IMPLEMENTATION OF AN EXTUBATION PROTOCOL IN PATIENTS OF A NEUROSURGICAL HOSPITAL

Paes d' Assumpção Vital I1, Gaspari C1, Jaccoud AC1
1Instituto Estadual do Cérebro Paulo Niemeyer, Physical Therapy, Rio de Janeiro, Brazil

Background: Extubation failure in a neurocritical Intensive Care Unit (ICU) is difficult to predict. It is associated with increased mortality as well as higher financial costs due to prolonged hospitalization. Specifically, neurocritical patients present with many challenges when it comes to extubation because they require large amounts of intravenous fluids to improve cerebral perfusion, a factor well known to hinder successful extubation. It is also known that neuromuscular weakness and decreased level of consciousness are associated with extubation failure, although the degree of weakness and the level of alertness required for successful extubation are unclear. In addition, this patient population may have unique breathing patterns that may hinder extubation. Specifically for the patient with neurocritical disease, predictors of extubation failure were identified as low score at Glasgow Coma Scale (GCS), pneumonia, atelectasis, duration of mechanical ventilation, location of stroke, and examination findings as a weak orolingual control, a non-preserved vomit reflex and an inability to close the eyes. The guidelines proposed for orotracheal extubation are generalized and usually not intended specifically for patients with neurocritical diseases.

Purpose: The purpose of the study is to describe the steps of implementing an orotracheal extubation protocol in the physiotherapy department of a neurosurgical center and to evaluate the outcome of orotracheal reintubation rate after implementation of the protocol.

Methods: This is a descriptive retrospective study. The steps taken for the implementation of an orotracheal extubation protocol of neurosurgical patients at Instituto Estadual do Cérebro Paulo Niemeyer were described. Data from 7 months before and 12 months after the implementation of the protocol were compared.

Results: A checklist for the capability for the Spontaneous Breathing Trial (SBT) composed of 14 items was created. Patients who passed the checklist were submitted to SBT. A SBT of 60 minutes with the following parameters was followed: pressure support of 0cmH2O , positive end expiratory pressure of 0cmH2O and FiO2 of 40%. During the SBT, four tests were performed every 30 minutes: cuff leak test, Rapid Shallow Breathing Index (RSBI), test of four commands (closed eyes, cough, wiggle toes and show two fingers of the hand) and pharyngeal reflex test. Data were documented in in a specific worksheet form by recording and monitoring activities. Physiotherapy staff was trained. In the first seven months after the hospital was an average reintubation rate after programmed extubation of 41.2% was observed. After the implementation of the protocol and training of the physiotherapy team, the indicators showed an average rate of 9.3% reintubations after scheduled extubation, equivalent to a reduction of 31.9% in relation to the period without protocol implementation.

Conclusion(s): The implementation of an extubation protocol for neurocritical patients requires time and professional training, but it is feasible and has resulted in a better prognosis for the patients submitted to the protocol.

Implications: The performance of orotracheal pre-extubation tests, together with the clinical evaluation of the patient, leads to a safer procedure with less chance os failure.

Keywords: physicaltherapy, neurosurgery, extubation

Funding acknowledgements: None

Topic: Critical care; Outcome measurement; Neurology

Ethics approval required: No
Institution: Instituto Estadual do Cérebro Paulo Niemeyer
Ethics committee: None
Reason not required: The data used are institutional, not specific to patients.


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