Tracheotomy is a commonly used measure in clinical rescue of critically ill patients, and it has an important impact on the survival outcome of patients. The time of extubation directly affects the recovery process of the patient. This article reviews the research progress of extubation management of tracheotomy patients at home and abroad, and mainly summarizes and elaborates from four aspects, including the role of the multidisciplinary team in tracheostomy management, where tracheostomy patients are extubated, conditions for extubation in tracheotomy patients, and wound care after extubation in tracheotomy patients. The purpose is to provide a reference for the selection of extubation timing and extubation management for patients with tracheotomy, to improve the success rate of extubation and improve the quality of life of patients.
ObjectiveTo investigate the application value of noninvasive ventilation (NIV) performed in patients with unplanned extubation (UE) in intensive care unit (ICU).MethodsThis was a retrospective analysis. The clinical data, application of NIV, reintubation rate and prognosis of UE patients in the ICU of this hospital from January 2014 to December 2018 were reviewed, and the patients were assigned to the control group or the NIV group according to the application of NIV after UE. The data between the two groups were compared and the application effects of NIV in UE patients were evaluated.ResultsA total of 66 UE patients were enrolled in this study, including 44 males and 22 females and with an average age of (64.2±16.1) years. Out of them, 41 patients (62.1%) used nasal catheter or mask for oxygenation as the control group, 25 patients (37.9%) used NIV as the NIV group. The Acute Physiology andChronic Health EvaluationⅡ score of the control group and the NIV group were (18.6±7.7) vs. (14.8±6.3), P=0.043. The causes of respiratory failure in the control group and the NIV group were as follows: pneumonia 16 patients (39.0%) vs. 7 patients (28.0%), postoperative respiratory failure 7 patients (17.1%) vs. 8 patients (32.0%), chronic obstructive pulmonary disease 8 patients (19.5%) vs. 6 patients (24.0%), others 5 patients (12.2%) vs. 4 patients (16.0%), heart failure 3 patients (7.3%) vs. 0 patients (0%), nervous system diseases 2 (4.9%) vs. 0 patients (0%), which showed no significant difference between the two groups. Mechanical ventilation time before UE were (12.5±19.8) vs (12.7±15.2) d (P=0.966), PaO2 of the control group and the NIV group before UE was (114.9±37.4) vs. (114.4±46.3)mm Hg (P=0.964), and oxygenation index was (267.1±82.0) vs. (257.4±80.0)mm Hg (P=0.614). Reintubation rate was 65.9% in the control group and 24.0% in the NIV group (P=0.001). The duration of mechanical ventilation was (23.9±26.0) vs. (21.8±26.0)d (P=0.754), the length of stay in ICU was (34.4±36.6) vs. (28.5±25.8)d (P=0.48). The total mortality rate in this study was 19.7%. The mortality rate in the control group and NIV group were 22.0% and 16.0% (P=0.555).ConclusionPatients with UE in ICU may consider using NIV to avoid reintubation.
ObjectiveTo explore the predictive factors for extubation in mechanically ventilated patients with moderate to severe traumatic brain injury (TBI). MethodsMechanically ventilated adult patients with moderate to severe brain injuries admitted to the People’s Hospital of Hunan province were selected between April 2020 and March 2022. The general data, neurological function and airway protective ability of the patients were collected. The patients were divided into successful extubation and failed extubation groups based on extubation outcomes. The differences in various indicators between the two groups were compared. Univariate and multivariate logistic regression analyses were conducted to determine the influencing factors for tracheal tube extubation in patients with moderate to severe TBI. Receiver operating characteristic (ROC) curves were plotted to analyze the predictive value of each indicator for extubation in TBI patients. ResultsA total of 263 patients with moderate to severe TBI were included in the analysis, with 183 patients in the successful extubation group and 80 patients in the failed extubation group. The successful extubation group had higher Glasgow coma scale (GCS) and cough peak flow (CPF) compared to the failed extubation group. The incidence of ventilator-associated pneumonia (VAP), duration of mechanical ventilation, length of ICU stay, and length of hospital stay were all lower in the successful extubation group. Univariate and multivariate logistic regression analyses showed that the predictive factors for tracheal tube extubation in patients with moderate to severe TBI were CPF and GCS at the time of extubation. Adjusting for confounding factors, every 1 L/min increase in CPF at the time of extubation reduced the risk of extubation failure by 2% [odds ratio (OR) = 0.98, 95% confidence interval (CI) 0.97 - 0.99], and every 1-point increase in GCS reduced the risk of extubation failure by 12% (OR = 0.88, 95%CI 0.79 - 0.98). ROC curve analysis showed that CPF, GCS, GCS eye, and GCS motor had predictive value for tracheal tube extubation in patients with moderate to severe TBI. When patients simultaneously met the criteria of GCS≥8 (GCS motor≥5, GCS eye≥3) and CPF ≥68.5 L/min, the diagnostic value for predicting successful extubation was highest, with an area under the ROC curve of 0.946 (95%CI 0.917 - 0.975), sensitivity of 0.850, and specificity of 0.907. ConclusionCPF ≥ 68.5 L/min and GCS ≥ 8 have clinical guiding value for successful extubation in mechanically ventilated patients with moderate to severe traumatic brain injury.
ObjectiveTo evaluate the effect of different doses of dexmedetomidine on hemodynamics during endotracheal extubation of laparoscopic cholecystectomy in patients with hypertension. MethodsA total of 120 hypertension patients ready to undergo laparoscopic cholecystectomy under general anesthesia between December 2013 and December 2014 were chosen to be our study subjects. They were randomly divided into 4 groups with 30 patients in each:saline control group (group C), low-dose dexmedetomidine hydrochloride injection group (group D1), moderate-dose dexmedetomidine hydrochloride injection group (group D2), and high-dose dexmedetomidine hydrochloride injection group (group D3). The anesthesia methods and drugs were kept the same in each group, and 20 mL of saline, 0.25, 0.50, 1.00 μg/kg dexmedetomidine (diluted to 20 mL with saline) were given to group C, D1, D2, and D3 respectively 15 minutes before the end of surgery. Time of drug administration was set to 15 minutes. We observed and recorded each patient's mean arterial pressure (MAP) and heart rate (HR) in 5 particular moments:the time point before administration (T1), immediately after administration (T2), extubation after administration (T3), one minute after extubation (T4), and 5 minutes after extubation (T5). Surgery time, recovery time, extubation time and the number of adverse reactions were also detected. ResultsCompared at with, MAP and HR increased significantly at the times points of T3, T4, T5 compared with T1 and T2 in Group C and group D1 (P<0.05), while the correspondent difference was not statistically significant in group D2 and D3 (P>0.05). Compared with group C, MAP and HR decrease were not significantly at the time points of T3, T4, T5 in group D1 (P>0.05). However, MAP and HR decrease at times points of T3, T4, T5 in group D2 and D3 were significantly different from group C and D1 (P<0.05). After extubation, there were two cases of dysphoria in group C and two cases of somnolence in group D3, but there were no cases of dysphoria, nausea or shiver in group D1, D2, D3. ConclusionIntravenously injecting moderate dose of dexmedetomidine 15 minutes before the end of surgery can effectively reduce patients' cardiovascular stress response during laparoscopic cholecystectomy extubation for patients with hypertension, and we suggest a dose of 0.5 μg/kg of dexmedetomidine.
Objective To evaluate and summarize the relevant evidence of oxygenation strategies with tracheal intubation after extubation for adult in intensive care unit (ICU), and to provide evidence-based practice for the development of scientific and effective strategies tracheal intubation after extubation for ICU adult patients. Methods Evidence-based databases, related guideline websites, association websites and original databases were searched by computer for literature about oxygenation strategies with tracheal intubation after extubation for ICU adults patients was extracted. The retrieval time was from the establishment of the databases to May 2023. Two researchers trained in evidence-based practice evaluated the quality of the included literature and extracted evidence from the literature that met the quality evaluation criteria. Results A total of 18 articles were included, including 7 guidelines, 4 clinical decisions, 2 expert consensus, 4 systematic reviews and 1 randomized controlled trial. A total of 22 pieces of best evidence were formed, including 7 aspects of basic principles, evaluation, selection, parameter setting, withdrawal, effect evaluation and precautions. ConclusionThe medical staff should select the best evidence based on the actual clinical situation and the patient’s own needs, and adjust the oxygenation strategies to reduce the rate of tracheal intubation and improve the prognosis of patients.
ObjectiveTo retrospectively analyze the causes and risk factors of unplanned extubation (UE) in cancer patients during peripherally inserted central catheter (PICC) retention, so as to provide references for effectively predicting the occurrence of UE. Methods27 998 cancer patients who underwent PICC insertion, maintenance and removal in the vascular access nursing center of our hospital from January 2016 to June 2023 were retrospectively analyzed. General information, catheterization information, and maintenance information were collected. The Chi-squared test was used for univariate analysis, multivariate analysis was used by binary unconditional logistic regression. They were randomly divided into modeling group and internal validation group according to the ratio of 7∶3. The related nomogram prediction model and internal validation were established. ResultsThe incidence of UE during PICC retention in tumor patients was 2.80% (784/27 998 cases). Univariate analysis showed that age, gender, diagnosis, catheter retention time, catheter slipping, catheter related infection, catheter related thrombosis, secondary catheter misplacement, dermatitis, and catheter blockage had an impact on UE (P<0.05). Age, diagnosis, catheter retention time, catheter slipping, catheter related infection, catheter related thrombosis, secondary catheter misplacement, and catheter blockage are independent risk factors for UE (P<0.05). Based on the above 8 independent risk factors, a nomogram model was established to predict the risk of UE during PICC retention in tumor patients. The ROC area under the predicted nomogram was 0.90 (95%CI 0.89 to 0.92) in the modeling group, and the calibration curve showed good predictive consistency. Internal validation showed that the area under the ROC curve of the prediction model was 0.91 (95%CI 0.89 to 0.94), and the trend of the prediction curve was close to the standard curve. ConclusionPatients aged ≥60 years, non chest tumor patients, catheter retention time (≤6 months), catheter slipping, catheter related infections, catheter related thrombosis, secondary catheter misplacement, and catheter blockage increase the risk of UE. The nomogram model established in this study has good predictive ability and discrimination, which is beneficial for clinical screening of patients with different degrees of risk, in order to timely implement targeted prevention and effective treatment measures, and ultimately reduce the occurrence of UE.
ObjectiveTo investigate the effect of timing of removal of drainage tube on complications after radical thyroidectomy by da Vinci robot.MethodsThree hundred and fifteen patients with thyroid cancer treated by da Vinci robot from July 2014 to December 2018 in our department were reviewed. The patients were divided into two groups according to the amount of drainage fluid at extubation: observation group (99 cases) and control group (216 cases). The extubation indication: in the observation group, the drainage volume was less than 20 mL for 24 hours in two days; in the control group, according to most clinical concepts, the drainage volume was less than 10 mL for 24 hours in two days. The infection rate of wound and tunnel, the incidence of hematoma, wound healing, the time of drainage tube removal and the time of hospitalization were observed.ResultsThere were no significant difference in infection rate, hematoma incidence and wound healing rate between the observation group and the control group (P>0.05). The postoperative extubation time and hospitalization time in the observation group was significantly shorter than that in the control group (P<0.05).ConclusionsAfter the radical operation of thyroid cancer by Leonardo da Vinci robot, taking the amount of wound drainage fluid less than 20 mL/24 hours for 2 days as the time of extubation does not increase the incidence of complications, but it can significantly shorten the time of extubation and hospitalization of patients, which can be widely used in clinical practice.
ObjectiveTo compare the incidence of complications after removal of chest drainage tube in the early and late stages after sublobectomy for non-small cell lung cancer (NSCLC), and to analyze the factors affecting postoperative pleural drainage volume (PDV), so as to explore the countermeasures and achieve rapid postoperative rehabilitation. MethodsThe patients with NSCLC who underwent minimally invasive sublobectomy in our hospital from January to October 2021 were enrolled. According to the median time of extubation, the patients were divided into an early extubation group (time with tube≤3 days) and a late extubation group (time with tube>3 days). The patients were matched via propensity score matching with a ratio of 1:1 and a caliper value of 0.02. The incidence of complications and perioperative parameters after removal of the thoracic drainage tube were analyzed and compared between the two groups, and univariate and multiple linear regression analyses were performed. ResultsA total of 157 patients were enrolled, including 79 males and 78 females, with an average age of (58.22±11.06) years. There were 76 patients in the early extubation group, 81 patients in the late extubation group, and 56 patients were in each group after propensity score matching. Compared with late extubation group, there was no significant difference in the incidence of infection after extubation (10.7% vs. 16.1%, P=0.405) or pleural effusion after extubation (5.4% vs. 3.6%, P=0.647) in early extubation group, and there was no second operation in both groups. Univariate analysis showed that smoking history (P=0.001), postoperative serum albumin reduction value (P=0.017), surgical approach (P=0.014), lesion location (P=0.027), differentiation degree (P=0.041), TNM stage (P=0.043), number of dissected lymph nodes (P=0.016), and intraoperative blood loss (P=0.016) were infuencing factors for increased postoperative PDV. Multiple linear regression analysis showed that smoking history (P=0.002), postoperative serum albumin reduction value (P=0.041), and the number of dissected lymph nodes (P=0.023) were independent risk factors for increased postoperative PDV. ConclusionThere is no significant difference in the incidence of complications after extubation between early and late extubations. Preoperative smoking history, excessive postoperative serum albumin decreases, and excessive number of dissected lymph nodes during the surgery are independent risk factors for increased postoperative PDV.
Objective To explore the application value of failure mode and effect analysis (FMEA) in the risk management of unplanned extubation after esophageal cancer surgery. Methods A total of 1 140 patients who underwent esophageal cancer surgery in our department from January 2015 to May 2017 were selected as a control group, including 948 males and 192 females with an average age of 64.45±4.53 years. FMEA was used to analyze the risk management process of unplanned extubation. The potential risk factors in each process were found by calculating the risk priority number (RPN) value, and the improvement plan was formulated for the key process with RPN>125 points. Then 1 117 patients who underwent esophageal cancer surgery from June 2017 to December 2019 were selected as a trial group, including 972 males and 145 females with an average age of 64.60±5.22 years, and the FMEA risk management mode was applied.Results The corrective measures were taken to optimize the high-risk process, and the RPN values of 9 high-risk processes were reduced to below 125 points after using FMEA risk management mode. The rate of unplanned extubation in the trial group was lower than that in the control group (P<0.05). Conclusion The application of FMEA in the risk management of unplanned extubation after esophageal cancer surgery can reduce the rate of unplanned extubation, improve the quality of nursing, and ensure the safety of patients.
ObjectiveTo investigate the variation regularity about volume of drainage after initial thyroidectomy, and to find out the time points of safety extubation and the time points of risk extubation. MethodsBetween September 2013 and April 2014, the clinical date of 71 cases of thyroid tumor who underwent thyroidectomy were prospectively analyzed and completely random designed. The patients were indwelling drain after thyroidectomy, the volume of drainage liquid were registered at each point of time in period of 48 hours after operation and analyzed its the variation regularity. ResultsThe volume of drainage fluid in 48 h after operation was gradually decreased in 71 patients. The reduce speed of volume of drainage fluid in the 12 h after operation was faster, then was significantly slower, and gradually stabilized. The amount of the drainage fluid reached the peak in 2 h after operation in 22 cases, and then gradually decreased and reached the stabilization. ConclusionsThe 2 hours after thyroidectomy is the risk drainage removing time when is relatively safe. The 12 hours after thyroidectomy is the safety drainage removing time, after that there is no longer any meaning to keep drainage tube.