extubation icu critical care

1. EXTUBATION IN NEUROSURGICAL
PATIENTS WITH LOW
GCS:CONSIDERATIONS

2. CASE
• 30 YEAR OLD
• MALE
• LEFT MCA INFARCT
• E4 V1 M5
• INTUBATED – FI02-30 PERCENT ON CPAP

3. DILEMA
TRACHEOSTOMY EXTUBATION
UNCERTAINITY??
In general critical care medicine, it is usually assumed that restored
conscious behavior is a prerequisite FoR extubation.

4. FACTORS INFLUENCE EXTUBATION FAILURE
• Poor cough reflex
• Severe neurological weakness and disability
• Infections
• Respiratory muscle weakness
American guidelines suggest weaning - adequate mentation -
GCS greater than or equal to 13

5. Literature
Anesthesiology 2017
2019, Journal of Anaesthesiology Clinical Pharmacology

6.  RCT- France
 140 PATIENTS
 2013-2015
 GCS less than or
equal to 12
STUDY 1

7. INCLUSION CRITERIA
• Brain structural lesions (isolated
traumatic brain injury)
• Subarachnoid hemorrhage
• Spontaneous intracerebral hematoma
• Acute ischemic stroke
• Hypoxic–ischemic encephalopathy
• NEUROSURGICAL
adult patients with initial
GCS ≤ 12 (before
intubation)
• Intubated for neurologic
reason and ventilated
for > 48 h.

8. EXCLUSION CRITERIA
• Spinal cord injury,
• status epilepticus,
• Disorder of consciousness caused by alcohol or other
intoxication,
• Central nervous system infection
• Self-extubation

9. METHODS
No tracheostomy was performed before any extubation attempt, unless
the patient failed > three SBT
After resolution of acute organ dysfunctions - Sedative drugs
withdrawal - Eligibility for a SBT was daily assessed.
Patients were extubated when they succeeded SBT irrespective of their
neurologic status and upper-airway function.
Post extubation-Standard oxygen therapy ( No highflow or No NIV)

10. Defn
• Respiratory failure necessitating reventilation
was defined as the occurrence of at least two
signs among
• Oxygen therapy > 9 L·/min to maintain oxygen
saturation greater than 90%
• Respiratory rate > 35 /min with accessory
respiratory muscles involvement,
• Respiratory or cardiac arrest
• Major tracheal secretions with inadequate
cough
• PaCO2 > 50 mmhg with ph < 7.35
• Heart rate >120/min, S
• Systolic blood pressure >200 mmhg or <90
mmhg.
Extubation failure was
defined as the need for
ventilatory support after
extubation using tracheal
intubation or NIV during
ICU stay.

11. RESULTS

12. Extubation failure –
Overall - 43 (31%) patients
Within 48 hours-31 [24%]
RESULTS

13. RESULTS

15. Causes of extubation failure
• Hypersecretion-67 percent
• Stridor – 14 percent
• Univariate analysis
• Confusion assessment method - Confusion
• Brainstem and arousal capabilities

16. DISCUSSION
• Coplin et al. demonstrated that brain-injured patients meeting
standard weaning criteria could be extubated irrespective of their
upper-airway function and their mental status.
• In their cohort, some patients with a GCS as low as 4 tolerated
extubation.
• Extubation’s delay was associated with increased risk of pneumonia
and prolonged length of stay.

17. DISCUSSION
• Coplin et al. reported that comatose patients (GCS less than or equal
to 8) with absent or weak gag and/or cough reflex sustained
extubation, while the presence of spontaneous cough and low
suctioning frequency were associated with better extubation
outcomes.

18. STUDY 2

19. METHODOLOGY

20. METHODOLOGY

21. METHODOLOGY

22. BASELINE GCS

23. RESULTS

25. Conclusion
• Neurosurgical patients with low GCS can be considered for trial of
extubation if they pass SBT trial.
• Assessment of airway care score helps in screening patients for
extubation
• It is expected that patients who have intact gag reflux and deglutition
have better rate of successful extubation.
• It significantly reduced days of Mechanical ventilation, Number of icu
days, overall outcome and cost burden.

26. •THANK YOU