Ghosh Supradip, Chawla Aayush, Jhalani Ranupriya, Salhotra Ripenmeet, Arora Garima, Nagar Satyanarayan, Bhadauria Abhay S, Mishra Kirtee, Singh Amandeep, Lyall Aditya
Department of Critical Care Medicine, Fortis-Escorts Hospital, Faridabad, Haryana, India.
Department of Anesthesia and Critical Care Medicine, MP Birla Hospital, Chittorgarh, Rajasthan, India.
Indian J Crit Care Med. 2020 Dec;24(12):1185-1192. doi: 10.5005/jp-journals-10071-23673.
Prophylactic use of noninvasive ventilation (NIV) is recommended following extubation in patients at high risk of extubation failure. In a prospective cohort study, we examined the impact of prophylactic NIV in this subset of patients, potentially exploring the risk factors for extubation failure in them and the impact of extubation failure on organ function. We also explored the effect of fluid balance on extubation failure or success in this high-risk patient subgroup.
Consecutive adult patients (≥18 years) admitted in the mixed intensive care unit (ICU) of a tertiary care center, between January 1, 2018, and December 31, 2019, who passed a spontaneous breathing trial (SBT) following at least 12 hours of invasive mechanical ventilation and put on prophylactic NIV for being at a high risk of extubation failure, were prospectively followed throughout their hospital stay. Extubation failure was defined as developing respiratory failure within 72 hours postextubation requiring reintubation or still requiring NIV support at 72 hours postextubation.
A total of 85 patients were included in the study. 11.8% of patients had extubation failure at 72 hours with an overall reintubation rate of 10.5%. Higher age ( < 0.05), longer duration of invasive ventilation ( < 0.05), and higher sequential organ failure assessment (SOFA) score at extubation ( < 0.05) were identified as risk factors for extubation failure in univariate analysis. However, in the multivariate analysis, only a higher SOFA score remained statistically significant in forward logistic regression analysis ( < 0.05). We found a clear trend toward worsening organ function score in the extubation failure group in the first 72 hours postextubation, suggesting extubation failure as a risk factor for organ dysfunction. Cumulative fluid balance was higher both at extubation and in subsequent 3 days postextubation in the failure group, but the differences were not statistically significant.
Higher age, longer duration of invasive ventilation, and higher baseline SOFA score at extubation remain risk factors for extubation failure even in this high-risk subset of patients on prophylactic NIV. Extubation failure is associated with the worsening of organ function. A trend toward higher cumulative fluid balance both at extubation and postextubation, suggests aggressive de-resuscitation as a potentially helpful strategy in preventing extubation failure.
Ghosh S, Chawla A, Jhalani R, Salhotra R, Arora G, Nagar S, . Outcome of Prophylactic Noninvasive Ventilation Following Planned Extubation in High-risk Patients: A Two-year Prospective Observational Study from a General Intensive Care Unit. Indian J Crit Care Med 2020;24(12):1185-1192.
对于拔管失败风险较高的患者，建议在拔管后预防性使用无创通气（NIV）。在一项前瞻性队列研究中，我们研究了预防性NIV对这部分患者的影响，可能探索他们拔管失败的危险因素以及拔管失败对器官功能的影响。我们还探讨了液体平衡对这一高危患者亚组拔管失败或成功的影响。
2018年1月1日至2019年12月31日期间，在一家三级医疗中心的混合重症监护病房（ICU）收治的连续成年患者（≥18岁），在接受至少12小时有创机械通气后通过了自主呼吸试验（SBT），且因拔管失败风险高而接受预防性NIV，在其整个住院期间进行前瞻性随访。拔管失败定义为拔管后72小时内发生呼吸衰竭需要重新插管，或拔管后72小时仍需要NIV支持。
共有85例患者纳入研究。11.8%的患者在72小时时拔管失败，总体重新插管率为10.5%。单因素分析中，年龄较大（<0.05）、有创通气时间较长（<0.05）以及拔管时序贯器官衰竭评估（SOFA）评分较高（<0.05）被确定为拔管失败的危险因素。然而，在多因素分析中，只有较高的SOFA评分在前向逻辑回归分析中仍具有统计学意义（<0.05）。我们发现拔管失败组在拔管后的前72小时内器官功能评分有明显恶化趋势，提示拔管失败是器官功能障碍的一个危险因素。失败组在拔管时以及拔管后的随后3天内累积液体平衡均较高，但差异无统计学意义。
即使在接受预防性NIV的这一高危患者亚组中，年龄较大、有创通气时间较长以及拔管时基线SOFA评分较高仍是拔管失败的危险因素。拔管失败与器官功能恶化有关。拔管时和拔管后累积液体平衡有升高趋势，提示积极的液体复苏减量作为预防拔管失败的一种潜在有用策略。
Ghosh S, Chawla A, Jhalani R, Salhotra R, Arora G, Nagar S,. 高危患者计划拔管后预防性无创通气的结果：一项来自综合重症监护病房的两年前瞻性观察研究。《印度重症医学杂志》2020；24(12):1185 - 1192。
