Who Is Safe to Extubate in the Neuroscience Intensive Care Unit?

Bösel, Julian

doi:10.1055/s-0037-1608773

Cited by 22 publications

(13 citation statements)

References 64 publications

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“…Many attempts have been made to identify predictors of extubation failure or success in neurocritically ill patients, and to establish extubation scores for neuro-ICU populations, but results remain controversial. 11 This is critical, as delayed extubation in neuro-ICU patients not meeting established extubation criteria leads to increasing complications, including VAP and prolonged ICU stay, while earlier and later extubated patients do not differ regarding reintubation rates. 12 We aimed to investigate the frequency of mechanical ventilation in adult patients in SE and its clinical associations, to identify early predictors at SE onset of prolonged postictal mechanical ventilation after SE, and to determine the associated outcomes of prolonged postictal mechanical ventilation.…”

Section: Introductionmentioning

confidence: 99%

Prolonged mechanical ventilation in patients with terminated status epilepticus and outcome: An observational cohort study

et al. 2021

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Objective: Classical clinical characteristics associated with successful or unsuccessful extubation are unreliable in neurocritically ill patients, and attempts to predict successful extubation in this context have failed. We aimed to investigate the frequency of mechanical ventilation (MV) in adult patients in status epilepticus (SE) and its clinical associations, to identify predictors at SE onset of prolonged postictal MV, and to determine the associated outcomes with prolonged MV. Methods:From 2012 to 2018, SE patients treated in intensive care units at a Swiss academic care center were included. Multivariable Poisson regression adjusting for potential confounders, such as continuously administered anesthetics, was performed to identify risks for postictal MV for >24 h after SE and its association with no return to neurologic function and death. Linear regression was performed to identify correlations between the durations of administered specific anesthetics and postictal MV.Results: Of 262 patients, 42% were ventilated, with 24% being on ventilators for >24 h after SE. Patients with prolonged postictal MV were extubated at a median of 7 days, with 56% not being extubated on the day of successful weaning from MV because of altered consciousness and/or lack of airway-protective reflexes.After extubation, noninvasive ventilation and reintubation were rarely needed.Prolonged postictal MV was associated with increased risk for death independent of potential confounders, including fatal etiology of SE, age, SE severity, and use of anesthetics (relative risk for every additional day = 2.7, p = .024). At SE onset, decreased consciousness and presumed fatal etiology predicted prolonged postictal MV. Anesthetics were associated with prolonged MV, but linear regression could not identify significant correlations.

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Section: Introductionmentioning

confidence: 99%

Prolonged mechanical ventilation in patients with terminated status epilepticus and outcome: An observational cohort study

et al. 2021

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“…Another common source of uncertainty when preparing for potential DFE is the patient with a depressed neurologic status, whether it be from intracranial pathology such cerebral vascular accidents (CVA), traumatic brain injury (TBI), toxic metabolic encephalopathy, or those with peripheral neuromuscular disorders. In fact, it's estimated that DFE rate in neuroscience-ICU (NICU) may be as high as 20–40% [41]. These patients may have appropriate respiratory mechanics, but when extubated demonstrate an inability to protect their airways [41,42 ▪ ,43–45].…”

Section: Defining the Problem Of The Failed Or Difficult Extubationmentioning

confidence: 99%

“…In fact, it's estimated that DFE rate in neuroscience-ICU (NICU) may be as high as 20–40% [41]. These patients may have appropriate respiratory mechanics, but when extubated demonstrate an inability to protect their airways [41,42 ▪ ,43–45]. In a recent meta-analysis, Wang et al [45] demonstrated that there are additional factors that predispose neurologically injured adults to DFE – the absence of a gag reflex, lower Glasgow Coma Scale (GCS) (7–9T), duration of MV >24 h, thick secretions, or coexisting pulmonary disease.…”

Section: Defining the Problem Of The Failed Or Difficult Extubationmentioning

confidence: 99%

Extubation of the potentially difficult airway in the intensive care unit

Joffe

Barnes

2022

Current Opinion in Anaesthesiology

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Purpose of reviewExtubation in the intensive care unit (ICU) is associated with a failure rate requiring reintubation in 10–20% patients further associated with significant morbidity and mortality. This review serves to highlight recent advancements and guidance on approaching extubation for patients at risk for difficult or failed extubation (DFE).Recent findingsRecent literature including closed claim analysis, meta-analyses, and national society guidelines demonstrate that extubation in the ICU remains an at-risk time for patients. Identifiable strategies aimed at optimizing respiratory mechanics, patient comorbidities, and airway protection, as well as preparing an extubation strategy have been described as potential methods to decrease occurrence of DFE.SummaryExtubation in the ICU remains an elective decision and patients found to be at risk should be further optimized and planning undertaken prior to proceeding. Extubation for the at-risk patient should be operationalized utilizing easily reproducible strategies, with airway experts present to guide decision making and assist in reintubation if needed.

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“…Unfortunately, those widespread criteria cannot easily be extrapolated to neurocritical patients. EF rates in neurological intensive care unit (NICU) studies are reported to range up to 40% 12 – 14 . Moreover, NICU patients show longer duration of ventilation and have higher rates of ventilator-induced pneumonia and mortality compared to general ICU populations 15 – 17 .…”

Section: Introductionmentioning

confidence: 99%

Quantitative EEG may predict weaning failure in ventilated patients on the neurological intensive care unit

Welte

Gabriel

Hopfengärtner

et al. 2022

Sci Rep

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Neurocritical patients suffer from a substantial risk of extubation failure. The aim of this prospective study was to analyze if quantitative EEG (qEEG) monitoring is able to predict successful extubation in these patients. We analyzed EEG-monitoring for at least six hours before extubation in patients receiving mechanical ventilation (MV) on our neurological intensive care unit (NICU) between November 2017 and May 2019. Patients were divided in 2 groups: patients with successful extubation (SE) versus patients with complications after MV withdrawal (failed extubation; FE), including reintubation, need for non-invasive ventilation (NIV) or death. Bipolar six channel EEG was applied. Unselected raw EEG signal underwent automated artefact rejection and Short Time Fast Fourier Transformation. The following relative proportions of global EEG spectrum were analyzed: relative beta (RB), alpha (RA), theta (RT), delta (RD) as well as the alpha delta ratio (ADR). Coefficient of variation (CV) was calculated as a measure of fluctuations in the different power bands. Mann–Whitney U test and logistic regression were applied to analyze group differences. 52 patients were included (26 male, mean age 65 ± 17 years, diagnosis: 40% seizures/status epilepticus, 37% ischemia, 13% intracranial hemorrhage, 10% others). Successful extubation was possible in 40 patients (77%), reintubation was necessary in 6 patients (12%), 5 patients (10%) required NIV, one patient died. In contrast to FE patients, SE patients showed more stable EEG power values (lower CV) considering all EEG channels (RB: p < 0.0005; RA: p = 0.045; RT: p = 0.045) with RB as an independent predictor of weaning success in logistic regression (p = 0.004). The proportion of the EEG frequency bands (RB, RA RT, RD) of the entire EEG power spectrum was not significantly different between SE and FE patients. Higher fluctuations in qEEG frequency bands, reflecting greater fluctuation in alertness, during the hours before cessation of MV were associated with a higher rate of complications after extubation in this cohort. The stability of qEEG power values may represent a non-invasive, examiner-independent parameter to facilitate weaning assessment in neurocritical patients.

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Who Is Safe to Extubate in the Neuroscience Intensive Care Unit?

Cited by 22 publications

References 64 publications

Prolonged mechanical ventilation in patients with terminated status epilepticus and outcome: An observational cohort study

Prolonged mechanical ventilation in patients with terminated status epilepticus and outcome: An observational cohort study

Extubation of the potentially difficult airway in the intensive care unit

Quantitative EEG may predict weaning failure in ventilated patients on the neurological intensive care unit

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