This randomized controlled trial compared two spontaneous breathing trial (SBT) strategies: a 2-hour T-piece trial versus a 30-minute trial with pressure support ventilation (PSV) of 8 cmH2O. The Kaplan-Meier curves showed a significantly higher rate of successful extubation, defined as being free of invasive ventilation for 72 hours, in the PSV group compared to the T-piece group. Reasons for reintubation were not significantly different between groups. While the T-piece SBT was less well tolerated, the PSV SBT of 30 minutes was sufficient to assess breathing ability without increasing post-extubation respiratory failure rates.
1) Variceal bleeding occurs in patients with cirrhosis and portal hypertension when enlarged veins in the esophagus or stomach (varices) rupture.
2) Management of variceal bleeding involves stabilizing the patient, performing endoscopy within 12 hours to identify varices, and administering vasoactive drugs to control bleeding along with antibiotics to prevent infection. Endoscopic variceal ligation or sclerotherapy can help stop active bleeding from varices.
3) For non-variceal upper GI bleeding, endoscopic treatment with adrenaline, coagulation, or clips is usually attempted first. Surgery may be needed for uncontrolled or recurrent bleeding after failed endoscopic attempts.
Peritoneal dialysis is a treatment for kidney failure that uses the peritoneal membrane in the abdomen as a filter. It involves infusing dialysate fluid into the abdomen through a catheter for diffusion and osmosis to occur. There are various types of peritoneal dialysis including continuous ambulatory peritoneal dialysis, automated peritoneal dialysis, and intermittent peritoneal dialysis. Nursing management focuses on preventing infections, monitoring for fluid overload, managing pain, and providing education on catheter care and lifestyle adjustments. Peritoneal dialysis offers patients greater independence compared to hemodialysis.
The document discusses the management of upper gastrointestinal bleeding (UGIB) in the emergency room. It recommends initial resuscitation including IV access and fluid resuscitation. Patients should be risk stratified using scoring systems like Rockall or Blatchford to determine need for endoscopy. Early endoscopy within 24 hours is recommended to identify risk level and manage high risk lesions. Post-endoscopy, high-dose PPIs should be given and H. pylori testing and treatment initiated if positive to prevent rebleeding.
1) Variceal bleeding occurs in patients with cirrhosis and portal hypertension when enlarged veins in the esophagus or stomach (varices) rupture.
2) Management of variceal bleeding involves stabilizing the patient, performing endoscopy within 12 hours to identify varices, and administering vasoactive drugs to control bleeding along with antibiotics to prevent infection. Endoscopic variceal ligation or sclerotherapy can help stop active bleeding from varices.
3) For non-variceal upper GI bleeding, endoscopic treatment with adrenaline, coagulation, or clips is usually attempted first. Surgery may be needed for uncontrolled or recurrent bleeding after failed endoscopic attempts.
Peritoneal dialysis is a treatment for kidney failure that uses the peritoneal membrane in the abdomen as a filter. It involves infusing dialysate fluid into the abdomen through a catheter for diffusion and osmosis to occur. There are various types of peritoneal dialysis including continuous ambulatory peritoneal dialysis, automated peritoneal dialysis, and intermittent peritoneal dialysis. Nursing management focuses on preventing infections, monitoring for fluid overload, managing pain, and providing education on catheter care and lifestyle adjustments. Peritoneal dialysis offers patients greater independence compared to hemodialysis.
The document discusses the management of upper gastrointestinal bleeding (UGIB) in the emergency room. It recommends initial resuscitation including IV access and fluid resuscitation. Patients should be risk stratified using scoring systems like Rockall or Blatchford to determine need for endoscopy. Early endoscopy within 24 hours is recommended to identify risk level and manage high risk lesions. Post-endoscopy, high-dose PPIs should be given and H. pylori testing and treatment initiated if positive to prevent rebleeding.
This document provides guidance on the management of upper gastrointestinal bleeding (UGIB). It outlines the following key points:
1. Initial steps include assessing hemodynamic stability, IV access, monitoring, fluid resuscitation, and basic lab tests. Endoscopy within 24 hours is critical for diagnosis and treatment.
2. For non-variceal bleeding, endoscopic therapies like injection, thermal coagulation, and clipping are first-line. Refractory or high-risk bleeding may require surgery.
3. Variceal bleeding requires urgent endoscopic ligation or sclerotherapy. Transjugular intrahepatic portosystemic shunting or surgical shunting may be needed if initial measures
TURP is a procedure to relieve urinary symptoms from an enlarged prostate. It carries risks due to the elderly patient population and long duration. A thorough pre-op assessment helps determine anesthesia technique, with subarachnoid block preferred. Potential complications include hypotension, hemorrhage, bladder perforation, hypothermia, and the rare but serious TURP syndrome caused by excessive fluid absorption. Close monitoring is needed to rapidly identify and treat any issues.
The document discusses urolithiasis (urinary stone disease), including its aetiopathogenesis (causes and development) and treatment. It outlines that urinary stones form due to supersaturation of urine and crystallization of minerals like calcium oxalate. Stones are classified based on location, composition, and other factors. Clinical presentation varies from asymptomatic to symptoms of pain, hematuria, and obstruction. Treatment involves medical measures like increased fluid intake or surgical procedures like shockwave lithotripsy, ureteroscopy, and open surgery depending on stone characteristics and patient factors. Prevention focuses on dietary modifications and treating underlying metabolic abnormalities.
Management of upper gi bleeding email copynadiagulnaz
- Acute upper gastrointestinal bleeding is a common medical emergency that can have high mortality.
- Risk assessment using tools like the Blatchford and Rockall scores helps determine urgency of endoscopy and predict outcomes.
- Endoscopy within 24 hours of admission is recommended to treat bleeding lesions through methods like injection, thermal coagulation, or band ligation of varices.
- Post-endoscopic management involves PPIs, transfusions targeting a hemoglobin of 70-90 g/L, H. pylori treatment if present, and continued medications like terlipressin or beta blockers to prevent rebleeding.
Surgery in Bleeding disorders- A challenging problem to all surgeonsSelvaraj Balasubramani
Surgery in patients with bleeding disorders requires careful evaluation and management to minimize bleeding risks. The document discusses:
1) The physiology of hemostasis including the vessel wall, platelet, and coagulation responses.
2) Evaluation of patients including history, exam, and screening tests to identify bleeding disorders.
3) Four case examples of patients who bled excessively during or after surgery, who were found to have thrombocytopathy, hemophilia, or other disorders.
4) Common bleeding disorders surgeons may encounter including thrombocytopenia, thrombocytopathy, hemophilia A/B, von Willebrand disease, DIC, and liver disease.
5) Guidelines
A 54-year-old man presented with melena for 2 days after taking ibuprofen for lower back pain. Evaluation showed hemodynamic stability and risk factors of NSAID use. The differential diagnosis for acute upper GI bleeding includes peptic ulcer disease, varices, tumors, and Mallory-Weiss tears. Endoscopic therapy with clips or cautery can control bleeding from ulcers or varices. Adjuvant PPIs reduce rebleeding rates from ulcers.
1) Malignant ascites is a buildup of fluid in the abdominal cavity caused by disrupted fluid balance and drainage due to cancer.
2) Current treatment approaches include paracentesis/abdominal drainage to relieve symptoms, diuretic therapy to reduce fluid buildup, and peritoneovenous shunts to drain fluid directly from the abdomen to the bloodstream.
3) However, there is limited research evaluating these different treatment methods, and no consensus on the best approach for managing malignant ascites.
This document provides information on the assessment and management of upper GI bleeding. It defines types of upper GI bleeding and outlines a stepwise approach. Initial steps include resuscitation, transfusion if needed, and risk stratification. Diagnosis involves history, exam, nasogastric lavage and endoscopy. Endoscopy allows identification of the bleeding source and endoscopic treatment. Surgery is considered if bleeding persists after other measures. The document reviews causes of bleeding and management of peptic ulcer bleeding specifically.
Laparoscopy can be used to both diagnose and treat abdominal trauma. It is most effective for hemodynamically stable patients with penetrating injuries or blunt trauma with unclear internal injuries. Key benefits are lower morbidity rates compared to open surgery and ability to identify injuries often missed on imaging like diaphragmatic tears or mesenteric lacerations. The procedure allows for therapeutic repair of injuries to organs like liver, stomach or bowel when laparoscopic expertise is available. Contraindications include hemodynamic instability, clear need for open surgery, or limited laparoscopic resources.
1. The document discusses the triage and assessment of abdominal trauma. It outlines the principles of trauma management including treating the greatest threat to life first.
2. The primary and secondary surveys are described in detail, covering the assessment of the airway, breathing, circulation, disability, and exposure. Specific injuries to the abdomen like liver and spleen injuries are also discussed.
3. Investigations for abdominal trauma including focused assessment with sonography, diagnostic peritoneal lavage, CT scans, and grades of injuries are provided. The management of positive findings is also summarized.
Acute mesenteric ischemia is a sudden reduction in blood flow to the small intestine that can be caused by blockages or issues with the arteries or veins supplying the intestine. It has a high mortality rate of 25-80% if not treated promptly. Diagnosis involves imaging like CT scans to identify abnormalities in the bowel walls or presence of gas in the blood vessels. Treatment depends on the underlying cause but may include aggressive resuscitation, antibiotics, revascularization procedures to restore blood flow, or bowel resection if parts of the intestine are found to be non-viable. Post-operative management focuses on lifelong anticoagulation to prevent future episodes.
This document provides information on laparoscopic surgery:
- It was first introduced in the 20th century and has since been used for various gynaecological and general surgical procedures.
- The main physiological concerns during laparoscopy are related to insufflation of carbon dioxide including increased intra-abdominal pressure and hypercarbia.
- Laparoscopy has advantages like less pain, shorter recovery time and hospital stay compared to open surgeries.
- Expertise is required due to challenges like impaired touch sensation and inability to have a 3D view.
Portal hypertension occurs when blood pressure in the portal vein system leading to the liver is elevated above normal levels. It has many potential causes but is most commonly caused by cirrhosis of the liver. Diagnosis involves blood tests, imaging like ultrasound and endoscopy. Management depends on the underlying cause but often involves endoscopic procedures to treat variceal bleeding and may progress to surgical shunts, TIPSS, or liver transplantation in advanced cirrhosis.
This document discusses upper gastrointestinal bleeding, which is bleeding that occurs proximal to the ligament of Treitz. It lists various potential causes of upper GI bleeding, including gastric ulcers, esophageal varices, esophagitis, and gastric erosions. Clinical features are outlined, with hematochezia being the most severe sign. Endoscopy is the most accurate diagnostic test. Treatment involves stabilizing the patient, administering IV PPIs, performing endoscopy to locate the bleeding site and provide therapeutic intervention such as epinephrine injection. Peptic ulcer bleeding has a low mortality unless rebleeding occurs, while esophageal variceal bleeding has high rebleeding and mortality rates.
This document discusses anaesthetic considerations for transurethral resection of the prostate (TURP). TURP requires large volumes of irrigating fluid which can cause complications if absorbed in large quantities. Regional anaesthesia is preferred to allow for early detection of issues like TURP syndrome. Close monitoring of fluid balance, electrolytes and vital signs is important to manage risks of fluid overload, hyponatremia and other imbalances from irrigating fluid absorption. Prevention involves limiting fluid volume and pressure and prompt treatment of any abnormalities that develop.
This document discusses the management of surgical emergencies. It begins by outlining the signs of shock and how to assess patients presenting with shock. It then discusses the immediate management of shock, including fluid resuscitation and appropriate investigations. Specific investigations discussed include full blood count, electrolytes, blood glucose, and coagulation profile. The document also discusses appropriate intravenous fluid selection and oxygen delivery. Principles of management are discussed for conditions like upper gastrointestinal bleeding and lower gastrointestinal bleeding.
This document provides an overview of mesenteric vascular occlusion including:
- It affects the blood supply to the gastrointestinal tract and has high mortality.
- CT scanning is the preferred diagnostic method and can detect bowel wall thickening or lack of enhancement.
- Treatment involves resuscitation, antibiotics, surgery to remove clots or place stents, and resecting non-viable bowel.
- Goals are to diagnose the cause, restore blood flow, and assess bowel viability.
This document discusses the management of surgical emergencies like shock and gastrointestinal bleeding. It begins by outlining the signs of shock and appropriate initial screening tests for surgical emergencies which include FBC, electrolytes, blood glucose, coagulation profile, and blood grouping. Upper gastrointestinal bleeding causes and management are then outlined, including endoscopic therapies for bleeding peptic ulcers. Lower gastrointestinal bleeding causes, classification as major vs minor, and investigation approach are also summarized. Finally, approaches to common urological emergencies like hematuria, urolithiasis, BPH, bladder cancer and renal cell carcinoma are presented.
The document describes a computer software program for semi-automated diagnosis of urodynamic studies. It outlines the rationale for developing the software to minimize incorrect diagnoses and improve standardization. The software utilizes published guidelines and literature on urodynamic terminology, techniques, tracing interpretation and diagnosis of lower urinary tract conditions. Validation studies of the software's accuracy are still underway.
How to manage a case of acute exacerbation of COPD according to GOLD guidelines. Sincere thanks to Dr. Amardeep Toppo who has prepared most of this presentation.
This document defines ventilator-associated pneumonia (VAP) and identifies factors that increase risk. It also outlines effective strategies for reducing VAP incidence, including proper hand hygiene, oral care, keeping patients' heads of bed elevated, rotational therapy for immobile patients, limiting sedation, and following best practices for ventilation and airway management. Regular monitoring and a multidisciplinary team approach can help implement evidence-based guidelines to decrease VAP rates.
This document provides guidance on the management of upper gastrointestinal bleeding (UGIB). It outlines the following key points:
1. Initial steps include assessing hemodynamic stability, IV access, monitoring, fluid resuscitation, and basic lab tests. Endoscopy within 24 hours is critical for diagnosis and treatment.
2. For non-variceal bleeding, endoscopic therapies like injection, thermal coagulation, and clipping are first-line. Refractory or high-risk bleeding may require surgery.
3. Variceal bleeding requires urgent endoscopic ligation or sclerotherapy. Transjugular intrahepatic portosystemic shunting or surgical shunting may be needed if initial measures
TURP is a procedure to relieve urinary symptoms from an enlarged prostate. It carries risks due to the elderly patient population and long duration. A thorough pre-op assessment helps determine anesthesia technique, with subarachnoid block preferred. Potential complications include hypotension, hemorrhage, bladder perforation, hypothermia, and the rare but serious TURP syndrome caused by excessive fluid absorption. Close monitoring is needed to rapidly identify and treat any issues.
The document discusses urolithiasis (urinary stone disease), including its aetiopathogenesis (causes and development) and treatment. It outlines that urinary stones form due to supersaturation of urine and crystallization of minerals like calcium oxalate. Stones are classified based on location, composition, and other factors. Clinical presentation varies from asymptomatic to symptoms of pain, hematuria, and obstruction. Treatment involves medical measures like increased fluid intake or surgical procedures like shockwave lithotripsy, ureteroscopy, and open surgery depending on stone characteristics and patient factors. Prevention focuses on dietary modifications and treating underlying metabolic abnormalities.
Management of upper gi bleeding email copynadiagulnaz
- Acute upper gastrointestinal bleeding is a common medical emergency that can have high mortality.
- Risk assessment using tools like the Blatchford and Rockall scores helps determine urgency of endoscopy and predict outcomes.
- Endoscopy within 24 hours of admission is recommended to treat bleeding lesions through methods like injection, thermal coagulation, or band ligation of varices.
- Post-endoscopic management involves PPIs, transfusions targeting a hemoglobin of 70-90 g/L, H. pylori treatment if present, and continued medications like terlipressin or beta blockers to prevent rebleeding.
Surgery in Bleeding disorders- A challenging problem to all surgeonsSelvaraj Balasubramani
Surgery in patients with bleeding disorders requires careful evaluation and management to minimize bleeding risks. The document discusses:
1) The physiology of hemostasis including the vessel wall, platelet, and coagulation responses.
2) Evaluation of patients including history, exam, and screening tests to identify bleeding disorders.
3) Four case examples of patients who bled excessively during or after surgery, who were found to have thrombocytopathy, hemophilia, or other disorders.
4) Common bleeding disorders surgeons may encounter including thrombocytopenia, thrombocytopathy, hemophilia A/B, von Willebrand disease, DIC, and liver disease.
5) Guidelines
A 54-year-old man presented with melena for 2 days after taking ibuprofen for lower back pain. Evaluation showed hemodynamic stability and risk factors of NSAID use. The differential diagnosis for acute upper GI bleeding includes peptic ulcer disease, varices, tumors, and Mallory-Weiss tears. Endoscopic therapy with clips or cautery can control bleeding from ulcers or varices. Adjuvant PPIs reduce rebleeding rates from ulcers.
1) Malignant ascites is a buildup of fluid in the abdominal cavity caused by disrupted fluid balance and drainage due to cancer.
2) Current treatment approaches include paracentesis/abdominal drainage to relieve symptoms, diuretic therapy to reduce fluid buildup, and peritoneovenous shunts to drain fluid directly from the abdomen to the bloodstream.
3) However, there is limited research evaluating these different treatment methods, and no consensus on the best approach for managing malignant ascites.
This document provides information on the assessment and management of upper GI bleeding. It defines types of upper GI bleeding and outlines a stepwise approach. Initial steps include resuscitation, transfusion if needed, and risk stratification. Diagnosis involves history, exam, nasogastric lavage and endoscopy. Endoscopy allows identification of the bleeding source and endoscopic treatment. Surgery is considered if bleeding persists after other measures. The document reviews causes of bleeding and management of peptic ulcer bleeding specifically.
Laparoscopy can be used to both diagnose and treat abdominal trauma. It is most effective for hemodynamically stable patients with penetrating injuries or blunt trauma with unclear internal injuries. Key benefits are lower morbidity rates compared to open surgery and ability to identify injuries often missed on imaging like diaphragmatic tears or mesenteric lacerations. The procedure allows for therapeutic repair of injuries to organs like liver, stomach or bowel when laparoscopic expertise is available. Contraindications include hemodynamic instability, clear need for open surgery, or limited laparoscopic resources.
1. The document discusses the triage and assessment of abdominal trauma. It outlines the principles of trauma management including treating the greatest threat to life first.
2. The primary and secondary surveys are described in detail, covering the assessment of the airway, breathing, circulation, disability, and exposure. Specific injuries to the abdomen like liver and spleen injuries are also discussed.
3. Investigations for abdominal trauma including focused assessment with sonography, diagnostic peritoneal lavage, CT scans, and grades of injuries are provided. The management of positive findings is also summarized.
Acute mesenteric ischemia is a sudden reduction in blood flow to the small intestine that can be caused by blockages or issues with the arteries or veins supplying the intestine. It has a high mortality rate of 25-80% if not treated promptly. Diagnosis involves imaging like CT scans to identify abnormalities in the bowel walls or presence of gas in the blood vessels. Treatment depends on the underlying cause but may include aggressive resuscitation, antibiotics, revascularization procedures to restore blood flow, or bowel resection if parts of the intestine are found to be non-viable. Post-operative management focuses on lifelong anticoagulation to prevent future episodes.
This document provides information on laparoscopic surgery:
- It was first introduced in the 20th century and has since been used for various gynaecological and general surgical procedures.
- The main physiological concerns during laparoscopy are related to insufflation of carbon dioxide including increased intra-abdominal pressure and hypercarbia.
- Laparoscopy has advantages like less pain, shorter recovery time and hospital stay compared to open surgeries.
- Expertise is required due to challenges like impaired touch sensation and inability to have a 3D view.
Portal hypertension occurs when blood pressure in the portal vein system leading to the liver is elevated above normal levels. It has many potential causes but is most commonly caused by cirrhosis of the liver. Diagnosis involves blood tests, imaging like ultrasound and endoscopy. Management depends on the underlying cause but often involves endoscopic procedures to treat variceal bleeding and may progress to surgical shunts, TIPSS, or liver transplantation in advanced cirrhosis.
This document discusses upper gastrointestinal bleeding, which is bleeding that occurs proximal to the ligament of Treitz. It lists various potential causes of upper GI bleeding, including gastric ulcers, esophageal varices, esophagitis, and gastric erosions. Clinical features are outlined, with hematochezia being the most severe sign. Endoscopy is the most accurate diagnostic test. Treatment involves stabilizing the patient, administering IV PPIs, performing endoscopy to locate the bleeding site and provide therapeutic intervention such as epinephrine injection. Peptic ulcer bleeding has a low mortality unless rebleeding occurs, while esophageal variceal bleeding has high rebleeding and mortality rates.
This document discusses anaesthetic considerations for transurethral resection of the prostate (TURP). TURP requires large volumes of irrigating fluid which can cause complications if absorbed in large quantities. Regional anaesthesia is preferred to allow for early detection of issues like TURP syndrome. Close monitoring of fluid balance, electrolytes and vital signs is important to manage risks of fluid overload, hyponatremia and other imbalances from irrigating fluid absorption. Prevention involves limiting fluid volume and pressure and prompt treatment of any abnormalities that develop.
This document discusses the management of surgical emergencies. It begins by outlining the signs of shock and how to assess patients presenting with shock. It then discusses the immediate management of shock, including fluid resuscitation and appropriate investigations. Specific investigations discussed include full blood count, electrolytes, blood glucose, and coagulation profile. The document also discusses appropriate intravenous fluid selection and oxygen delivery. Principles of management are discussed for conditions like upper gastrointestinal bleeding and lower gastrointestinal bleeding.
This document provides an overview of mesenteric vascular occlusion including:
- It affects the blood supply to the gastrointestinal tract and has high mortality.
- CT scanning is the preferred diagnostic method and can detect bowel wall thickening or lack of enhancement.
- Treatment involves resuscitation, antibiotics, surgery to remove clots or place stents, and resecting non-viable bowel.
- Goals are to diagnose the cause, restore blood flow, and assess bowel viability.
This document discusses the management of surgical emergencies like shock and gastrointestinal bleeding. It begins by outlining the signs of shock and appropriate initial screening tests for surgical emergencies which include FBC, electrolytes, blood glucose, coagulation profile, and blood grouping. Upper gastrointestinal bleeding causes and management are then outlined, including endoscopic therapies for bleeding peptic ulcers. Lower gastrointestinal bleeding causes, classification as major vs minor, and investigation approach are also summarized. Finally, approaches to common urological emergencies like hematuria, urolithiasis, BPH, bladder cancer and renal cell carcinoma are presented.
The document describes a computer software program for semi-automated diagnosis of urodynamic studies. It outlines the rationale for developing the software to minimize incorrect diagnoses and improve standardization. The software utilizes published guidelines and literature on urodynamic terminology, techniques, tracing interpretation and diagnosis of lower urinary tract conditions. Validation studies of the software's accuracy are still underway.
How to manage a case of acute exacerbation of COPD according to GOLD guidelines. Sincere thanks to Dr. Amardeep Toppo who has prepared most of this presentation.
This document defines ventilator-associated pneumonia (VAP) and identifies factors that increase risk. It also outlines effective strategies for reducing VAP incidence, including proper hand hygiene, oral care, keeping patients' heads of bed elevated, rotational therapy for immobile patients, limiting sedation, and following best practices for ventilation and airway management. Regular monitoring and a multidisciplinary team approach can help implement evidence-based guidelines to decrease VAP rates.
This document discusses various ventilatory strategies for treating ALI/ARDS, including:
- Positive end-expiratory pressure (PEEP) which reduces atelectasis and improves oxygenation.
- Controlled mechanical ventilation aims to decrease ventilatory inequalities and distribute flow better while limiting plateau pressure.
- Low tidal volume ventilation as per the ARDSnet trial reduces mortality compared to conventional tidal volumes.
- Recruitment maneuvers use high pressures to reopen collapsed alveoli but can cause barotrauma and hemodynamic instability if not done carefully.
- Other strategies discussed include prone positioning, high frequency ventilation, airway pressure release ventilation and partial liquid ventilation. The goal is
This document discusses airway secretion clearance techniques in the ICU, including mechanical insufflation-exsufflation (MIE). It provides a timeline of MIE devices including the CoughAssist. A case study describes how MIE was used successfully via face mask in an 18-year-old post-op patient to avoid intubation. Typical treatment protocols for the CoughAssist E-70 are outlined. Studies show MIE can improve respiratory parameters and allow extubation of restrictive patients to noninvasive ventilation. The evidence suggests MIE is safe and effective for both obstructive and restrictive lung diseases.
This study aimed to determine if rapidly lowering systolic blood pressure to 110-139 mmHg improves outcomes for patients with intracerebral hemorrhage, compared to standard treatment lowering it to 140-179 mmHg. Over 8500 patients were screened and 1000 were randomized to aggressive or standard treatment groups. There was no significant difference in the primary outcome of death or disability at 90 days between groups. The study suggests that intensive blood pressure reduction does not improve outcomes for intracerebral hemorrhage patients.
UK based multicentric trial involving 364 critically ill patients who were deemed difficult to wean, was conducted to prove shorter time to liberation from mechanical ventilation with non invasive weaning compared to invasive weaning.
The document provides 3 case studies on different types of shock: hypovolemic shock from blood loss after surgery, cardiogenic shock following a heart attack, and septic shock from an untreated urinary tract infection. Each case study outlines the patient's presentation, relevant medical history, assessments, diagnostic findings, and shock management including fluid resuscitation and vasoactive medications. The goal is for students to apply their knowledge of shock pathophysiology and management using a case study approach.
This document discusses various clinical procedures including oxygen therapy, central venous therapy, electrocardiography, and pulse oximetry. It provides details on the purpose, indications, delivery systems or principles, nurse responsibilities, documentation, and considerations for each procedure. Common procedures like administering oxygen via nasal cannula or mask, inserting central venous lines, performing electrocardiograms, and monitoring pulse oximetry are explained.
Ventilator-associated pneumonia (VAP) is a type of hospital-acquired pneumonia that occurs in patients on mechanical ventilation for more than 48 hours. It is diagnosed using clinical criteria like fever, leukocytosis, and radiographic evidence of pneumonia combined with microbiological testing of respiratory samples. Treatment involves administering antibiotics based on the local hospital antibiogram, with empiric therapy targeting likely gram-positive and gram-negative pathogens. Prevention strategies focus on reducing ventilator days through daily weaning assessments and using bundles of care involving oral hygiene, elevation of the head, and peptic ulcer/DVT prophylaxis.
This document discusses various ventilatory strategies for treating ALI/ARDS, including:
- Using low tidal volumes (6 ml/kg) instead of conventional volumes to decrease mortality.
- Using PEEP to recruit collapsed lung units and prevent atelectrauma.
- Pressure-controlled ventilation to limit peak pressures while maintaining oxygenation.
- Permissive hypercapnia to decrease lung injury even if it increases CO2 levels.
- Prone positioning and recruitment maneuvers to improve oxygenation by opening collapsed alveoli.
- High frequency ventilation and airway pressure release ventilation as rescue therapies.
Weaning from mechanical ventilation , also called ventilator liberation, refers to the process of the patient assuming more and more of the work of breathing and finally demonstrating that ventilator support is no longer required.
Simply it means the process of withdrawing mechanical ventilatory support and transferring the work of breathing from the ventilator to the patient . Weaning can be accomplished with an endotrachel tube ( ETT) or a tracheostomy tube in place.
In the case of the ETT, the final step in the process is the removal of the tube( extubation). With a tracheostomy, the final step may be the ability to breath spontaneously for a designated period of time with the tube in place.
Weaning success is defined as absence of ventilatory support 48 hours following the extubation.
While the spontaneous breaths are unassisted by mechanical ventilation, supplemental oxygen, bronchodilators, low level pressure support ventilation or continuous positive airway pressure (CPAP) may be used to support and maintain adequate spontaneous ventilation and oxygenation.
Purpose
The purpose is to assess the probability that mechanical ventilation can be successfully discontinued.as
75% of mechanically ventilated patients are easy to be weaned off the ventilator with simple process.
10-15% of patients require a use of a weaning protocol over a 24-72 hours.
5-10% require a prolonged weaning plan.
1% of patients become dependent on chronic mechanical ventilation.
Indication
Improvement of the cause of respiratory failure.
Absence of major system dysfunction.
Appropriate level of oxygenation.
Adequate ventilatory status.
Intact airway protective mechanism.
Contraindication
Altered sensorium either drowsiness or restlessness.
Spo2 ˂90%
Rising PaCO2 with drop in PH
Tachypnoea ˃35/ min
Tachycardia ˃120 /min
Drop in systolic blood pressure
Sweating
Cold clammy skin
Signs of diaphragmatic weakness
Paradoxical abdominal wall movement
Assessment of readiness for weaning
Hemodynamic stability
Minimum inotropic support
Adequate cardiac output
Afebrile
Hematocrite greater than 25%
Respiratory stability
Improved chest x-ray
Arterial oxygen tension (PaO2) greater than 60mm Hg with fraction of inspired oxygen ( FiO2) less than 0.5
PaO2/FiO2 greater than 300 mm Hg
Positive end expiratory pressure (PEEP) less than 0-5 cm H2O
Vital capacity (VC) 10-15ml/kg
Spontaneous tidal volume (VT) 5ml/Kg
Respiratory rate less than 30 breaths/mim
Minute ventilation 5-10 L/min
Negative inspiratory pressure greater than -20cm H2O
Rapid shallow breathing index (RSBI) less than 105
metabolic factors stable
Electrolytes within normal range.
ABGs( Arterial blood gases) normalized
Other
Adequate management of pain and anxiety.
Patient is well rested
Weaning criteria
Weaning criteria are used to evaluate the readiness of a patient for a weaning trial and the likelihood of weaning success.
Clinical criteria
Ventilatory criteria
Oxygenation criteria
How University of Utah Health's Burn Trauma ICU Eliminated Central Line Infec...University of Utah
Is zero possible? In the case of central line infections, the answer once was no. A CLABSI (central line associated blood stream infection) was once considered a car crash, or an expected inevitability of care. When University of Utah’s Burn Trauma Intensive Care Unit started treating CLABSIs like a plane crash, or a tragedy demanding in-depth investigation and cultural change, zero became possible. This presentation outlines the process and how to implement in your institution. To learn more, visit Accelerate: https://uofuhealth.utah.edu/accelerate/
Air leaks in Thoracic Surgery [Auto-saved].pptxRohanReddy66
This document discusses postoperative air leaks in thoracic surgery. It begins by defining different types of air leaks and prolonged air leaks. It then discusses challenges in qualitatively and quantitatively assessing air leaks and different grading systems. Risk factors for air leaks are outlined as well as measures that can be taken preoperatively, intraoperatively, and postoperatively to prevent and treat air leaks. Specific challenges posed by bronchopleural fistulas are also reviewed along with treatment options.
Practices and better development goals of ot technologistSurgicaltechie.com
The document outlines best practices for maintaining quality care in operating theaters (OT) and intensive care units (ICU). It discusses following protocols like the WHO safety checklist, proper sterilization and disposal of equipment and materials, ensuring a safe environment for patients and staff through practices like laminar airflow and radiation safety gear. Specific guidelines are provided for equipment handling and monitoring of patients, including ventilators, ultrasound machines and arterial lines to optimize outcomes.
The document summarizes various evidence-based bundles developed by IHI and CDC to prevent healthcare-associated infections from central lines, ventilators, and urinary catheters. It describes the components of the central line bundle (hand hygiene, barrier precautions, chlorhexidine skin antisepsis, optimal site selection, and daily line necessity review). It also outlines the central line maintenance bundle, ventilator bundle, and urinary catheter bundle, explaining each component and its rationale.
The document discusses various aspects of mechanical ventilation including indications for use, parts of the ventilator, measurements of ventilatory mechanics, types of ventilation modes including non-invasive and invasive modes, initial ventilator settings, and criteria for weaning patients off the ventilator. It provides details on modes like volume control, pressure control, SIMV, and PSV as well as parameters to monitor and consider when setting up the ventilator for a patient and assessing readiness to wean.
1. The document discusses various modes of mechanical ventilation including volume control, pressure control, SIMV, and PSV. It describes the settings, parameters, and considerations for each mode.
2. Initial ventilator settings should aim for adequate oxygenation and ventilation while minimizing work of breathing. Settings like tidal volume, respiratory rate, and PEEP are adjusted based on factors like patient size and condition.
3. Weaning from mechanical ventilation involves gradually reducing support through methods like spontaneous breathing trials, decreasing SIMV frequency, and lowering pressure support levels to assess the patient's ability to breathe independently. Readiness criteria and a stepwise protocol are
Ventilator-associated pneumonia (VAP) is a common hospital-acquired infection that prolongs mechanical ventilation and ICU stays. It has a high mortality rate of 20-50%. Risk factors include prolonged mechanical ventilation, supine positioning, and use of sedatives. Diagnosis is difficult due to non-specific signs. New tools like LUPPIS aim to aid early diagnosis. Prevention strategies recommended by guidelines include early mobility, oral care, subglottic secretion drainage, and selective decontamination in some settings.
The document discusses weaning patients from mechanical ventilation. It defines weaning as the process of withdrawing ventilator support and describes the main steps as assessing patient readiness, using methods like a T-piece trial or pressure support ventilation to gradually reduce support, and monitoring for signs of fatigue or deterioration. Key factors that must be evaluated for readiness include respiratory muscle strength and endurance, ventilatory drive, gas exchange, and hemodynamic status. Nursing plays an important role in explaining the process, monitoring patients, and providing encouragement during weaning trials.
journal club and critical appraisal checklist
intensive recruitment versus moderate recruitment strategy in postop cardiac surgery patients to avaoid postop pulmonary complications
Chronic venous disease (CVD) refers to abnormalities of the venous system that are long-lasting in nature and may cause signs or symptoms. CVD ranges from varicose veins to more advanced chronic venous insufficiency. Risk factors include age, female sex, obesity, prolonged standing, family history, and parity. The venous system consists of superficial veins like the great saphenous vein and deep veins like the femoral vein. Pathophysiology involves valve incompetence and reflux in the superficial system and obstruction or reflux in the deep system. Clinical presentation varies but includes heaviness, aching, cramps, and skin changes classified from C1 to C6. Investigation involves duplex ultrasound scanning and treatment options range from compression
1. Abdominal vascular injuries can be lethal due to hemorrhage. Management may include non-operative, endovascular, or operative approaches.
2. Blunt injuries often cause retroperitoneal hematomas in four zones, while penetrating injuries usually require opening the hematoma.
3. Most arterial injuries can be repaired, while venous injuries can often be ligated if extensive, with monitoring for sequelae.
The document discusses trauma to the pancreas. It begins with an overview of pancreatic anatomy and mechanisms of injury. It then describes the clinical presentation and methods for diagnosis of pancreatic trauma, including CT, MRCP, and ERCP. The document outlines a proposed revised grading system for pancreatic injuries from Grade I to V. It concludes with a discussion of management strategies depending on the grade of injury, including expectant management, surgery such as distal pancreatectomy or pancreaticoduodenectomy, and complications.
1) Duodenal trauma can present during laparotomy or be detected on CT scans. Isolated duodenal hematomas may be managed non-operatively with NG tube and TPN.
2) Operative procedures for duodenal trauma include duodenal repair and ancillary procedures like periduodenal drainage and feeding jejunostomy.
3) Complications include duodenal fistula and increased morbidity with major vascular injury, pancreatic injury, or injury-operation delay over 24 hours. Overall mortality is usually due to major vascular injury and ranges from 5-30%.
Breast cancer is a disease where breast cells grow out of control, and is one of the leading causes of cancer death in women. Screening methods include mammography and ultrasound to check for abnormalities. The diagnosis involves a history, physical exam, imaging tests, and pathology to determine the stage. Treatment depends on the stage and includes surgery such as mastectomy or lumpectomy, radiation therapy, and systemic therapies like chemotherapy, hormone therapy, or targeted drugs.
This document provides information about the anatomy of the scalp and skull, including the layers of the scalp and the structures underneath. It also references sources that describe the brain's ventricular system and how to interpret CT scans of the brain, noting some types of injuries that may appear such as epidural hematoma, subdural hemorrhage, subarachnoid hemorrhage, cerebral contusions, and intracerebral hemorrhages.
Cervical spine trauma can cause serious injuries to the vertebrae and spinal cord. A general surgeon provides an overview of cervical spine anatomy and classifications of injuries. Key points include that the cervical spine is made up of 7 vertebrae and has significant lordosis. Injuries are evaluated based on clinical exam, imaging, and stability classifications. Common injuries discussed are craniovertebral junction injuries, axis fractures, and subaxial cervical injuries. Initial management focuses on immobilization and identification of neurological deficits, while treatment depends on the injury and stability. Complications include spinal cord injury, which can impact respiratory and cardiovascular function.
1. The document outlines the steps for the primary and secondary survey in the initial assessment of a trauma patient. It includes assessing the airway, breathing, circulation, disability, and exposure (ABCDE) and describes adjuncts like monitoring, imaging, catheter placement, investigations and treatments.
2. The primary survey involves a rapid assessment of life threats and stabilization, including airway management, breathing and ventilation, hemorrhage control, neurological assessment, and environmental control.
3. After initial stabilization, the secondary survey involves a full head-to-toe examination, gathering a medical history, considering transfer, and continued monitoring of the patient.
This document discusses common findings on CT brain scans related to various head injuries, including extradural hematoma (EDH), subdural hematoma (SDH), subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH), and brain contusions. It provides details on the visual appearance and timing of injuries, such as EDH appearing lens shaped in the acute phase, SDH potentially associated with bridging veins tears, and chronic SDH displaying septations.
This document outlines damage control surgery techniques for trauma patients. Damage control surgery aims to control hemorrhage and contamination through limited operations, followed by intensive care resuscitation and reoperation. Specific techniques are described for the thorax, vasculature, liver, pancreas, spleen, and hollow viscera. Temporary abdominal closure is commonly used to prevent abdominal compartment syndrome before planned reoperation and definitive repair. Complications of open abdomen like fluid/protein loss and intestinal fistula require careful management.
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3. Management focuses on reducing pelvic volume to control bleeding through techniques such as pelvic binding, preperitoneal pelvic packing, external fixation, and angiographic embolization.
This document provides an overview of common gastric problems for interns, including approaches to epigastric pain, alarm features in dyspeptic patients, and gastrointestinal evaluation of iron deficiency anemia. It discusses peptic ulcer disease, including causes, complications like bleeding and perforation, and treatment options. Evaluation of epigastric pain involves ruling out life-threatening conditions before considering treatments for conditions like gastritis. Endoscopy is recommended for dyspeptic patients with alarm features or risk factors for malignancy.
Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), is a common and preventable cause of hospital death. VTE results from an interaction between venous stasis, hypercoagulability, and endothelial injury. Risk factors include advanced age, immobilization, surgery, trauma, cancer, and genetic or acquired thrombophilias. DVT presents with leg pain, swelling, and discoloration while PE causes shortness of breath, chest pain, and potentially cardiovascular collapse. Diagnosis involves D-dimer testing, ultrasound for DVT, and CT pulmonary angiography for PE. Treatment includes anticoagulation with heparin, low
This document discusses guidelines for treating head and cervical spine trauma. The key points are:
1) The primary goals for head trauma are to prevent secondary brain injury through oxygenation and prompt transfer to a trauma center, with CT scans not delaying transfer.
2) Cervical spine injury must be considered in multiple trauma patients and immobilized to prevent neurological worsening. Indications for immobilization include altered mental status, spinal symptoms, or concerning mechanism of injury.
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This document provides information on various skin, soft tissue, and hand infections including severity classifications. It describes conditions like abscesses, folliculitis, furuncles, carbuncles, erysipelas, cellulitis, and necrotizing fasciitis. For necrotizing fasciitis, it emphasizes the need for aggressive and rapid treatment including emergent debridement and antibiotics to prevent high mortality rates. It also covers specific hand infections like paronychia, felon, pyogenic flexor tenosynovitis, and bursal infections.
This document discusses the clinical evaluation of patients with vascular disease. It describes how to use patient history and physical examination to determine if a patient has arterial, venous, or lymphatic disease. The clinical presentation may include pain, weakness, sensory issues, discoloration, swelling, ulceration or varicosities. A physical exam of arterial disease involves inspection of the skin and hair and palpation of pulses to check for differences between sides.
The skin is the largest organ and its health plays a vital role among the other sense organs. The skin concerns like acne breakout, psoriasis, or anything similar along the lines, finding a qualified and experienced dermatologist becomes paramount.
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These lecture slides, by Dr Sidra Arshad, offer a simplified look into the mechanisms involved in the regulation of respiration:
Learning objectives:
1. Describe the organisation of respiratory center
2. Describe the nervous control of inspiration and respiratory rhythm
3. Describe the functions of the dorsal and respiratory groups of neurons
4. Describe the influences of the Pneumotaxic and Apneustic centers
5. Explain the role of Hering-Breur inflation reflex in regulation of inspiration
6. Explain the role of central chemoreceptors in regulation of respiration
7. Explain the role of peripheral chemoreceptors in regulation of respiration
8. Explain the regulation of respiration during exercise
9. Integrate the respiratory regulatory mechanisms
10. Describe the Cheyne-Stokes breathing
Study Resources:
1. Chapter 42, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 36, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 13, Human Physiology by Lauralee Sherwood, 9th edition
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1. WEANING VENTILATOR AND EXTUBATION:
STRATEGIES ON
SPONTANEOUS BREATHING TRIAL
FACEBOOK: HAPPY FRIDAY KNIGHT
9TH APRIL, 2020
2. BACK TO THE BASIC…
• Indications for intubation
• Indications for mechanical ventilation
• Weaning ventilator strategies
• Extubation
• Journal club: Pressure support VS T-piece during SBT on successful
extubation
4. INDICATIONS FOR MECHANICAL VENTILATION
• Patients unable to oxygenate without high FiO2 or CPAP
• Patients unable to do the work of breathing without mechanical
ventilation
Wilson WC, Grande CM, Hoyt DB. Trauma critical care. New York: Informa Healthcare, 2007.
5. Wilson WC, Grande CM, Hoyt DB. Trauma critical care.
New York: Informa Healthcare, 2007.
Davidson C, Treacher D. Respiratory Critical Care. London:
Arnolds, 2002.
6. WEANING VENTILATION STRATEGIES
1. Clinically stable:
• Central nervous system: normal CNS function, no sedation
• Cardiovascular system: hemodynamically stable
• Respiratory system: FiO2 0.4, PEEP 5 cmH2O, O2 sat > 92:
2. Spontaneous breathing trial (SBT)
3. Assess weaning parameter: rapid shallow breathing index (RSBI)
4. Assess extubation parameter: cuff leak test
5. extubation
Wilson WC, Grande CM, Hoyt DB. Trauma critical care. New York: Informa Healthcare, 2007.
Davidson C, Treacher D. Respiratory Critical Care. London: Arnolds, 2002.
7. WEANING VENTILATION STRATEGIES: SBT
• T-piece 2 h
• SIMV mode
• PSV mode: reduce PS until 5 - 8 cmH2O
Wilson WC, Grande CM, Hoyt DB. Trauma critical care. New York: Informa Healthcare, 2007.
Davidson C, Treacher D. Respiratory Critical Care. London: Arnolds, 2002.
8. WEANING VENTILATION STRATEGIES: RSBI
• RSBI = RR (bpm) / tidal volume (L)
• RSBI < 100-105 b/L predicts successful extubation (accuracy 85%)
Wilson WC, Grande CM, Hoyt DB. Trauma critical care. New York: Informa Healthcare, 2007.
Davidson C, Treacher D. Respiratory Critical Care. London: Arnolds, 2002.
9. EXTUBATION STRATEGIES
• Assess risk factors for postextubation stridor: airway edema, vocal
cords ulcer and cyst, RLN injury
• evaluation of periglottic swelling:
• Cuff-leak test
• Fiberoptic bronchoscopy
• Imaging study: laryngeal ultrasound
Wilson WC, Grande CM, Hoyt DB. Trauma critical care. New York: Informa Healthcare, 2007.
Davidson C, Treacher D. Respiratory Critical Care. London: Arnolds, 2002.
10. EXTUBATION STRATEGIES: CUFF-LEAK TEST
• ATS recommend cuff-leak test in high risk of postextubation stridor
• if failed, administer systemic steroids for at least 4 hours before
extubation
• Positive cuff-leak test is defined by < 110 ml of different between
exhaled volume
• before cuff deflation
• After cuff deflation
Cuff Leak Test for the Diagnosis of Post-Extubation Stridor: A Multicenter Evaluation Study. Journal of intensive care medicine. 2019: 34(5):391-
396.
12. INTRODUCTION
• Daily screening of respiratory function by SBT decreases ventilation
duration
• After SBT and extubation, 10 – 25% require reintubation higher
morbidity
• Most common modes of SBT are T-piece and PSV, 30 minutes to 2 hours
• No evidence: which one has a higher successful extubation rate
• This study compared between:
• More demanding T-piece for 2 hour
• Less demanding PSV 8 cmH2O for 30 minutes
13. METHODS
• From January 2016 through April 2017
• 18 Spanish intensive care units: multicenter randomized clinical
trial
• Approved by ethic committee of each hospital
• All patients were informed consent
14. METHODS
• Inclusion criteria:
• Patients at 18 years or older
• Undergoing mechanical ventilation at least 24 hours
• Fulfilled weaning criteria
• Exclusion criteria:
• Patients with tracheostomies
• Patients with do-not-reintubate orders
15. METHODS: WEANING CRITERIA
• Improvement of condition leading to intubation
• Hemodynamically stable: SBP 90-160 mmHg, HR < 140/min, no or low
dose vasopressors
• GCS ≥ 13
• Respiratory stability: O2sat > 90%, FiO2 ≤ 0.4, RR < 35/min,
spontaneous TV > 5 ml/kg, RR/TV < 100 beat/L, maximal Pi > 15 cmH2O
• Noncopious secretion: < 3 aspiration in last 8 hours
16. METHODS: RANDOMIZATION
• 1:1 ratio
• means of tables of computer-generated random numbers in
blinded blocks of 4 patients for each center.
• A central administrator who was not involved in the analyses used
an opaque envelope to allocate patients to receive one of the two
treatments
• The intervention was not blinded for the investigators or attending
physicians
17. METHODS: INTERVENTIONS
• Before randomization, physicians decide on extubation strategy
(whether to reconnect the patient to the ventilator for 1 hour before
extubation and whether to administer noninvasive ventilation or high-
flow nasal cannula after extubation)
• Patients randomized to
• Highly demand 2-hr T-piece
• Less demand PSV 8 cmH2O and PEEP 0
• Patients were extubated after successful SBT
• No ABG was required but if so, the results were recorded
18. METHODS: INTERVENTIONS
• Physicians record dyspnea using Borg dyspnea scale
• 0 – 10
• 0 = no dyspnea
• 10 = maximal dyspnea
• Ask at the beginning and end of SBT, and without ventilator
19. METHODS: INTERVENTIONS
• If not tolerate SBT back to ventilator with these failure criteria:
• agitation, anxiety
• low level of consciousness(Glasgow Coma Scale score <13)
• respiratory rate higher than 35/min and/or use of accessory muscles
• oxygen saturation by pulse oximetry less than 90% with FiO2 higher than 0.5
• heart rate higher than 140/min or greater than a 20% increase from baseline
• systolic blood pressure lower than 90 mm Hg
• development of arrhythmia
20. METHODS: INTERVENTIONS
• Additional SBTs were not protocolized, and mode and duration were left to the discretion of
attending teams
• Respiratory failure within 72 hours of extubation was defined as the occurrence of at least 1
of the following:
• respiratory acidosis with pH lower than 7.32 and PaCO2 higher than 45 mm Hg
• oxygen saturation less than 90% with FiO2 higher than 0.5
• respiratory rate higher than 35/min
• low level of consciousness (Glasgow Coma Scale score <13)
• severe agitation
• clinical signs of respiratory fatigue.
21. METHODS: INTERVENTIONS
• Treatment of postextubation respiratory failure was not protocolized
• When noninvasive ventilation was used, duration, maximum inspiratory
and expiratory pressures, and maximum FiO2 were recorded
• When respiratory failure was treated with a high flow nasal cannula,
duration, maximum flow, and maximum FiO2 were recorded
• Patients needing reintubation within 72 hours were NOT
randomized again for weaning, but the need for tracheostomy and the
date of final liberation from mechanical ventilation were registered
22. METHODS: OUTCOMES
• primary outcome: successful extubation free of invasive
mechanical ventilation 72 hours after the first SBT
• Secondary outcomes:
• rate of reintubation
• ICU and hospital lengths of stay
• hospital and 90-day mortality
23. METHODS: OUTCOMES
• Exploratory outcomes:
• time to reintubation and reasons for reintubation
• Incidence of tracheostomy
• Use of noninvasive ventilation and high-flow nasal cannula as
prophylaxis against postextubation respiratory failure and to treat it.
24. METHODS: OUTCOMES
• Post hoc outcomes:
• ICU mortality
• Borg Dyspnea Scale score at the end of the SBT
• patients’ confidence in their ability to breathe without the ventilator
• arterial blood analysis after successful SBT
25. METHODS: STATISTICAL ANALYSIS
• a successful extubation rate of 75% and an absolute increase in successful
extubation of 7% were expected required sample for an α=.05 and a power
of 80% was estimated to be 540 patients in each group
• Using intention-to-treat principle with no exclusion after randomization
• Patients extubated outside of protocol were analyzed as having a failed SBT
• No participants were excluded from main or secondary analyses because of
missing or incomplete data.
• Reintubation was recorded only among patients who completed the trial
26. METHODS: STATISTICAL ANALYSIS
• Categorical variables are presented as absolute and relative
frequencies.
• Continuous variables are summarized as medians and interquartile
ranges (IQRs) for nonnormal distributions
• The Mann-Whitney U was used for nonparametric continuous variables
• To compare categorical variables, the 2χ test was used, except when
expected frequencies in contingency tables were less than 5, in which
case the Fisher exact test or the Monte Carlo method was used
27. METHODS: STATISTICAL ANALYSIS
• Time-to-event outcomes were analyzed with Kaplan Meier curves and compared by
log-rank test
• For the time-to event outcome of 72-hour successful extubation
• deaths occurring before 72 hours were introduced in the survival analysis as
censored data
• Event or censored times for all patients were calculated from the time of
randomization.
• Crude hazard ratios and 95% confidence intervals were calculated using a univariable
Cox proportional regression model to estimate the effect size of randomization group
• Proportionality of hazards was verified by examining Schoenfeld residual plots
28. METHODS: STATISTICAL ANALYSIS
• A post hoc random-effects multilevel logistic regression
model was used to determine variables associatedwith 72-hour
successful extubation, taking into account the effect of hospital
• Patient characteristics that were associated with 72-hour
successful extubation in the bivariable analysis were introduced in
the random-effects multilevel logistic regression model as first-
level variables andhospital as a second-level variable (random
effect)
29. METHODS: STATISTICAL ANALYSIS
• Odds ratios (ORs) and median ORs with 95% confidence intervals were
used to measure the association between each covariate and 72-hour
successful extubation.
• The median OR is a measure of the variation between rates of 72-hour
successful extubation at different hospitals that is unexplained by the
modeled risk factors defined as the median of the set of ORs that
could be obtained by comparing 2 patients with identical patient-level
characteristics from 2 randomly chosen hospitals
30. • Covariates were introduced in the random-effects multilevel logistic
regression model using a researcher-controlled backward exclusion
strategy
• Post hoc analyses were performed for primary, secondary, exploratory,
and post hoc outcomes among the following populations:
• patients extubated after the first SBT
• patients extubated outside of protocol
• patients treated per protocol
• several subgroups defined by baseline demographic characteristics
METHODS: STATISTICAL ANALYSIS
31. • Effect sizes were evaluated by computing absolute risk differences with 95% confidence
intervals for binary outcomes and differences in means with 95% confidence intervals for
continuous outcomes.
• Figures were plotted for unadjusted risk ratios and 95% confidence intervals in the subgroup
analysis by
• age
• days of mechanical ventilation
• APACHE II score
• Chronic obstructive pulmonary disease (COPD)
• medical, surgical, or trauma admission
• No tests for interaction were conducted for the subgroup analyses
METHODS: STATISTICAL ANALYSIS
32. • A 2-sided α=.05 was considered statistically significant
• Data were analyzed using SPSS version 22(IBM Corp) and Stata
version 14 (StataCorp)
• Subgroup analysis graphs were generated using R version 3.5.2 (R
Foundation for Statistical Computing)
• There was no adjustment for multiple comparisons
• Results of the subgroup analyses and the analyses for secondary and
exploratory outcomes should be interpreted as exploratory
METHODS: STATISTICAL ANALYSIS
34. • No patient loss follow up
DEMOGRAPHICS: NO
DIFFERENCE
35.
36. THE KAPLAN-MEIER
CURVES SHOW A
SIGNIFICANT
DIFFERENCE,
WITH A HIGHER
SUCCESSFUL
EXTUBATION RATE IN
THE PSV GROUP
(HAZARD RATIO,
1.54; 95% CI, 1.19-
1.97; P < .001])
39. • In this RCT: PSV group results in:
• Higher rate of successful extubation
• The higher rate was related to more patients being extubated after the
PSV-SBT
• suggesting that a less demanding SBT better allows critically ill patients to
demonstrated their ability to sustain breathing
DISCUSSION
40. • A recent meta-analysis concluded that breathing through
a T piece requires the same amount of work as breathing after
extubation
• the authors recommended that SBTs should be performed with T
pieces because this approach better reflects the physiologic
conditions after extubation
• Physicians may be concerned that patients with low PSV and PEEP
could develop RS failure after extubation
DISCUSSION
41. • The current study found that the T-piece SBT was less
well tolerated than the PSV SBT, although the work of breathing
with the T piece may have been similar to breathing spontaneously
• But reintubation rate was not significantly different in the 2 groups
• No respiratory failure was observed after extubation from PSV
• incidence of cardiac arrest was very low and higher in the T-piece
group
DISCUSSION
42. • Vallverdu et al: 64% of T-piece SBT failed SBT in first 30 minutes
• Liang et al: identify characteristics of patients who failed SBT:
• older
• more cardiopulmonary disease
• spent more time receiving mechanical ventilation before the SBT
• undergone more previous SBTs
• These patients may need longer SBT what about 30 minutes?
DISCUSSION
43. • In the present study: 30 minutes of PSV-SBT was enough to
check patients’ ability to breathe without increasing the rates
of post extubation respiratory failure and reintubation
• Self-extubation during the SBT was more common in the T-piece
group: tolerance of 30-min PSV is better than 30-min T-piece but
latter group received longer MV
DISCUSSION
44. • 2-hr T-piece and 2-hr PSV:
• Matic et al: Higher rate of successful extubation in PSV group
• Ezingeard et al: some patients can’t tolerate T-piece but PSV is okay
without difference on reintubation rate
• These result in T-piece is not the best way to check patients’ ability
to breathe
DISCUSSION
45. • In this study:
• Reintubation rate: no difference
• Logistic regression analysis showed that the 30-minute PSV
SBT was associated with successful extubation
• Extubation failure associated with longer MV and COPD
• Hospital mortality and 90-day mortality: significantly higher in the T-piece
group but cannot be explained by reintubation rate, days of MV after
failed SBT, APACHE II, or hospital LOS
DISCUSSION
46. • No protocol for prophylactic use of noninvasive ventilation and
high-flow nasal cannula after extubation no conclusion about
the use of NIV and high flow nasal cannula for postextubation
respiratory failure
• Patients extubated outside of protocol could be expected to
influence the main results, but the sensitivity analysis ruled out
such bias
• Investigators and attending physicians were not blinded
LIMITATIONS
47. • Among mechanically ventilated patients, an SBT consisting of
30 minutes of PSV, compared with 2 hours of T-piece ventilation,
led to significantly higher rates of successful extubation.
• These findings support the use of a shorter, less demanding
ventilation strategy for SBTs
CONCLUSION
49. CRITICAL APPRAISAL
• CASP checklist: 11 questions on
• Are the results of the study valid?
• What are the results?
• Will the results help locally?
50. DID THE TRIAL ADDRESS A CLEARLY FOCUSED ISSUE?
• Yes
• PICO:
• P: patients who have met weaning ventilator criteria
• I: 30 min PSV-SBT
• C: 2 hr T-piece-SBT
• O: successful extubation
51. WAS THE ASSIGNMENT OF PATIENTS TO TREATMENTS
RANDOMISED?
• Yes, block of 4
• But investigators and attending physicians were not blinded
52. WERE ALL OF THE PATIENTS WHO ENTERED THE TRIAL
PROPERLY ACCOUNTED FOR AT ITS CONCLUSION?
• Yes
• No patients loss follow up
62. MY OPINION
• Very good
• Borg dyspnea scale is subjective
• Demographic: no neurosurgical patients
• T-piece disadvantages
• Require extra equipment
• Require disconnection from the ventilator: no intrinsic monitor (ex: apnea
monitoring) introduces risk and chance for medical error