Utilization of immediate extubation in a multidisciplinary pathway for pediatric liver transplantation associated with improved postoperative outcomes

BACKGROUND

Immediate extubation is becoming more common in liver transplantation. However, limited data exist on how to identify pediatric patients with potential for successful immediate extubation and how this intervention may affect recovery.

METHODS

This retrospective review evaluated patients who underwent liver transplantation from 2015 to 2021 at Children's Healthcare of Atlanta. Preoperative status and intraoperative management were evaluated and compared. Outcomes comprised thrombosis, surgical reexploration, retransplantation, as well as reintubation, high flow nasal cannula (HFNC) usage, postoperative infection, the length of stay (LOS), and mortality.

RESULTS

A total of 173 patients were analyzed, with 121 patients (69.9%) extubated immediately. The extubation group had older age (median 4.0 vs 1.25 years, p = .048), lower PELD/MELD (28 vs. 34, p = .03), decreased transfusion (10.2 vs. 41.7 mL/kg, p < .001), shorter surgical time (332 vs. 392 min, p < .001), and primary abdominal closure (81% vs. 40.4%, p < .001). Immediate extubation was associated with decreased HFNC (0.21 vs. 0.71 days, p = .02), postoperative infection (9.9% vs. 26.9%, p = .007), mortality (0% vs. 5.8%, p = .036), and pediatric intensive care unit LOS (4.7 vs. 11.4 days, p < .001). The complication rate was lower in the extubation group (24.8% vs. 36.5%), but not statistically significant.

CONCLUSIONS

Approximately 70% of patients were able to be successfully extubated immediately, with only 2.5% requiring reintubation. Those immediately extubated had decreased need for HFNC, lower infection rates, shorter LOS, and decreased mortality. Our results show that with proper patient selection and a multidisciplinary approach, immediate extubation allows for improved recovery without increased respiratory complications after pediatric liver transplantation.

Smooth Emergence from General Anesthesia after Deep Extubation in a Pediatric Patient Diagnosed with Catecholaminergic Polymorphic Ventricular Tachycardia: A Case Report

Background: Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a rare genetic disorder where catecholamine causes bidirectional ventricular tachycardia, potentially leading to cardiac arrest. In patients undergoing surgery, sympathetic responses can be triggered in situations associated with surgical stimulations as well as high anxiety before the surgery, anesthetic maneuvers such as endotracheal intubation and extubation, and postoperative pain. Therefore, planning for surgery demands meticulous attention to anesthesia during the perioperative period in order to prevent potentially life-threatening arrhythmias. Case: We discuss a case of an 11-year-old male pediatric patient with known CPVT who required elective strabismus surgery for exotropia involving both eyes. After thorough planning of general anesthesia to minimize catecholamine response, sufficient anesthesia and analgesia were achieved to blunt the stressful response during intubation and maintained throughout the surgical procedure. Complete emergence was achieved after deep extubation, and the patient did not complain of pain or postoperative nausea and vomiting. Conclusions: Anesthesiologists should not only be able to plan and manage the catecholamine response during surgery but also anticipate and be prepared for situations that may lead to arrhythmias before and after the procedure. In certain cases, deep extubation can be beneficial as it reduces hemodynamic changes during the extubation process.

Accuracy of lung and diaphragm ultrasound in predicting infant weaning outcomes: a systematic review and meta-analysis

Background

Although lung and diaphragm ultrasound are valuable tools for predicting weaning results in adults with MV, their relevance in children is debatable. The goal of this meta-analysis was to determine the predictive value of lung and diaphragm ultrasound in newborn weaning outcomes.

Methods

For eligible studies, the databases MEDLINE, Web of Science, Cochrane Library, PubMed, and Embase were thoroughly searched. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) method was used to evaluate the study's quality. Results were gathered for sensitivity, specificity, diagnostic odds ratio (DOR), and the area under the curve of summary receiver operating characteristic curves (AUSROC). To investigate the causes of heterogeneity, subgroup analyses and meta-regression were conducted.

Results

A total of 11 studies were suitable for inclusion in the meta-analysis, which included 828 patients. The pooled sensitivity and specificity of lung ultrasound (LUS) were 0.88 (95%CI, 0.85-0.90) and 0.81 (95%CI, 0.75-0.87), respectively. The DOR for diaphragmatic excursion (DE) is 13.17 (95%CI, 5.65-30.71). The AUSROC for diaphragm thickening fraction (DTF) is 0.86 (95%CI, 0.82-0.89). The most sensitive and specific method is LUS. The DE and DTF were the key areas where study heterogeneity was evident.

Conclusions

Lung ultrasonography is an extremely accurate method for predicting weaning results in MV infants. DTF outperforms DE in terms of diaphragm ultrasound predictive power.

Noninvasive Respiratory Support following Extubation in Preterm Infants

The use of noninvasive respiratory support is widespread in newborn infants with respiratory distress. As the use of noninvasive respiratory support has increased, so too have the number of modes available. Among these modes, low-flow nasal cannula and nasal continuous positive airway pressure (NCPAP) have been used for a long time and have known efficacy and safety in newborn infants needing respiratory support. High-flow nasal cannula (HFNC) has been newly introduced, and its efficacy and safety are currently being investigated. Bilevel nasal continuous positive airway pressure and nasal intermittent positive-pressure ventilation are often used when NCPAP or HFNC therapy fails. More recently, noninvasive neurally adjusted ventilatory assist and noninvasive high-frequency oscillatory ventilation have been introduced, and their efficacy and safety are currently under evaluation. Comparison of the efficacy and safety among various modes of noninvasive respiratory support after extubation in preterm infants is helping to clarify the position of each mode. The clarification of the strength and characteristics of each device within the same mode will become important as a future direction of noninvasive respiratory support after extubation in such subjects. However, no research has yet reported on long-term outcomes in preterm infants receiving noninvasive respiratory support after extubation. Therefore, further research is needed to evaluate the long-term outcomes.

Protocol for a randomised controlled trial comparing two CPAP levels to prevent extubation failure in extremely preterm infants

INTRODUCTION

Respiratory distress syndrome is a complication of prematurity and extremely preterm infants born before 28 weeks' gestation often require endotracheal intubation and mechanical ventilation. In this high-risk population, mechanical ventilation is associated with lung injury and contributes to bronchopulmonary dysplasia. Therefore, clinicians attempt to extubate infants as quickly and use non-invasive respiratory support such as nasal continuous positive airway pressure (CPAP) to facilitate the transition. However, approximately 60% of extremely preterm infants experience 'extubation failure' and require reintubation. While CPAP pressures of 5-8 cm H2O are commonly used, the optimal CPAP pressure is unknown, and higher pressures may be beneficial in avoiding extubation failure. Our trial is the Extubation CPAP Level Assessment Trial (ÉCLAT). The aim of this trial is to compare higher CPAP pressures 9-11 cm H2O with a current standard pressures of 6-8 cmH2O on extubation failure in extremely preterm infants.

METHODS AND ANALYSIS

200 extremely preterm infants will be recruited prior to their first extubation from mechanical ventilation to CPAP. This is a parallel group randomised controlled trial. Infants will be randomised to one of two set CPAP pressures: CPAP 10 cmH2O (intervention) or CPAP 7 cmH2O (control). The primary outcome will be extubation failure (reintubation) within 7 days. Statistical analysis will follow standard methods for randomised trials on an intention to treat basis. For the primary outcome, this will be by intention to treat, adjusted for the prerandomisation strata (GA and centre). We will use the appropriate parametric and non-parametric statistical tests.

ETHICS AND DISSEMINATION

Ethics approval has been granted by the Monash Health Human Research Ethics Committees. Amendments to the trial protocol will be submitted for approval. The findings of this study will be written into a clinical trial report manuscript and disseminated via peer-reviewed journals (on-line or in press) and presented at national and international conferences.Trial registration numberACTRN12618001638224; pre-results.

Successful experience in dealing with tooth aspiration after extubation: a case report

There is a high incidence of tooth injury or loss due to endotracheal intubation or extubation. Tooth injury may be costly or even life threatening. In particular, tooth aspiration may cause airway obstruction, aspiration pneumonitis, or lung collapse, but tooth aspiration after tracheal extubation is rarely reported and easily overlooked. A missing tooth after extubation can be more dangerous. However, there are no practical guidelines and standard intervention strategies to deal with a loose or missing tooth. This article presents the case of a 67-year-old man who underwent laparoscopic colectomy for a colonic tumor under general anesthesia, and whose left maxillary incisor was loose. After surgery, the loose tooth was missing and we had to go through a difficult process to find it. Finally, a chest X-ray revealed a foreign body located in the trachea, and it was successfully removed by fiber-bronchoscopy. The patient woke up with no discomfort and was discharged without complications on the third day after surgery. Based on our experience in this case, we put forward a complete and effective flowchart named "VICTOR" as an option for the prevention of tooth loss and aspiration during surgical procedures and for locating a missing tooth in a timely, appropriate and safe way during the perioperative period.

Impact of Spontaneous Breathing Trials in Cardiorespiratory Stability of Preterm Infants

BACKGROUND

A spontaneous breathing trial (SBT) is commonly used to determine extubation readiness in patients receiving mechanical ventilation. However, the physiological impact of such a trial in preterm infants has not been well described. This study aimed to investigate the effects of a 3-min SBT on the cardiorespiratory stability of these infants.

METHODS

A retrospective analysis of prospectively collected data was done for infants < 37 weeks gestational age who were extubated after a successful 3-min SBT. Heart rate, [Formula: see text], breathing frequency, exhaled tidal volume, and Silverman Andersen Respiratory Severity Score (SA-RSS) to assess work of breathing, before and at the end of the SBT, were recorded and compared using nonparametric paired Mann-Whitney tests. A secondary analysis was done between extubation success (ie, 72 h without the need for re-intubation) and failure groups. Differences were considered statistically significant if P < .05.

RESULTS

A total of 90 SBTs were performed in 70 premature infants; 65 had a successful SBT, and 5 failed the SBT. Of the 65 infants who had a successful SBT and were extubated, 6 failed extubation (9.2%). Subjects had a median (interquartile range [IQR]) gestational age of 30 (27-33) weeks at birth, a birthweight of 1,240 (860-1,790) g, and weight at extubation of 1,790 (1,440-2,500) g. Cardiorespiratory stability was noted by a significant decrease in median (IQR) exhaled tidal volume (6.4 [4.9-8.4] mL/kg vs 5.2 (3.8-6.6] mL/kg, P < .001), a significant increase in mean ± SD breathing frequency (45.1 ± 11.4 vs 52.6 ± 14.4 breaths/min, P < .001), and a significant median (IQR) increase in work of breathing (SA-RSS of 1 [1-2] vs 2 [1-3], P < .001) at the end of the SBT. Respiratory instability was more remarkable in the success group.

CONCLUSIONS

In preterm infants receiving prolonged mechanical ventilation, the performance of a 3-min SBT was associated with increased respiratory instability while still leading to a 10% extubation failure rate. Therefore, the routine use of SBTs to assess extubation readiness in this population is not recommended until there are clear standards and definitions, as well as good accuracy to identify failures.

Effect of post-extubation high-flow nasal cannula on reintubation in elderly patients: a retrospective propensity score-matched cohort study

Background:

Studies of mechanically ventilated patients with a low risk of reintubation have suggested that the use of high-flow nasal cannula (HFNC) oxygen therapy reduces the risk of reintubation compared with conventional oxygen therapy (COT). However, the effect of HFNC following extubation in elderly patients with a high risk of reintubation remains unclear.

Methods:

All consecutive medical intensive care unit (ICU) patients aged >65 years who were mechanically ventilated for >24 h were prospectively registered between July 2017 and June 2018. Control was obtained from a historical database of patients attending the same ICU from January 2012 to December 2013. A total of 152 patients who underwent HFNC after planned extubation according to institutional protocols (HFNC group) were compared with a propensity-matched historical control group who underwent COT (n = 175, COT group). The primary outcome was the proportion of reintubated patients within 48 h after planned extubation.

Results:

One hundred patients from the HFNC group and 129 patients from the COT group were matched by a propensity score that reflected the probability of receiving HFNC, and all variables were well matched. Post-extubation respiratory failure (41.0% versus 33.3%, p = 0.291) and reintubation rate within 48 h (16.0% versus 11.6%, p = 0.436) did not differ between the HFNC and COT groups. However, decreased levels of consciousness as a sign of post-extubation respiratory failure (27.0% versus 11.7%, p = 0.007) were significantly increased in the HFNC group compared with the COT group.

Conclusion:

Among elderly patients who underwent planned extubation, HFNC was not associated with a decrease in the risk of reintubation. Further prospective study evaluating the clinical benefits of post-extubation HFNC in elderly patients is needed.

The reviews of this paper are available via the supplemental material section.

Effect of Pharmacological Agents Administered for Attenuating the Extubation Response on the Quality of Extubation: A Systematic Review

Background

Several drugs have been tried to obtund the hemodynamic extubation response but all have variable side effects that may affect the quality of short-term recovery.

Objective

Our primary objective was to evaluate the effect of pharmacological agents, such as dexmedetomidine, local anesthetics, and so on, administered for attenuating the extubation response on the quality of extubation, as judged by the presence or absence of cough, sedation, and laryngospasm/bronchospasm in adult patients who had undergone general anesthesia. A secondary objective was to evaluate the effect of these drugs on other immediate post-extubation complications such as respiratory depression, desaturation, bradycardia, hypotension, and nausea and vomiting (PONV).

Methods

This is a systematic review of (randomized controlled trials) RCTs with meta-analysis. The Medical Literature Analysis and Retrieval System Online (MEDLINE), Cumulative Index of Nursing and Allied Health Literature (CINAHL), and Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched for RCTs on the effect of pharmacological agents on both the hemodynamic extubation response as well as the quality of extubation.

Results

Fourteen out of 24 included studies were subjected to a meta-analysis. The risk of cough was less likely in the intervention group as compared to control groups (OR 0.26, 95% CI 0.15 to 0.46, p<0.00001, I²=35%). Sedation, hypotension (OR= 10.47; 95% CI: 1.86, 58.80, p=0.008, I²=0%), and bradycardia (OR= 6.57; 95% CI: 2.09, 20.64, p=0.001, I²=0%) were reported with dexmedetomidine. Only one study reported laryngospasm with dexmedetomidine and two studies with opioids.

Conclusion

Dexmedetomidine 0.4 to 0.5 ug/kg was associated with smooth extubation, minimal coughing, no laryngospasm/ bronchospasm, and with stable hemodynamics, without causing respiratory depression, PONV, and desaturation. However, in higher doses (more than 0.5 ug/kg), it caused bradycardia, hypotension, and sedation. Other pharmacological agents, such as local anesthetics, calcium channel blockers, and opioids, did not attenuate cough associated with extubation.

Impact of limb weakness on extubation failure after planned extubation in medical patients

BACKGROUND AND OBJECTIVE

Limb muscle weakness is associated with difficult weaning. However, there are limited data on extubation failure. The objective of this cohort study was to evaluate the association between limb muscle weakness according to the Medical Research Council (MRC) scale and extubation failure rates among patients in a medical intensive care unit (ICU).

METHODS

All consecutive medical ICU patients who were mechanically ventilated for more than 24 h and who were weaned according to protocol were prospectively registered, and limb muscle weakness was assessed using the MRC scale on the day of planned extubation. Association of limb muscle weakness with extubation failure within 48 h following planned extubation was evaluated with logistic regression analysis.

RESULTS

Over the study period, 377 consecutive patients underwent planned extubation through a standardized weaning process. Extubation failure occurred in 106 (28.1%) patients. Median scores on the MRC scale for four limbs were lower in patients with extubation failure (14, interquartile range (IQR) 12-16) than in patients without extubation failure (16, IQR 12-18; P = 0.024). In addition, extubation failure rates decreased significantly with increasing quartiles of MRC scores (P for trend <0.001). In multivariable analysis, MRC scores ≤10 points were independently associated with extubation failure within 48 h (adjusted OR 2.131, 95% CI: 1.071-4.240, P = 0.031).

CONCLUSION

Limb muscle weakness assessed on the day of extubation was found to be independently associated with higher extubation failure rates within 48 h following planned extubation in medical patients.

Evaluation of Endotracheal Tube Scraping on Airway Resistance

BACKGROUND

Spontaneous breathing trials (SBTs) are used to assess the readiness for discontinuation of mechanical ventilation. When airway resistance (R_aw) is elevated, the imposed work of breathing can lead to prolongation of mechanical ventilation. Biofilm and mucus build-up within the endotracheal tube (ETT) can increase R_aw. Scraping the ETT can remove the biofilm build-up and decrease mechanical R_aw. The primary aim of this study was to evaluate the impact of ETT scraping on R_aw. The secondary aim was to determine whether decreasing R_aw would impact subsequent SBT success.

METHODS

Intubated, mechanically ventilated subjects were enrolled if they failed an SBT and had an R_aw of > 10 cm H₂O/L/s. SBT failure was based on institutional guidelines, and R_aw was calculated by subtracting the difference between the measured peak and plateau pressures using a square flow waveform with an inspiratory flow set at 60 L/min. The endOclear device was inserted into the ETT and withdrawn per manufacturer's guidelines. Scraping was repeated until the ETT was cleared. Change in R_aw was compared pre- and post-ETT scraping using a paired t test. A Mann-Whitney U test evaluated the difference in percentage change in R_aw between SBT groups.

RESULTS

Twenty-nine subjects completed the study. The mean pre- and post-ETT scraping R_aw values were 15.17 ± 3.83 and 12.05 ± 3.19 cm H₂O/L/s, respectively (P < .001). Subsequent SBT success was 48%; however, there was no difference in percentage change in R_aw between subsequent passed SBT (18.61% [interquartile range 8.90-33.93%]) and failed SBT (23.88% [interquartile range 0.00-34.80%]), U = 78.5, z = -0.284, P = .78. No adverse events were noted with ETT scraping.

CONCLUSIONS

This study demonstrated that ETT scraping can reduce R_aw. The decrease in R_aw post-ETT scraping did not affect subsequent SBT success.

Case-control Study on Risk Factors of Unplanned Extubation Based on Patient Safety Model in Critically Ill Patients with Mechanical Ventilation

PURPOSE

This study aimed to identify risk factors of unplanned extubation in intensive care unit (ICU) patients with mechanical ventilation using a patient safety model.

METHODS

This study was designed to be a case-control study. Data collection sheets, including 29 risk factors of unplanned extubation in mechanically ventilation patients were retrospectively collected based on a patient safety model over 3 years. From 41,207 mechanically ventilated patients, 230 patients were identified to have unplanned extubation during their ICU stay. Based on the characteristics of the cohort of 230 patients who had unplanned extubation, 460 case control comparison groups with planned extubation were selected by matching age, gender and diagnosis.

RESULTS

Risk factors of unplanned extubation were categorized as people, technologies, tasks, environmental factors and organizational factors, by five components of the patient safety model. The results showed the risk factors of unplanned extubation as admission route [odds ratio (OR) = 1.8], Glasgow Coma Scale-motor (OR = 1.3), Acute Physiology and Chronic Health Evaluation score (OR = 1.06), agitation (OR = 9.0), delirium (OR = 11.6), mode of mechanical ventilation (OR = 3.0-4.1) and night shifts (OR = 6.0). The significant differences were found between the unplanned and the planned extubation groups on the number of reintubation (4.3% vs. 79.6%, p < .001), ICU outcome at the time of discharge (χ² = 50.7, p < .001), and length of stay in the ICU (27.0 ± 33.0 vs. 43.8 ± 43.5) after unplanned extubation.

CONCLUSION

ICU nurses should be able to recognize the risk factors of unplanned extubation related with the components of the safety model so as to improve patient safety by minimizing the risk for unplanned extubation.

Tracheal extubation of the adult intensive care patient with a predicted difficult airway - a narrative review

Management of the difficult airway is an important, but as yet poorly-studied, component of intensive care management. Although there has been a strong emphasis on prediction and intubation of the difficult airway, safe extubation of the patient with a potentially difficult airway has not received the same attention. Extubation is a particularly vulnerable time for the critically ill patient and, because of the risks involved and the consequences of failure, it warrants specific consideration. The Royal College of Anaesthetists 4th National Audit Project highlighted differences in the incidence and consequences of major complications during airway management between the operating room and the critical care environment. The findings in the section on Intensive Care and Emergency Medicine reinforce the importance of good airway management in the critical care environment and, in particular, the need for appropriate guidelines to improve patient safety. This narrative review focuses on strategies for safe extubation of the trachea for patients with potentially difficult upper airway problems in the intensive care unit.

Extubation outcome after a successful spontaneous breathing trial: A multicenter validation of a 3-factor prediction model

The aim of the present study was to validate, and if necessary update, a predictive model previously developed using a classification and regression tree (CART) algorithm for predicting successful extubation (ES) using a new cohort. This prospective cohort study enrolled adults admitted to 10 intensive care units, who had successfully passed a spontaneous breathing trial (SBT) and were considered ready for extubation. After extubation, the patients were followed up for 48 h. The primary outcome measure was ES, defined as the ability to maintain spontaneous unassisted breathing for >48 h after extubation. The 3-factor CART model was applied to patients in this cohort. The predicted probability of ES for each patient in this validation cohort was calculated based on the original CART model using the Laplace correction method. The performance was assessed by discrimination and calibration. A decision curve analysis was used assess the clinical net benefit (NB). Extubation failure (EF) occurred in 90/530 patients (17%). Among the 90 patients, 72 (13.6%) were reintubated, while 18 patients remained on rescue noninvasive ventilation within 48 h after extubation. The original CART model showed high discrimination but only moderate calibration with predicted probabilities that were systematically lower than expected. The original CART model was updated, and the updated model preserved excellent discrimination (area under the receiver operating characteristic curve, 0.91; 95% confidence interval, 0.87 to 0.93), but exhibited near-perfect calibration (calibration slope, 1; intercept, 0). Between threshold probabilities of 50 and 80%, the NB of using this updated model is significantly improved compared with the current strategy. The updated CART model may be used to estimate the predicted probability of ES after a successful SBT for individual patients. Applying this model appears to produce a substantial clinical consequence with regard to potential reduction in unexpected EFs.

High-flow nasal cannula versus conventional oxygen therapy after endotracheal extubation: a randomized crossover physiologic study

OBJECTIVE

Compare the short-term benefit of high-flow nasal cannula (HFNC) with non-rebreathing mask in terms of change in dyspnea, physiologic variables, and patient comfort in subjects after endotracheal extubation.

METHODS

A randomized crossover study was conducted in a 10-bed respiratory care unit in a university hospital. Seventeen mechanically ventilated subjects were randomized after extubation to either Protocol A (applied HFNC for 30 min, followed by non-rebreathing mask for another 30 min) or Protocol B (applied non-rebreathing mask for 30 min, followed by HFNC for another 30 min). The level of dyspnea, breathing frequency, heart rate, blood pressure, oxygen saturation, and patient comfort were recorded. The results were expressed as mean ± SD, frequency, or percentage. Categorical variables were compared by chi-square test or Fisher exact test, and continuous variables were compared by dependent or paired t test. Statistical significance was defined as P < .05.

RESULTS

Seventeen subjects were divided into 2 groups: 9 subjects in Protocol A and 8 subjects in Protocol B. The baseline characteristics and physiologic parameters before extubation were not significantly different in each protocol. At the end of study, HFNC indicated less dyspnea (P = .04) and lower breathing frequency (P = .009) and heart rate (P = .006) compared with non-rebreathing mask. Most of the subjects (88.2%) preferred HFNC to non-rebreathing mask.

CONCLUSIONS

HFNC can improve dyspnea and physiologic parameters, including breathing frequency and heart rate, in extubated subjects compared with conventional oxygen therapy. This device may have a potential role for use after endotracheal extubation.