the intensive care unit, aged ≥18 years, and mechanically ventilated for ≥48 hr were retrospectively enrolled. The time to first oral intake, barriers to oral intake, daily changes, and clinical outcomes were assessed. Multiple logistic regression analysis adjusted for baseline characteristics was used to determine the association between time to first post-extubation oral intake and ADL independence. Result: Among the 136 patients, 74 were assigned to the ADL independence group and 62 to the dependence group. The time to first post-extubation oral intake was significantly associated with ADL independence (adjusted p = < 0.001) and was a predictor of ADL independence at discharge. Respiratory and dysphagia-related factors (odds ratio [OR] 0.35; 95% confidence interval [CI] 0.15–0.82, p = 0.015 and OR 0.07; CI 0.01–0.68, p = 0.021, respectively) were significantly associated with the ADL independence at discharge. Conclusion: Respiratory and dysphagia-related factors, as barriers to the initiation of oral intake after extubation, were significantly associated with ADL independence at discharge. [ABSTRACT FROM AUTHOR]

This article discusses a 62-year-old woman who has a long term diagnoses of Rheumatoid Arthritis, and had frequent hospitalization for recurrent pneumonia. In the current hospitalization, she suffered from severe pneumonia complicated with respiratory failure, and received endotracheal intubation with mechanical ventilator use. After treatment, she was extubated and high-flow nasal cannula was applied afterwards for avoiding re-intubation. Data was collected from October 19th to November 3rd, 2020, through direct care, observations, physical assessments, conversation and chart reviews, and comprehensive assessments of the physical, psychological, social and spiritual aspects were implemented. Three health problems were identified: ineffective respiratory patterns, impaired skin integrity and anxiety. During the intensive care period, the writer established a healthy nurse-patient relationship, leading the patient to perform lung rehabilitation for improving respiratory pattern. Also, observing and listening to the patient with positive feedback minimized her anxiety. Meanwhile, using cross-team cooperation to draw up caring strategies. Owing to individualized nursing intervention, the patient successfully weaned from the mechanical ventilator. The writer hopes this nursing experience could assist nurses in taking care of these types of patients in the future. [ABSTRACT FROM AUTHOR]

This article describes the caring experience of a male patient with oral cancer who was admitted to the intensive care unit due to massive bleeding after endotracheal tube placement. The care period was from May 7th to May 10th, 2022. Data was collected through communication via writing, observation, physical assessment, and medical record review. The patient's health problems were identified as ineffective airway clearance, anxiety, and sleep disturbance by using Kolcaba's Theory of Comfort as an evaluation framework. Chest physiotherapy, pulmonary rehabilitation exercises, and teaching of deep breathing and coughing were provided to improve respiratory clearance function. In addition, music therapy and adjustment of the sleep environment were provided to improve the patient's overall comfort. Finally, the patient's extubation was successful and they were transfer out of the ICU. We suggested that the Theory of Comfort can be used more extensively as an assessment tool in the future to evaluate the physiological, psychological, social-cultural, and environmental factors that affect patients and promote a balance and comfort in their physical and mental health. [ABSTRACT FROM AUTHOR]

In patients with intubation, the endotracheal tube oppresses the throat for a long time, causing laryngeal ulcers or paralysis of the recurrent laryngeal nerve, resulting in reduced swallowing efficiency. After extubation, evaluation of swallowing and oral rehabilitation exercises should be performed as soon as possible to strengthen swallowing muscle strength and reflex, so as to achieve safe eating. Based on the analysis of the current practices, it was established that the completeness of swallowing care performed by nursing staff in extubated patients is 34.3%. Contributing reasons include: the nursing staff's swallowing care cognition is 55%; the in-hospital evaluation form is not applicable; the swallowing care process is incomplete; there is no swallowing care guide and unified assessment tool for patients after extubation. In order to improve current practice, the following steps were taken: revising the swallowing training evaluation form and swallowing care flow chart; the production of swallowing assessment kits and oral rehabilitation exercise videos covering the five steps of swallowing care; and holding educational courses on swallowing care. After the implementation of the project, the completeness of swallowing care performed by nursing staff increased from 34.3% to 92.3%. The cognitive accuracy increased from 55% to 95.3%, thus reaching the project goal to maintain patient safety and improve nursing quality. [ABSTRACT FROM AUTHOR]

Background and Objectives: Extubation success in ICU patients is crucial for reducing ventilator-associated complications, morbidity, and mortality. The Rapid Shallow Breathing Index (RSBI) is a widely used predictor for weaning from mechanical ventilation. This study aims to determine the predictive value of serial RSBI measurements on extubation success in ICU patients on mechanical ventilation. Materials and Methods: This prospective observational study was conducted on 86 ICU patients at Hitit University between February 2024 and July 2024. Patients were divided into successful and unsuccessful extubation groups. RSBI values were compared between these groups. Results: This study included 86 patients (32 females, 54 males) with a mean age of 54.51 ± 12.1 years. Extubation was successful in 53 patients and unsuccessful in 33. There was no significant difference in age and intubation duration between the groups (p = 0.246, p = 0.210). Significant differences were found in RSBI-1a and RSBI-2 values (p = 0.013, p = 0.011). The median RSBI-2a was 80 in the successful group and 92 in the unsuccessful group (p = 0.001). The ΔRSBI was higher in the unsuccessful group (p = 0.022). ROC analysis identified optimal cut-off values: RSBI-2a ≤ 72 (AUC 0.715) and ΔRSBI ≤ −3 (AUC 0.648). RSBI-2a ≤ 72 increased the likelihood of successful extubation by 10.8 times, while ΔRSBI ≤ −3 increased it by 3.4 times. Using both criteria together increased the likelihood by 28.48 times. Conclusions: Serial RSBI measurement can be an effective tool for predicting extubation success in patients on IMV. These findings suggest that serially measured RSBI may serve as a potential indicator for extubation readiness. [ABSTRACT FROM AUTHOR]

Introduction: Noninvasive High-Frequency Oscillatory Ventilation (NHFOV) is increasingly being adopted to reduce the need for invasive ventilation after extubation. Objectives: To evaluate the benefits and harms of NHFOV as post-extubation respiratory support in newborns compared to other non‐invasive respiratory support modes. Material & methods: We included randomized controlled trials comparing NHFOV with other non-invasive modes post-extubation in newborns. Data sources were MEDLINE (via Pubmed), Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure, WHO international clinical trials registry platform and Clinical Trial Registry, forward and backward citation search. Methodological quality of studies was assessed by Cochrane's Risk of Bias tool 1.0. Results: This systematic review included 21 studies and 3294 participants, the majority of whom were preterm. NHFOV compared to nasal continuous positive airway pressure (NCPAP) reduced reintubation within seven days (RR 0.34, 95% CI 0.22 to 0.53) after extubation. It also reduced extubation failure (RR 0.39, 95% CI 0.30 to 0.51) and reintubation within 72 hrs (RR 0.40, 95% CI 0.31 to 0.53), bronchopulmonary dysplasia (RR 0.59, 95% CI 0.37 to 0.94) and pulmonary air leak (RR 0.46, 95% CI 0.27 to 0.79) compared to NCPAP. The rate of reintubation within seven days (RR 0.62, 95% CI 0.18 to 2.14) was similar whereas extubation failure (RR 0.65, 95% CI 0.50 to 0.83) and reintubation (RR 0.68, 95% CI 0.52 to 0.89) within 72 hrs were lower in NHFOV group compared to nasal intermittent positive pressure ventilation. There was no effect on other outcomes. Overall quality of the evidence was low to very low in both comparisons. Conclusions: NHFOV may reduce the rate of reintubation and extubation failure post-extubation without increasing complications. Majority of the trials were exclusively done in preterm neonates. Further research with high methodological quality is warranted. [ABSTRACT FROM AUTHOR]

Objective Dexamethasone has been associated with early extubation and shorter duration of mechanical ventilation in preterm infants. High doses or prolonged courses of dexamethasone may be associated with poor neurodevelopmental outcomes. Study Design This is an observational cohort study assessing the efficacy of a low-dose short dexamethasone course combined with postextubation bubble continuous positive airway pressure (bCPAP) strategy on rates of successful extubation and reduction of the duration of invasive mechanical ventilation in extremely preterm infants. We compared the short-term outcomes of implementing such strategy on a group of infants with birth weight <750 g to a historical cohort. Results Among infants intubated for at least 10 days, median time to extubation from starting the dexamethasone course was 2 days (interquartile range: 1–3). Total duration of intubation was significantly shorter in infants who received dexamethasone compared with the control groups (21 ± 6 vs. 30 ± 10 days, p = 0.03), and although statistically nonsignificant, duration to wean to 21% bCPAP was shorter compared with the control group (48 ± 13 vs. 74 ± 29 days, p = 0.06). Conclusion A low-dose short dexamethasone course combined with postextubation bCPAP intervention may be associated with successful early extubation and shorter duration of mechanical ventilation. Key Points Noninvasive strategies may not succeed in infants < 750 g birth weight. Bubble CPAP has been shown to be associated with reduced complications including chronic lung disease. Postnatal dexamethasone therapy may succeed in conjunction with bubble CPAP to reduce reintubation. [ABSTRACT FROM AUTHOR]

Background: Normal saline (NS) infusion in large volumes may result in hyperchloremic metabolic acidosis and renal compromise. Balanced crystalloid (BC) with physiochemical composition akin to that of plasma may avoid these problems associated with NS. The present study aimed to evaluate effects of NS versus BC on acid–base balance and renal functions in patients undergoing intracranial tumor resection surgeries. Methods: Fifty adult patients scheduled to undergo elective neurosurgery for intracranial tumor resection were randomized to receive either NS or BC as intraoperative or maintenance fluid. Metabolic and renal parameters were estimated prior to induction (baseline), at 1 h and 2 h after induction, at the end of surgery and 4 h after extubation. Serum neutrophil gelatinase-associated lipocalin (NGAL) was measured postoperatively. Brain relaxation score was assessed by the operating surgeon. Results: Baseline values of variables were similar between the groups. At rest of the observed time-points, pH was significantly lower, while blood urea, serum creatinine, sodium, chloride, NGAL and plasma osmolality were significantly higher in the NS group as compared to the BC group. Brain relaxation score, serum bicarbonate and base excess were comparable between the two groups. Conclusion: Use of balanced crystalloid (plasmalyte) resulted in better metabolic and renal profile as compared to normal saline in neurosurgical patients. [ABSTRACT FROM AUTHOR]

Purpose: We aimed to evaluate the ability of the peripheral perfusion index (PPI) to predict reintubation of critically ill surgical patients. Methods: This prospective observational study included mechanically ventilated adults who were extubated after a successful spontaneous breathing trial (SBT). The patients were followed up for the next 48 h for the need for reintubation. The heart rate, systolic blood pressure, respiratory rate, peripheral arterial oxygen saturation (SpO2), and PPI were measured before-, at the end of SBT, 1 and 2 h postextubation. The primary outcome was the ability of PPI 1 h postextubation to predict reintubation using area under the receiver operating characteristic curve (AUC) analysis. Univariate and multivariate analyses were performed to identify predictors for reintubation. Results: Data from 62 patients were analysed. Reintubation occurred in 12/62 (19%) of the patients. Reintubated patients had higher heart rate and respiratory rate; and lower SpO2 and PPI than successfully weaned patients. The AUC (95%confidence interval) for the ability of PPI at 1 h postextubation to predict reintubation was 0.82 (0.71–0.91) with a negative predictive value of 97%, at a cutoff value of ≤ 2.5. Low PPI and high respiratory rate were the independent predictors for reintubation. Conclusion: PPI early after extubation is a useful tool for prediction of reintubation. Low PPI is an independent risk factor for reintubation. A PPI > 2.5, one hour after extubation can confirm successful extubation. [ABSTRACT FROM AUTHOR]

Background: Remimazolam tosilate (RT) is a new, ultrashort-acting benzodiazepine. Here, we investigated the efficacy and safety of RT for general anesthesia in patients undergoing Laparoscopic Cholecystectomy (LC). Methods: In this study, 122 patients undergoing laparoscopic cholecystectomy were randomly allocated to receive either remimazolam tosilate (Group RT) or propofol group (Group P). RT was administered as a slow bolus of 0.3 mg kg− 1 for induction, followed by 1.0–2.0 mg kg− 1 h− 1 for maintenance of general anesthesia. Propofol was started at 2 mg kg− 1 and followed by 4–10 mg kg− 1 h− 1 until the end of surgery. The primary outcome was the time to bispectral index (BIS) ≤ 60. The secondary outcome included the time to loss of consciousness (LoC), and the time to extubation. Adverse events were also assessed. Results: A total of 112 patients were recruited for study participation. Among them, the time to BIS ≤ 60 in Group RT was longer than that in Group P (Group RT: 89.3 ± 10.7 s; Group P: 85.9 ± 9.7 s, P > 0.05). While the time to LoC comparing remimazolam and propofol showed no statistical significance (Group RT: 74.4 ± 10.3 s; Group P: 74.7 ± 9.3 s, P > 0.05). The time to extubation in Group RT was significantly longer than that in Group P (Group RT: 16.0 ± 2.6 min; Group P: 8.8 ± 4.3 min, P < 0.001). Remimazolam tosilate had more stable hemodynamics and a lower incidence of hypotension during general anesthesia. Conclusions: Remimazolam tosilate can be safely and effectively used for general anesthesia in patients undergoing Laparoscopic Cholecystectomy. It maintains stable hemodynamics during induction and maintenance of general anesthesia compared with propofol. Further studies are needed to validate the findings. Trial registration: Chictr.org.cn ChiCTR2300071256 (date of registration: 09/05/2023). [ABSTRACT FROM AUTHOR]

Objective: To explore the relationship between the timing of non-emergency surgery in mild or asymptomatic SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) infected individuals and the quality of postoperative recovery from the time of confirmed infection to the day of surgery. Methods: We retrospectively reviewed the medical records of 300 cases of mild or asymptomatic SARS-CoV-2 infected patients undergoing elective general anaesthesia surgery at Yijishan Hospital between January 9, 2023, and February 17, 2023. Based on the time from confirmed SARS-CoV-2 infection to the day of surgery, patients were divided into four groups: ≤2 weeks (Group A), 2–4 weeks (Group B), 4–6 weeks (Group C), and 6–8 weeks (Group D). The primary outcome measures included the Quality of Recovery-15 (QoR-15) scale scores at 3 days, 3 months, and 6 months postoperatively. Secondary outcome measures included postoperative mortality, ICU admission, pulmonary complications, postoperative length of hospital stay, extubation time, and time to leave the PACU. Results: Concerning the primary outcome measures, the QoR-15 scores at 3 days postoperatively in Group A were significantly lower compared to the other three groups (P < 0.05), while there were no statistically significant differences among the other three groups (P > 0.05). The QoR-15 scores at 3 and 6 months postoperatively showed no statistically significant differences among the four groups (P > 0.05). In terms of secondary outcome measures, Group A had a significantly prolonged hospital stay compared to the other three groups (P < 0.05), while other outcome measures showed no statistically significant differences (P > 0.05). Conclusion: The timing of surgery in mild or asymptomatic SARS-CoV-2 infected patients does not affect long-term recovery quality but does impact short-term recovery quality, especially for elective general anaesthesia surgeries within 2 weeks of confirmed infection. Therefore, it is recommended to wait for a surgical timing of at least greater than 2 weeks to improve short-term recovery quality and enhance patient prognosis. [ABSTRACT FROM AUTHOR]

Objective: The supraglottic airway device (SGAD), which is widely used in anesthesia practice, is a safe method. The timing of SGAD removal is still controversial. The aim of this study was to compare conventional and ultrasonographic methods in deciding the timing of removal in patients with SGAD placement under general anesthesia. Methods: One hundred patients who underwent surgery under general anesthesia in a university hospital and underwent SGAD placement were included in the study. During the awakening process, patients were divided into two groups: the conventional group and the USG group. In the USG group, diaphragm thickness was recorded preoperatively and intraoperatively before SGAD removal. In the ultrasonography (USG) group, the SGAD was removed in patients with a diaphragmatic thickness (Δtdi) ratio of 20% or more in the USG measurement of the diaphragm. In the conventional group, SGAD removal was decided after eye opening, obeying orders, spontaneous or commanded breathing that produced >4 mL kg-1 tidal volume. Patients in both groups were compared in terms of SpO2 values, SGAD removal time, hemodynamic changes and postoperative complications. Results: There was no statistically significant difference between the groups in terms of completion of the operation and duration of anesthesia. No statistically significant difference was observed between the SGAD removal times in both groups. Heart rate, mean arterial pressure, systolic arterial pressure, diastolic arterial pressure and peripheral oxygen saturation values were similar in preoperative, intraoperative and postoperative periods between the groups. There was no difference in complication status in the postoperative period. Conclusion: Conventional methods do not have sufficient objectivity in deciding the time of SGAD removal in patients with SGAD placement. Ultrasonographic evaluation of diaphragmatic thickening has not been shown to be superior to the conventional method of deciding the timing of SGAD removal. However, the use of USG has the advantage of collecting measurable and objective data independent of the anesthesia provider. The lack of significant difference between the two groups may be explained by the experience of the clinician making the decision with the conventional method, and ultrasonographic evaluation may provide additional information to inexperienced users. Further studies are needed in other surgical procedures, risk groups and age groups to determine whether the use of USG in extubation decision-making would be useful. [ABSTRACT FROM AUTHOR]

Background: Artificial airways are essential in various clinical settings to maintain a patient's airway and provide necessary support for ventilation and oxygenation. These devices are commonly temporary and come in several types, each serving specific purposes. Understanding the indications, types, and proper care of artificial airways is crucial for health care professionals to ensure patients receive optimal care and prevent complications. Objective: This article aims to review the indications for using artificial airways and discuss the most commonly used types, including supraglottic airway devices, endotracheal tubes, tracheostomy tubes, and laryngectomy tubes. It also provides insights into the procedures involved in intubation and percutaneous tracheostomy and offers guidance on patient management, emphasizing assessment, oral care, suctioning, and humidification for patients with these airway devices. Conclusion: This article underscores the significance of understanding artificial airways, not just as a set of skills but as a commitment to patient welfare. Health care professionals who master the knowledge and care of these devices can significantly contribute to their patients' well-being and quality of life. [ABSTRACT FROM AUTHOR]

Early extubation has been adopted in many settings within cardiothoracic surgery, with several advantages for patients. We sought to determine the association of timing of extubation in lung transplant recipients' short- and long-term outcomes. Adult, primary lung transplants were identified from the United Network for Organ Sharing database. Recipients were stratified based on the duration of postoperative ventilation: 1) None (NV); 2) <5 Days (<5D); and 3) 5+ Days (5+D). Comparative statistics were performed, and both unadjusted and adjusted survival were analyzed with Kaplan–Meier Methods and a Cox proportional hazard model. A multivariable model including recipient, donor, and transplant characteristics was created to examine factors associated with NV. 28,575 recipients were identified (NV = 960, <5D = 21,959, 5+D = 5656). The NV group had shorter median length of stay (P < 0.01) and lower incidence of postoperative dialysis (P < 0.01). The NV and <5D groups had similar survival, while 5+D recipients had decreased survival (P < 0.01). The multivariable model demonstrated increased donor BMI, center volume, ischemic time, single lung transplant, and transplantation between 2011 and 2015 were associated with NV (P < 0.01 for all). Use of donation after cardiac death donors and transplantation between 2016 and 2021 was associated with postoperative ventilator use. Patients extubated early after lung transplantation have a shorter median length of stay without an associated increase in mortality. While not all patients are appropriate for earlier extubation, it is possible to extubate patients early following lung transplant. Further efforts are necessary to help expand this practice and ensure its' success for recipients. [ABSTRACT FROM AUTHOR]

Despite prior publications of clinical practice guidelines related to ventilator liberation, some questions remain unanswered. Many of these questions relate to the details of bedside implementation. We, therefore, formed a guidelines committee of individuals with experience and knowledge of ventilator liberation as well as a medical librarian. Using Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology, we make the following recommendations: (1) We suggest that calculation of a rapid shallow breathing index is not needed to determine readiness for a spontaneous breathing trial (SBT) (conditional recommendation; moderate certainty); (2) We suggest that SBTs can be conducted with or without pressure support ventilation (conditional recommendation, moderate certainty); (3) We suggest a standardized approach to assessment and, if appropriate, completion of an SBT before noon each day (conditional recommendation, very low certainty); and (4) We suggest that FIO2 should not be increased during an SBT (conditional recommendation, very low certainty). These recommendations are intended to assist bedside clinicians to liberate adult critically ill patients more rapidly from mechanical ventilation. [ABSTRACT FROM AUTHOR]

Invasive mechanical ventilation is prevalent and associated with considerable morbidity. Pediatric critical care teams must identify the best timing and approach to liberating (extubating) children from this supportive care modality. Unsurprisingly, practice variation varies widely. As a first step to minimizing that variation, the first evidence-based pediatric ventilator liberation guidelines were published in 2023 and included 15 recommendations. Unfortunately, there is often a substantial delay before clinical guidelines reach widespread clinical practice. As such, it is important to consider bar- riers and facilitators using a systematic approach during implementation planning and design. In this narrative review, we will (1) summarize guideline recommendations, (2) discuss recent evidence and identify practice gaps relating to those recommendations, and (3) hypothesize about potential barriers and facilitators to their implementation in clinical practice. [ABSTRACT FROM AUTHOR]

BACKGROUND: Re-intubation is necessary in 2% to 30% of cases of patients receiving a planned extubation. This procedure is associated with prolonged mechanical ventilation, a greater need for tracheostomy, a higher incidence of ventilator-associated pneumonia, and higher mortality. The aim of this study was to evaluate the effect of re-intubation within 48 h on mortality after planned extubation by using a randomized controlled trial database. METHODS: Secondary analysis of a multi-center randomized trial, which evaluated the effect of reconnection to mechanical ventilation for 1 h after a successful spontaneous breathing trial, followed by extubation. The study included adult subjects who received invasive mechanical ventilation for > 12 h. The subjects were divided into an extubation failure group and an extubation success group. The outcome was in-hospital mortality. Two multivariate logistic regression models were constructed to identify independent factors associated with mortality. RESULTS: Among the 336 subjects studied, extubation failed in 52 (15.4%) and they were re-intubated within 48 h. Most re-intubations occurred between 12 and 24 h after planned extubation (median [interquartile range] 16 [6-36] h). Mortality of the extubation failure group was higher both in the ICU (32.6% vs 6.6%; odds ratio [OR] 6.77, 95% CI 3.22-14.24; P < .001) and in-hospital (42.3% vs 14.0%; OR 4.47, 95% CI 2.34-8.51; P < .001) versus the extubation success group. Multivariate logistic regression analyses showed that re-intubation within 48 h was independently associated with both ICU mortality (OR 6.10, 95% CI 2.84-13.07; P < .001) and in-hospital mortality (OR 3.36, 95% CI 1.67-6.73; P = .001). In-hospital mortality was also associated with rescue noninvasive ventilation after extubation (OR 2.44, 95% CI 1.25-4.75; P = .009). CONCLUSIONS: Re-intubation within 48 h after planned extubation was associated with mortality in subjects who were critically ill. [ABSTRACT FROM AUTHOR]

Background: Prone position (PP) has been widely used in the COVID-19 pandemic for ARDS management. However, the optimal length of a PP session is still controversial. This study aimed to evaluate the effects of prolonged versus standard PP duration in subjects with ARDS due to COVID-19. Methods: This was a single-center, randomized controlled, parallel, and open pilot trial including adult subjects diagnosed with severe ARDS due to COVID-19 receiving invasive mechanical ventilation that met criteria for PP between March-September 2021. Subjects were randomized to the intervention group of prolonged PP (48 h) versus the standard of care PP (-16 h). The primary outcome variable for the trial was ventilator-free days (VFDs) to day 28. Results: We enrolled 60 subjects. VFDs were not significantly different in the standard PP group (18 [interquartile range [IQR] 0-23] VFDs vs 7.5 [IQR 0-19.0] VFDs; difference, -10.5 (95% CI -3.5 to 19.0, P = .08). Prolonged PP was associated with longer time to successful extubation in survivors (13.00 [IQR 8.75-26.00] d vs 8.00 [IQR 5.00-10.25] d; difference, 5 [95% CI 0-15], P = .001). Prolonged PP was also significantly associated with longer ICU stay (18.5 [IQR 11.8-25.3] d vs 11.50 [IQR 7.75-25.00] d, P = .050) and extended administration of neuromuscular blockers (12.50 [IQR 5.75-20.00] d vs 5.0 [IQR 2.0-14.5] d, P = .005). Prolonged PP was associated with significant muscular impairment according to lower Medical Research Council values (59.6 [IQR 59.1-60.0] vs 56.5 [IQR 54.1-58.9], P = .02). Conclusions: Among subjects with severe ARDS due to COVID-19, there was no difference in 28-d VFDs between prolonged and standard PP strategy. However, prolonged PP was associated with a longer ICU stay, increased use of neuromuscular blockers, and greater muscular impairment. This suggests that prolonged PP is not superior to the current recommended standard of care. [ABSTRACT FROM AUTHOR]

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This paper presents a case of Enterococcus cecorum (E. cecorum) meningitis with bacteremia in a middle-aged woman who had previously undergone a splenectomy. Within 24 hours, the bacterium was identified from a blood culture. The patient was clinically diagnosed with meningitis, which was radiologically verified by an MRI brain scan. Fortunately, she had a favorable outcome. To the best of our knowledge, this is the first reported case of E. cecorum-induced meningitis in humans and the second documented incidence of E. cecorum infection in humans in Australia. The purpose of this case report is to emphasize the potential for serious human infections caused by an extremely rare pathogen. [ABSTRACT FROM AUTHOR]

Purpose: Awake extubation and deep extubation are commonly used anesthesia techniques. In this study, the safety of propofol-assisted deep extubation in the dental treatment of children was assessed. Materials and methods: Children with severe caries who received dental treatment under general anesthesia and deep extubation between January 2017 and June 2023 were included in this study. Data were collected on the following variables: details and time of anesthesia, perioperative vital signs, and incidence of postoperative complications. The incidence of laryngeal spasm (LS) was considered to be the primary observation indicator. Results: The perioperative data obtained from 195 children undergoing dental treatment was reviewed. The median age was 4.2 years (range: 2.3 to 9.6 years), and the average duration of anesthesia was 2.56 h (range 1 to 4.5 h). During intubation with a videoscope, purulent mucus was found in the pharyngeal cavity of seven children (3.6%); LS occurred in five of them (2.6%), and one child developed a fever (T = 37.8 °C) after discharge. Five children (2.6%) experienced emergence agitation (EA) in the recovery room. Also, 13 children (6.7%) experienced epistaxis; 10 had a mild experience and three had a moderate experience. No cases of airway obstruction (AO) and hypoxemia were recorded. The time to open eyes (TOE) was 16.3 ± 7.2 min. The incidence rate of complications was 23/195 (11.8%). Emergency tracheal reintubation was not required. Patients with mild upper respiratory tract infections showed a significantly higher incidence of complications (P < 0.001). Conclusions: Propofol-assisted deep extubation is a suitable technique that can be used for pediatric patients who exhibited non-cooperation in the outpatient setting. Epistaxis represents the most frequently encountered complication. Preoperative upper respiratory tract infection significantly increases the risk of complications. The occurrence of EA was notably lower than reported in other studies. [ABSTRACT FROM AUTHOR]

Background: Protective ventilation seems crucial during early Acute Respiratory Distress Syndrome (ARDS), but the optimal duration of lung protection remains undefined. High driving pressures (ΔP) and excessive patient ventilatory drive may hinder lung recovery, resulting in self-inflicted lung injury. The hidden nature of the ΔP generated by patient effort complicates the situation further. Our study aimed to assess the feasibility of an extended lung protection strategy that includes a stepwise protocol to control the patient ventilatory drive, assessing its impact on lung recovery. Methods: We conducted a single-center randomized study on patients with moderate/severe COVID-19-ARDS with low respiratory system compliance (CRS < 0.6 (mL/Kg)/cmH2O). The intervention group received a ventilation strategy guided by Electrical Impedance Tomography aimed at minimizing ΔP and patient ventilatory drive. The control group received the ARDSNet low-PEEP strategy. The primary outcome was the modified lung injury score (mLIS), a composite measure that integrated daily measurements of CRS, along with oxygen requirements, oxygenation, and X-rays up to day 28. The mLIS score was also hierarchically adjusted for survival and extubation rates. Results: The study ended prematurely after three consecutive months without patient enrollment, attributed to the pandemic subsiding. The intention-to-treat analysis included 76 patients, with 37 randomized to the intervention group. The average mLIS score up to 28 days was not different between groups (P = 0.95, primary outcome). However, the intervention group showed a faster improvement in the mLIS (1.4 vs. 7.2 days to reach 63% of maximum improvement; P < 0.001), driven by oxygenation and sustained improvement of X-ray (P = 0.001). The intervention group demonstrated a sustained increase in CRS up to day 28 (P = 0.009) and also experienced a shorter time from randomization to room-air breathing (P = 0.02). Survival at 28 days and time until liberation from the ventilator were not different between groups. Conclusions: The implementation of an individualized PEEP strategy alongside extended lung protection appears viable. Promising secondary outcomes suggested a faster lung recovery, endorsing further examination of this strategy in a larger trial. Clinical trial registration This trial was registered with ClinicalTrials.gov (number NCT04497454) on August 04, 2020. [ABSTRACT FROM AUTHOR]

Background: The spontaneous breathing trial (SBT) technique that best balance successful extubation with the risk for reintubation is unknown. We sought to determine the comparative efficacy and safety of alternative SBT techniques. Methods: We searched Medline, EMBASE, and the Cochrane Central Register of Controlled Trials from inception to February 2023 for randomized or quasi-randomized trials comparing SBT techniques in critically ill adults and children and reported initial SBT success, successful extubation, reintubation (primary outcomes) and mortality (ICU, hospital, most protracted; secondary outcome) rates. Two reviewers screened, reviewed full-texts, and abstracted data. We performed frequentist random-effects network meta-analysis. Results: We included 40 RCTs (6716 patients). Pressure Support (PS) versus T-piece SBTs was the most common comparison. Initial successful SBT rates were increased with PS [risk ratio (RR) 1.08, 95% confidence interval (CI) (1.05–1.11)], PS/automatic tube compensation (ATC) [1.12 (1.01 –1.25), high flow nasal cannulae (HFNC) [1.07 (1.00–1.13) (all moderate certainty), and ATC [RR 1.11, (1.03–1.20); low certainty] SBTs compared to T-piece SBTs. Similarly, initial successful SBT rates were increased with PS, ATC, and PS/ATC SBTs compared to continuous positive airway pressure (CPAP) SBTs. Successful extubation rates were increased with PS [RR 1.06, (1.03–1.09); high certainty], ATC [RR 1.13, (1.05–1.21); moderate certainty], and HFNC [RR 1.06, (1.02–1.11); high certainty] SBTs, compared to T-piece SBTs. There was little to no difference in reintubation rates with PS (vs. T-piece) SBTs [RR 1.05, (0.91–1.21); low certainty], but increased reintubation rates with PS [RR 2.84, (1.61–5.03); moderate certainty] and ATC [RR 2.95 (1.57–5.56); moderate certainty] SBTs compared to HFNC SBTs. Conclusions: SBTs conducted with pressure augmentation (PS, ATC, PS/ATC) versus without (T-piece, CPAP) increased initial successful SBT and successful extubation rates. Although SBTs conducted with PS or ATC versus HFNC increased reintubation rates, this was not the case for PS versus T-piece SBTs. [ABSTRACT FROM AUTHOR]

BACKGROUND: Unintended extubations remain a common complication across neonatal intensive care units, with very low birthweight infants being the most vulnerable of them all. Ongoing efforts across different institutions exist with the goal of reducing the rate of unintended extubations to keep a median rate of <2 events per 100 ventilator days as defined by the Vermont Oxford Network. Our objective was to reduce unintended extubations in the very low birthweight infant in a large delivery hospital to ≤2/100 ventilator days. METHODS: A collaborative group was formed between two academic health institutions targeting training and implementation of the Children's National unintended extubation system, focusing on endotracheal tube securement methods and surveillance protocols. RESULTS: The unintended extubation rate decreased from 3.23 to 0.64 per 100 ventilator days. Changes were implemented from 2018–2020 with a sustained reduction in the unintended extubation rate of 1.54 per 100 ventilator days. Most events occurred between 12 : 00 pm –4 : 00 pm and the commonest cause was spontaneous (25%) followed by dislodgment during repositioning (19%). CONCLUSION: Very low birth weight infants present a challenge to endotracheal tube maintenance due to their developmental and anatomical changes during their neonatal intensive care unit stay. Successful reduction of unintended extubations in the very low birthweight infant can be achieved by adaptation of successful protocols for older infants. [ABSTRACT FROM AUTHOR]

Background: It is unclear whether other cardiac biomarkers than NT-proBNP can be useful in the risk stratification of patients weaning from mechanical ventilation. The aim of this study is to summarize the role of ischemic cardiac biomarkers in predicting spontaneous breathing trial (SBT) or extubation failure. Methods: We systematically searched Embase, MEDLINE, Web of Science, and Cochrane Central for studies published before January 2024 that reported the association between ischemic cardiac biomarkers and SBT or extubation failure. Data were extracted using a standardized form and methodological assessment was performed using the QUIPS tool. Results: Seven observational studies investigating four ischemic cardiac biomarkers (Troponin-T, Troponin-I, CK-MB, Myoglobin) were included. One study reported a higher peak Troponin-I in patients with extubation failure compared to extubation success (50 ng/L [IQR, 20–215] versus 30 ng/L [IQR, 10–86], p = 0.01). A second study found that Troponin-I measured before the SBT was higher in patients with SBT failure in comparison to patients with SBT success (100 ± 80 ng/L versus 70 ± 130 ng/L, p = 0.03). A third study reported a higher CK-MB measured at the end of the SBT in patients with weaning failure (SBT or extubation failure) in comparison to weaning success (8.77 ± 20.5 ng/mL versus 1.52 ± 1.42 ng/mL, p = 0.047). Troponin-T and Myoglobin as well as Troponin-I and CK-MB measured at other time points were not found to be related to SBT or extubation failure. However, most studies were underpowered and with high risk of bias. Conclusions: The association with SBT or extubation failure is limited for Troponin-I and CK-MB and appears absent for Troponin-T and Myoglobin, but available studies are hampered by significant methodological drawbacks. To more definitively determine the role of ischemic cardiac biomarkers, future studies should prioritize larger sample sizes, including patients at risk of cardiac disease, using stringent SBTs and structured timing of laboratory measurements before and after SBT. [ABSTRACT FROM AUTHOR]

Unplanned extubations (UE) frequently occur in critical care units. These events are precipitated by many risk factors and are associated with adverse outcomes for patients. We reviewed the current literature to examine factors related to UE and presented the analysis of 41 articles critical to the topic. Our review has identified specific risk factors that we discuss in this review, such as sedation strategies, physical restraints, endotracheal tube position, and specific nursing care aspects associated with an increased incidence of UE. We recommend interventions to reduce the risk of UE. However, we recommend that bundled rather than a single intervention is likely to yield higher success, given the heterogeneity of factors contributing to increasing the risk of UE. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Unplanned extubations (UEs) can be a frequent problem and are associated with adverse outcomes. This quality improvement initiative sought to reduce UEs from tube dislodgement in a level IV NICU utilizing methods applicable to other ICUs and performed with minimal monetary funds. METHODS: From January 2019 to July 2023, an interdisciplinary quality improvement team used the Model for Improvement and performed sequential interventions to improve the outcome measure of UEs per 100 ventilator days. Process measures included adherence to a modified, site-specific UE care bundle derived from the Solutions for Patient Safety network, whereas the number of endotracheal tube-related pressure injuries was used as a balancing measure. Statistical process control charts and established rules for special cause variation were applied to analyze data. RESULTS: Sequential interventions reduced the rate of UEs from a baseline of 2.3 to 0.6 UEs per 100 ventilator days. Greater than 90% adherence with the UE care bundle and apparent cause analysis form completion occurred since December 2020. There were no endotracheal tube-related pressure injuries. CONCLUSIONS: A sustained reduction in UEs was demonstrated. Leveraging a multidisciplinary team allowed for continuous UE analysis, which promoted tailored consecutive interventions. UE care bundle audits and the creation of a postevent debrief guide, which helped providers share a common language, were the most impactful interventions. Next steps include disseminating these interventions to other ICUs across our hospital enterprise. These low-cost interventions can be scalable to other NICUs and PICUs. [ABSTRACT FROM AUTHOR]

Background: Delayed extubation and transfer to the intensive care unit (ICU) in children undergoing major scoliosis surgery may increase postoperative complications, prolong hospital stay, and increase medical expenses; however, whether a child will require delayed extubation or transfer to the ICU after scoliosis orthopedic surgery is not fully understood. In this study, we reviewed the risk factors for delayed extubation and transfer to the ICU after scoliosis orthopedic surgery in children. Method: The electronic medical records of pediatric patients (≤ 18 years) who underwent posterior spinal fusion surgery between January 2018 and November 2021 were reviewed and analyzed. Patient characteristics (age, sex, body mass index, American Society of Anesthesiologists, ASA, grade, preoperative lung function, and congenital heart disease), preoperative Cobb angle, scoliosis type, correction rate, vertebral fusion segments, pedicle screws, surgical osteotomy, intraoperative bleeding, intraoperative allogeneic transfusion, intraoperative hemoglobin changes, intraoperative mean arterial pressure changes, intraoperative tidal volume (ml/kg predicted body weight), surgical time, postoperative extubation, and transfer to the ICU were collected. The primary outcomes were delayed extubation and transfer to the ICU. Multivariate logistic regression models were used to determine the risk factors for delayed extubation and ICU transfer. Results: A total of 246 children who satisfied the inclusion criteria were enrolled in this study, of whom 23 (9.3%) had delayed extubation and 81 (32.9%) were transferred to the ICU after surgery. High ASA grade (odds ratio [OR] 5.42; 95% confidence interval [CI] 1.49–19.78; p = 0.010), high Cobb angle (OR 1.04; 95% CI 1.02–1.07; p < 0.001), moderate to severe pulmonary dysfunction (OR 10.9; 95% CI 2.00–59.08; p = 0.006) and prolonged surgical time (OR 1.01; 95% CI 1.00–1.03; p = 0.040) were risk factors for delayed extubation. A high Cobb angle (OR 1.02; 95% CI 1.01–1.04; p = 0.004), high intraoperative bleeding volume (OR 1.06; 95% CI 1.03–1.10; p = 0.001), allogeneic transfusion (OR 3.30; 95% CI 1.24–8.83; p = 0.017) and neuromuscular scoliosis (OR 5.38; 95% CI 1.59–18.25; p = 0.007) were risk factors for transfer to the ICU. A high Cobb angle was a risk factor for both delayed extubation and ICU transfer. Age, sex, body mass index, number of vertebral fusion segments, correction rate, and intraoperative tidal volume were not associated with delayed postoperative extubation and ICU transfer. Conclusion: The most common risk factor for delayed extubation and ICU transfer in pediatric patients who underwent posterior spinal fusion was a high Cobb angle. Determining risk factors for a poor prognosis may help optimize perioperative respiratory management strategies and planning of postoperative care for children undergoing complicated spinal surgery. [ABSTRACT FROM AUTHOR]

The German guidelines for airway management aim to optimize the care of patients undergoing anesthesia or intensive care. The preanesthesia evaluation is an important component for detection of anatomical and physiological indications for difficult mask ventilation and intubation. If predictors for a difficult or impossible mask ventilation and/or endotracheal intubation are present the airway should be secured while maintaining spontaneous breathing. In an unexpectedly difficult intubation, attempts to secure the airway should be limited to two with each method used. A video laryngoscope is recommended after an unsuccessful direct laryngoscopy. Therefore, a video laryngoscope should be available at every anesthesiology workspace throughout the hospital. Securing the airway should primarily be performed with a video laryngoscope in critically ill patients and patients at risk of pulmonary aspiration. Experienced personnel should perform or supervise airway management in the intensive care unit. [ABSTRACT FROM AUTHOR]

Objective：To observe the effect of personalized respiratory breathing training on pulmonary function in patients with tracheotomy after stroke. Method：Fifty-two post-stroke tracheotomy patients who met the inclusion criteria were divided into a control group （n=26) and an intervention group （n=26). During the observation period, one patient in the control group and one in the intervention group each was lost to follow-up. The control group was given the postural drainage combined with vibration expectoration on the basis of routine rehabilitation, while the intervention group was given individualized breathing training on the basis of the control group. The observation period was 6 weeks, and the pulmonary function, diaphragmatic muscle mobility, diaphragmatic muscle thickening rate, extubation time and extubation success rate were compared between the two groups. Result：Before training, there were no significant differences in pulmonary function indexes （FVC, FEV1 and PEF), diaphragmatic activity（DEq, DEd), and diaphragm thickening rate（DTF)between the two groups（P> 0.05). After 6 weeks of training, the FVC, FEV1, PEF, DEq, DEd and DTF of the two groups were significantly improved compared with those before training （P<0.05)；and the intervention group was more significantly improved than the control group （P<0.05)；The extubation time in the intervention group was significantly shorter than that in the control group （P<0.05)；and the success rate of extubation in the intervention group was 92%, which was significantly higher than that in the control group （68.0%), and the difference was statistically significant（P<0.05). Conclusion: Personalized respiratory training can more effectively improve the pulmonary function of tracheotomy patients after stroke, shorten the removal time of tracheal cannula, and improve the success rate of extubation. [ABSTRACT FROM AUTHOR]

The decision to extubate patients on invasive mechanical ventilation is critical; however, clinician performance in identifying patients to liberate from the ventilator is poor. Machine Learning-based predictors using tabular data have been developed; however, these fail to capture the wide spectrum of data available. Here, we develop and validate a deep learning-based model using routinely collected chest X-rays to predict the outcome of attempted extubation. We included 2288 serial patients admitted to the Medical ICU at an urban academic medical center, who underwent invasive mechanical ventilation, with at least one intubated CXR, and a documented extubation attempt. The last CXR before extubation for each patient was taken and split 79/21 for training/testing sets, then transfer learning with k-fold cross-validation was used on a pre-trained ResNet50 deep learning architecture. The top three models were ensembled to form a final classifier. The Grad-CAM technique was used to visualize image regions driving predictions. The model achieved an AUC of 0.66, AUPRC of 0.94, sensitivity of 0.62, and specificity of 0.60. The model performance was improved compared to the Rapid Shallow Breathing Index (AUC 0.61) and the only identified previous study in this domain (AUC 0.55), but significant room for improvement and experimentation remains. [ABSTRACT FROM AUTHOR]

The incidence of extubation failure varies between 2 and 25% depending on the studied population. Few studies have been conducted in burn victims. To determine the incidence, causes, risk factors and outcome of burned patients after a failed extubation, a retrospective single-center case-control study was conducted over a period of 3 years (January 2018-December 2021). All burned patients aged over 16, ventilated for at least 24 hours and having had at least one extubation attempt were included. Extubation failure was defined as the need for re-intubation within 48 hours. Eighty-eight patients had planned extubation. These patients were divided into 2 groups comparable in terms of age and sex. Failure group: including patients with failed extubation (N=34) and a success group (N=64) including patients who succeeded. The incidence of extubation failure was 36.6%. Hypophosphatemia, anemia <8g/dl, duration of mechanical ventilation of 8,5 days and abundant secretions during extubation were identified as risk factors for extubation failure (p<0.05). The main cause of failure was retention of secretion (50%). Extubation failure was associated with prolonged length of stay (34 vs. 19 days, P=0.005), increased infectious complications (P=0.007) and mortality rate (79.4%, 1.5%, P<0.001). [ABSTRACT FROM AUTHOR]

Background: Intubated preterm infants 326/7 weeks or less of gestation in a mid-Atlantic level IV neonatal intensive care unit (NICU) faced a high number of ventilator days. Based on 6 weeks of electronic health record (EHR) chart audits of extubations in this NICU in 2021, 44% of preterm infants 326/7 weeks or less of gestation were intubated for more than 28 days, with an average of 23 days on a ventilator. This NICU lacked a standardized extubation guideline providing criteria to drive extubation eligibility. Purpose: The purpose of this quality improvement (QI) project was to implement and evaluate the effectiveness of an extubation readiness guideline in preterm infants 326/7 weeks or less of gestation in a mid-Atlantic level IV NICU. Methods: This project occurred over a 17-week period in 2021. Implementation included a multidisciplinary committee formation, identification of champions, NICU staff education, completion of a guideline checklist by bedside nursing (for eligible patients), clinician reminders, and chart audits for collection of pre-/postimplementation data. Staff education completion, guideline use and compliance, demographic patient data, ventilator days, time to first extubation, and need for reintubation were tracked. Results: Postimplementation data indicated decreased need for intubation for more than 28 days, ventilator days, and days to first extubation attempt. Implications for Practice and Research: Results suggested that implementation of the evidence-based guideline was effective in decreasing average total ventilator days for preterm infants 326/7 weeks or less of gestation. [ABSTRACT FROM AUTHOR]

Background: Subtotal petrosectomy (STP) has attracted massive interest over last two decades. The aim is to present our experience of this uncommon surgery. The indications, outcomes, and our variation in surgical technique would be presented and literature reviewed. Methods: A retrospective observational study of all patients who underwent STP at a tertiary care center in India was analyzed. Results: A total of 9 ears (in 8 patients) underwent STP over last 5 years at our center. The pathological conditions for which STP was done included chronic otitis media squamous (four ears), middle ear tumors (three ears), petrous apicitis (one ear), and traumatic cerebrospinal fluid (CSF) otorhinorrhea (one ear). The indication of STP included disease clearance (eight ears), unserviceable hearing (seven ears), hearing rehabilitation with otological implants (six ears), and intraoperative CSF gusher (one ear). Intraoperative indications included CSF gusher, large tegmen defect with erosion of apical turn of cochlea, and erosion of anterior bony wall of external auditory canal. The mean follow-up period was 36 months (range of 6 months to 60 months). None of the patients had any dehiscence of blind sac closure or secondary acquired cholesteatoma on imaging. Conclusions: STP facilitates disease clearance by providing unmatchable exposure in difficult otological scenarios and additionally isolates middle ear cleft from external environment, thereby eliminating problems of mastoid cavity. Furthermore, it also prepares ear for second stage otological implants. It is a safe surgery with minimal complications. [ABSTRACT FROM AUTHOR]

The article evaluates the efficacy of dexmedetomidine versus fentanyl in managing hemodynamics, recovery, and postoperative pain in morbidly obese patients undergoing laparoscopic sleeve gastrectomy. It compares extubation times, intraoperative hemodynamic stability, and pain scores, finding dexmedetomidine superior in reducing extubation time and postoperative pain compared to fentanyl.

BackgroundDespite decades of research on predictors of extubation success, use of ventilatory support after extubation is common and 10-20% of patients require re-intubation. Proportional assist ventilation (PAV) mode automatically calculates estimated total work of breathing (total WOB). Here, we assessed the performance of total WOB to predict extubation failure in invasively ventilated subjects.MethodsThis prospective observational study was conducted in 6 adult ICUs at an academic medical center. We enrolled intubated subjects who successfully completed a spontaneous breathing trial, had a rapid shallow breathing index < 105 breaths/min/L, and were deemed ready for extubation by the primary team. Total WOB values were recorded at the end of a 30-min PAV trial. Extubation failure was defined as any respiratory support and/or re-intubation within 72 h of extubation. We compared total WOB scores between groups and performance of total WOB for predicting extubation failure with receiver operating characteristic curves.ResultsOf 61 subjects enrolled, 9.8% (n = 6) required re-intubation, and 50.8% (n = 31) required any respiratory support within 72 h of extubation. Median total WOB at 30 min on PAV was 0.9 J/L (interquartile range 0.7-1.3 J/L). Total WOB was significantly different between subjects who failed or were successfully extubated (median 1.1 J/L vs 0.7 J/L, P = .004). The area under the curve was 0.71 [95% CI 0.58-0.85] for predicting any requirement of respiratory support and 0.85 [95% CI 0.69-1.00] for predicting re-intubation alone within 72 h of extubation. Total WOB cutoff values maximizing sensitivity and specificity equally were 1.0 J/L for any respiratory support (positive predictive value [PPV] 70.0%, negative predictive value [NPV] 67.7%) and 1.3 J/L for re-intubation (PPV 26.3%, NPV 97.6%).ConclusionsThe discriminative performance of a PAV-derived total WOB value to predict extubation failure was good, indicating total WOB may represent an adjunctive tool for assessing extubation readiness. However, these results should be interpreted as preliminary, with specific thresholds of PAV-derived total WOB requiring further investigation in a large multi-center study.

BackgroundThis systematic review and meta-analysis aim to systematically assess the diagnostic accuracy of lung ultrasound in predicting weaning failure from mechanical ventilation in critically ill patients.MethodsWe searched the relevant literature up to January 2024 in the databases Web of Science, Cochrane Library, Embase, and PubMed. Two researchers independently screened eligible studies and extracted data; disagreements, if any, were resolved through discussion or consultation with a third-party expert. The quality of the included studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Statistical analyses were performed using Review Manager version 5.3 and Stata version 18.0, applying bivariate random-effects models to estimate sensitivity, specificity, diagnostic odds ratios, and their 95% confidence intervals, as well as to summarize receiver operating characteristic curves. Inter-study heterogeneity was assessed using the I-squared statistic, and potential sources of heterogeneity were explored by meta-regression analysis. The study follows the guidelines for Preferred Reporting Items for Systematic Reviews and Meta-Analyses in reporting.ResultsFourteen studies were included in the systematic review, of which 13 studies (totaling 988 patients) were included in the meta-analysis. The meta-analysis revealed an overall sensitivity of 0.86 (95% confidence interval: 0.77–0.91) and a specificity of 0.75 (95% confidence interval: 0.66–0.83) for lung ultrasound in predicting extubation failure. The area under the receiver operating characteristic curve was 0.87 (95% confidence interval: 0.84–0.89). Meta-regression analysis identified lung ultrasound thresholds, reference standards (extubation outcomes), and study flow and time bias as significant factors influencing diagnostic accuracy.ConclusionThis systematic review and meta-analysis demonstrated that lung ultrasound has high diagnostic accuracy in predicting extubation failure in mechanically ventilated critically ill patients. Despite some study heterogeneity, lung ultrasound proved to be a reliable predictive tool for extubation failure. Future research should focus on standardizing the definition of extubation failure, exploring the impact of different thresholds on the predictive ability of lung ultrasound, and validating its application in various clinical settings to enhance its utility and accuracy in clinical practice.Systematic review registrationThis systematic review and meta-analysis was registered with PROSPERO (registration number: CRD42024555909). The study adhered to the guidelines set by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Details of the PROSPERO protocol can be found in Supplementary Table 1.