Implications of extubation failure and prolonged mechanical ventilation in the postoperative period following elective intracranial surgery

Early Extubation After Elective Infratentorial Craniotomy: Results of the International PRICE Survey

BACKGROUND

Early extubation, defined as removal of the endotracheal tube at the end of surgery before transfer to a designated postoperative care area, is associated with better outcomes after elective infratentorial craniotomy. The Predicting Infratentorial Craniotomy Extubation (PRICE) project was an international survey designed to estimate the rate of early extubation after elective infratentorial craniotomy, as reported by neuroanesthesiologists, neurosurgeons, and neurocritical care specialists.

METHODS

Following research ethics board waiver, the 15-question online PRICE survey was circulated to the members of 5 international medical societies over a 15-week period.

RESULTS

One hundred and ninety of 5453 society members completed the survey (3.5% response rate). Respondents represented a total of 99 institutions from 92 cities, in 27 countries. While 84 of 188 (44.7%) respondents reported achieving early extubation in more than 95% of cases, 43 of 188 (22.9%) reported extubating fewer than 75% of cases early. The proportion of physicians who reported extubating at least 75% of cases early was greater in high-volume compared with low-volume institutions (73.5% vs. 50.9%, respectively; P =0.003) and among anesthesiologists compared with other specialties (75.6% vs. 45.6%, respectively; P <0.001). Preoperative bulbar dysfunction, preoperative altered consciousness and the course of surgery were the 3 factors with the biggest impact on the decision to extubate early versus late among respondents.

CONCLUSIONS

The reported rate of early extubation after elective infratentorial craniotomy varies widely between institutions, with respondents from high-volume institutions reporting greater rates of early extubation than those from lower-volume centers. The course of surgery, evidence of bulbar dysfunction, and altered consciousness, appear to affect the decision to extubate early more than other predictors.

Effect of positioning and expiratory rib-cage compression on atelectasis in a patient who required prolonged mechanical ventilation: a case report

BACKGROUND

Pulmonary complications can be caused by intraoperative mechanical ventilation. In particular, prolonged mechanical ventilation is associated with a high mortality rate, a risk of pulmonary complications, prolonged hospitalization, and an unfavorable discharge destination. Pre- and postoperative rehabilitation are important for the resolution of pulmonary complications in acute cases. However, there has been a lack of studies on interventions for pulmonary rehabilitation of patients with chronic pulmonary complications caused by prolonged mechanical ventilation. Accordingly, we describe the effect of pulmonary rehabilitation in such a patient.

CASE PRESENTATION

We examined a 63-year-old Japanese woman with hypoxic-ischemic encephalopathy after subarachnoid hemorrhage who required prolonged mechanical ventilation. Radiographic and computed tomographic images revealed atelectasis of the right upper lobe. In addition, this atelectasis reduced the tidal volume, minute volume, and oxygen saturation and caused an absence of breath sounds in the right upper lobe during auscultation. We aimed to ameliorate the patient's atelectasis and improve her ventilation parameters by using positioning and expiratory rib-cage compression after endotracheal suctioning. Specifically, the patient was seated in Fowler's position, and mild pressure was applied to the upper thorax during expiration, improving her inspiratory volume. Immediately, breath sounds were audible in the right upper lobe. Furthermore, resolution of the patient's atelectasis was confirmed with chest radiography performed on the same day. In addition, her ventilation parameters (tidal volume, minute volume, and oxygen saturation) improved.

CONCLUSIONS

Our results indicate that physical therapists should consider application of specific positioning and expiratory rib-cage compression in patients who exhibit atelectasis because of prolonged mechanical ventilation.

Predicting postoperative tracheostomy requirement in children undergoing surgery for posterior fossa tumors

PURPOSE

Posterior fossa tumor (PFT) resection can be associated with postoperative respiratory failure. We aimed to identify risk factors predicting tracheostomy dependence in children after PFT resection.

METHODS

Retrospective chart review of all children undergoing PFT resection from April 2007 to May 2017 at our institution was performed.

RESULTS

A total of 197 patients were included; 12 (6.1%) required tracheostomy placement at a mean 69.1 days postoperatively (SD 112.7, range 7-388). Patients requiring tracheostomy were younger (3.4 vs. 6.8 years, p < 0.01), more likely to have postoperative dysphagia (91.7% vs. 17.3%, p < 0.01), and more likely to have an ependymoma (41.7% vs. 15.1%, p < 0.01) or astrocytoma (25.0% vs. 8.1%, p < 0.01). Patients with eventual tracheostomy were less likely extubated immediately postoperatively (45.5% vs. 79.6%, p < 0.01), had longer intubation duration postoperatively (5.7 vs. 0.5 days, p < 0.01), and had higher rates of reintubation within 48 h (63.6% vs. 1.3%, p < 0.01). Patients requiring tracheostomy had longer hospital length of stay (45.8 vs. 15.3 days, p < 0.01) and ICU stay postoperatively (13.5 vs. 2.1 days, p < 0.01). Of those requiring tracheostomy, three (25.0%) were decannulated by 1 year postoperatively. Decannulation rates did not vary by age (p < 0.47), extubation failure (p < 0.24), duration of intubation (p < 0.10), tumor histology (p < 0.23), or tumor grade (p < 0.13).

CONCLUSION

Lower cranial neuropathy following PFT resection is common. Identifying risk factors correlated with need for tracheostomy can help identify patients who may benefit from early tracheostomy, reducing prolonged intubation trauma, time on mechanical ventilation, and length of stay.

Comparison of "cough peak expiratory flow measurement" and "cough strength measurement using the white card test" in extubation success: A randomized controlled trial

Background:

Failed extubation and subsequent re-intubation in ventilated patients can lead to many adverse consequences, including organizational and personal expenditures. Extubation decisions based on subjective methods are a major contributor to extubation failure. This study compared the effect of cough peak expiratory flow (PEF) measurement and cough strength measurement using the white card test (WCT) on extubation success.

Materials and Methods:

This randomized clinical trial was conducted in two groups in 2018 on 88 ventilated patients in intensive care units of Imam Reza Hospital in Mashhad, Iran. Ninety patients were divided into two groups of 45, but two were excluded from the white card group. The criteria established for extubation included PEF ≥60 L/min during coughing in the cough PEF group and noticing card humidity in the WCT group. In both groups, extubation success was determined as the sole outcome and was compared with the standard PEF and cough strength. The researcher who assessed the outcome and statistician were blinded about group allocation.

Results:

Extubation success was measured as 97.8% in the cough PEF group and 76.7% in the WCT group (P = 0.003) during the first 24 h. In the second 24 h, however, successful extubation was reported as 90.9% in the cough PEF group and 60.6% in the WCT group (P = 0.002).

Conclusion:

Using the cough PEF rate increases the likelihood of extubation success and reduces adverse effects, and is recommended to be used for extubation decision-making.

Middle Range Theory for the Nursing Diagnosis of Dysfunctional Ventilatory Weaning Response

PURPOSE

To propose a middle range theory (MRT) that establishes the theoretical basis for the nursing diagnosis dysfunctional ventilatory weaning response (DVWR) (00034).

DATA SOURCES

Integrative literature review.

DATA SYNTHESIS

The MRT includes the main concepts, pictorial diagrams, propositions, and causal relationships for use in clinical practice.

CONCLUSIONS

The MRT developed for the DVWR allowed us to list 13 clinical antecedent and 21 consequent findings related to this nursing diagnosis that occurs when ventilatory weaning fails.

IMPLICATIONS FOR NURSING PRACTICE

The clinical indicators and causal relationships described in the MRT may serve as a basis for nurses to understand the dysfunctional weaning process.

Incidence and predictors of postoperative pulmonary complications in patients undergoing craniotomy and excision of posterior fossa tumor

Background and Aims:

Infratentorial neurosurgical procedures are considered high risk for the development of postoperative pulmonary complications (POPCs), prolonging hospital stay of patients with substantial morbidity and mortality.

Material and Methods:

Patients between the ages of 18 and 65 years, who underwent elective surgery for posterior fossa tumors over a period of two years, were reviewed. Data including American Society of Anesthesiologists physical status; comorbidities like hypertension, diabetes mellitus and hypothyroidism, history of smoking, obstructive sleep apnea, respiratory symptoms, lower cranial nerve (LCN) palsy; intraoperative complications such as hemodynamic alterations suggestive of brain stem or cranial nerve handling, tight brain as informed by the operating neurosurgeon, blood loss, and transfusion; and postoperative duration of mechanical ventilation, tracheostomy, POPCs, length of ICU and hospital stay, general condition of the patient at discharge, and cause of in-hospital mortality were collected. POPC was defined as the presence of atelectasis, tracheobronchitis, pneumonia, bronchospasm, respiratory failure, reintubation, or weaning failure.

Results:

Case files of 288 patients fulfilling the study criteria were analyzed; POPCs were observed in 35 patients (12.1%). On multivariate analysis, postoperative blood transfusion, LCN palsy, prolonged ICU stay, and tracheostomy were found to be independent predictors of POPC.

Conclusions:

The incidence of POPC was 12.1% following infratentorial tumor surgery. The predictors for the occurrence of POPCs were postoperative blood transfusion, LCN palsy, prolonged ICU stay, and tracheostomy.

Perioperative risk factors for postoperative respiratory failure

The study aimed to identify the risk factors for respiratory failure after surgery. Postoperative respiratory failure (PRF) was defined as prolonged intubation after surgery or reintubation after unsuccessful extubation. We conducted a retrospective analysis of the following risk factors: age, obesity as reflected by body mass index (BMI), gender, patient admitted to hospital (in-patient status) vs. outpatient surgery, smoking, hypertension, chronic obstructive pulmonary disease (COPD), diabetes, abnormal liver function, anaemia, respiratory infection, physical condition as reflected by ASA class, case type (elective or emergency), anaesthesia type, and surgical duration. The incidence of PRF was found to be 2.4%. Independent risk factors were older age, inpatient status, hypertension, COPD, elective procedure, surgical duration >2 hours, and ASA class ≥3. The study concludes that PRF results in significant postoperative complications. Minimising these risks is essential in improving PRF and subsequently surgical outcomes.

Analysis of the Risk Factors Associated with Prolonged Intubation or Reintubation after Anterior Cervical Spine Surgery

BACKGROUND

Standardized postoperative airway management is essential for patients undergoing anterior cervical spine surgery (ACSS). The paucity of clinical series evaluating these airway complications after ACSS has been resulted in a significant limitation in statistical analyses.

METHODS

A retrospective cohort study was performed regarding airway distress (intubation for more than 24 hours or unplanned reintubation within 7 days of operation) developed after ACSS. If prevertebral soft tissue swelling was evident after the operation, patients were managed with prolonged intubation (longer than 24 hours). Preoperative and intraoperative patient data, and postoperative outcome (time to extubation and reintubation) were analyzed.

RESULTS

Between 2008 and 2016, a total of 400 ACSS were performed. Of them, 389 patients (97.25%) extubated within 24 hours of surgery without airway complication, but 11 patients (2.75%) showed postoperative airway compromise; 7 patients (1.75%) needed prolonged intubation, while 4 patients (1.00%) required unplanned reintubation. The mean time for extubation were 2.75 hours (range: 0-23 hours) and 50.55 hours (range: 0-250 hours), respectively. Age (P = 0.015), diabetes mellitus (P = 0.003), operative time longer than 5 hours (P = 0.048), and estimated blood loss (EBL) greater than 300 mL (P = 0.042) were associated with prolonged intubation or reintubation. In prolonged intubation group, all patients showed no airway distress after extubation.

CONCLUSION

In ACSS, postoperative airway compromise is related to both patients and operative factors. We recommend a prolonged intubation for patients who are exposed to these risk factors to perform a safe and effective extubation.

Airway Management Protocol After Anterior Cervical Spine Surgery: Analysis of the Results of Risk Factors Associated With Airway Complication

STUDY DESIGN

Retrospective comparative cohort analysis.

OBJECTIVE

To evaluate the effect of postoperative airway management protocol (ASAN Extubation Protocol, AEP) on incidence of airway complications for patients undergoing anterior cervical spine surgery (ACSS).

BACKGROUND

Postoperative airway compromise remains crucial for patients undergoing ACSS. Despite the potential severity of these complications, the data in the published literature addressing this issue is sparse.

METHODS

A retrospective cohort study was performed regarding airway complications (postoperative airway edema requiring unplanned reintubation or tracheostomy) between groups of patients undergoing ACSS before and after applying our standardized protocol (AEP) for postoperative extubation. The AEP was developed based on 5 clinical risk factors reported having relation to airway complication. Postoperative patients with any oneor more risk factors were kept intubated for at least overnight and extubation was conducted according to the amount of prevertebral soft tissue swelling.

RESULTS

A total of 538 ACSS patients were identified from 2008 to 2016. The nonprotocol group (before protocol application, 275 patients) and the Protocol group (after protocol, 263 patients) were compared; airway complication rates were significantly different between two groups (nonprotocol: 3.64% (10/275) vs.

PROTOCOL

0.76% (2/263), P = 0.024). The possible factors that may increase airway complication include operative indications (P = 0.002), trauma (P = 0.000), medical comorbidity risk (P = 0.011), combined anterior and posterior surgery (P = 0.002), and operation time longer than 5 hours (P = 0.045). In multivariate analysis, medical comorbidity risk, trauma, and airway protocol adoption were significant factors. AEP reduced the airway complication rate by odds ratio 0.125 (P = 0.013).

CONCLUSION

Postoperative airway complication is not very common after ACSS. AEP contributed to reduce the incidence of airway complications. The potentially life-threatening event of loss of airway patency, even though it is a rare complication, should be cautiously analyzed with identification of risk factors before the surgery.

LEVEL OF EVIDENCE

2.

The effect of reintubation on ventilator-associated pneumonia and mortality among mechanically ventilated patients with intubation: A systematic review and meta-analysis

OBJECTIVES

This meta-analysis summarized the risks that reintubation impose on ventilator-associated pneumonia (VAP) and mortality.

BACKGROUND

Extubation failure increases the probability of poor clinical outcomes pertaining to mechanical ventilation.

METHODS

Literature published during a 15-year period was retrieved from PubMed, Web of Knowledge databases, the Embase (Excerpa Medica database), and the Cochrane Library. Data involving reintubation, VAP, and mortality were extracted for a meta-analysis.

RESULTS

Forty-one studies involving 29,923 patients were enrolled for the analysis. The summary odds ratio (OR) between VAP and reintubation was 7.57 (95% confidence interval [CI] = 3.63-15.81). The merged ORs for mortality in hospital and intensive care unit were 3.33 (95% CI = 2.02-5.49) and 7.50 (95% CI = 4.60-12.21), respectively.

CONCLUSIONS

Reintubation can represent a threat to survival and increase the risk of VAP. The risk of mortality after reintubation differs between planned and unplanned extubation. Extubation failure is associated with a higher risk of VAP in the cardiac surgery population than in the general population.

Predictors for Airway Complications Following Single- and Multilevel Anterior Cervical Discectomy and Fusion

STUDY DESIGN

A retrospective, multivariate analyses of a prospectively collected multicenter database.

OBJECTIVE

The aim of this study was to evaluate the risk factors for postoperative airway complications following single- and multilevel anterior cervical discectomy and fusion (ACDF).

SUMMARY OF BACKGROUND DATA

Airway compromise following ACDF may result in catastrophic outcome. However, its predictors have not been identified by a multi-institutional study.

METHODS

Patients who underwent ACDF between 2011 and 2013 were selected from the American College of Surgeons National Surgical Quality Improvement Program database. Multiple logistic regression analysis was performed to identify the risk factors for airway compromise following ACDF.

RESULTS

Twelve thousand one hundred eighty-five patients were analyzed in this study. Our multivariate analysis identified older age, male gender, dependent functional status, chronic obstructive pulmonary disease, bleeding disorder, American Society of Anesthesiology class >2, Wound Class >2, and prolonged operative durations as significant predictors of postoperative airway compromise following ACDF. Surprisingly, multilevel and corpectomy procedures were not significant risk factors for airway complication following ACDF.

CONCLUSION

We identified significant risk factors for airway compromise following ACDF procedures. While ACDF is considered a safe procedure, postoperative airway complication can lead to disastrous outcome. Continued efforts to elucidate preoperative risk factors and subsequent optimization are warranted to improve outcomes in ACDF.

LEVEL OF EVIDENCE

3.

Risk factors for post-operative respiratory failure among 94,621 neurosurgical patients from 2006 to 2013: a NSQIP analysis

INTRODUCTION

Post-operative respiratory failure can occur after neurosurgical operations. Identification of risk factors for respiratory failure after neurosurgery may help guide clinical decision-making, decrease length of stay, improve patient outcomes, and lower costs.

METHODS

We performed a search of the ACS-NSQIP database for all patients undergoing operations with a neurosurgeon from 2006 to 2013. We analyzed demographics, past medical history, and post-operative respiratory failure, defined as unplanned intubation and/or ventilator dependence for more than 48 h post-operatively.

RESULTS

Of 94,621 NSQIP-reported neurosurgical patients from 2006 to 2013, 2325 (2.5 %) developed post-operative respiratory failure. Of these patients, 1270 (54.6 %) were male, with an overall mean age of 60.59 years; 571 (24.56 %) were current smokers and 756 (32.52 %) were ventilator-dependent. Past medical history included dyspnea in 204 patients (8.8 %), COPD in 198 (8.5 %), and congestive heart failure in 66 (2.8 %). The rate of post-operative respiratory failure decreased from 4.1 % in 2006 to 2.1 % in 2013 (p < 0.001). Of the 2325 patients with respiratory failure, 1061 (45.6 %) underwent unplanned intubation post-operatively and 1900 (81.7 %) were ventilator-dependent for more than 48 h. The rate of both unplanned intubation (p < 0.001) and ventilator dependence (p < 0.001) decreased significantly from 2006 to 2013. Multivariate analysis demonstrated that significant risk factors for respiratory failure included inpatient status (p < 0.001, OR = 0.165), age (p < 0.001, OR = 1.014), diabetes (p = 0.001, OR = 1.489), functional dependence prior to surgery (p < 0.001, OR = 2.081), ventilator dependence (p < 0.001, OR = 10.304), hypertension requiring medication (p = 0.005, OR = 1.287), impaired sensorium (p < 0.001, OR = 2.054), CVA/stroke with or without neurological deficit (p < 0.001, OR = 2.662; p = 0.002, OR = 1.816), systemic sepsis (p < 0.001, OR = 1.916), prior operation within 30 days (p = 0.026, OR = 1.439), and operation type (cranial relative to spine, p < 0.001, OR = 4.344, Table 4).

CONCLUSIONS

Based on the NSQIP database, risk factors for respiratory failure after neurosurgery include pre-operative ventilator dependence, alcohol use, functional dependence prior to surgery, stroke, and recent operation. The overall rate of respiratory failure decreased from 4.1 % in 2006 to 2.1 % in 2013 according to these data.

Perioperative Predictors of Extubation Failure and the Effect on Clinical Outcome After Infratentorial Craniotomy

BACKGROUND The purpose of the study was to analyze the risk factors for failed extubation in subjects submitted to infratentorial craniotomy. MATERIAL AND METHODS Patients aged over 18 years who received infratentorial craniotomy for brain tumor resection were consecutively included in this study. Perioperative variables were collected and analyzed. Univariate analyses and multiple logistic regression were used to derive factors related to failed extubation. Patients had follow-up care until either out of hospital or death. RESULTS Throughout the course of the study, 2118 patients were eligible and 94 (4.4%) suffered from extubation failure at some point during their hospital stay. Five factors were recognized as independent risk factors for postoperative failed extubation: craniotomy history, preoperative lower cranial nerve dysfunction, tumor size, tumor position, and maximum change in blood pressure (BP) during the operation. Failed extubation was related to a higher incidence rate of pneumonia, mortality, unfavorable Glasgow Outcome Scale score, longer stay in the neuro-intensive care unit (ICU) and hospitalization, and higher hospitalization costs compared with successful extubation. CONCLUSIONS History of craniotomy, preoperative lower cranial nerve dysfunction, tumor size, tumor position, and maximum change in BP during the operation were independent risk factors related to postoperative failed extubation in patients submitted to infratentorial craniotomy. Extubation failure raises the incidences of postoperative pneumonia, mortality, and higher hospitalization costs, and prolongs neuro-ICU and postoperative length of stay.

Perioperative problems in patients with brainstem tumors and their influence on patient outcome

Background and Aims:

Patients with brainstem tumors have many associated systemic abnormalities and are prone to develop perioperative complications. We studied the problems associated with brainstem tumors and their influence on the postoperative neurological outcome.

Material and Methods:

Retrospective review of records of patients who underwent surgery for brainstem tumors over a period of 8 years was done. Preoperative variables, perioperative complications and neurological outcome as assessed by Glasgow Outcome Scale at the time of hospital discharge were noted. Association between perioperative factors and the unfavorable neurological outcome was evaluated.

Results:

Data of 70 patients were retrieved, 7 patients were excluded from the study because of incomplete data and data analysis was carried out for 63 patients. We found that lower cranial nerve palsies (32%) and hydrocephalus (43%) were common preoperatively. Various intraoperative problems encountered were hemodynamic instability (56%), major blood loss requiring blood transfusion (40%) and venous air embolism (11%), and postoperative problems were meningitis (51%), hypokalemia (38%), chest infection (21%), seizure (11%), deterioration of Glasgow Coma Scale (GCS, 11%), hyponatremia (8%), hydrocephalus (6%), respiratory distress (3%) and operatives site hematoma (3%). Fifty-six (89%) patients had favorable outcome at hospital discharge whereas, 7 (11%) had an unfavorable outcome. There was no association between pre- and intra-operative factors and the neurological outcome. Deterioration of GCS, chest infection, and the need for reintubation and tracheostomy were associated with unfavorable neurological outcome.

Conclusion:

Patients of brainstem tumors are at increased risk of perioperative complications. Some of the postoperative complications were associated with unfavorable neurological outcome.

Extubation failure influences clinical and functional outcomes in patients with traumatic brain injury

OBJECTIVE

To evaluate the association between extubation failure and outcomes (clinical and functional) in patients with traumatic brain injury (TBI).

METHODS

A prospective cohort study involving 311 consecutive patients with TBI. The patients were divided into two groups according to extubation outcome: extubation success; and extubation failure (defined as reintubation within 48 h after extubation). A multivariate model was developed in order to determine whether extubation failure was an independent predictor of in-hospital mortality.

RESULTS

The mean age was 35.7 ± 13.8 years. Males accounted for 92.3%. The incidence of extubation failure was 13.8%. In-hospital mortality was 4.5% and 20.9% in successfully extubated patients and in those with extubation failure, respectively (p = 0.001). Tracheostomy was more common in the extubation failure group (55.8% vs. 1.9%; p < 0.001). The median length of hospital stay was significantly greater in the extubation failure group than in the extubation success group (44 days vs. 27 days; p = 0.002). Functional status at discharge was worse among the patients in the extubation failure group. The multivariate analysis showed that extubation failure was an independent predictor of in-hospital mortality (OR = 4.96; 95% CI, 1.86-13.22).

CONCLUSIONS

In patients with TBI, extubation failure appears to lengthen hospital stays; to increase the frequency of tracheostomy and of pulmonary complications; to worsen functional outcomes; and to increase mortality.

Incidence, risk factors, and outcomes of postoperative airway management after cervical spine surgery

STUDY DESIGN

Retrospective database analysis.

OBJECTIVE

To identify the incidence and risk factors for a prolonged intubation or an unplanned reintubation after cervical spine surgery (CSS).

SUMMARY OF BACKGROUND DATA

Patients who undergo CSS occasionally require prolonged mechanical ventilation or an unplanned reintubation for airway support. Despite the potential severity of these complications, there are limited data in the published literature addressing this issue.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was queried to identify patients who underwent a CSS. Patients who required a prolonged intubation more than 48 hours or an unplanned reintubation after CSS were compared with those without airway compromise. Preoperative patient characteristics, intraoperative variables, hospital length of stay, 30-day complication rates, and mortality were compared between the cohorts. An α ≤ 0.001 denoted statistical significance. A multivariate regression model was used to identify independent predictors for a prolonged intubation and an unplanned reintubation.

RESULTS

A total of 8648 cervical spine procedures were identified from 2006 to 2011 of which 54 patients (0.62%) required prolonged ventilation and 56 patients (0.64%) underwent a postoperative reintubation. Patients who required postoperative airway management were older and demonstrated a greater comorbidity burden (P < 0.001). In addition, the affected cohorts demonstrated a significantly greater rate of readmissions, reoperations, postoperative complications, and mortality (P < 0.001). Regression analysis identified the independent predictors for prolonged ventilation to include a history of cardiac disease and dialysis along with a low preoperative albumin level (P < 0.05). Similarly, the independent risk factors for a postoperative reintubation included a history of recent weight loss more than 10%, recent operation within 30 days, low preoperative hematocrit, and a high serum creatinine (P < 0.05).

CONCLUSION

Postoperative airway management is a rare complication after CSS. A prolonged intubation and an unplanned reintubation carry a greater rate of postoperative complications and mortality. High-risk patients should be identified prior to surgery to mitigate the risk factors for postoperative airway compromise.

LEVEL OF EVIDENCE

3.

Factors influencing delayed extubation after infratentorial craniotomy for tumour resection: a prospective cohort study of 800 patients in a Chinese neurosurgical centre

OBJECTIVES

To investigate prospectively the rate of, and factors influencing, delayed extubation following infratentorial craniotomy in a Chinese neurosurgical centre.

METHODS

Patients undergoing infratentorial craniotomy for tumour resection were prospectively enrolled and stratified according to whether extubation was attempted in the operating theatre (early extubation) or not (delayed extubation). Pre- and intraoperative variables were collected and analysed. Multiple logistic regression analysis was performed, to identify factors related to delayed extubation.

RESULTS

The study included 800 patients, 398 (49.8%) of whom underwent delayed extubation. The overall rate of extubation failure was 3.6%. Independent factors related to delayed extubation were: preoperative lower cranial nerve dysfunction; hydrocephalus; tumour location; duration of surgery ≥ 6 h; estimated blood loss ≥ 1000 ml. Compared with patients in the early extubation group, those in the delayed extubation group had a higher rate of pneumonia, longer intensive care unit and postoperative hospital stays, and higher hospitalization costs.

CONCLUSIONS

Brain stem and lower cranial nerve function were the main factors affecting extubation decision-making. Further research is required, to establish criteria for delayed extubation following infratentorial craniotomy.

Pulmonary research recently published in Brazilian journals

We reviewed original articles in the field of pulmonary medicine that had been recently published in 12 Brazilian journals--general or specialty journals--excluding the Brazilian Journal of Pulmonology. All were journals indexed for the Institute for Scientific Information Web of Knowledge. The selection of articles was based on the "continuously variable rating" concept. We have organized the articles by category.