Javier Lorenzo, MD

Abstract

OBJECTIVE: Weaning parameters are well studied in patients undergoing first time extubation. Fewer data exists to guide re-extubation of patients who failed their first extubation attempt. It is reasonable to postulate that improved weaning parameters between the first and second extubation attempt would lead to improved rates of re-extubation success. To investigate, we studied a cohort of patients who failed their first extubation attempt and underwent a second attempt at extubation. We hypothesized that improvement in weaning parameters between the first and the second extubation attempt is associated with successful reextubation.INTERVENTIONS: Rapid shallow breathing index (RSBI), maximum inspiratory pressure (MIP), vital capacity (VC), and the blood partial pressure of CO2 (PaCO2) were measured and recorded in the medical record prior to extubation along with demographic information. We examined the relationship between the change in extubation and re-extubation weaning parameters and re-extubation success.MEASUREMENTS AND MAIN RESULTS: A total of 1283 adult patients were included. All weaning parameters obtained prior to re-extubation differed between those who were successful and those who required a second reintubation. Those with reextubation success had slightly lower PaCO2 values (39.5 7.4 mmHg vs. 41.6 9.1 mmHg, p = 0.0045) and about 13% higher vital capacity volumes (1021 410 mL vs. 907 396 mL, p = 0.0093). Lower values for RSBI (53 32 breaths/min/L vs. 69 42 breaths/min/L, p < 0.001) and MIP (-41 12 cmH2O vs. -38 13 cm H2O), p = 0.0225) were seen in those with re-extubation success. Multivariable logistical regression demonstrates lack of independent associated between the change in parameters between the 2 attempts and re-extubation success.CONCLUSIONS: The relationship between the changes in extubation parameters through successive attempts is driven primarily by the value obtained immediately prior to re-extubation. These findings do not support waiting for an improvement in extubation parameters to extubate patients who failed a first attempt at extubation if extubation parameters are compatible with success.

View details for DOI 10.1177/0885066620988675

View details for PubMedID 33461374

View details for DOI 10.7759/cureus.10691

View details for Web of Science ID 000573185700003

View details for Web of Science ID 000530000201325

Abstract

In this report, we present a case of a patient with a history of complex airway anatomy secondary toSagliker syndrome(SS) who presented with acute exacerbation of chronic respiratory failure. The patient's difficult airway, complicated medical comorbidities, and poor psychosocial status posed a unique challenge for providing safe care during an emergency.The perioperative anesthesia service (PAS), led by critical care anesthesiologists, coordinated a multidisciplinary airway management plan.The PAS team also assisted this medically complex patient with her decision-making process. A 37-year-old female with SS, which is characterized by irreversible disfiguring of head and neck anatomy secondary to end-stage renal disease (ESRD) and poorly controlled hyperparathyroidism, presented with acute exacerbation of chronic respiratory failure due to hypervolemia. The patient's respiratory status rapidly deteriorated despite aggressive hemodialysis, requiring transfer to the ICU. Given the challenging anatomy and poor respiratory reserve in this patient, the PAS team helped coordinate a comprehensive airway plan that involved transnasal fiberoptic intubation, and in case of emergency, extracorporeal membrane oxygenation (ECMO) as a bridge to a surgical airway. During the decision-making process, the patient was found to be in psychological distress and had limited insights into her condition. The PAS team helped facilitated multidisciplinary goals-of-care discussions for the patient and her family.Fortunately, the patient's oxygenation improved with noninvasive oxygen support and aggressive hemodialysis without the need for intubation.She was discharged with outpatient follow-up appointments arranged to discuss long-term management. This is the first reported case of SS in the United States. The early involvement by the PAS team helped coordinate a multidisciplinary care plan for this patient with a difficult airway and complex comorbidities.This report highlights an innovative airway algorithm for a potentially "cannot-intubate, cannot ventilate" complex airway, and the PAS team's role in providing support for the patient's physical and psychological needs, suggesting that a comprehensive perioperative service can improve the quality and safety of care, not only for surgical patients but also for medically complex patients as well.

View details for DOI 10.7759/cureus.10691

View details for PubMedID 33133856

View details for PubMedCentralID PMC7593211

Abstract

COVID-19 is a global pandemic caused by SARS-CoV-2. Infection is associated with significant morbidity and mortality. Individuals with pre-existing cardiovascular disease or evidence of myocardial injury are at risk for severe disease and death. Little is understood about the mechanisms of myocardial injury or life-threatening cardiovascular sequelae. (Levelof Difficulty: Intermediate.).

View details for DOI 10.1016/j.jaccas.2020.05.032

View details for PubMedID 32835266

View details for PubMedCentralID PMC7259914

View details for Web of Science ID 000498593400028

Abstract

To characterize alterations in Spanish language medical interpretation during pediatric critical care family meetings.Descriptive, observational study using verbatim transcripts of nine PICU family meetings conducted with in-person, hospital-employed interpreters.A single, university-based, tertiary children's hospital.Medical staff, family members, ancillary staff, and interpreters.None.Interpreted speech was compared with original clinician or family speech using the qualitative research methods of directed content analysis and thematic analysis. Alterations occurred in 56% of interpreted utterances and included additions, omissions, substitutions, editorializations, answering for the patient/clinician, confessions, and patient advocacy. Longer utterances were associated with more alterations.To minimize interpreter alterations during family meetings, physicians should speak in short utterances (fewer than 20 words) and ask interpreters to interrupt in order to facilitate accurate interpretation. Because alterations occur, physicians may also regularly attempt to assess the family's understanding.

View details for PubMedID 28777199