Implementation of a nurse-led protocol for early extubation after cardiac surgery: A pilot study

BACKGROUND

Protocols for nurse-led extubation are as safe as a physician-guided weaning in general intensive care unit (ICU). Early extubation is a cornerstone of fast-track cardiac surgery, and it has been mainly implemented in post-anaesthesia care units. Introducing a nurse-led extubation protocol may lead to reduced extubation time.

AIM

To investigate results of the implementation of a nurse-led protocol for early extubation after elective cardiac surgery, aiming at higher extubation rates by the third postoperative hour.

METHODS

A single centre prospective study in an 18-bed, consultant-led Cardiothoracic ICU, with a 1:1 nurse-to-patient ratio. During a 3-wk period, the protocol was implemented with: (1) Structured teaching sessions at nurse handover and at bed-space (all staff received teaching, over 90% were exposed at least twice; (2) Email; and (3) Laminated sheets at bed-space. We compared "standard practice" and "intervention" periods before and after the protocol implementation, measuring extubation rates at several time-points from the third until the 24th postoperative hour.

RESULTS

Of 122 cardiac surgery patients admitted to ICU, 13 were excluded as early weaning was considered unsafe. Therefore, 109 patients were included, 54 in the standard and 55 in the intervention period. Types of surgical interventions and baseline left ventricular function were similar between groups. From the third to the 12th post-operative hour, the intervention group displayed a higher proportion of patients extubated compared to the standard group. However, results were significant only at the sixth hour (58% vs 37%, P = 0.04), and not different at the third hour (13% vs 6%, P = 0.33). From the 12th post-operative hour time-point onward, extubation rates became almost identical between groups (83% in standard vs 83% in intervention period).

CONCLUSION

The implementation of a nurse-led protocol for early extubation after cardiac surgery in ICU may gradually lead to higher rates of early extubation.

A 4-year implementation strategy of aggressive post-resuscitation care and temperature management after cardiac arrest

BACKGROUND

target temperature management (TTM) not only improves neurological outcome and survival but has given momentum to a more aggressive and comprehensive treatment after resuscitation. Yet, implementation issues represent the main obstacle to systematic treatment with TTM and aggressive post-resuscitation care. We devised a strategy to introduce, monitor and improve the quality of aggressive treatment after resuscitation, including TTM.

METHODS

standard operative procedures on aggressive post-resuscitation care, written jointly by physicians and nurses, were introduced in November 2004. Data of all resuscitated patients admitted to the ICU were prospectively acquired for 4 years. Periodic audits (every 16 months) were programmed, leading to three equally long periods. Several critical issues were identified after each audit and addressed subsequently, leading to a growing complexity of care. Moreover, after 2 years we introduced an educational programme with medical credits for all staff attending critically ill patients. Neurological outcome and survival at hospital discharged were compared to historical controls of the preceding 22 months.

RESULTS

129 consecutively resuscitated patients were admitted to the ICU in the 4-year study period. Of these, 96 (74%) were treated with TTM and aggressive post-resuscitation care. Favourable neurological recovery among patients discharged alive significantly improved in the 4-year intervention period (81% vs. 50% in historical controls, p<0.01). A composite endpoint of mortality and poor neurological outcome also improved (64% vs. 82% respectively, p<0.05). Overall survival increased throughout the 4 years, leading to a significant improvement in the 3rd period compared to historical controls (60% vs. 35%; p<0.05).

CONCLUSIONS

we propose a strategy to successfully introduce and implement TTM and aggressive post-resuscitation care via standard operative procedures, periodic audits and feedback. Continuous education among other factors contributed to a significant improvement in neurological outcome and a progressive increase in survival.

Clinical biomarkers in brain injury: a lesson from cardiac arrest

Cardiac arrest (CA) is the primary cause of death in industrialized countries. Successful resuscitation rate is estimated of about 40%, but a good neurological outcome remains difficult to achieve. The majority of resuscitated victims suffers of a pathophysiological entity termed as "post resuscitation disease". Today's efforts are mainly pointed to the chain of survival, often devoting less attention to post-resuscitation care. Resuscitated patients are often victims of nihilistic therapeutic approach, with clinicians failing to promptly institute strategies that mitigate the ischemia-reperfusion injury to vital organs. Only after 72 hours prognostication can be realistically attempted. Neurological evaluation relies on a combination of clinical, instrumental and laboratoristic parameters, since no one alone holds a specificity of 100%. Biochemical markers, such as neuron specific enolase and S-100b, may contribute to predict prognosis after CA. To the contrary, when used individually the necessary precision remains poorly characterized. Biochemical studies suffer from substantial methodological differences hampering attempts to summarize their findings. We review the information available on biochemical markers of brain damage for neurological prognostication after CA.

Cardiac dysfunction in patients affected by subarachnoid haemorrhage affects in-hospital mortality: A systematic review and metanalysis

BACKGROUND

Subarachnoid haemorrhage (SAH) is a life-threatening condition with associated brain damage. Moreover, SAH is associated with a massive release of catecholamines, which may promote cardiac injury and dysfunction, possibly leading to haemodynamic instability, which in turn may influence a patient's outcome.

OBJECTIVES

To study the prevalence of cardiac dysfunction (as assessed by echocardiography) in patients with SAH and its effect on clinical outcomes.

DESIGN

Systematic review of observational studies.

DATA SOURCES

We performed a systematic search over the last 20 years on MEDLINE and EMBASE databases.

ELIGIBILITY CRITERIA

Studies reporting echocardiography findings in adult patients with SAH admitted to intensive care. Primary outcomes were in-hospital mortality and poor neurological outcome according to the presence or absence of cardiac dysfunction.

RESULTS

We included a total of 23 studies (4 retrospective) enrolling 3511 patients. The cumulative frequency of cardiac dysfunction was 21% (725 patients), reported as regional wall motion abnormality in the vast majority of studies (63%). Due to the heterogeneity of clinical outcome data reporting, a quantitative analysis was carried out only for in-hospital mortality. Cardiac dysfunction was associated with a higher in-hospital mortality [odds ratio 2.69 (1.64 to 4.41); P < 0.001; I2 = 63%]. The GRADE of evidence assessment resulted in very low certainty of evidence.

CONCLUSION

About one in five patients with SAH develops cardiac dysfunction, which seems to be associated with higher in-hospital mortality. The consistency of cardiac and neurological data reporting is lacking, reducing the comparability of the studies in this field.

Tracheostomy Practice in the Italian Intensive Care Units: A Point-Prevalence Survey

Background and Objectives: A tracheostomy is a frequently performed surgical intervention in intensive care units (ICUs) for patients requiring prolonged mechanical ventilation. This procedure can offer significant benefits, including reduced sedation requirements, improved patient comfort, and enhanced airway management. However, it is also associated with various risks, and the absence of standardized clinical guidelines complicates its implementation. This study aimed to determine the prevalence of tracheostomy among ICU patients, while also evaluating patient characteristics, complication rates, and overall outcomes related to the procedure. Materials and Methods: We conducted an observational, cross-sectional, point-prevalence survey across eight ICUs in Italy. Data were collected over two 24 h periods in March and April 2024, with a focus on ICU characteristics, patient demographics, the details of tracheostomy procedures, and associated complications. Results: Among the 92 patients surveyed in the ICUs, 31 (33.7%) had undergone tracheostomy. The overall prevalence of tracheostomy was found to be 9.1%, translating to a rate of 1.8 per 1000 admission days. The mean age of patients with a tracheostomy was 59.5 years (SD = 13.8), with a notable predominance of male patients (67.7%). Neurological conditions were identified as the most common reason for ICU admission, accounting for 48.4% of cases. Tracheostomy procedures were typically performed after a mean duration of 12.9 days of mechanical ventilation, primarily due to difficulties related to prolonged weaning (64.5%). Both early and late complications were observed, and 19.35% of tracheostomized patients did not survive beyond one month following the procedure. The average length of stay in the ICU for these patients was significantly extended, averaging 43.0 days (SD = 34.3). Conclusions: These findings highlight the critical role of tracheostomy in the management of critically ill patients within Italian ICUs. The high prevalence and notable complication rates emphasize the urgent need for standardized clinical protocols aimed at optimizing patient outcomes and minimizing adverse events. Further research is essential to refine current practices and develop comprehensive guidelines for the management of tracheostomy in critically ill patients.

The Effects of On-Pump and Off-Pump Coronary Artery Bypass Surgery on Metabolic Profiles in the Early Postoperative Period

OBJECTIVE

Hyperlactatemia and base deficit (BD) are markers of adverse outcome after cardiac surgery, and their derangement can be influenced by the use of extracorporeal circulation. The authors hypothesized a better postoperative metabolic profile in off-pump coronary artery bypass grafting (OPCABG) compared with "on-pump" coronary artery bypass grafting (ONCABG).

DESIGN

This was a retrospective study, with consecutive data collected for 1 year from electronic medical records.

SETTING

Cardiothoracic intensive care unit at a tertiary university hospital.

PARTICIPANTS

The study comprised 339 patients who underwent elective coronary artery bypass grafting (ONCABG [n = 215], OPCABG [n = 124]).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The metabolic (arterial lactatemia, pH, and BD) and hemodynamic (inotropic/vasopressor support) parameters of OPCABG and ONCABG patients were compared at 7 predefined time points (intensive care admission and the 1st, 3rd, 6th, 12th, 18th, and 24th postoperative hours). For each output of interest, mixed-effects linear regression models were used (with time as random-effect to allow for clustering of repeated measures) and adjusted for a predetermined set of covariates. Arterial lactatemia and pH were comparable at all time points; BD was worse in the ONCABG group overall (p = 0.01) and at most time points (except at the 1st and 24th postoperative hours). For the whole period, inotropic support was more common in ONCABG patients (p<0.05), whereas vasopressor use was more frequent in the OPCABG group (p< 0.05).

CONCLUSIONS

Improved postoperative BD values were demonstrated in the OPCABG group, although pH and lactatemia were similar between groups. Inotropic support was less common in the OPCABG group at the expense of more frequent vasopressor support.

Prevalence and prognosis of hyperdynamic left ventricular systolic function in septic patients: a systematic review and meta-analysis

PURPOSE

The prevalence of hyperdynamic left ventricular (LV) systolic function in septic patients and its impact on mortality remain controversial. In this systematic review and meta-analysis, we investigated the prevalence and association of hyperdynamic LV systolic function with mortality in patients with sepsis.

METHODS

We searched MEDLINE, Cochrane Central Register of Controlled Trials, and Embase. Primary outcomes were the prevalence of hyperdynamic LV systolic function in adult septic patients and the associated short-term mortality as compared to normal LV systolic function. Hyperdynamic LV systolic function was defined using LV ejection fraction (LVEF) of 70% as cutoff. Secondary outcomes were heart rate, LV end-diastolic diameter (LVEDD), and E/e' ratio.

RESULTS

Four studies were included, and the pooled prevalence of hyperdynamic LV systolic function was 18.2% ([95% confidence interval (CI) 12.5, 25.8]; I2 = 7.0%, P < 0.0001). Hyperdynamic LV systolic function was associated with higher mortality: odds ratio of 2.37 [95%CI 1.47, 3.80]; I2 = 79%, P < 0.01. No difference was found in E/e' (P = 0.43) between normal and hyperdynamic LV systolic function, while higher values of heart rate (mean difference: 6.14 beats/min [95%CI 3.59, 8.69]; I2 = 51%, P < 0.0001) and LVEDD (mean difference: - 0.21 cm [95%CI - 0.33, - 0.09]; I2 = 73%, P < 0.001) were detected in patients with hyperdynamic LV systolic function.

CONCLUSION

The prevalence of hyperdynamic LV systolic function is not negligible in septic patients. Such a finding is associated with significantly higher short-term mortality as compared to normal LV systolic function.

The Effect of Recruitment Maneuvers on Cerebrovascular Dynamics and Right Ventricular Function in Patients with Acute Brain Injury: A Single-Center Prospective Study

BACKGROUND

Optimization of ventilatory settings is challenging for patients in the neurointensive care unit, requiring a balance between precise gas exchange control, lung protection, and managing hemodynamic effects of positive pressure ventilation. Although recruitment maneuvers (RMs) may enhance oxygenation, they could also exert profound undesirable systemic impacts.

METHODS

The single-center, prospective study investigated the effects of RMs (up-titration of positive end-expiratory pressure) on multimodal neuromonitoring in patients with acute brain injury. Our primary focus was on intracranial pressure and secondarily on cerebral perfusion pressure (CPP) and other neurological parameters: cerebral autoregulation [pressure reactivity index (PRx)] and regional cerebral oxygenation (rSO2). We also assessed blood pressure and right ventricular (RV) function evaluated using tricuspid annular plane systolic excursion. Results are expressed as the difference (Δ) from baseline values obtained after completing the RMs.

RESULTS

Thirty-two patients were enrolled in the study. RMs resulted in increased intracranial pressure (Δ = 4.8 mm Hg) and reduced CPP (ΔCPP = -12.8 mm Hg) and mean arterial pressure (difference in mean arterial pressure = -5.2 mm Hg) (all p < 0.001). Cerebral autoregulation worsened (ΔPRx = 0.31 a.u.; p < 0.001). Despite higher systemic oxygenation (difference in partial pressure of O2 = 4 mm Hg; p = 0.001) and unchanged carbon dioxide levels, rSO2 marginally decreased (ΔrSO2 = -0.5%; p = 0.031), with a significant drop in arterial content and increase in the venous content. RV systolic function decreased (difference in tricuspid annular plane systolic excursion = -0.1 cm; p < 0.001) with a tendency toward increased RV basal diameter (p = 0.06). Grouping patients according to ΔCPP or ΔPRx revealed that those with poorer tolerance to RMs had higher CPP (p = 0.040) and a larger RV basal diameter (p = 0.034) at baseline.

CONCLUSIONS

In patients with acute brain injury, RMs appear to have adverse effects on cerebral hemodynamics. These findings might be partially explained by RM's impact on RV function. Further advanced echocardiography monitoring is required to prove this hypothesis.

Use of a Combined Laryngo-Bronchoscopy Approach in Difficult Airways Management: A Pilot Simulation Study

OBJECTIVE

There are several airway devices available for difficult tracheal intubation (DTI) management, but the failure rate remains high. The use of laryngoscopy to facilitate the fibreoptic-bronchoscope intubation (CLBI) has been increasingly reported in DTI situations, but it has not been formally studied yet.

METHODS

We designed a single-centre simulation study on DTI (neck rigidity and tongue oedema) comparing three techniques: direct laryngoscopy (DL), video-laryngoscopy (VLS) and CLBI. Eighteen anaesthesiologists naïve to VLS/CLBI approaches, participated in the study. The primary outcome was the intubation rate at the first attempt. Secondary outcomes were an overall time-to-intubate (TTI) and time-to-ventilate (TTV), success at the second and third attempt and ease of intubation as evaluated by a subjective 5-point Likert scale.

RESULTS

The CLBI technique had a higher success rate at the first attempt than DL (66% vs 22%, p=0.007), while VLS did not (44%, p=0.16). A trend towards higher success at the third attempt was found for both VLS and CLBI vs DL (p=0.07 and p=0.06, respectively). The VLS had a shorter overall TTV than DL (88±60 vs 121±59 sec, respectively, p=0.04) and a trend towards a shorter TTI (81±61 vs 116±64 sec, respectively, p=0.06). The CLBI approach showed a non-significantly lower TTI/TTV as compared to DL (p=0.10 and p=0.16, respectively). Anaesthesiologists judged that the intubation with VLS (3.7±1.0) and CLBI (3.8±1.0) was easier than with DL (1.7±0.8, both p<0.001).

CONCLUSION

In a simulated DTI scenario, CLBI had a higher success rate at the first attempt than DL, while VLS did not. By the third attempt, both rescue techniques had a trend towards a higher success rate than DL. The CLBI technique seems a promising alternative for the management of DTI.

Continuous Erector Spinae Plane Block as Postoperative Analgesic Technique for Robotic-Assisted Thoracic Surgery: A Case Series

Introduction

The erector spinae plane block (ESPB) is a recently implemented analgesic technique initially reported for thoracic analgesia and subsequently adopted for both intra- and postoperative pain management. Thoracic surgery is among the most painful surgical procedures, even when conducted with minimally invasive approach. Robotic-assisted thoracic surgery (RATS) challenges the traditional analgesic regimens as one of its aims is to decrease the patient’s length of stay (LOS) whilst achieving optimal postoperative pain management. Furthermore, there is lots of growing evidence on the impact of poorly controlled postoperative pain (PP) on the development of chronic post-surgical pain (CPSP). In these case series, we aim to describe our preliminary experience of postoperative pain management with continuous ESPB in the field of RATS.

Case Series Presentation

In eight consecutive patients undergoing elective RATS procedure, we performed the ESPB after surgery with an initial bolus of local anesthetic followed by catheter insertion for continuous infusion. The infusion of local anesthetic lasted for the first two postoperative days. The effectiveness of the ESPB was evaluated through serial pain assessment with numeric rate scale (NRS) score, both at rest and during movement every 6 hours. Any analgesic rescue drug prescription was reported. We noted that the ESPB strongly reduced the prescription of opioids and of rescue analgesic. In our series, only one patient needed opioids during the first two postoperative days, and no rescue analgesic administration was noted in the remaining cases.

Conclusion

We report a small but promising experience regarding postoperative pain management with continuous ESPB performed after RATS. We implemented the ESPB before surgery. Larger studies on postoperative pain management with continuous regional blocks in thoracic surgery are warranted.

Red Blood Cell Transfusion Guided by Hemoglobin Only or Integrating Perfusion Markers in Patients Undergoing Cardiac Surgery: A Systematic Review and Meta-Analysis With Trial Sequential Analysis

OBJECTIVE

Strategies for red blood cell (RBC) transfusion in patients undergoing cardiac surgery have been traditionally anchored to hemoglobin (Hb) targets. A more physiologic approach would consider markers of organ hypoperfusion.

DESIGN

The authors conducted a systematic review and meta-analysis with trial sequential analysis of randomized controlled trials (RCTs).

SETTING

Cardiac surgery.

PARTICIPANTS

Adult patients.

INTERVENTION

RBC transfusion targeting only Hb levels compared with strategies combining Hb values with markers of organ hypoperfusion.

MEASUREMENTS AND MAIN RESULTS

Primary outcomes were the number of RBC units transfused, the number of patients transfused at least once, and the average number of transfusions. Secondary outcomes were postoperative complications, intensive care (ICU) and hospital lengths of stay, and mortality. Only 2 RCTs were included (n = 257 patients), and both used central venous oxygen saturation (ScvO2) as a marker of organ hypoperfusion (cut-off: <70% or ≤65%). A transfusion protocol combining Hb and ScvO2 reduced the overall number of RBC units transfused (risk ratio [RR]: 1.57 [1.33-1.85]; p < 0.0001, I2 = 0%), and the number of patients transfused at least once (RR: 1.33 [1.16-1.53]; p < 0.0001, I2 = 41%), but not the average number of transfusions (mean difference [MD]: 0.18 [-0.11 to 0.47]; p = 0.24, I2 = 66%), with moderate certainty of evidence. Mortality (RR: 1.29, [0.29-5.77]; p = 0.73, I2 = 0%), ICU length-of-stay (MD: -0.06 [-0.58 to 0.46]; p = 0.81, I2 = 0%), hospital length-of-stay (MD: -0.05 [-1.49 to 1.39];p = 0.95, I2 = 0%), and all postoperative complications were not affected.

CONCLUSIONS

In adult patients undergoing cardiac surgery, a restrictive protocol integrating Hb values with a marker of organ hypoperfusion (ScvO2) reduces the number of RBC units transfused and the number of patients transfused at least once without apparent signals of harm. These findings were preliminary and warrant further multicentric research.