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9 results

  • Increased physiologic dead space fraction is associated with mortality after comprehensive stage 2 operation

  • Dariya Hardisky, Divyaam Satija, Andrew R. Yates, Tamara Clark, Robin Alexander, Mark Galantowicz, Sergio A. Carrillo
  • Journal:
    Cardiology in the Young , First View
    Published online by Cambridge University Press:
    18 October 2024, pp. 1-7
    • Article
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  • Objective:

    Our objective was to assess the predictive value of physiologic dead space fraction for mortality in patients undergoing the comprehensive stage 2 operation.

    Methods:

    This was a single-centre retrospective observational study conducted at a quaternary free-standing children’s hospital specialising in hybrid palliation of single ventricle cardiac disease. 180 patients underwent the comprehensive stage 2 operation. 76 patients (42%) underwent early extubation, 59 (33%) standard extubation, and 45 (25%) delayed extubation. We measured time to extubation, post-operative outcomes, length of stay and utilised Fine gray models, Youden’s J statistic, cumulative incidence function, and logistic regression to analyse outcomes.

    Results:

    Delayed extubation group suffered significantly higher rates of mortality (31.1% vs. 6.8%), cardiac arrest (40.0% vs. 10.2%), stroke (37.8% vs. 11.9%), and need for catheter (28.9% vs. 5.1%) and surgical intervention (24.4% vs. 8.5%) (P < 0.001). Physiologic dead space fraction was significantly higher in the delayed extubation group and in non-survivors with a value of 0.3, which was found to be the discriminatory point by Youden’s J statistic. For a 0.1 unit increase in physiologic dead space fraction on post-operative day 1, the odds of a patient expiring increase by a factor of 2.26 (95% CI 1.41–3.97, p < 0.001) and by a factor of 3.79 (95% CI 1.65–11.7, p 0.01) on post-operative day 3.

    Conclusions:

    Delayed extubation impacts morbidity and mortality in patients undergoing the comprehensive stage 2 operation. Increased physiologic dead space fraction in the first 60 hours after arrival to the ICU is associated with higher mortality.

  • Chapter 21 - Extubation

  • from Section 1 - Airway Management: Background and Techniques
  • Edited by Tim Cook, Michael Seltz Kristensen
  • Book:
    Core Topics in Airway Management
    Published online:
    03 October 2020
    Print publication:
    03 December 2020, pp 177-184

  • Summary

    Extubation and emergence are high-risk phases of anaesthesia which accounted for 28% of the anaesthesia cases reported to the Fourth National Audit Project of the Difficult Airway Society and the Royal College of Anaesthetists. Problems generally relate to the patient’s anatomy, physiology or to the context in which extubation is carried out. Minor issues such as coughing and breath-holding are common, more serious complications such as aspiration, laryngospasm, post-obstructive pulmonary oedema and hypoxic brain injury are often preventable with proper planning. In this chapter we discuss how to formulate an extubation strategy including risk stratification, planning, awake and deep extubation and modifications aimed at reducing the risk of complications. An awake extubation is suitable for most patients but special techniques such as supraglottic airway exchange, remifentanil infusion or the use of an airway exchange catheter may be helpful in high-risk situations. Post-operative care does not end when the tracheal tube has been removed, handover and documentation are essential components of the extubation plan.

  • 27 - Atmospheric monitoring outside the healthcare environment and within enclosed environments: a historical perspective

  • from 1 - Ventilation
  • Edited by J. S. Gravenstein, University of Florida, Michael B. Jaffe, Nikolaus Gravenstein, University of Florida, David A. Paulus, University of Florida
  • Book:
    Capnography
    Published online:
    05 August 2011
    Print publication:
    17 March 2011, pp 261-271

  • Summary

    This chapter focuses on the use of capnography to optimize and minimize the length of mechanical ventilation. Mechanical ventilation can be divided into three phases: acute stabilization, pre-weaning, and weaning/ extubation readiness testing. Alveolar minute ventilation is determined from the volumetric capnogram. Liberation from mechanical ventilation implies the use of an extubation readiness test to withdraw mechanical ventilation as soon as the patient meets extubation criteria regardless of the level of ventilatory support. A myriad of adversities make weaning and liberation from mechanical ventilation an extremely important clinical issue. With the majority of intensive care unit (ICU) patients requiring mechanical ventilation, minimizing the duration of mechanical ventilation while optimizing the potential for successful extubation is crucial in the management of critically ill patients. Capnography, both time-based and volumetric, allows mechanical ventilatory strategies to be designed with clear, precise, objective criteria.

  • Chapter 25 - ENT surgery

  • from Section 3 - Specialties
  • Edited by Ian Calder, Adrian Pearce
  • Book:
    Core Topics in Airway Management
    Published online:
    10 January 2011
    Print publication:
    16 December 2010, pp 227-243

  • Summary

    An extubation plan should always be formulated. Extubation in a deep plane of anaesthesia is an advanced technique. One-third of aspiration events occur after extubation. Every extubation technique should ensure minimal interruption in the delivery of oxygen to the patient's lungs, and should extubation fail, ventilation should be achievable with the minimal difficulty or delay. The choice of extubation position reflects a balance between the risks of vomiting post-extubation, and subsequent inhalation and soiling of the lungs, and potential respiratory embarrassment and ease of assisting ventilation. The depth of anaesthesia at the time of extubation is highly important because of the risk of life-threatening laryngospasm. Peri-extubation insertion of a laryngeal mask airway (LMA) is a useful technique for airway maintenance in the recovery period with less airway obstruction and coughing, and higher saturations than either deep or awake extubation. An airway exchange catheter (AEC) is a useful aid.

  • Propofol as a bridge to extubation for high-risk children with congenital cardiac disease

  • Sarena N. Teng, Jon Kaufman, Angela S. Czaja, Robert H. Friesen, Eduardo M. da Cruz
  • Journal:
    Cardiology in the Young / Volume 21 / Issue 1 / February 2011
    Published online by Cambridge University Press:
    19 October 2010, pp. 46-51
  • Background

    Children with congenital cardiac defects may have associated chromosomal anomalies, airway compromise, and/or pulmonary hypertension, which can pose challenges to adequate sedation, weaning from mechanical ventilation, and successful extubation. Propofol, with its unique properties, may be used as a bridge to extubation in certain cardiac populations.

    Materials and methods

    We retrospectively reviewed 0–17-year-old patients admitted to the Cardiac Intensive Care Unit between January, 2007 and September, 2008, who required mechanical ventilation and received a continuous infusion of propofol as a bridge to extubation. Medical charts were reviewed for demographics, associated comorbidities, as well as additional sedation medications and haemodynamic trends including vital signs and vasopressor support during the peri-infusion period. Successful extubation was defined as no re-intubation required for respiratory failure within 48 hours. Outcomes measured were successful extubation, evidence for propofol infusion syndrome, haemodynamic stability, and fluid and inotropic requirements.

    Results

    We included 11 patients for a total of 12 episodes. Propofol dose ranged from 0.4 to 5.6 milligram per kilogram per hour with an average infusion duration of 7 hours. All patients were successfully extubated, and none demonstrated worsening metabolic acidosis suggestive of the propofol infusion syndrome. All patients remained haemodynamically stable during the infusion with average heart rates and blood pressures remaining within age-appropriate ranges. One patient received additional fluid but no increase in vasopressors was needed.

    Conclusions

    This study suggests that propofol infusions may allow for successful extubation in a certain population of children with congenital cardiac disease. Further studies are required to confirm whether propofol is an efficient and safe alternative in this setting.

  • 18 - Weaning, extubation and de-cannulation

  • Edited by Iain Mackenzie
  • Book:
    Core Topics in Mechanical Ventilation
    Published online:
    14 October 2009
    Print publication:
    30 October 2008, pp 331-371

  • Summary

    The process of withdrawing mechanical ventilation is commonly referred to as 'weaning', but in the literature the term has acquired two distinct meanings, having been described as either (1) the process of gradually decreasing ventilatory support to return the work of breathing back to the patient or (2) a means of determining when patients have the ability to be safely liberated from the ventilator. In this chapter the term 'weaning' refers to the process of returning the work of breathing back to the patient. Determining readiness for extubation or de-cannulation is dealt with as a separate issue. Un-assisted spontaneous ventilation has two indispensable requisites: firstly, the ability to initiate rhythmic inspiratory effort, and secondly the muscular strength and stamina to maintain tidal ventilation. The establishment of a spontaneous respiratory rhythm is challenged in three ways: primary post-ventilation apnoea, failure to sustain an acceptable minute ventilation, and repeated periods of apnoea.

  • Comparison of intravenous metoprolol, verapamil and diltiazem on the attenuation of haemodynamic changes associated with tracheal extubation

  • D. Yörükoǧlu, A. Göktug, Z. Alanoǧlu, M. Tulunay
  • Journal:
    European Journal of Anaesthesiology / Volume 16 / Issue 7 / July 1999
    Published online by Cambridge University Press:
    16 August 2006, pp. 462-467
    Print publication:
    July 1999

  • Changes in heart rate, systolic, diastolic and mean blood pressure were measured after extubation in 60 ASA Grade I and II patients to assess the effects of diltiazem (0.2 mg kg−1), verapamil (0.05 mg kg−1) and metoprolol (0.02 mg kg−1) given as a bolus 2 min before tracheal extubation. All the haemodynamic variables measured increased significantly after extubation in the control and diltiazem groups when compared with the base-line recordings (P<0.05). Metoprolol effectively blocked the increases in heart rate after extubation and the increase in blood pressure in this group was less when compared with the control group (P<0.05). Verapamil alleviated the increase in both heart rate and blood pressure. However, profound hypotension and bradycardia requiring therapy, occurred in the verapamil group. For this reason, careful observation is necessary when using variverapamil and the routine use of this drug in patients with coronary artery disease requires further studies.

  • Attenuation of the haemodynamic responses to noxious stimuli in patients undergoing cataract surgery. A comparison of magnesium sulphate, esmolol, lignocaine, nitroglycerine and placebo given i.v. with induction of anaesthesia

  • A. A. van den Berg, D. Savva, N. M. Honjol
  • Journal:
    European Journal of Anaesthesiology / Volume 14 / Issue 2 / March 1997
    Published online by Cambridge University Press:
    12 September 2006, pp. 134-147
    Print publication:
    March 1997

  • A study was conducted on 100 middle-aged to elderly patients (n=52, healthy; n=48, suffering from either diabetes, hypertension, ischaemic heart disease or combination of these diseases) undergoing cataract extraction to assess the effects of laryngoscopy and tracheal intubation, anaesthesia and surgery, eye bandaging and tracheal extubation, saline (control), magnesium sulphate 40 mg kg−1, esmolol 4.0 mg kg−1, lignocaine 1.5 mg kg−1 and glyceryl trinitrate 7.5 μg kg−1 given i.v. at induction of anaesthesia on heart rate (HR), blood pressure (BP), rate-pressure product (RPP) and pressure-rate quotient (PRQ). Anaesthesia was standardized. Haemodynamic responses and requirements for atropine, ephedrine and labetalol to maintain HR and BP during surgery were similar inhealthy and diseased patients, and in the test drug groups. Differences produced by the test drugs were evident until 5 min following intubation. Esmolol prevented rises in HR and RPP. Glyceryl trinitrate prevented a rise in BP, but was associated with tachycardia and a fall in PRQ to < 1.0. Magnesium sulphate and lignocaine did not prevent responses to laryngoscopy and tracheal intubation, and were associated with rises in RPP. Application of the eye dressing and tracheal extubation at the end of surgery each caused significant increases in HR, BP and RPP in all groups.