Examining the impact of Buerger-Allen exercises on alleviating muscle cramps in extubated patients

Objective:This study aimed to evaluate the effectiveness of Buerger-Allen exercise(BAE)in reducing muscle cramps among recently extubated patients in the intensive care unit(ICU).Materials and Methods:A quantitative,quasi-experimental design was employed,involving 92 recently extubated ICU patients randomly assigned to either an experimental or control group.The experimental group underwent BAE,a three-step intervention targeting lower extremity circulation and muscle cramp reduction.The exercises included the elevation of lower extremities,foot and leg exercises,and a rest and recovery phase,administered twice daily for 10 days.The control group received standard nursing care without any specific exercise regimen.Muscle cramp severity was assessed using the modified Penn Spasm Frequency Scale before and after the intervention.Results:The experimental group showed a significant reduction in muscle cramp severity score postintervention,with the mean scores decreasing from 6.83±1.66 to 4.22±1.45(t=10.21,P=0.001).The control group experienced a smaller reduction,with scores decreasing from 6.98±1.57 to 6.43±1.37(t=2.810,P=0.007).Between-group analysis confirmed a significant difference postintervention,with the experimental group improving more(t=8.242,P=0.001).The Mann–Whitney U test also highlighted a significant difference between groups after the intervention(U=494.5,P=0.001),validating the effectiveness of BAE.Conclusion:BAE significantly reduces muscle cramp severity in recently extubated ICU patients,suggesting that this nonpharmacological intervention can effectively improve patient outcomes and aid in postextubation recovery.

Relevant clinical factors for early extubation in living-donor liver transplantation: A single-center retrospective cohort study

BACKGROUND Clinical guidelines for early extubation after liver transplantation remain lacking,with significant variations in the rates of early extubation across transplantation centers.AIM To identify clinical factors,including the use of epidural analgesia,associated with early extubation in living-donor liver transplantation(LDLT).METHODS The medical records of LDLT recipients were analyzed in this study,categorizing them based on extubation timing as delayed(leaving the operating room without extubation)or early(tracheal tube removed immediately after surgery).A multivariate binary logistic regression analysis was performed.Subgroup analysis was conducted,excluding patients contraindicated for epidural analgesia owing to significant coagulopathy.RESULTS Total of 159 patients,93(58.5%)underwent early extubation.Relevant clinical factors of early extubation were shorter anhepatic time[adjusted odds ratio(OR)=0.439,95%confidence interval(CI):0.232-0.831;P=0.011],absence of high-dose vasoactive drug use at the end of surgery(OR=0.235,95%CI:0.106-0.519;P<0.001),and the use of epidural analgesia(OR=15.730,95%CI:1.919-128.919;P=0.010).In a subgroup analysis of 67 patients,epidural analgesia remained a relevant clinical factor for early extubation(adjusted OR=19.381,95%CI:2.15-174.433;P=0.008).CONCLUSION Shorter anhepatic time,absence of high-dose vasoactive drug use at the end of surgery,and the use of epidural analgesia are relevant clinical factors of early extubation following LDLT.

Unique method for removal of knotted lumbar epidural catheter: A case report

BACKGROUND Combined spinal-epidural(CSE)anesthesia is the preferred anesthesia method for cesarean delivery.The use of an epidural catheter is essential for administering additional drugs intraoperatively and managing postoperative pain.However,the insertion of epidural catheters is associated with various complications,such as total spinal anesthesia,symptoms indicative of spinal nerve root irritation,and challenges in epidural catheter removal.CASE SUMMARY We present a case report of a challenging epidural catheter removal due to knotting.The lumbar computed tomography scan results revealed that the catheter formed a tight knot in the epidural space.We used a novel extubation method and successfully removed the catheter.CONCLUSION The operator can use opposite forces to"spiral"apart the spinal joints by positioning the patient's body in a specific position.The findings indicate that,when combined with imaging examination results,this method is effective for the removal of epidural catheters.

Fast track anesthesia for liver transplantation: Review of the current practice

Historically,patients undergoing liver transplantation were left intubated and extubated in the intensive care unit(ICU)after a period of recovery.Proponents of this practice argued that these patients were critically ill andneed time to be properly optimized from a physiological and pain standpoint prior to extubation.Recently,there has been a growing movement toward early extubation in transplant centers worldwide.Initially fueled by research into early extubation following cardiac surgery,extubation in the operating room or soon after arrival to the ICU,has been shown to be safe with proper patient selection.Additionally,as experience at determining appropriate candidates has improved,some institutions have developed systems to allow select patients to bypass the ICU entirely and be admitted to the surgical ward after transplant.We discuss the history of early extubation and the arguments in favor and against fast track anesthesia.We also described our practice of fast track anesthesia at Mayo Clinic Florida,in which,we extubate approximately 60%of our patients in the operating room and send them to the surgical ward after a period of time in the post anesthesia recovery unit.

Effects of propofol versus urapidil on perioperative hemodynamics and intraocular pressure during anesthesia and extubation in ophthalmic patients

AIM: To compare the effect of propofol versus urapidil on hemodynamics and intraocular pressure during anesthesia and extubation for ophthalmic patients. METHODS: Eighty-two surgical patients (Class: ASA I-II) were randomly assigned to propofol (n = 41) and urapidil groups (n = 41). Their gender, age, body mass, operation time and dosage of anesthetics had no significant difference between the two groups (P > 0.05). The patients of propofol and urapidil groups were given propofol (1.5mg/kg) and urapidil (2.5mg/kg) respectively; and two drugs were all diluted with normal saline to 8mL. Then the drugs were given to patients by slow intravenous injection. After treatment, the patients were conducted immediate suction, tracheal extubation, and then patients wore oxygen masks for 10 minutes. By double-blind methods, before the induction medication, at the suction, and 5, 10 minutes after the extubation, we recorded the systolic and diastolic blood pressure (BP), heart rate (HR), pH, PaO2, PaCO2, SaO(2) and intraocular pressure (TOP) respectively. The complete recovery time of the patients with restlessness (on the command they could open eyes and shaking hands) was also recorded during the extubation. The data were analyzed by using a professional SPSS 15.0 statistical software. RESULTS: The incidence of cough, restlessness and glossocoma was significantly lower in the propofol group than that in the urapidil group after extubation (P < 0.05). There were no episodes of hypotension, laryngospasm, or severe respiratory depression. There was no statistical difference in recovery time between two groups (P > 0.05). In propofol group, the BP and HR during extubation and thereafter had no significant difference compared with those before induction, while they were significantly lower than those before giving propofol (P < 0.05), and had significant difference compared with those in urapidil group (P < 0.05). Compared to preinduction, the BP of urapidil group showed no obvious increase during aspiration and extubation. The HR of urapidil group had little changes after being given urapidil, and it was obviously increased compared with that before induction. The stimulation of aspiration and extubation caused less cough and agitation in propofol group than that in urapidil group (P < 0.05). The IOP of propofol group showed no obvious increase during extubation compared with that in preinduction, while in the urpidil group, extubation caused IOP significantly increased (P < 0.05). The changes in these indicators between the two groups had no significant difference (P > 0.05). CONCLUSION: Compared to urapidil, propofol is superior for preventing the cardiovascular and stress responses and IOP increases during emergence and extubation for the ophthalmic patients. Moreover, it has no effects on patient's recovery.

High-flow nasal cannula oxygen therapy and noninvasive ventilation for preventing extubation failure during weaning from mechanical ventilation assessed by lung ultrasound score: A single-center randomized study

BACKGROUND: We sought to demonstrate the superiority of a targeted therapy strategy involving high-flow nasal cannula oxygen(HFNCO_(2)) therapy and noninvasive ventilation(NIV) using lung ultrasound score(LUS) in comparison with standard care among patients in the intensive care unit(ICU) who undergo successful weaning to decrease the incidence of extubation failure at both 48 hours and seven days.METHODS: During the study period, 98 patients were enrolled in the study, including 49 in the control group and 49 in the treatment group. Patients in the control group and patients with an LUS score <14 points(at low risk of extubation failure) in the treatment group were extubated and received standard preventive care without NIV or HFNCO_(2). Patients with an LUS score ≥14 points(at high risk of extubation failure) in the treatment group were extubated with a second review of the therapeutic optimization to identify and address any persisting risk factors for postextubation respiratory distress;patients received HFNCO2 therapy combined with sessions of preventive NIV(4-8 hours per day for 4-8 sessions total) for the first 48 hours after extubation.RESULTS: In the control group, 13 patients had the LUS scores ≥14 points, while 36 patients had scores <14 points. In the treatment group, 16 patients had the LUS scores ≥14 points, while 33 patients had scores <14 points. Among patients with the LUS score ≥14 points, the extubation failure rate within 48 hours was 30.8% in the control group and 12.5% in the treatment group, constituting a statistically significant difference(P<0.05). Conversely, among patients with an LUS score <14 points, 13.9% in the control group and 9.1% in the treatment group experienced extubation failure(P=0.61). The length of ICU stay(9.4±3.1 days vs. 7.2±2.4 days) was significantly different and the re-intubation rate(at 48 hours: 18.4% vs. 10.2%;seven days: 22.4% vs. 12.2%) significantly varied between the two groups(P<0.05). There was no significant difference in the 28-day mortality rate(6.1% vs. 8.2%) between the control and treatment groups.CONCLUSIONS: Among high-risk adults being weaned from mechanical ventilation and assessed by LUS, the NIV+HFNCO_(2) protocol does not lessen the mortality rate but reduce the length of ICU stay, the rate of extubation failure at both 48 hours and seven days.

Predictive value of the unplanned extubation risk assessment scale in hospitalized patients with tubes

BACKGROUND Critical patients often had various types of tubes,unplanned extubation of any kind of tube may cause serious injury to the patient,but previous reports mainly focused on endotracheal intubation.The limitations or incorrect use of the unplanned extubation risk assessment tool may lead to improper identification of patients at a high risk of unplanned extubation and cause delay or nonimplementation of unplanned extubation prevention interventions.To effectively identify and manage the risk of unplanned extubation,a comprehensive and universal unplanned extubation risk assessment tool is needed.AIM To assess the predictive value of the Huaxi Unplanned Extubation Risk Assessment Scale in inpatients.METHODS This was a retrospective validation study.In this study,medical records were extracted between October 2020 and September 2021 from a tertiary comprehensive hospital in southwest China.For patients with tubes during hospitalization,the following information was extracted from the hospital information system:age,sex,admission mode,education,marital status,number of tubes,discharge mode,unplanned extubation occurrence,and the Huaxi Unplanned Extubation Risk Assessment Scale(HUERAS)score.Only inpatients were included,and those with indwelling needles were excluded.The best cut-off value and the area under the curve(AUC)of the Huaxi Unplanned Extubation Risk Assessment Scale were been identified.RESULTS A total of 76033 inpatients with indwelling tubes were included in this study,and 26 unplanned extubations occurred.The patients’HUERAS scores were between 11 and 30,with an average score of 17.25±3.73.The scores of patients with or without unplanned extubation were 22.85±3.28 and 17.25±3.73,respectively(P<0.001).The results of the correlation analysis showed that the correlation coefficients between each characteristic and the total score ranged from 0.183 to 0.843.The best cut-off value was 21,and there were 14135 patients with a high risk of unplanned extubation,accounting for 18.59%.The Cronbach’sα,sensitivity,specificity,positive predictive value,and negative predictive value of the Huaxi Unplanned Extubation Risk Assessment Scale were 0.815,84.62%,81.43%,0.16%,and 99.99%,respectively.The AUC of HUERAS was 0.851(95%CI:0.783-0.919,P<0.001).CONCLUSION The HUERAS has good reliability and predictive validity.It can effectively identify inpatients at a high risk of unplanned extubation and help clinical nurses carry out risk screening and management.

Clinical practice of early extubation after liver transplantation

BACKGROUND: Anesthetic practices such as early tracheal extubation facilitate postoperative recovery. Early extubation after liver transplantation has been adopted by some centers in the recent two decades. No universal clinical guidelines are used and questions remain. This review aimed to address the current status of early extubation after liver transplantation. DATA SOURCES: A literature search of MEDLINE and ISI Web of Knowledge databases was performed using terms such as liver transplantation, early extubation, immediate tracheal extubation fast tracking or fast track anesthesia and postoperative tracheal extubation. Additional papers were identified by a manual search of the references in the key articles. RESULTS: Review of the available literature provided an insight into the definition, evolution, advantages and risks of early extubation, and anesthetic techniques that prompt early extubation in liver transplant patients. Early extubation has proved to be feasible and safe in these patients, but the outcomes are still uncertain. CONCLUSIONS: Early extubation after liver transplantation is feasible, safe and cost-effective in the majority of patients and has been increasingly accepted as an option for conventional postoperative ventilation. Comprehensive and individualized evaluation of the patient’s condition before extubation by an experienced anesthesiologist is the cornerstone of success Understanding of its effect on the outcome remains incomplete In the future, additional trials are required to establish universal early extubation guidelines and to determine its benefits for patients and practitioners.

Early tracheotomy for acute severe asthma

BACKGROUND： Few studies have reported the effects of early tracheotomy in acute severe asthmatic patients. We report two patients with acute severe asthma who were successfully treated with early tracheotomy. METHODS：The two patients with acute severe asthma were retrospectively reviewed. They had been treated at the Department of Emergency and Critical Care, Renji Hospital, Shanghai Jiaotong University School of Medicine. RESULTS： They developed progressively hypercapnia and severe acidosis, and were not improved after conventional therapies. Early tracheotomy after mechanical ventilation decreased airway resistance and work of breathing, and corrected hypercapnia and acidosis. Adequate gas exchange was maintained after tracheotomy. The two patients were subsequently weaned from mechanical ventilation and discharged. CONCLUSION：Early tracheotomy could be a valuable approach in certain patients with severe asthma.

A Comparative Study between Dexmedetomidine Alone versus Combined Low Dose of Dexmedetomidine and Lidocaine for the Hemodynamic Response to Endotracheal Extubation in Patient Undergoing Abdominal Surgery—A Prospective Randomized Controlled Study

Background: Tracheal extubation is related to many side effects of hemodynamic, especially for patients with comorbid states. The study compared the validity of dexmedetomidine 1 μg/kg and low combination dose of dexmedetomidine 0.5 μg/kg plus Lidocaine 1 mg/kg in softening hemodynamic stress response and estimated quality of extubation in study groups. Materials and Methods: The patients in our study, one hundred and fifty of both gender, ASA class I &II patients, aged 20 - 50 years old subject to elective abdominal operations under general anesthesia were allocated into three equal groups. Anesthetic technique was standardized. Before extubation by 10 minutes, the patients in Group N, D, and DL have given 0.9% normal Saline intravenous bolus infusion, dexmedetomidine 1 μg/kg and Dexmedetomidine 0.5 μg/kg, respectively within a 10-minute period. Before complete extubation by 90 seconds, in the three groups by syringe ten cc volumes and at time of extubation, Group N and D patients received 0.9% normal Saline intravenous bolus infusion, but in Group DL received Lidocaine 1 mg/kg then extubation completed. Heart rate (HR), Diastolic BP (DBP), Systolic BP (SBP), and Mean Arterial Pressure (MAP) were noted at baseline, at the reverse, extubation, 2, 4, 6, 8, 10 min and at the regular times after that for two hours. Extubation quality was assessed by extubation quality scale. Aldrete’s recovery score and Ramsay sedation score were also recorded and also any complications were noted and recorded. Results: All the hemodynamic parameters significantly elevated extubation and numerous periods of observation in the normal saline group than dexmedetomidine and dexmedetomidine plus Lidocaine group (p-value = 0.001). Response of tachycardia was seen in 41 (82%) in patients of N group, compared to 18 (36%) and 20 (40%) in D & DL group respectively (p = 0.001). Hypertensive response statistically significant noticed in 40 (80%) patients of N group, 9 (18%) of D group and 12 (24%) of DL group (p = 0.001). Tachycardia duration and the response of hypertension were significantly prolonged in the control group. As regards extubation quality, the three groups differed in D Groups (1.93 ± 0.57) and DL (1.51 ± 0.57) had decreased scores compared to group N (2.67 ± 0.48) modulating smoother extubation (p Conclusion: Low combined dose of (Dexmedetomidine 0.5 μg/kg plus Lidocaine 1 mg/kg) IV was useful as much as Dexmedetomidine 1 μg/kg IV in softening hemodynamic stress responses during emergence.

Combined Echocardiography and Lung Ultrasound for Extubation Outcome Prediction in Children after Cardiac Surgery

Background:Children are at risk of extubation failure after congenital heart disease surgery.Such cases should be identified to avoid possible adverse consequences of failed extubation.This study aimed to identify ultrasound predictors of successful extubation in children who underwent cardiac surgery.Methods:Children aged 3 months to 6 years who underwent cardiac surgery(if they were intubated for>6 h and underwent a spontaneous breathing trial)were included in this study.Results:We included 83 children who underwent surgery for congenital heart disease.Transthoracic echocardiography and lung ultrasound were performed immediately before spontaneous breathing trials.Upon spontaneous breathing trial completion,respiratory parameters,including arterial blood gas analysis and frequency-to-tidal volume ratio,were similarly recorded.For outcome assessment,all children were followed up for 48 h after extubation.We successfully extubated 57 children(68.7%).These children were significantly older and weighed more but had shorter aortic cross-clamp and cardiopulmonary bypass times.Children who could not be weaned or extubated had prolonged total mechanical ventilation and pediatric intensive care unit stay.In the multivariate regression analysis,a lung ultrasound score≥12 and ejection fraction≥40%immediately before spontaneous breathing trials were the only independent predictors of successful extubation.When combined,the lung ultrasound score and an ejection fraction≥40%showed a better diagnostic performance than every other isolated variable(lung ultrasound,N-terminal-pro-B-type natriuretic peptide,and frequency-to-tidal volume ratio).Conclusions:The combination of lung ultrasound and transthoracic echocardiography immediately before the spontaneous breathing trial effectively predicts extubation outcomes in children after cardiac surgery.

Fast Track Extubation Post Coronary Artery Bypass Graft: A Retrospective Review of Predictors of Clinical Outcomes

Introduction: Fast track (FT) cardiac surgery and early extubation (EE) are aimed at safe and effective rapid post-operative progression to discharge, and have been practiced for more than two decades. Their goal is to optimize patient care perioperatively in order to decrease costs without negatively affecting morbidity and mortality. However, the factors that predict successful EE are poorly understood, and patients with significant co-morbidities are frequently excluded from protocols. We hypothesize that independent of disease severity, early extubation leads to shorter hospital stays and can be performed safely without negatively affecting outcomes. Materials and Methods: We performed a retrospective review of 919 patients who underwent coronary artery bypass grafting (CABG) at the Southern Arizona Veteran’s Affairs Health Care System medical center over 7 years. We collected pre-operative data regarding patients’ NYHA classification, presence and severity of cerebral vascular disease, peripheral vascular disease, pulmonary disease, diabetes and hypertension. Intra-operative variables were also recorded including ASA scores, ischemic times, and time to extubation. Finally, post-operative variables such as rates of reintubation and tracheotomy, and both length of ICU and total hospital stay were also compared. Results: Prolonged periods of ischemia were found to predict a delayed extubation (HR = 0.992;CI = 0.988 - 0.997, p = 0.0015) while small body surface area (HR = 1.57;CI = 1.13, 2.17, p = 0.007) and higher pre-operative functional status of the patient, such as independent versus dependent status (HR =1.68;CI = 1.30 - 2.16, p = 1.33;CI = 1.03 - 1.70, p = 0.03) were found to be associated with earlier extubation. The early extubation (EE) group (those extubated in less than the median 7.3 hours) had an average hospital stay of 5.1 ± 4.0 days, versus 7.8 ± 8.1 days in the delayed group (>4 hours), p Conclusions: In our study population, pre-operative functional class and total body surface area predicted those patients able to tolerate early extubation after cardiac surgery. Prolonged ischemia resulted in delayed extubation. Patients that were extubated in less than 4 hours had shorter ICU and hospitalization stays, while there was no significant difference between the two groups in rate of reintubation or tracheotomy.

Implementation of a nurse-led protocol for early extubation after cardiac surgery: A pilot study

BACKGROUND Protocols for nurse-led extubation are as safe as a physician-guided weaning in general intensive care unit(ICU).Early extubation is a cornerstone of fast-track cardiac surgery,and it has been mainly implemented in post-anaesthesia care units.Introducing a nurse-led extubation protocol may lead to reduced extubation time.AIM To investigate results of the implementation of a nurse-led protocol for early extubation after elective cardiac surgery,aiming at higher extubation rates by the third postoperative hour.METHODS A single centre prospective study in an 18-bed,consultant-led Cardiothoracic ICU,with a 1:1 nurse-to-patient ratio.During a 3-wk period,the protocol was implemented with:(1)Structured teaching sessions at nurse handover and at bed-space(all staff received teaching,over 90%were exposed at least twice;(2)Email;and(3)Laminated sheets at bed-space.We compared“standard practice”and“intervention”periods before and after the protocol implementation,measuring extubation rates at several time-points from the third until the 24th postoperative hour.RESULTS Of 122 cardiac surgery patients admitted to ICU,13 were excluded as early weaning was considered unsafe.Therefore,109 patients were included,54 in the standard and 55 in the intervention period.Types of surgical interventions and baseline left ventricular function were similar between groups.From the third to the 12th post-operative hour,the intervention group displayed a higher proportion of patients extubated compared to the standard group.However,results were significant only at the sixth hour(58%vs 37%,P=0.04),and not different at the third hour(13%vs 6%,P=0.33).From the 12th post-operative hour time-point onward,extubation rates became almost identical between groups(83%in standard vs 83%in intervention period).CONCLUSION The implementation of a nurse-led protocol for early extubation after cardiac surgery in ICU may gradually lead to higher rates of early extubation.

Negative Pressure Pulmonary Edema on Extubation of a 9-Month-Old Baby Boy

Background: Negative Pressure Pulmonary Edema (NPPE) is an uncommon, but well recognized clinical entity that continues to be reported as a complication of upper airway obstructions during induction or emergence. It results from the negative intrathoracic pressure generated with spontaneous ventilation with concurrent upper airway obstruction. Aim: To present an unusual case of NPPE and review the pathophysiology and treatment. Case: It usually occurs in young healthy athletic adults. We are reporting NPPE in a nine-month-old ex-premature baby. We discuss his intraoperative events leading to NPPE, subsequent intraoperative course and treatment. Conclusion: NPPE needs to be promptly recognized and treated. If the edema resolves, the patient can be successfully extubated, but should be observed overnight.

Healthcare Quality According to ICU Level of Care

Introduction: Little is known about the quality of healthcare in intensive care units (ICUs) in Poland. Data on patients hospitalized in ICUs in Warsaw and the results of their treatment are scarce. This information, crucial for improving the quality of ICU healthcare services, is not collected routinely. Quality indicators are essential in the concept of holistic quality management. Implementation of these indicators in ICUs is a complex and time-consuming process. Systematic increase in demand for quality assessment tools that can reflect real conditions of the practices of ICUs, prompts the search for effective solutions. Methods: The study included 12,155 patients hospitalized in 16 ICUs of Warsaw hospitals (8 ICUs, n = 3293 of the first level of care, and 8 ICUs, n = 8862 of the second level) between 1st January 2017 and 31st December 2018. ICUs in pediatric and oncological hospitals were excluded from the study. Characteristics and demography of patients as well as the structure, treatment and human resources of the ICUs in Warsaw were analyzed. Length of stay, unexpected extubations, nosocomial infections, ICU readmissions and standardized mortality ratios (SMR) were retrieved from National Health Fund, Ministry of Health, and other public databases. Results: In primary level ICUs patients’ age (66.42 vs. 64.43 years;p = 0.005) and comorbidity rate (30.56% vs. 22.78%, p = 0.037) were higher when compared to ICUs of the second level of care. The crude mortality rate in ICUs in Warsaw was significantly higher than in other EU countries and differed between ICUs of the first and the second level (34.77% vs. 24.53%, respectively;p = 0.004). SMRs were however very low: 0.71 and 0.64 (ns), respectively. ICU readmission rate, unexpected extubations, central catheter related infections, and length of stay were identical in both groups. More patients were admitted to ICU form emergency department and/or discharged home in Level 1 ICUs (18.9% vs 12.9%, p Conclusions: There are no major differences in quality of care provided by Level 1 and Level 2 ICUs in Poland, although more rigorous adhesion to admission and discharge policies is needed. Implementation of the instruments for assessing quality of ICUs including benchmarking, self-assessment of departments and evaluation of changes resulting from audits according to the Deming cycle is of utmost importance. Standardization of quality measures and markers, communication, and cooperation in reporting and creation of ICU medical registers is necessary to improve the quality of healthcare.

A Comparison of Five Adhesive Tapes for Securing Endotracheal Tube in a Manikin

Background: Adhesive tape is the common method for endotracheal tube (ETT) secured to prevent tube displacement and unplanned extubation in an anesthesia setting. However, it is unclear which tape is superior for ETT fixation among the various tapes used in clinical practice. This study examines the force required to move 2 cm ETT and extubate ETT from an intubation manikin with five different adhesive tapes. Methods: We orally intubated an adult intubation manikin with an inner-diameter 7.5 mm ETT, inflated the cuff to 20 cm H2O. Then we secured ETT with five different adhesive tapes (Transpore tapeTM, Urgosyval tape®, TransporeTM White tape, Multipore tape, DuraporeTM tape) in a conventional fixation method. A digital force gauge was connected to the ETT and pulled in a direction erected to the oral cavity. We measured the force required to move 2 cm ETT and extubate ETT (defined as 5 cm ETT displacement) from the manikin. Data were analyzed with one-way analysis of variance, with P < 0.05. Results: DuraporeTM tape had the largest average force of 2 cm displacement (58.9 ± 5.7N) (P < 0.05). The extubation force of DuraporeTM tape (59.7 ± 4.9N) was larger than Urgosyval® tape (40.4 ± 2.9N) (P < 0.05), TransporeTM tape (48.7 ± 5.1N) (P < 0.05), Transpore WhiteTM tape (48.7 ± 5.1N) (P < 0.05). Conclusion: DuraporeTM tape was superior to the other four tapes (TransporeTM tape, Urgosyval® tape, TransporeTM white tape, Multipore tape) in holding the ETT in place in the manikin.

Reducing the Rate of Unplanned Extubation of Venous Access in Perioperative Patients

Objective:To investigate the application effect of quality control circle activities in reducing the rate of unplanned extubation of venous access in perioperative patients.Methods:The quality control circle method was used to analyze the causes,identify the actual causes of unplanned out-of-control,take corresponding measures,formulate corresponding countermeasures,implement standardized management,and carry out continuous improvement.Results:Following the implementation of quality control circle activities,the rate of unplanned extubation of venous access in perioperative patients decreased from 27.35%before improvement to 3.42%after improvement.Conclusion:The use of quality control circle activities in the safety management of venous access in perioperative patients is conducive to reducing the rate of unplanned extubation of venous access in perioperative patients.

降低ICU非計劃性拔管的改善方案

目的降低ICU氣管插管病患之非計劃性拔管(unplanned extubation,UEX)率。方法2010年1~5月,發現在73位氣管插管留置病患中,發生UEX 6人次,拔除率為8.2%。分析原因後發現:缺乏適當約束2人次(33.3%),躁動未適當使用鎮靜劑2人次(33.3%),缺乏有效溝通1人次(16.6%),氣囊破裂滑脫1人次(16.6%)。結果由2010年6~10月,在58位氣管插管留置病患中,UEX發生事件下降為3人次,拔除率為5.1%,明顯達到目的。結論充分認識UEX的風險因素、有價值的風險評估指標,對UEX事件進行全面的系統分析,採取預見性的醫療護理措施,是保證患者置管安全、降低UEX發生率的有效手段。

Computer-driven automated weaning reduces weaning duration in difficult-to-wean patients

Background Weaning difficulties occur in 31% of total intubated patients, and result in prolonged weaning duration. A computer-driven automated weaning system can perform a spontaneous breathing trial （SBT） automatically and display a message when the trial is successfully passed. Such a system might have a beneficial effect on difficult-to-wean patients. The aim of this study was to examine whether the computer-driven automated weaning system can accelerate discontinuation of mechanical ventilation and improve outcomes in difficult-to-wean patients. Methods This randomized controlled study included 39 difficult-to-wean patients who failed their first spontaneous breathing trial. Before initiating weaning, eligible patients were randomly allocated to wean by computer-driven automated weaning system （CDW group, n=19） or a physician-controlled local protocol （PW group, n=20）. Weaning duration, defined as the time from inclusion until first extubation, was the primary endpoint. Secondary endpoints were total duration of mechanical ventilation, the length of intensive care unit （ICU） stay, the number of reintubations, the mortality rate in the ICU, the number of noninvasive ventilations, the number of complications in the ICU, and the number of ventilator-associated pneumonia cases. Results The weaning duration was reduced with the computer-driven weaning as compared with the usual protocol （median 29.0 hours vs. 45.5 hours, P=0.044）. Total duration of mechanical ventilation and duration of the ICU stay did not differ between the CDW and PW groups. There was no difference in the number of reintubations between the CDW and PW groups （3 and 4 patients, P=0.732）. The study groups showed comparable numbers of tracheostomy, self- extubations, ventilator-associated pneumonia, and non-invasive ventilation. Mortality in the ICU was similar in the CDW and the PW groups （21.1% vs. 20.0%, P=0.935）. Conclusion The computer-driven automated weaning system can reduce weaning duration in difficult-to-wean patients as compared with a physician-controlled weaninq protocol.

Oxygenation strategies after extubation of critically ill and postoperative patients

In intensive care units(ICUs),the decision to extubate is a critical one because mortality is particularly high in case of reintubation.Around 15%of patients ready to be weaned offa ventilator experience extubation failure leading to reintubation.The use of high-flow nasal oxygen and non-invasive ventilation are two alternatives of standard oxygen supplementation that may help to prevent reintubation.High-flow nasal oxygen and non-invasive ventilation,may be used to prevent reintubation in patients with low(e.g.,patients without comorbidities and with short durations of mechanical ventilation)and high risk(e.g.,patients>65 years and those with underlying cardiac disease,chronic respiratory disorders,and/or hypercapnia at the time of extubation)of reintubation,respectively.However,non-invasive ventilation used as a rescue therapy to treat established post-extubation respiratory failure could increase mortality by delaying reintubation,and should therefore be used very carefully in this setting.The oxygenation strategy to be applied in postoperative patients is different from the patients who are extubated in the ICUs.Standard oxygen after a surgical procedure is adequate,even following major abdominal or cardio-thoracic surgery,but should probably be switched to high-flow nasal oxygen in patients with hypoxemic.Unlike in patients experiencing post-extubation respiratory failure in ICUs wherein non-invasive ventilation may have deleterious effects,it may actually improve the outcomes in postoperative patients with respiratory failure.This review discusses the different clinical situations with the aim of choosing the most effective oxygenation strategy to prevent post-extubation respiratory failure and to avoid reintubation.