Survey about the Extubation Practice among Anaesthesiologists in Kosovo

Multimodal prevention of emergence cough following nasal endoscopic surgery under general anesthesia: a double-blind randomized trial

Purpose

Cough during emergence from anesthesia is a common problem and may cause adverse events. Monotherapy faces uncertainty in preventing emergence cough due to individual differences. We aimed to evaluate the efficacy and safety of multimodal intervention for preventing emergence cough in patients following nasal endoscopic surgery.

Methods

In this double-blind randomized trial, 150 adult patients undergoing nasal endoscopic surgery were randomly allocated into three groups. For the control group (n = 50), anesthesia was performed according to clinical routine, no intervention was provided. For the double intervention group (n = 50), normal saline 3 mL was sprayed endotracheally before intubation, 0.4 μg/kg dexmedetomidine was infused over 10 min after intubation, and target-controlled remifentanil infusion was maintained at an effect-site concentration of 1.5 ng/mL before extubation after surgery. For the multimodal intervention group (n = 50), 0.5% ropivacaine 3 mL was sprayed endotracheally before intubation, dexmedetomidine and remifentanil were administered as those in the double intervention group. The primary endpoint was the incidence of emergence cough, defined as single cough or more from end of surgery to 5 min after extubation.

Results

The incidences of emergence cough were 98% (49/50) in the control group, 90% (45/50) in the double group, and 70% (35/50) in the multimodal group, respectively. The incidence was significantly lower in the multimodal group than those in the control (relative risk 0.71; 95% CI 0.59 to 0.86; p < 0.001) and double (relative risk 0.78; 95% CI 0.63 to 0.95; p = 0.012) groups; the difference between the double and control groups was not statistically significant (relative risk 0.92; 95% CI 0.83 to 1.02; p = 0.20). The severity of sore throat was significantly lower in the multimodal group than that in the control group (median difference-1; 95% CI -2 to 0; p = 0.016). Adverse events did not differ among the three groups.

Conclusion

For adult patients undergoing endonasal surgery, multimodal intervention including ropivacaine topical anesthesia before intubation, dexmedetomidine administration after intubation, and remifentanil infusion before extubation after surgery significantly reduced emergence cough and was safe.

Effect of different head-high lateral extubation on adverse reactions in the peri-extubation period of pediatric OSAS surgery under general anesthesia

BACKGROUND

Children with OSAS are prone to various airway complications during tracheal extubation after tonsillectomy and adenoidectomy due to oropharyngeal secretions and oozing blood. However, few studies have examined the effect of position on airway complications after tracheal extubation in children with OSAS. The aim of this study was to investigate the appropriate position for extubation in children with OASA.

METHODS

A total of 459 children aged 3-14 years with OSAS who underwent tonsillectomy and adenoidectomy were recruited for this study. All children were treated with the same surgical approach and standard anesthesia methods of induction of anesthesia, tracheal intubation and maintenance of anesthesia. At the end of surgery, the children were delivered to the post anesthesia care unit and randomly divided into three groups: Group A: Head-high 0° in lateral position; Group B: Head-high 15° in lateral position; Group C: Head-high 30° in lateral position. The main outcomes of this study were the pulse oxygen saturation (SpO₂) and the Sedation-Agitation Scale (SAS) scores of the children after extubation, the outflow of oral-nasal secretions and the respiratory complications. Secondary outcomes were blood pressure, heart rate, end-respiratory carbon dioxide, respiratory rate, and post-operative awakening time of the children in three groups.

RESULTS

Data from a total of 423 children were statistically analyzed, 141 in Group A, 142 in Group B, and 140 in Group C. The main results showed a significant decrease in choking response after extubation in Group B (46.5%) and Group C (40.7%) compared to Group A (60.3%) (P < 0.05). The SAS score for postoperative agitation was higher in Group A (4.6 [Formula: see text] 0.9) than in Group B (4.4 [Formula: see text] 0.7) and Group C (4.3 [Formula: see text] 0.6) (P < 0.05). Also the SpO₂ after extubation was higher in Group B (97.2%) and Group C (97.1%) than in Group A (95.8%) (P < 0.05). In contrast, there was no difference in the occurrence of respiratory complication and postoperative agitation in children between Group B and Group C (all P > 0.05). In addition, there was no difference in the amount of oral-nasal secretions among the children in the three groups (all P > 0.05).

CONCLUSION

The head-high 15° lateral position and head-high 30° lateral position can reduce the incidence of airway complications and agitation and provide safe and comfortable extubation conditions for children during the peri-extubation period after tonsillectomy and adenoidectomy, which has certain clinical guidance value.

TRIAL REGISTRATION

Registration Number: NO.ChiCTR2200055835(20,01,2022) https://www.chictr.org.cn.

Comparison of Two Extubation Techniques in Critically Ill Adult Subjects: The ExtubAR Randomized Clinical Trial

BACKGROUND

Two orotracheal extubation techniques are described in the literature: the traditional technique and the positive-pressure technique. Although prior studies reported better clinical outcomes with the positive-pressure extubation technique, its superiority has not been extensively studied yet. This study was to determine whether the positive-pressure orotracheal extubation technique, compared with the traditional orotracheal extubation technique, reduces the incidence of major postextubation complications (up to 60 min) in critically ill adult subjects.

METHODS

This was a multi-center randomized clinical trial. Subjects age > 18 y, requiring invasive mechanical ventilation through an endotracheal tube, who met the orotracheal extubation criteria were included and randomized to traditional extubation group (removing the endotracheal tube by applying continuous endotracheal suctioning during the entire procedure) or positive-pressure group (application of pressure support mode at 15/10 cm H₂O during cuff deflation and extubation). The primary measure was postextubation major complications, defined as the clinical evidence of at least one of the following: desaturation, upper-airway obstruction, or vomiting.

RESULTS

A total of 725 subjects was randomly assigned to the traditional extubation group (n = 358) and positive-pressure group (n = 367). Seventeen subjects were eliminated and not included in the per-protocol analysis. Of 708 subjects, 185 (26.1%) developed at least one major complication. The incidence was 27.8% (96/345) in the traditional group compared with 24.5% (89/363) in the positive-pressure group. No statistically significant differences were observed between the 2 groups (absolute risk 3% [95 CI -3 to 10]; relative risk, 0.88 [95 CI 0.69-1.13], P = .32).

CONCLUSIONS

Despite the trend toward the positive-pressure group, no statistically significant differences were observed. Our findings agree with the literature in that positive-pressure extubation is a safe procedure; therefore, both techniques may be used during extubation in critically ill adult patients.

A descriptive survey of tracheal extubation practices among Indian anaesthesiologists

BACKGROUND AND AIMS

This study assesses the extubation practices of anaesthesiologists and whether these practices differ from existing guidelines.

METHODS

The literature related to tracheal extubation was searched and a validated questionnaire was designed to assess practices of tracheal extubation. The questionnaire included techniques, manoeuvres, preparation, timing and plan of extubation. The survey link was shared with eligible participants. The responses were assessed using Statistical Package for Social Sciences (SPSS) software.

RESULTS

Of the 1264 respondents, 66.8% keep difficult airway cart ready only when difficult extubation is anticipated. Only 12.3% of respondents perform deep extubation with supraglottic airway device (SAD) exchange while 73.3% of respondents perform awake extubation with pharmacological control for preventing haemodynamic fluctuations. In the case of anticipated difficult extubation, 48.3% anaesthesiologists prefer the airway exchange catheter (AEC) exchange technique. Of all, 84.8% anaesthesiologists administer 100% oxygen before performing extubation and 81.7% continue to oxygenate during and 83.9% provide oxygen after extubation in all patients. In the case of suspected airway edema or collapse or surgical cause for airway compromise, 70% anaesthesiologists perform a leak test. The most preferred plan of extubation in patients with suspected airway collapse after surgery is direct extubation in fully awake position (54.6%). In patients with anticipated difficult extubation, 50.8% anaesthesiologists prefer to ventilate for 24 hours and reassess.

CONCLUSION

We observed that the extubation practices vary widely among anaesthesiologists. Almost half of the anaesthesiologists were unaware of extubation guidelines.

The Relationship between the Timing of Sugammadex Administration and the Upper Airway Obstruction during Awakening from Anesthesia: A Retrospective Study

Background and Objectives: The harmonization of recovery of consciousness and muscular function is important in emergence from anesthesia. Even if muscular function is recovered, tracheal extubation without adequate recovery of consciousness may increase the risk of respiratory complications. In particular, upper airway obstruction is one of the common respiratory complications and can sometimes be fatal. However, the association between the timing of sugammadex administration and the upper airway obstruction that can occur during awakening from anesthesia has rarely been studied. Materials and Methods: The medical records of 456 patients who had surgery under general endotracheal anesthesia (GETA) at the Haeundae Paik Hospital between October 2017 and July 2018 and who received intravenous sugammadex to reverse rocuronium-induced neuromuscular blockade were analyzed. The correlations between bispectral index (BIS) and minimum alveolar concentration (MAC) at the time of sugammadex administration, the incidence of complications, and the time to tracheal extubation were analyzed to investigate how different timings of sugammadex administration affected upper airway obstruction after tracheal extubation. Conclusions: The effect of BIS and the duration from anesthetic discontinuation to sugammadex administration on upper airway obstruction was not statistically significant. However, the odds ratio of complication rates with MAC < 0.3 compared with MAC ≥ 0.3 was 0.40 (95% confidence interval 0.20 to 0.81, p = 0.011), showing a statistically significant increase in risk with MAC ≥ 0.3 for upper airway obstruction.

Incidence of immediate postextubation complications in critically Ill adult patients

BACKGROUND

Postextubation complication rates vary among studies. It is necessary to standardize a method to identify postextubation complications and determine their potential association with extubation failure and reintubation in critically ill adult patients.

OBJECTIVES

To describe immediate (up to 60 min) endotracheal postextubation complications in critically ill adult patients and determine whether these complications are associated with extubation failure.

METHODS

Secondary analysis of a Randomized Clinical Trial that included 240 critically ill adult patients, who were eligible for extubation. Overall complications include at least one major complication (upper airway obstruction, desaturation, vomiting, post-obstructive pulmonary edema) and/or minor complications (bronchospasm, severe cough, hypertension, tachycardia, tachypnea, poor respiratory mechanics).

RESULTS

Incidence of overall, major and minor complications was 71.2%, 30.9% and 62.7%, respectively. Forty (16.9%) patients failed extubation, and thirty (12.7%) were reintubated. Of 168 patients who developed a postextubation complication, 137 (81.5%) were successfully extubated. Only major complications were significantly associated with reintubation after extubation failure (p<0.001).

CONCLUSION

We have observed high incidence rates of overall, major and minor complications. The development of major complications was statistically significantly associated with extubation failure and reintubation. It is still unknown whether the identification and treatment of immediate postextubation complications have positive effects on patients' clinical course or whether the complications are a mere effect of the extubation procedure.

Effect of using the Suction Above Cuff Endotracheal Tube (SACETT) on postoperative respiratory complications in rhinoplasty: a randomized prospective controlled trial

Background: The Suction Above Cuff Endotracheal Tube (SACETT) has a dorsal port above the cuff designed to enable the continuous or intermittent suctioning of secretions from the subglottic space. Thus, it facilitates the suctioning of excessive secretions above the cuff and around the glottis.

Objectives: In this study, we investigated the effect of the using the SACETT on laryngospasm and postoperative complications in rhinoplasty operations.

Methods: This randomized controlled clinical trial enrolled 132 patients undergoing rhinoplasty. The patients were randomly divided into two groups: Suction above Cuff Endotracheal Tube (n=66; Group SA) and classic endotracheal tube (n=66; Group C). Complications following general anesthesia were statistically analyzed among the two groups.

Results: The incidence of postoperative laryngospasm (p=0.02) and respiratory complications was found to be lower in Group SA than in Group C. In addition, the incidence of agitation (p=0.035), postoperative nausea, and vomiting (PONV) (p=0.041), which required antiemetic drug administration, swallowing difficulty (p=0.012), and sore throat (p=0.027) were found to be lower in Group SA than in Group C.

Conclusion: We suggest that using the SACETT in rhinoplasty reduces the incidence of postoperative respiratory complications as well as the incidence of agitation, sore throat, swallowing difficulty, and PONV.

Clinical Trial Number: NCT03584503