Search Results (69)

Fast-track extubation has emerged as a vital component of Enhanced Recovery After Surgery pathways, designed to optimize recovery and resource utilization after cardiac surgery, contrasting with traditional prolonged ventilation. This review explores the evidence supporting fast-track extubation, detailing patient selection criteria based on preoperative risk factors and functional status and outlining perioperative management strategies. It synthesizes findings from various studies, including randomized controlled trials, retrospective studies, and meta-analyses, focusing on intraoperative techniques such as low-dose opioids, neuromuscular blockade reversal, controlled cardiopulmonary bypass duration, judicious inotrope use, and minimal transfusion, alongside structured postoperative protocols emphasizing early sedative weaning and spontaneous breathing trials. Results demonstrate that fast-track extubation decreases intensive care unit stay, reduces costs and ventilator-associated complications, with a safety comparable to conventional care. Prolonged cardiopulmonary bypass time, dependency on inotropes, and intraoperative blood transfusions are identified as critical predictors of fast-track extubation failure. In conclusion, the successful implementation of fast-track extubation protocols requires a collaborative, multidisciplinary approach, proving essential for improving patient outcomes, minimizing complications such as postoperative delirium, and enhancing hospital efficiency in cardiac surgery. Further research should aim to refine patient selection and standardize protocols across healthcare systems. Full article

Objectives: To assess risk factors for post-extubation stridor in children and its impact on clinical outcomes. Methods: Prospective cohort study with children aged from 0 to 13 years who were intubated or underwent orotracheal intubation in the pediatric intensive care units (PICU) of two tertiary public hospitals. The outcome of interest was the occurrence of post-extubation stridor. The information collected included patient characteristics, comorbidities, history of airway manipulation, and factors related to orotracheal intubation. A logistic regression was used to identify potential risk factors for post-extubation stridor; data were analyzed until hospital discharge, death, or referral to another facility. Results: A total of 239 children were included, with a median age of 1.3 years and a duration of intubation of three days. Post-extubation stridor was observed in 57.3% of children. A multivariate analysis included prehospital or non-specialized hospital intubation, trauma or complications during intubation, and orotracheal intubation longer than seven days as risk factors for stridor. Children with stridor had a longer PICU length of stay, longer duration of invasive mechanical ventilation, and were often managed with non-invasive ventilation (p < 0.05). Most children with extubation failure (p = 0.001) and cardiorespiratory arrest (p = 0.03) presented with stridor. Conclusions: Risk factors for post-extubation stridor included intubation performed in prehospital or non-specialized hospitals, orotracheal intubation longer than seven days, and trauma or complications during intubation. Children with stridor had a worse prognosis, with longer stays in the PICU and on mechanical ventilation and higher rates of extubation failure. Full article

Background and Clinical Significance: Intermediate-high-risk pulmonary embolism is characterized by right-ventricular dysfunction and positive cardiac biomarkers in the absence of hemodynamic instability. Current guidelines recommend anticoagulation with vigilant monitoring, and reserve systemic fibrinolysis for patients who deteriorate hemodynamically. However, some patients may experience physiologic decompensation manifested by refractory hypoxemia rather than hypotension, despite preserved systemic perfusion and normal lung parenchyma. In such cases, oxygenation failure reflects the severity of perfusion impairment and incipient right-ventricular-circulatory collapse. Whether this scenario justifies systemic fibrinolysis remains uncertain. Case Presentation: We present a 75-year-old man, five days after arthroscopic meniscus repair, presenting with acute dyspnea, tachycardia, and severe respiratory failure despite normal chest radiography. Laboratory findings revealed elevated troponin-I and brain natriuretic peptide, and echocardiography demonstrated marked right-ventricular dilation. Computed tomographic pulmonary angiography confirmed extensive bilateral central emboli with preserved lung parenchyma. Despite high-flow nasal oxygen at 100% fraction of inspired oxygen, respiratory failure worsened, necessitating intubation under lung-protective settings. With catheter-directed therapy unavailable and transfer unsafe, a multidisciplinary team administered staged systemic fibrinolysis with alteplase, pausing heparin during infusion. No bleeding or surgical complications occurred. Oxygenation and right-ventricular indices improved promptly. The patient was extubated on day 2, discharged from intensive care unit on day 7, and remained asymptomatic with normal echocardiography at 3 months. Conclusions: Refractory hypoxemia in intermediate-high-risk, normotensive pulmonary embolism, particularly when parenchymal disease and ventilator confounding are excluded, may represent an early form of circulatory decompensation warranting rescue reperfusion. In the absence of catheter-directed options and with acceptable bleeding risk, staged full-dose systemic fibrinolysis can be life-saving and physiologically justified. This case supports expanding the concept of “clinical deterioration” in intermediate-risk pulmonary embolism to include isolated, unexplained respiratory failure, highlighting the need for future trials to refine individualized reperfusion thresholds. Full article

A 3-year-old West Highland White Terrier presented to our hospital with dyspnea following aspiration of barium contrast medium during diagnostic imaging for a suspected esophageal foreign body (day 0). Barium contrast radiography had revealed a foreign body in the lower esophagus. During anesthesia, the patient regurgitated and developed respiratory failure and cyanosis. Despite immediate intubation, suction, and ventilatory management, respiratory parameters remained poor. Respiratory support with extracorporeal membrane oxygenation (ECMO) enabled control of blood gas parameters, and tracheobronchial lavage with temporary complete airway occlusion was performed. ECMO was withdrawn once the respiratory status normalized (total support time: 3 h). Considering the possibility of hypoxia-induced brain damage, the patient was extubated on day 1. The dog was alert, changed positions, and drank water independently 5 h after extubation. However, neurological symptoms were observed 1 h later. Cranial magnetic resonance imaging was performed on day 6 owing to persistent neurological symptoms. Although no ECMO-related complications, such as cerebral infarction, hemorrhage, or herniation, were observed, the white matter exhibited hyposignal, indicating hypoxic encephalopathy. The patient died on day 8, without improvement in neurological symptoms. ECMO is an effective treatment option for dogs with respiratory failure, and its prompt introduction may improve survival. Full article

Background: Persistent pulmonary hypertension of the newborn (PPHN) remains a life-threatening condition resulting from failure of postnatal circulatory adaptation. Inhaled nitric oxide (iNO) is the standard first-line therapy; however, limited access or inadequate response highlight the need for alternative treatments. Milrinone, a selective phosphodiesterase-3 inhibitor with nitric oxide-independent vasodilatory and inotropic properties, has been proposed as one such option. Methods: In this study we present a case series of three neonates with PPHN—term (41 weeks), late preterm (35 weeks), and extremely preterm (23 weeks)—treated with intravenous milrinone in a neonatal unit without immediate access to iNO. A narrative literature review was also conducted, focusing on clinical outcomes, safety, and therapeutic applicability. Results: Milrinone was initiated within the first 24 h of life. In the term and late-preterm infants, oxygenation and echocardiographic parameters improved within 48 h, with normalization of shunt direction and successful extubation by days 4–10. Transient systemic hypotension occurred in both cases and required dose adjustment or vasoactive support. In the extremely preterm neonate, only temporary hemodynamic improvement was achieved, followed by severe intraventricular hemorrhage and coagulopathy, possibly exacerbated by vasodilatory and antiplatelet effects of milrinone. Conclusions: Milrinone may serve as a feasible adjunct or bridging therapy for PPHN when iNO is unavailable. However, its use requires careful hemodynamic and neurological monitoring, particularly in very preterm infants. Further studies are needed to confirm safety and define optimal dosing across gestational ages. Full article

Weaning from invasive mechanical ventilation (IMV) is a key element in the management of critically ill patients, encompassing the entire process of discontinuing IMV. Despite its importance, considerable uncertainties remain regarding the optimal strategies to achieve successful weaning. Early weaning is crucial, as IMV is associated with complications related to high mortality rates, such as prolonged weaning and intubation-associated pneumonia (IAP). This review aims to highlight the role of non-invasive respiratory supports (NIRSs), including non-invasive ventilation (NIV) and high-flow nasal cannulas (HFNCs), as a therapeutic bridge between IMV dependency and spontaneous breathing. NIV and HFNCs are recommended to prevent post-extubation respiratory failure (PERF) in high-risk and low-risk patients, respectively, and their combination appears effective in high-risk populations. On the other hand, NIV is not advised in established non-hypercapnic PERF, as it may increase mortality by delaying intubation; however, it can facilitate extubation in patients with hypercapnic respiratory failure. NIRSs may also benefit patients at high risk of post-operative pulmonary complications such as acute respiratory failure (ARF), with either NIV or HFNCs being appropriate. In light of this evidence, appropriate NIRSs selection and application may be pivotal in achieving successful weaning and better outcomes in critically ill patients. Full article

Background and Objectives: Enhancing recovery after cardiac surgery involves minimally invasive procedures, early extubation/mobilization, and swift discharge. While mechanical ventilation is often essential post-operation, prolonged invasive ventilation (IMV) increases mortality risk. Duration is influenced by patient factors (age and comorbidities), surgical complexity, and complications. Prognostic scores like EuroSCORE II, sequential organ failure assessment (SOFA), the Charlson Comorbidity Index (CCI), and the vasoactive–inotropic score (VIS) help to predict ventilation needs. The aim of this study is to analyze the effect of pre-/post-operation factors and procedure type as predictors of ventilation time. Materials and Methods: This is a retrospective cohort observational study analyzing factors affecting the duration of postoperative mechanical ventilation in elective cardiac surgical patients treated between 1 January and 31 December 2024 in a tertiary center in continental Croatia. Patients were stratified into two groups according to the duration of IMV: normal (first three quartiles) and prolonged (upper quartile). In total, 493 elective cardiac surgical patients operated on under general endotracheal anesthesia with sternotomy or mini-sternotomy were admitted postoperatively to the cardiovascular ICU and mechanically ventilated during the observed period, and 463 patients were included in the final analysis after the exclusion criteria had been applied. Results: The mean age was 64.7 ± 9.8 years, and 28.7% of the cohort were females while 71.3% were males. The median Charlton Comorbidity Index was 4 (IQR 3–5), the VIS was 2 (IQR 0–3), the SOFA score at ICU admission was 5 (IQR 3–6), and the adjusted SOFA score was 3 (IQR 2–4). In the multivariate logistic regression model, a significant effect of female sex (OR 1.98), age (OR 1.05), VIS (OR 1.05), and history of previous cardiac surgery (OR 6.67) on the duration of mechanical ventilation was observed. In the time-to-extubation multivariate analysis, there was a significant effect of re-do surgery (HR 3.70), corrected SOFA score (HR 1.14), and VIS (HR 1.05) on the duration of mechanical ventilation. There was no significant effect of the type of surgery (CABG, aorta, aortic valve, mitral/tricuspid valve, or other) or the amount of chest tube drainage on the duration of mechanical ventilation. Conclusions: A history of previous cardiac surgery and the vasoactive–inotropic score during the first 24 postoperative hours in the ICU are the strongest predictors of the duration of mechanical ventilation after elective cardiac surgery, with a statistically significant effect present in both the logistic regression model and hazard ratio analysis. Further analyses with more variables are warranted in the future to refine the prognostic model. Full article

Early prediction of weaning outcomes in mechanically ventilated patients has significant potential to influence the duration of treatment as well as associated morbidity and mortality. This study aimed to investigate the utility of signal analysis using electromyographic diaphragm (EMG) and electrocardiography (ECG) signals to classify the success or failure of weaning in mechanically ventilated patients. Electromyographic signals of 40 subjects were recorded using 5-channel surface electrodes placed around the diaphragm muscle, along with an ECG recording through a 3-lead Holter system during extubation. EMG and ECG signals were recorded from mechanically ventilated patients undergoing weaning trials. Linear and nonlinear signal analysis techniques were used to assess the interaction between diaphragm muscle activity and cardiac activity. Supervised machine learning algorithms were then used to classify the weaning outcomes. The study revealed clear differences in diaphragmatic and cardiac patterns between patients who succeeded and failed in the weaning trials. Successful weaning was characterised by a higher ECG-derived respiration amplitude, whereas failed weaning was characterised by an elevated EMG amplitude. Furthermore, successful weaning exhibited greater oscillations in diaphragmatic muscle activity. Spectral analysis and parameter extraction identified 320 parameters, of which 43 were significant predictors of weaning outcomes. Using seven of these parameters, the Naive Bayes classifier demonstrated high accuracy in classifying weaning outcomes. Surface electromyographic and electrocardiographic signal analyses can predict weaning outcomes in mechanically ventilated patients. This approach could facilitate the early identification of patients at risk of weaning failure, allowing for improved clinical management. Full article

Background: Patients with congenital heart disease can associate malformations. The most frequent complications are those related to the airways, which produce prolonged cardiovascular postoperative. Objectives: Describe pathology, bronchoscopy indications, and findings in patients with heart pathology and persistent breath failure to improve prognosis and determine an early treatment. Methods: Retrospective descriptive study of bronchoscopies performed during 24 years in pediatric patients with congenital heart disease with surgery indication and persistent respiratory symptomatology. Results: We performed 199 fibrobronchoscopies in 144 patients, with an average of 1.4 fibrobronchoscopies per patient. A total of 58% were male. The mean age was 27.5 months (5 days–13 years). Valvular disease was the most frequent congenital heart disease, followed by the transposition of large vessels. The most frequent indications were stridor (42.7%) and persistent atelectasis (24.6%), followed by extubation failure (12.4%) and pump output (6.2%). The majority of the findings were found in the upper airway (56%), with a clear predominance of malacias (32%), while in the lower airway, extrinsic compression was highlighted (42%). Conclusions: Flexible fiberoptic bronchoscopy is a useful and rapid method for the diagnosis of airway malformations associated with congenital heart diseases that may have a relevant role in its management and prognosis. Full article

Background/Objectives: Early pain exposure in newborns is linked to negative short- and long-term outcomes. Preterm infants often require endotracheal intubation for mechanical ventilation or brief laryngoscopy for surfactant administration via Less Invasive Surfactant Administration (LISA) or Intubation–Surfactant–Extubation (INSURE). While premedication before intubation is well-studied, data regarding premedication for LISA/INSURE are limited. We aimed to explore premedication practices for intubation and LISA/INSURE procedures across Neonatal Intensive Care Units (NICUs) in Israel. Methods: An anonymous online questionnaire comprising 27 questions about premedication practices was distributed to neonatal caregivers in Israel. The questions addressed the use of premedication before intubation or LISA/INSURE, the existence of written protocols, pharmacological agents employed, and caregiver satisfaction with the medications used. Results: Questionnaires were collected between January and July 2023, yielding 69 responses from 20 NICUs. Almost all respondents (95.7%) routinely use premedication before intubation, but only 65.7% use it for LISA/INSURE. For non-emergency intubations, extremely low-birth-weight (ELBW) infants received premedication less often than the general neonatal population (75.4% vs. 95.7%, respectively). Most caregivers (91.2%) did not report increased procedure failure associated with premedication during LISA/INSURE. The vast majority of Israeli caregivers do not include muscle relaxants in their premedication regimen for intubation. Dual therapy regimens yielded higher satisfaction rates than monotherapy. Higher complication rates, particularly respiratory depression, were observed with Fentanyl, especially when used as monotherapy. Conclusions: Significant variations exist in premedication practices among caregivers across Israeli NICUs. Premedication is commonly administered for intubation but is considerably less frequent for LISA/INSURE, despite these procedures also being painful. ELBW infants received less premedication. Notably, muscle relaxants are infrequently used for premedication by Israeli NICU caregivers. Full article

Background/Objectives: Mechanical ventilation is essential in the management of acute respiratory failure (RF); however, prolonged use increases the risk of complications. Accurate predictors are therefore needed to guide timely weaning. The Rapid Shallow Breathing Index (RSBI), the dead space to tidal volume ratio (VD/VT), and the Integrative Weaning Index (IWI) are among the key indices used to assess weaning readiness. This study aimed to examine whether these indices differ between patients with Type 1 (hypoxemic) and Type 2 (hypercapnic) respiratory failure who were successfully extubated in the emergency department, in order to explore their physiologic variability across respiratory failure phenotypes. Methods: This cross-sectional study included 35 adult patients (23 with Type 1 RF, 12 with Type 2 RF) who were successfully weaned from mechanical ventilation in the Emergency Department of a tertiary care hospital between 2022 and 2024. RSBI, VD/VT, IWI, and arterial blood gas parameters were recorded. Descriptive and comparative statistical analyses were performed, with significance set at p < 0.05. Results: There were no significant differences in age, gender, or comorbidities between the groups. Type 2 RF patients had higher FiO₂ requirements (37.5% vs. 30.0%; p = 0.03) and PaCO₂ levels (49.1 ± 9.65 mmHg vs. 40.3 ± 4.49 mmHg; p < 0.001). The PaO₂/FiO₂ ratio was lower in the Type 2 group (169 ± 49.6) compared to the Type 1 group (244 ± 95.6; p = 0.017). VD/VT ratios were significantly higher in Type 2 RF patients (0.37 ± 0.04 vs. 0.29 ± 0.13; p = 0.046). RSBI values were identical between groups (40.0 in both; p = 1.00), and IWI values showed no significant difference (70.8 ± 30.7 vs. 79.3 ± 32.5; p = 0.45). Conclusions: Although RSBI and IWI values were similar across respiratory failure types, patients with Type 2 RF demonstrated higher VD/VT ratios and lower PaO₂/FiO₂, indicating reduced gas exchange and alveolar ventilation efficiency. These findings suggest that VD/VT may be a more useful parameter for assessing weaning readiness in hypercapnic patients. Full article

Background and Clinical Significance: The incidence of persistent ductus arteriosus (PDA) in preterm infants is the highest and depends on their birth weight (BW) and respiratory condition after birth. Previously, after the unsuccessful drug treatment, surgical ligation was the primary treatment option. However, according to clinical studies, the Amplatzer Piccolo Occluder was approved for PDA closure for patients ≥700 g. In our country, percutaneous PDA embolization has not been performed yet. Case Presentation: We present three premature infants with hemodynamically significant patent ductus arteriosus (hsPDA) in whom percutaneous occlusion was performed using the Amplatzer Piccolo Occluder (APO). The average gestational week (GW) was 27 ± 1, while body weight was 1030 ± 60 g. All patients had respiratory deterioration, with dilatation of the left heart chambers, and renal failure. The second developed a severe form of broncho-pulmonary dysplasia. Transthoracic echocardiography (TTE) examinations revealed a hemodynamically significant PDA (LA/Ao 1.8–2.2) and medical closure was unsuccessfully carried out. Due to the hemodynamically significant PDA maintenance in all neonates, transvenous PDA closure was performed using the APO (APO 9-PDAP-04-02-L, 9-PDAP-04-04-L, 9-PDAP-05-054L, respectively). The entire devices, with both retention discs, are implanted within the duct. TTE pointed out adequate device position without descending aorta, left pulmonary artery obstruction, residual shunt, and reverse remodelling of the left ventricle and left atrium. The first newborn was weaned from mechanical ventilation three days after the procedure and discharged three weeks after. The second patient was extubated 2 weeks after the procedure, and even the severe BPD, X-ray showed improvement. The third patient’s renal failure completely resolved, weaned from inotropic drug support and mechanical ventilation. Conclusions: Due to a significantly lower complication rate than surgical ligation, we will strive to make percutaneous PDA occlusion a new standard for treatment in newborns, especially preterm newborns, in our country. Full article

Background: Among patients with congenital heart disease, particularly those with a history of undergoing the Fontan operation, pregnancy presents a significant maternal–fetal risk, especially when complicated by severe valvular dysfunction. Lung reperfusion syndrome (LRS) is a rare but life-threatening complication occurring following valve intervention. Multidisciplinary management, including by Cardio-Obstetrics teams, is essential for optimizing outcomes in such high-risk cases. Methods: We present the case of a 37-year-old pregnant patient with previously repaired tetralogy of Fallot (via the Fontan procedure) who presented at 24 weeks gestation with worsening severe pulmonary stenosis and right-ventricular dysfunction. The patient had been lost to cardiac follow-up for over a decade. She experienced recurrent arrhythmias, including supraventricular and non-sustained ventricular tachycardia, prompting hospital admission. A multidisciplinary team recommended transcatheter pulmonic valve replacement (TPVR), performed at 28 weeks’ gestation. Results: Post-TPVR, the patient developed acute hypoxia and hypotension, consistent with Lung Reperfusion Syndrome, necessitating intensive cardiopulmonary support. Despite initial stabilization, progressive maternal respiratory failure and fetal compromise led to an emergent cesarean delivery. The neonate’s neonatal intensive care unit (NICU) course was complicated by spontaneous intestinal perforation, while the mother required intensive care unit (ICU)-level care and a bronchoscopy due to new pulmonary findings. She was extubated and discharged in stable condition on postoperative day five. Conclusions: This case underscores the complexity of managing severe congenital heart disease and valve pathology during pregnancy. Lung reperfusion syndrome should be recognized as a potential complication following TPVR, particularly in pregnant patients with Fontan physiology. Early involvement of a multidisciplinary Cardio-Obstetrics team and structured peripartum planning are critical to improving both maternal and neonatal outcomes. Full article

Background/Objectives: Preterm neonates with a birth weight (BW) of 500–1250 g who receive prophylactic methylxanthine have a lower rate of bronchopulmonary dysplasia and neurodevelopmental disability than their counterparts. In a meta-analysis of previous studies (published during 1985–1993, with no routine continuous positive airway pressure), extubation failure rates in preterm neonates with BW < 2500 g who received and did not receive methylxanthine were 25.0% and 50.6%, respectively (risk difference, −0.27; 95% confidence interval [CI], −0.39 to −0.15). However, no study to date has assessed the effects of prophylactic methylxanthine use on endotracheal extubation in infants weighing 1250–2499 g until now. Methods: First-time extubation was compared between 1:1 propensity score-matched methylxanthine and non-methylxanthine groups from a retrospective cohort of 541 neonates (born during 2014–2024). Results: The domains from the overall cohort and propensity-matched data included 541 and 192 neonates, respectively. In the propensity score-matched sample, the mean gestational age and BW were 30.9 ± 1.9 weeks and 1584 ± 273 g, respectively. The median 5-min Apgar score was 9 (range of 7–9). Extubation failure within 7 days occurred in 10 (10.4%) and 13 (13.5%) neonates in the methylxanthine (n = 96) and non-methylxanthine (n = 96) groups, respectively, with a risk difference (95% CI) of −0.03 (−0.12 to 0.06), p = 0.50, and hazard ratio (95% CI) of 0.76 (0.33 to 1.72), p = 0.51. Conclusions: In the current era with new non-invasive ventilation approaches, extubation failure in preterm neonates with a BW of 1250–2499 g is not significantly affected by the use of methylxanthine. Full article

Background: Stress-induced cardiomyopathy (SI-CM) is a transient left ventricular dysfunction triggered by emotional or physical stress, often resolving with supportive care. However, severe cases may progress to cardiogenic shock (CS), requiring mechanical circulatory support (MCS). High-profile transvalvular pumps (HPTP), a form of percutaneous ventricular assist device, offer promising hemodynamic support in acute heart failure. This report explores HPTP use in SI-CM-related CS through two complex clinical cases. Case Summary: Two elderly female patients presented with severe CS secondary to apical-variant SI-CM. Case 1 involved a 67-year-old woman with sepsis, colonic perforation, and recurrent SI-CM, leading to profound low-output shock despite multiple vasopressors and inotropes. HPTP was implanted via the axillary artery, allowing for surgical management of intra-abdominal pathology and eventual cardiac recovery. Case 2 featured a 77-year-old woman with multifocal pneumonia, severe mitral regurgitation, and complete heart block. HPTP implantation stabilized her hemodynamics, facilitated extubation, and led to full recovery of ventricular function. Results: Both patients showed marked improvement in cardiac output and systemic perfusion following HPTP insertion. Echocardiograms post-device removal revealed normalization of left ventricular ejection fraction (55–64%). Hemodynamic data confirmed reduced pulmonary capillary wedge pressure and systemic vascular resistance. Conclusion: These cases highlight the potential of HPTP in managing SI-CM-related CS, especially when traditional therapies are inadequate or contraindicated. HPTP can rapidly restore hemodynamic stability and support myocardial recovery. While current data are limited, these observations underscore the need for broader investigation into the role of HPTP in this setting. Full article