Early extubation after thymectomy is good for the patients with myasthenia gravis.
ABSTRACT: OBJECTIVES:Patients with myasthenia gravis (MG) often benefit from thymectomy, but the optimal timing of extubation following thymectomy in these patients remains unknown. This study of MG patients compared the effect of early and late extubation following thymectomy on clinical outcome. METHODS:We performed a study of data from 96 patients with MG who received thymectomy procedures, followed by early (?6 h) extubation, at our institution between October 2011 and November 2017. Patient clinical and demographic characteristics, preoperative data, and postoperative clinical outcomes were analyzed. Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study. RESULTS:The patients in the early extubation group (n?=?53) and late extubation group (n?=?43) had similar preoperative clinical and demographic characteristics. However, the early extubation group had a significantly longer duration of MG (24 months vs. 12 months, P?
Project description:OBJECTIVE:To determine whether a collaborative learning strategy-derived clinical practice guideline can reduce the duration of endotracheal intubation following infant heart surgery. DESIGN:Prospective and retrospective data collected from the Pediatric Heart Network in the 12 months pre- and post-clinical practice guideline implementation at the four sites participating in the collaborative (active sites) compared with data from five Pediatric Heart Network centers not participating in collaborative learning (control sites). SETTING:Ten children's hospitals. PATIENTS:Data were collected for infants following two-index operations: 1) repair of isolated coarctation of the aorta (birth to 365 d) and 2) repair of tetralogy of Fallot (29-365 d). There were 240 subjects eligible for the clinical practice guideline at active sites and 259 subjects at control sites. INTERVENTIONS:Development and application of early extubation clinical practice guideline. MEASUREMENTS AND MAIN RESULTS:After clinical practice guideline implementation, the rate of early extubation at active sites increased significantly from 11.7% to 66.9% (p < 0.001) with no increase in reintubation rate. The median duration of postoperative intubation among active sites decreased from 21.2 to 4.5 hours (p < 0.001). No statistically significant change in early extubation rates was found in the control sites 11.7% to 13.7% (p = 0.63). At active sites, clinical practice guideline implementation had no statistically significant impact on median ICU length of stay (71.9?hr pre- vs 69.2?hr postimplementation; p = 0.29) for the entire cohort. There was a trend toward shorter ICU length of stay in the tetralogy of Fallot subgroup (71.6?hr pre- vs 54.2?hr postimplementation, p = 0.068). CONCLUSIONS:A collaborative learning strategy designed clinical practice guideline significantly increased the rate of early extubation with no change in the rate of reintubation. The early extubation clinical practice guideline did not significantly change postoperative ICU length of stay.
Project description:Purpose:Postoperative acute kidney injury (AKI) is a frequent complication in elderly patients that increases morbidity and mortality. Approximately 1.7 million people die from AKI worldwide every year. Dexmedetomidine (Dex) is often used as an adjunct to multimodal analgesia. Our study investigated whether Dex could safely decrease the incidence of AKI in elderly patients undergoing major joint replacement. Methods:A single-center retrospective study was conducted in patients aged >65 years undergoing major joint replacement. Propensity score-matching analysis was used, and a total of 1,006 patients were matched successfully. The primary outcome was the incidence of postoperative AKI. Secondary outcomes included perioperative adverse complications, opioid consumption, time to extubation, and length of hospital stay. Results:Among the 1,006 patients included, postoperative AKI occurred in 9.3% (n=94). The Dex group (perioperative Dex infusion) had lower incidence of postoperative AKI than the control group (7.2% vs 11.5%, P=0.017). Compared with the control group, the Dex group had less opioid consumption (P<0.05), reduced time to extubation (P=0.004), and shorter length of hospital stay (P=0.001). The Dex group also showed higher incidence of bradycardia (20.1% vs 15.1%, P=0.038). There were no differences in intraoperative hypotension (19.5% vs 17.5%), postoperative nausea and vomiting (4.2% vs 5.4%), time in PACU (45.0±6.4 vs 45.5±6.2 minutes), or rate of ICU admission (9.7% vs 11.1%) between the Dex group and control group (All P>0.05). Conclusion:This retrospective study showed Dex infusion in elderly patients undergoing major joint replacement was associated with lower incidence of postoperative AKI, less opioid consumption, and shorter extubation time and hospital stay. However, the Dex group had higher incidence of bradycardia. We found no statistical differences in other perioperative adverse complications between the groups.
Project description:Purpose:In this study, the effect of intravenous vitamin C during surgery on the incidence of postoperative pulmonary complications (PPCs) in patients undergoing cardiopulmonary bypass and cardiac surgery was observed, and its protective effect on the lungs was evaluated to provide a reference for clinical medication. Patients and Methods:Patients undergoing cardiac surgery under cardiopulmonary bypass (CPB) were selected. The patients were divided into group A and group C by random sequence. Patients in group A received intravenous vitamin C 1 g 10 minutes after induction of anesthesia, 10 minutes before cardiac reanimation and at the moment of sternal closure. Patients in group C were intravenously injected with the same volume of saline at the same time. The primary outcome was the postoperative pulmonary complication severity score. Other outcomes were the incidence of PPCs, awakening time, extubation time, length of ICU stay, length of hospital stay, adverse events, oxygenation index (PaO2/FiO2), alveolar arterial oxygen partial pressure difference (A-aDO2), dynamic lung compliance (Cd) and static lung compliance (Cs). Results:Seventy patients completed the study. Compared to group C, the postoperative pulmonary complication score [2(2-3) vs 2(1-2); P=0.009] and the incidence of postoperative pulmonary complications (32.43% vs 12.12%; P =0.043) were lower in group A. There were no significant differences in awakening time, extubation time, length of ICU stay, length of hospital stay, adverse events, PaO2/FiO2, A-aDO2, Cs, and Cd between the two groups (P>0.05). Conclusion:In summary, this small randomized trial including low-risk cardiac surgery patients shows that intravenous vitamin C may safely be administered and may be helpful to prevent PPCs after cardiac surgery.
Project description:OBJECTIVES:The Pediatric Heart Network sponsored the multicenter Collaborative Learning Study that implemented a clinical practice guideline to facilitate early extubation in infants after repair of isolated coarctation of the aorta and tetralogy of Fallot. We sought to compare the anesthetic practice in the operating room and sedation-analgesia management in the ICU before and after the implementation of the guideline that resulted in early extubation. DESIGN:Secondary analysis of data from a multicenter study from January 2013 to April 2015. Predefined variables of anesthetic, sedative, and analgesia exposure were compared before and after guideline implementation. Propensity score weighted logistic regression analysis was used to determine the independent effect of intraoperative dexmedetomidine administration on early extubation. SETTING:Five children's hospitals. PATIENTS:A total of 240 study subjects who underwent repair of coarctation of the aorta or tetralogy of Fallot (119 preguideline implementation and 121 postguideline implementation). INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:Clinical practice guideline implementation was accompanied by a decrease in the median total intraoperative dose of opioids (49.7 vs 24.0 µg/kg of fentanyl equivalents, p < 0.001) and benzodiazepines (1.0 vs 0.4?mg/kg of midazolam equivalents, p < 0.001), but no change in median volatile anesthetic agent exposure (1.3 vs 1.5 minimum alveolar concentration hr, p = 0.25). Intraoperative dexmedetomidine administration was associated with early extubation (odds ratio 2.5, 95% CI, 1.02-5.99, p = 0.04) when adjusted for other covariates. In the ICU, more patients received dexmedetomidine (43% vs 75%), but concomitant benzodiazepine exposure decreased in both the frequency (66% vs 57%, p < 0.001) and cumulative median dose (0.5 vs 0.3?mg/kg of ME, p = 0.003) postguideline implementation. CONCLUSIONS:The implementation of an early extubation clinical practice guideline resulted in a reduction in the dose of opioids and benzodiazepines without a change in volatile anesthetic agent used in the operating room. Intraoperative dexmedetomidine administration was independently associated with early extubation. The total benzodiazepine exposure decreased in the early postoperative period.
Project description:BACKGROUND:Surgery for aortic coarctation requires special care during anesthesia due to severe pain during the lateral thoracotomy incision, intraoperative hemodynamic instability and the need for large doses of intra- and postoperative analgesics and vasodilators. Additionally, the postoperative care of patients is very important. AIMS:We aimed to compare ultrasound-guided paravertebral block performed using bupivacaine alone and bupivacaine with dexamethasone in terms of the intra- and postoperative analgesic requirements and hemodynamics, postoperative complications and ICU stay. STUDY DESIGN:This was a prospective, randomized, controlled, double-blinded study. METHODS:Fifty patients aged four to 12?months scheduled for aortic coarctation surgery were randomly divided into two equal groups (n?=?25). Patients in group D (dexamethasone) received 0.5?mg/kg bupivacaine 0.25% mixed with 0.1?mg/kg dexamethasone diluted with isotonic saline and those in group C (control) received 0.5?mg/kg bupivacaine 0.25% diluted with isotonic saline (total volume 15?ml in each group). Intraoperative fentanyl consumption and hemodynamics (heart rate, arterial blood pressure) at baseline, 1?min after induction, at skin incision, after 30?min, after clamping, after declamping and at the end of the surgery were recorded, along with the objective pain score (OPS) immediately postoperatively and at 4?h, 8?h, 12?h and 24?h postoperatively and the time to the first request for pethidine. The intra- and postoperative vasodilator doses, time to extubation, ICU stay duration and postoperative complications were also recorded. RESULTS:The postoperative OPS was significantly lower at 12 and 24?h in group D than in group C. The time to the first request for analgesia was significantly longer in group D than in group C (3.9?±?2.23 vs 8.6?±?0.69). Additionally, the time to extubation was significantly shorter in group D. CONCLUSION:The use of dexamethasone as an adjuvant in ultrasound-guided paravertebral block in paediatric patients undergoing surgery for aortic coarctation increased the duration of postoperative analgesia with a prolonged time to the first request for analgesics It was also associated with a decreased incidence of postoperative complications. TRIAL REGISTRATION:Trial registration number: NCT03074773 . (Prospectively registered). The initial registration date was 9/3/2017.
Project description:Fast track recovery is a care process goal after cardiac surgery. Intraoperative anesthetic depth may impact recovery, but the impact of brain monitoring on time to extubation and intensive care unit (ICU) length of stay after cardiac surgery has not been extensively studied. Our goal was to determine if BIS-guided anesthesia improves time to extubation compared to MAC-guided anesthesia in a cardiac surgery population.In this secondary outcome analysis of a randomized controlled study, we analyzed 294 patients undergoing elective coronary bypass grafting, valve replacements, and bypass plus valve replacements at a single tertiary referral center between February 1, 2009 and April 30, 2010. We analyzed cardiac surgery patients that had been randomized to BIS-guided anesthesia alerts (n?=?131) or MAC-guided anesthesia alerts (n?=?163). The primary outcome measure was time to extubation in the BIS-guided and anesthetic concentration-guided groups. Secondary outcomes were length of stay in the ICU and total postoperative hospital length of stay.Valid extubation time data were available for 247 of 294 patients. The median [IQR] time to extubation was 307 [215 to 771] minutes in the BIS group and 323 [196 to 730] minutes in the anesthetic concentration group (p?=?0.61). The median [IQR] ICU length of stay was 54 [29 to 97] hours versus 70 [44 to 99] hours (p?=?0.11). In terms of postoperative hospital length of stay, there was no difference between the groups with median [IQR] times of 6 [5-8] days (p?=?0.69) in each group.The use of intraoperative BIS monitoring during cardiac surgery did not change time to extubation, ICU length of stay or hospital length of stay. Data regarding BIS monitoring and recovery in an exclusively cardiac surgery population are consistent with recent effectiveness studies in the general surgical population.ClinicalTrials.gov number NCT00689091.
Project description:Thymectomy is the primary approach for the treatment of myasthenia gravis (MG). This retrospective study aimed to identify the clinical and demographical features that may impact the duration of mechanical ventilation (DMV), the long-term survival, and the quality of life (QOL) in patients with post-thymectomy myasthenic crisis (PTMC).We reviewed the patients who suffered from PTMC from June 2008 to November 2015. Cox proportional hazard regression analysis was used to identify potential prognostic factors that may impact DMV and long-term survival. Spearman bivariate correlation analysis was used to analyze the relationship between DMV and QOL. Statistical powers were calculated.In total, 70 patients with PTMC were enrolled. Alcohol abuse, high scores of Myasthenia Gravis Foundation of America (MGFA) classification and Clavien-Dindo classification were critical factors that remarkably delayed early extubation. High scores of Osserman's classification, MGFA classification, and Clavien-Dindo classification predicted a poor prognosis in PTMC patients. Occupational skills and job status were observed to be negatively affected in PTMC patients.To decrease the duration of mechanical ventilation, we suggest alcohol abstinence before the operation, appropriate preoperative treatment to decrease MGFA classification, and greater attention to the treatment of postoperative complications.
Project description:Background:The approaches to thoracoscopic thymectomy in myasthenia gravis (MG) are debatable. We developed a novel approach via subxiphoid and subcostal arch, with a significantly shorter duration of operation and hospital stay, less estimated blood loss, and lower postoperative pain. Methods:From December 2012 to December 2014, 77 myasthenia gravis patients with or without thymoma underwent thoracoscopic extended thymectomy at our hospital. Among them, 41 patients were operated via the subxiphoid and subcostal arch approach and the other 36 via the conventional unilateral approach. The patient outcomes were retrospectively reviewed and evaluated. Results:The thoracoscopic extended thymectomy was performed safely via the subxiphoid and subcostal arch approach. In this approach, no drainage tube was inserted after operation except in the first two patients. Two of the 41 patients were switched to trans-sternal approach due to the tight adhesion between the thymoma and the left innominate vein. No major complications occurred. Compared with the unilateral approach, the duration of the procedure via subxiphoid and subcostal arch was significantly shorter, with less estimated blood loss, shorter hospital-stay and lower postoperative pain (P<0.001). The cosmetic scores were comparable between the two groups (P=0.369). Conclusions:The novel subxiphoid and subcostal arch approach is technically feasible and safe. It is an acceptable alternative to conventional thoracoscopic extended thymectomy.
Project description:Objectives:Emergence delirium (ED) is a common neurologic complication that can not only distress children and their families in the early postanesthetic period, but can also have adverse effects on children in the long-term. This study aimed to investigate the effects of single-dose dexmedetomidine on ED in children with sevoflurane anesthesia and to observe postoperative behavioral changes through long-term follow-up. Methods:Patients aged 2-7 years, American Society of Anesthesiologists class (ASA) I or II, scheduled for tonsillectomy with and without adenoidectomy were randomized to receive dexmedetomidine 0.5 μg/kg (Group D) or volume-matched normal saline (Group C) over 10 minutes after induction of anesthesia. The primary outcome was the incidence of ED within 30 minutes after extubation. Other outcomes were the incidence of pain, extubation time, post-anesthesia care unit (PACU) length of stay after extubation, adverse events, and the incidence of negative postoperative behavioral changes (NPOBCs). Results:Ninety children completed the study. Compared with the control group (Group C), dexmedetomidine decreased the incidence of ED (31.1% vs 53.3%; P=0.033) and pain (28.9% vs 57.8%; P=0.006), but it prolonged extubation time (P⩽0.001). PACU length of stay after extubation and the percentage of adverse events were similar between groups. The incidence of NPOBCs in Group D was significantly lower at 1 and 7 days after discharge (33.3% vs 60.0%; P=0.011% and 24.4% vs 46.7%; P=0.028, respectively) than it was in Group C, but no significant difference was found at the 30th day. Conclusion:Dexmedetomidine 0.5 μg/kg reduced the incidence of ED after sevoflurane anesthesia and might be used to prevent NPOBCs. Clinical trials registration:ChiCTR1800016828.
Project description:BACKGROUND:Liberation and extubation are important for patients supported by mechanical ventilation. Extubation success is related to the duration of an intensive care unit (ICU) stay and mortality rate. High-flow nasal cannula (HFNC) oxygen therapy has physiological and clinical benefits in respiratory care. The present study compared clinical outcomes associated with HFNC and conventional oxygen therapy (COT) among patients at high risk for reintubation. METHODS:A single-center randomized clinical trial was conducted between March 2018 and June 2019. Sixty adults admitted to the ICU and who were at high-risk of reintubation and met the inclusion criteria were enrolled in this study. "High risk" for reintubation was defined as having at least one of the following risk factors: age > 65 years, Acute Physiology and Chronic Health Evaluation II score > 12 points on extubation day, obesity, poor expectoration, airway patency problems, difficult or prolonged weaning, and more than one comorbidity. The primary outcome of interest was reintubation within 72 hours. Secondary outcomes included duration of ICU and hospital stay, mortality rate, and time to reintubation. RESULTS:Of 60 patients, 31 received HFNC and 29 received COT (mean age, 78 ± 7.8 vs. 76 ± 6.5 years, respectively). Reintubation rate within 72 hours did not differ between the groups (3 patients [9.7%] vs. 1 patient [3.4%], respectively). Reintubation time was shorter among patients who received COT than among patients who received HFNC (0.5 hour vs. 25 hours), but this difference was not statistically significant. Duration of ICU did not differ between the groups (14.7 ± 9.6 days vs. 13.8 ± 15.7 days, for HFNC and COT, respectively). CONCLUSION:Among patients at high risk for reintubation, compared with COT, HFNC did not reduce the risk of reintubation within 72 hours.