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Predictors for Reintubation after Unplanned Endotracheal Extubation in Multidisciplinary Intensive Care Unit
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Bon Nyeo Koo, Shin Ok Koh, Tae Dong Kwon
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Korean J Crit Care Med. 2003;18(1):20-25.
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 Abstract
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- BACKGROUND
Unplanned endotracheal extubation is a potentially serious complication, as some patients may need reintubation while in very critical conditions that may increase the morbidity and mortality rates. We conducted a study to evaluate the predictors for reintubation after unplanned extubation. METHODS: Patients who presented unplanned extubation over a 35-month period in two multidisciplinary intensive care units of university affiliated hospital were included. Any replacement of an endotracheal tube within 48 hours after unplanned extubation was considered as reintubation. RESULTS: There were 62 episodes of unplanned endotracheal extubation in 56 patients (incidence rate 2.8%). Fifty seven episodes (91.9%) were deliberate self-extubation, while 5 episodes (8.1%) were accidental extubation. Reintubation was required in 42 episodes (67.7%). Only 44.4% (12/27) of the patients who presented unplanned extubation required reintubation during weaning period, while reintubation was mandatory in 85.7% (30/35) of the patients who presented unplanned extubation during full ventilatory support (P<0.001). The multiple logistic regression analysis was made to obtain a model to predict the need for reintubation as a dependent variable: ventilatory support mode (odds ratio: 12.0) was significantly associated with the need for reintubation. The model correctly classified the need of reintubation in 72.6% (45/62) of the patients. CONCLUSIONS: Reintubation in unplanned extubation strongly depended on the type of the mechanical ventilatory support. The probability of requiring reintubation after unplanned extubation was higher during full ventilatory support than during weaning period.
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Acute Respiratory Distress Syndrome after Severe Hypothermia and Hypotension Due to Near Drowning
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Ho Dong Park, Bon Nyeo Koo, Dong Woo Han, Seung Tak Han, Shin Ok Koh
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Korean J Crit Care Med. 2001;16(2):151-155.
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Abstract
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- The increase in short-term survival of near-drowning victims after an acute submersion episode has resulted in an increase of major complications. Two major complications are the development of acute respiratory distress syndrome and persistent hypoxic-ischemic central nervous system injury. A 43-year-old male patient was presented with acute respiratory distress syndrome after near drowning. He was severely hypothermic and hypotensive when he arrived to emergency department. His body temperature was 24oC. There was no pulse and no spontaneous respiration. He was treated with advanced life support measure. He was intubated and vasoactive drugs such as epinephrine and norepinephrine were used. On ICU admission, his blood pressure and pulse rate were 80/40 mmHg, 170 beats/min respectively. His oxygen saturation was 40~60% with 100% oxygen. We applied 16~30 cmH2O of PEEP with low tidal volume for recruitment. Patient was flipped over to prone position. Solu-medrol 1.0 g was infused. The blood pressure restored to 140/50 mmHg, and the pulse rate was normalized to 100 beats/min. The dose of vasopressors and inotropes were reduced and stopped 5 hour after the arrival. When the oxygenation has improved, the position was changed to supine and PEEP was lowered.
Eventually weaning was successful. Brain MRI and EEG showed global atrophy of cerebral cortex and moderate diffuse brain dysfunction respectively. He received tracheostomy since he was semi-comatose. He was transferred to general ward on 39th ICU day.
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Continuous Infusion of Ketamine in Mechanically Ventilated Patient in Septic Shock with Status Asthmaticus
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Bon Nyeo Koo, Shin Ok Koh, Sung Yong Park, Jae Kwang Shim, Sung Sik Chon
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Korean J Crit Care Med. 2000;15(2):108-112.
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- Ketamine is well known for its analgesic, bronchodilating and sympathetic stimulating effect. Hence, it has been widely used for induction of patients with hypotension or asthma and also for analgesic and sedating purposes in the ICU. We presented a 62 year old female patient with ventilator support in septic shock with refractory asthma whom we managed successfully with continuous intravenous infusion of ketamine postoperatively in the ICU. The patient had a history of asthma but had been asymptomatic recently and was scheduled for an emergent explo-laparotomy under the diagnosis of acute panperitonitis. Before the induction of anesthesia, the patient was in septic shock but no wheezing could be auscultated. After the induction of general anesthesia and endotracheal intubation, wheezing was apparent in both lung fields with a high peak inspiratory pressure. Inotropics, vasopressors and bronchodilators were promptly instituted without any improvement of asthma and the patient had to be transferred to the ICU with intubated after the operation. Clinical symptoms of asthma continued throughout the first day despite using bronchodilators under mechanical ventilation but, after starting the IV infusion of ketamine, there were decrease in the peak inspiratory pressure and wheezing with a subsequent improvement in the arterial blood gas analysis findings. We could also achieve considerable analgesic and sedating effect without any decrease in the blood pressure. The patient's general physical status improved and weaning with extubation was successfully done on the 21st day and was transferred to the general ward on the 28th day.
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