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The Risks Associated with Extubation in Postoperative Patients

Discuss about the Critical Evaluation of Airway Complication.

One of the greatest complications that arise in the post operative patients residing in the coronary Care Unit is related to respiratory distress and Airway blockage. These postoperative complications include laryngospasm aspiration and hypoxemia, and these complications are very common after any bypass graft surgery. 1 mechanism to avoid patients at wearing these complications in a post operative stage is performing endotracheal intubation which is one of the most abundantly utilised intervention techniques for management of airway complication in postoperative cardiac patients (Villafranca et al., 2013).

However, as beneficial as intubation methods are for reviving the postoperative cardiac patients struggling with airway complication, variety of different risks are associated with the extubation procedure. The clinical decision to perform extubation is based on the reading readiness test performed on the bed sheet that involves spontaneous breathing on 80 piece or low levels of ventilator reassessed. Naturally this procedure is associated with a lot of risk and failure in distribution mechanism is also very common affecting 10 to 20% of the cardiac patient popularity. However, it has to be mentioned that mortality rates associated with extubation failure in post- op patients is 20 to 25% which is relatively high.   Different studies suggest that adhering to a step-by-step standardized protocol before carrying out the extubation is known to help reduce the rate of extirpation failure and increases the recovery chances of the patient reduces the rate of extirpation failure and increases the recovery chances of the patients drastically (Villafranca et al., 2013). This assignment will focus on exploring the extubation criteria and associated interventions performed in ICU patients suffering with Airway clearance and  attempts to determine  whether it adheres to the best practice procedures or not taking the help of  critically evaluate in relevant and authentic article published on this issue

In case of any complications the most important intervention to be performed is Airway patency, and tracheal intubation serves that purpose. However after the purpose is served the removal of the tracheal tube is extremely necessity and this is the process of extubation. However the estimation procedure can sometimes result in mobility and mortality, one of the most frequent complications that are associated with the process of airway complication management by tracheal tubes, is the unplanned extubation (Anderson et al., 2011). In most cases specifically in the critical care units or coronary care unit at the patients the severity of the complication is escalated than the normal cases, unplanned extubation followed by re- intubation procedure is a necessary intervention. However, there are few literature that emphasizes on the challenges associated with exhibitions and the criteria based on which extubation intervention is carried out. It has to be understood that extirpation is a meticulous and highly risky procedure which can result in severe consequences if the protocol is not followed step by step. Hence the importance of standardizing the criteria based on which extubation will be carried out is extremely important for the safety and reducing the morbidity associated with this procedure. The purpose of this assignment is to evaluate the literature available on the Internet and explore how efficient these literature articles are in defining the criterion for extubation and how helpful excavation methods are in airway complication management.

Standardizing Extubation Criteria for Patient Safety

First and foremost, the extubation procedure and its risks should be taken into account, and the article “Difficult Airway Society Guidelines for the management of tracheal extubation” by Mitchel and coauthors, the information regarding extubation is hazardous and how extirpation management can help in treating critical patients is explained excellently (Mitchell et al., 2012).   Problems related with extubation are the challenges that airway reflexes pose. For instance exaggerated laryngeal reflexes is the most contributing factor for extubation complications. Along with that reduced airway reflection and dysfunctional reflexes are also few instances that complicate the intubation and extubation procedure for a critical patient.  another very important complication that can arise after incubation on extubation procedure is airway injury. It has to be mentioned in this context that these periglottic trauma are resultant from any transoesophageal echocardiography probes or nasogastric tubes being inserted during the entire procedure. And these complications not only make the procedure of insertion and extraction of tracheal tube extremely meticulous but also reduce the recovery chances of the patients and increase the hospital stay statistics exponentially. Apart from the clinical manifestations of the tracheal intubation and extubation intervention, there are some management flaws that result in complicating the intubation procedure and demanding unplanned extubation as well. This article explains the severe lack of compelling general principles available for the extirpation strategies that would fit all patients. According to the authors extubation is considered to be an electric process which makes the planning and execution part very important. The purpose of extubation management is to ensure that the patient’s lungs receive an interrupted flow of oxygen. 1 highly appreciated context of this particular article is that it has very helpful provided a detailed acceleration and explanation of b a s activation guidelines. It has to be understood that this particular Framework provides 4 step action plan for the execution of the activation procedure. In the first step the extubation is plant followed by the steps two where the peri- operative preparations for extubation is carried out. In the steps three extubation is performed in real time and in the steps four a thorough and extensive post extubation care is planned and carried out for the patient. As explained by the authors of this article 20 step by step actions questions each and every action before it is performed, hence this particular guideline is extremely precise and to the point if for exhibition procedures to be carried out in critical conditions. For instance in the step 1, presence of general and special airway risk factors is questioned meticulously, before carrying out the activation procedure in itself. Along with that during and post extubation care and management techniques are extensively explained in this particular article as well with answers the main question that this assignment represents. However we must not ignore that this article is based on a specific clinical framework and does incorporate only theories lacking any practical observations which significantly reduces the relatability of the article.

Exploring Relevant Articles on Extubation Procedures in ICU Patients


A different viewpoint is provided by the article ‘Unplanned extubation in the ICU: a marker of quality assurance of mechanical ventilation” , Where extubation procedure is viewed as a unnecessary complications and which can be seen as a significant and visible quality marker for the winning care that the patients receive in intensive care unit (Peñuelas, Frutos-Vivar & Esteban, 2011).  The authors argue that the main criteria for carrying out unplanned extubation is the complications that arise with previous intubation procedure. And a better every complication management technique will be ensuring that the initial intubation procedure is flawless and it does not require emergency unplanned extubation process to be carried out on the patients which has severe risk of complicating the condition of the patient further. The authors further argue that in order to reduce the need for unplanned exhibition, understanding all the associated factors of extubation is extremely important. The office describe that along with the clinical implications, the floors in the Healthcare staff like nursing workforce burnout, lack of a detailed and standardized protocol, lacking use of protective Gear on the patience to secure the tracheal tube,   even minor mis- placements are significant contribution factors behind the need or criteria of extirpation to be carried out (Peñuelas, Frutos-Vivar & Esteban, 2011). The authors propose that strategies for reducing these flaws like detecting short displacement, using safety gears on the patient, etc can reduce the need for extubation exponentially. All the while, critically evaluating the relevance of this article in this assignment, that despite providing a novel viewpoint to the study, it must not escape noticed that this article only emphasizes on strategies that can identify the disc for activation and eliminate that altogether, while not paying any attention show how the complications associated with extubation can be managed with adequate interventions.

Another article under evaluation here is by Nolan and Kelly, emphasizing on the broad Topic of airway complication management (Nolan & Kelly, 2011). The article discusses the incidences of difficult intubation and complications and providing possible intervention strategies that can successfully manage those complications. For instance this article discusses use of capnography, tracheostomy, anaesthesia induction for critically ill patients, and the challenges associated with these strategies are discussed in detail. Now one of the solutions discussed in the article to overcome the challenges that application brings forth in the ICU, intubation bundle is discussed significantly (Liu et al., 2010).  According to this article intubation reduces the application by 21 to 34 %, however the discs on complications associated with field intubation procedure resulting in unplanned extubation is also considered as one of the most influential confounding factors in this intervention strategy.  However the author suggest that at heading to a particular standardized Framework protocol can significantly reduce the flaws in the intubation procedure and in turn eliminate the need for unplanned extubation all together. Among the other Airway management techniques that are utilized in such scenarios, the authors describe a successful captain atrophy after intubation to verify proper ventilation to be the most effective one. Authors discuss that category is the most reliable and relevant method of intervention to confirm tracheal tube positioning and eliminate the risk of unplanned extubation. Cricothyroidotomy is another intervention that the authors suggest to be useful in airway management, along with managing human factors by training and skill improvement procedures (Maggiore et al., 2014).

Different Viewpoints on Extubation in ICU Patients

The article “Unplanned Endotracheal Extubations in the Intensive Care Unit: Systematic Review, Critical Appraisal, and Evidence-Based Recommendations” by Da Silva unplanned extubation and its consequences in detail as well (da Silva & Fonseca, 2012). This article it is a systematic review conducted on the rate of unplanned Expectations and the need for preventative strategies in the Airway management techniques to avoid and plant exhibition. Authors performed extensive and critical research from the database is like MEDLINE, EMBASE, CINAHL, LILACS etc.  The main where did that the systematic review provides is that the existing literature only emphasizes on the occurrences of unplanned x 2 patients and the computing factors that lead to add how that where there is a significant lack of research studies that focus on preventative strategies and reccomendation.

According to the article “The Decision to Extubate in the Intensive Care Unit”, the emphasis of the authors is on the decision to activate in the ICU (Thille et al., 2013). It has to be mentioned in this context that this article co-aligned perfectly with the question been asked in the assignments and their house recognition for providing such relevant and transferable data. In my own professionl experience I have observed that the most important factor regarding unplanned extubations are associated with not identifying the exact need of the patient, and in most cases the patient the patient worsen more after the extubation and intubation. It has to be understood, the major questions being asked in the assignment apart from proper and improvised Airway management techniques, is the criteria based on which exhibition procedures are carried. From my professional experience , the lack of a proper demarketed guideline standardizing both intubation procedure and weaning test interpretation is a major concern. The authors here suggest that extubation failures and complications that arise for extubation are mainly concerned with the inability of the health care staff to purchase the results of the winning readiness test properly. The authors rightfully propose that understanding the pathophysiology of the winning test are extremely essential as it takes place in instrumental role in the discussion for excavation which can possibly result in further complications for the patient is carried out imperfectly or without a proper need. Agreeing with previous studies discussed in this assignment the authors of the study also suggest that most of the extubation procedures are in fact and plan activation and result in need for reintubation. The author suggest that strategies should be identified planned and executed for both extubation management and weaning readiness test management, so that you better clinical decision making can be facilitated (Thille et al., 2013).

Intervention Techniques for Managing Airway Complication

The authors here propose an international consensus panel that has instructed meaning readiness test for extirpation to be performed only with the patients fulfills the following criteria, resolution for the primary reason for intubation, cardiovascular stability and close to no need of vasopressors, no need for continuous sedation, and continuous oxygenation (Thille et al., 2013). Hence this can be considered as the standardized protocol on criteria based on which winning readiness test and following extubation should be performed to confirm the absolute needed the patient for excavation and avoid associated with extubation and Reintubation. Help it can be concluded that this particular article has provided the answer to the first part of the question asked in the assignment perfectly and the criteria mentioned in the article can be considered the best best possible solution to the conundrum of unplanned extubation (White, 2014).

Conclusion:

Hence on a concluding note, it can be stated that extubation is an undoubtedly necessary procedure, however unplanned extubation is not the best practice for proper airway management to be carried out. Instead care should be taken to avoid unnecessary unplanned extubation when it follows a reintubation further complicating the condition of the patient. In such cases two best practice interventions should e adhering to the DAS extubation guideline and the criteria selected before carrying out a weaning test. And it can be hoped that adhering to these two standard protocols can effectively reduce the co morbidities associated with unplanned extubation failures significantly.

References:

Anderson, C. D., Bartscher, J. F., Scripko, P. D., Biffi, A., Chase, D., Guanci, M., & Greer, D. M. (2011). Neurologic examination and extubation outcome in the neurocritical care unit. Neurocritical care, 15(3), 490-497.

Brotfain, E., Zlotnik, A., Schwartz, A., Frenkel, A., Koyfman, L., Gruenbaum, S. E., & Klein, M. (2014). Comparison of the effectiveness of high flow nasal oxygen cannula vs. standard non-rebreather oxygen face mask in post-extubation intensive care unit patients. The Israel Medical Association journal: IMAJ, 16(11), 718-722.

da Silva, P. S. L., & Fonseca, M. C. M. (2012). Unplanned endotracheal extubations in the intensive care unit: systematic review, critical appraisal, and evidence-based recommendations. Anesthesia & Analgesia, 114(5), 1003-1014.

Devor, R., Wellnitz, C., Kang, P., Siddiqui, M., Nigro, J., Velez, D., & Willis, B. (2016). 216: PULMONARY DEAD SPACE FRACTION AND EXTUBATION SUCCESS IN CHILDREN AFTER CARDIAC SURGERY. Critical Care Medicine, 44(12), 131.

Iyer, N. P., Dickson, J., Ruiz, M. E., Chatburn, R., Beck, J., Sinderby, C., & Rodriguez, R. J. (2017). Neural Breathing Pattern in Newborn Infants Pre and Post?Extubation. Acta Paediatrica.

Jung, B., Moury, P. H., Mahul, M., de Jong, A., Galia, F., Prades, A., ... & Jaber, S. (2016). Diaphragmatic dysfunction in patients with ICU-acquired weakness and its impact on extubation failure. Intensive care medicine, 42(5), 853-861.

Liu, Y., Wei, L. Q., Li, G. Q., Lv, F. Y., Wang, H., Zhang, Y. H., & Cao, W. L. (2010). A decision-tree model for predicting extubation outcome in elderly patients after a successful spontaneous breathing trial. Anesthesia & Analgesia, 111(5), 1211-1218.

Lu, C. H., Wu, Z. F., Lin, B. F., Lee, M. S., Lin, C., Huang, Y. S., & Huang, Y. H. (2016). Faster extubation time with more stable hemodynamics during extubation and shorter total surgical suite time after propofol-based total intravenous anesthesia compared with desflurane anesthesia in lengthy lumbar spine surgery. Journal of Neurosurgery: Spine, 24(2), 268-274.

Maggiore, S. M., Idone, F. A., Vaschetto, R., Festa, R., Cataldo, A., Antonicelli, F., ... & Antonelli, M. (2014). Nasal high-flow versus Venturi mask oxygen therapy after extubation. Effects on oxygenation, comfort, and clinical outcome. American journal of respiratory and critical care medicine, 190(3), 282-288.

Mitchell, V., Dravid, R., Patel, A., Swampillai, C., & Higgs, A. (2012). Difficult Airway Society Guidelines for the management of tracheal extubation. Anaesthesia, 67(3), 318-340.

Nolan, J. P., & Kelly, F. E. (2011). Airway challenges in critical care. Anaesthesia, 66(s2), 81-92.

Peñuelas, Ó., Frutos-Vivar, F., & Esteban, A. (2011). Unplanned extubation in the ICU: a marker of quality assurance of mechanical ventilation. Critical Care, 15(2), 128.

Rittayamai, N., Tscheikuna, J., & Rujiwit, P. (2014). High-flow nasal cannula versus conventional oxygen therapy after endotracheal extubation: a randomized crossover physiologic study. Respiratory care, 59(4), 485-490.

Thille, A. W., Harrois, A., Schortgen, F., Brun-Buisson, C., & Brochard, L. (2011). Outcomes of extubation failure in medical intensive care unit patients. Critical care medicine, 39(12), 2612-2618.

Thille, A. W., Richard, J. C. M., & Brochard, L. (2013). The decision to extubate in the intensive care unit. American journal of respiratory and critical care medicine, 187(12), 1294-1302.

Villafranca, A., Thomson, I. A., Grocott, H. P., Avidan, M. S., Kahn, S., & Jacobsohn, E. (2013). The impact of bispectral index versus end-tidal anesthetic concentration-guided anesthesia on time to tracheal extubation in fast-track cardiac surgery. Anesthesia & Analgesia, 116(3), 541-548.

White, K. (2014). Extubation Readiness in the Pediatric Population. CHEST Journal, 146(4_MeetingAbstracts), 539A-539A.

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