Is routine extubation overnight safe in cardiac surgery patients?

Objectives

Expedient extubation after cardiac surgery has been associated with improved outcomes, leading to postoperative extubation frequently during overnight hours. However, recent evidence in a mixed medical-surgical intensive care unit population demonstrated worse outcomes with overnight extubation. This study investigated the impact of overnight extubation in a statewide, multicenter Society of Thoracic Surgeons database.

Extubación ultra fast-track vs. convencional tras cirugía cardiaca en un centro de referencia cardiovascular en Colombia. Estudio longitudinal

Introduction

The fast track / ultra-fast-track protocols are techniques used to optimise the patient care process and a quick recovery after cardiac surgery. They are one of the mainstays of efficient practice. With their use, the length of hospital and intensive care unit (ICU) stays are reduced, with a direct impact on costs and the quality of the health service.

Tracheal intubation

Tracheal intubation is the act of placing a tube into the trachea. The tube enables oxygen delivery and removal of carbon dioxide, while also allowing for the administration of pharmacological agents. Intubation is the most reliable method of maintaining an airway under anaesthesia, and for protection against aspiration of stomach contents. Traditionally, intubation is achieved by direct visualization of the glottis, but now indirect laryngoscopy (via a videolaryngoscope) is a common alternative. Prior to embarking upon intubation, a thorough patient history and examination must be undertaken by the laryngoscopist; equipment must be prepared and checked; a trained assistant present; and an experienced anaesthetist available in case assistance is required. Once the endotracheal tube has been placed, correct positioning must be confirmed via both clinical examination and monitoring, including capnography. Tracheal intubation is a procedure that should only be undertaken by trained operators and is not without risk. It is important to note that it is failure to oxygenate patients rather than failure to intubate that ultimately leads to serious morbidity and mortality. The Difficult Airway Society has produced guidelines on how to manage unanticipated difficulty in tracheal intubation; it is essential that every practitioner trained to intubate patients is familiar with these algorithms and the key principles of safe airway management.     

难治性气管异物的处理

目的　探讨难治性气管异物的处理方法。方法　回顾 1994～ 2 0 0 3年 10年内收治的 12 5 8例气管异物中 ,10 9例难治性气管异物 (塑料笔帽、鸡骨头、图钉、钢珠、苍耳子球、玩具、带壳花生米、气门芯等 )的处理过程。患者年龄最小的为 8个月 ,最大的为 43岁。异物史最长达 12年。结果　 89例难治性气管异物直接从支气管镜下取出 ,19例行气管切开 ,1例气门芯异物开胸取出。结论　在处理难治性气管异物时要做好充分的术前准备 ,正确判断和处理并发症。     

Gun shot wound neck

All penetrating neck wounds are potentially very dangerous and require emergency treatment. The choice of treatment for the stable patient remains controversial, a number of studies encouraging mandatory surgical exploration and a similar number encourage selective surgical exploration. Knowledge of the physical properties of the penetrating object or weapon can help to determine a treatment plan and predict the risk of injury- All tracheal and esophageal injuries with structural damage should be repaired primarily. A case of Gun Shot Wound Neck was air evacuated to Army Hospital R & R Delhi Cantt in a tracheostomised state. Patient was evaluated in detail, he had trachea esophageal fistula. The management of this case is discussed along with principles of management of war injuries.     

Effects of tracheal extubation on coronary blood flow,myocardial metabolism and systemic haemodynamic responses

Global coronary blood flow and metabolism were measured in seven patients on the first postoperative day following coronary revascularization to test the hypothesis that tracheal extubation produces adverse haemodynamic responses akin to those observed during tracheal intubation. Regional coronary flow and metabolic measurements were made in five of the seven patients. Extubation from a continuous positive airway pressure (CPAP) of 5 cm H₂O was associated with a statistically significant rise in cardiac index from 3.44 ± 0.23 L · min^-1 · m^-2 to 3.73 ± 0.15L·min^-1 ·m^-2 related to an increase in stroke index, without significant changes in heart rate, mean arterial and pulmonary capillary wedge pressure. Consequently the changes in myocardial oxygen consumption (8.52 ± 0.55 to 8.85 ± 0.93 ml · min^-1) and coronary blood flow (172 ± 18 to 179 ± 17 ml·min^-1) were less prominent than those reported during intubation, where substantial rises in myocardial oxygen consumption and coronary flow occurred. Two patients experienced cardiac lactate production but there were no changes in systemic or coronary haemodynamics, nor were there clinical or electrocardiographic signs of ischaemia. We conclude that extubation does not appear to be associated with adverse systemic or coronary haemodynamic responses in patients following coronary bypass grafting. However, the revascularized myocardium may remain vulnerable to anaerobic metabolism in the immediate postoperative period. Pour savoir si comme ľintubation, ľextubation de la trachée provoque des perturbations hémodynamiques, on a mesuré le métabolisme et la circulation coronarienne globale chez sept patients, au lendemain ďun pontage aorto-coronarien. On a aussi calculé les valeurs régionales de ces mêmes variables pour cinq ďentre eux. Ľindex cardiaque de 3.44 ± 0.23 L · min^-1 · m^-2 sous pression positive en respiration spontanée (CPAP) de 5 cm. H₂O s’est élevé à 3.73 ± 0.15 L · min^-1 · m^-2 post-extubation avec une augmentation significative du volume ďéjection. La fréquence cardiaque et les pressions artérielles moyennes et capillaires pulmonaires n’ont pas changé. Ainsi ľaugmentation de la consommation ďoxygène du myocarde de 8.52 ± 0.55 à 8.85 ± 0.93 ml · min^-1 et celle du flot coronarien de 172 ± 18 à 179 ± 17 ml · min^-1 ont été moindres que celles, importantes, déjà observées lors de ľintubation. On a noté chez deux patients une production de lactate par le myocarde, sans changement de ľhémodynamic systémique et coronarienne non plus que de signe clinique ou électrocardiographique ďischémie. Donc, après un pontage coronarien, ľextubation ne semble pas causer ďeffet néfaste sur les circulations systémique et coronarienne, toutefois, le myocarde revascularisé peut demeurer sensible au métabolisme anaérobique.     

大鼠气管上皮细胞体内—体外转化模型的研究

本研究建立了大鼠气管上皮细胞体内－体外转化模型，大鼠气管内滴注苯并芘，三天后处死大鼠，消化气管上皮细胞，接种于无血清完全培养基。细胞形成集落后，换为选择培养基继续培养五周，统计转化率。结果显示，２５ｍｇ／ｋｇ和５０ｍｇ／ｋｇ的苯并芘可诱导大鼠气管上皮细胞转化及微核增加，用同样方法研究了煤焦沥青提取物，结果表明，剂量为８ｍｇ／ｋｇ和２５ｍｇ／ｋｇ的煤焦沥青提取物能明显诱导大鼠气管上皮细胞转化。     

气管与主支气管肿瘤的影像诊断（附32例报告）

作者对３２例经病理证实的气管与主支气管良、恶性肿瘤的影像学表现进行分析，归纳为３型：腔内型、壁增厚型和腔内外型。后２种类型提示恶性，而无蒂的腔内型表现者不能鉴别良，恶性。作者还评价了常规体层、ＣＴ及ＭＲＩ诊断气管与主支气管肿瘤的优、缺点，讨论了影像诊断的作用。