| Extubación difícil |
Florence Gazabatt S.
Rev Chil Anest, 2010; 39: 167-173
La extubación es un proceso complejo donde intervienen múltiples variables tanto de la vía aérea como de la mecánica respiratoria, estados de conciencia, cardiovasculares, metabólicos, efecto
residual de drogas anestésicas, etc. Cualquiera de estas variables pueden por si sola afectar el éxito de la extubación convirtiendo el post-operatorio en un período de máxima vulnerabilidad.http://www.sachile.cl/upfiles/revistas/4ce147623b08d_gazabatt.pdf |
| ¿Deben los pacientes poder seguir órdenes antes de extubación? |
Should patients be able to follow commands prior to extubation?
King CS, Moores LK, Epstein SK.
Pulmonary Critical Care and Sleep Medicine Division, Walter Reed Army Medical Center, Washington, DC, USA.
Respir Care. 2010 Jan;55(1):56-65.
Abstract
The determination of optimal timing of liberation from mechanical ventilation requires a thorough assessment of multiple variables that can result in extubation failure. It is estimated that 5-20% of extubations fail. Traditional weaning parameters fail to predict extubation failure accurately, and attention has thus turned to improvements in extubation decision making through assessment of elements that may result in inability to protect the airway, such as excessive respiratory secretions, inadequate cough, and depressed mental status. Extubation is particularly controversial in patients with depressed mental status and inability to follow commands. When looking at univariate analyses, the reported studies are relatively evenly divided among those that did and did not find that inability to follow commands (ie, abnormal mental status) increases the risk of extubation failure. In addition, although extubation failure is a risk factor for poor overall outcome in heterogeneous populations, its impact on the patient failing with neurologic dysfunction has not been adequately determined. One limiting factor in all reported studies is how "inability to follow commands" is defined. The majority of studies use the Glasgow coma score, but this is difficult to determine in the intubated patient. Moreover, using the cutoff of Glasgow coma score >or= 8, favored by many authors, is questionable, as some patients with higher scores may be unable to follow commands. Currently it is agreed that many patients who are unable to follow commands, but have the ability to clear pulmonary secretions, can be safely extubated. A prospective, randomized trial using a more specific definition of "following commands" would certainly help remove some of the uncertainty in this patient population.
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| Extubación difícil. Informe de un caso |
Difficult extubation. A Case Report
Dr. Suresh Y. V.1 Dr. Sripada G. Mehandale2 Dr. Vijesh K. S.
Indian J Anaesth 2004:48:307-308
Summary
A female patient aged 35 years underwent hemithyroidectomy. At the end of surgery there was difficulty in removing the endotracheal tube. Transfixation of tube to the tracheal wall was thought of and confirmed with the help of image intensifier. Extubation was possible after re-exploration and suture removal.
http://medind.nic.in/iad/t04/i4/iadt04i4p307.pdf
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| Acceso continuo a las vías respiratorias para la extubación difícil: la eficacia del catéter de intercambio de las vías respiratorias. |
C ontinuous airway access for the difficult extubation: the efficacy of the airway exchange catheter.
Mort TC.
Department of Anesthesiology, Simulation Center, Hartford Hospital, Hartford, Connecticut 06015, USA. tmort@harthosp.org
Anesth Analg. 2007 Nov;105(5):1357-62Abstract
BACKGROUND: The American Society of Anesthesiologists Task Force on the Management of the Difficult Airway regards the concept of an extubation strategy as a logical extension of the intubation process, although the literature does not provide a sufficient basis for evaluating the merits of an extubation strategy. Use of an airway exchange catheter (AEC) to maintain access to the airway has been reported on only a limited basis. METHODS: I reviewed an observational analysis of a prospectively collected difficult airway quality improvement database for patients who were extubated over an AEC for a known or presumed difficult airway primarily in the intensive care unit. The data were reviewed for time to reintubation, number of attempts to reintubate the trachea, method of securing the airway, incidence of hypoxemia during reintubation, and complications encountered during reestablishment of the airway. RESULTS: Fifty-one patients with an indwelling AEC failed their extubation trial. Forty-seven of 51 AEC patients were successfully reintubated over the AEC (92%), with 41 of 47 on the first attempt (87%). In three of the four AEC reintubation failures, the AEC was inadvertently removed from the glottis during the reintubation process, and one patient had significant laryngeal edema precluding endotracheal tube advancement. CONCLUSIONS: Maintaining continuous access to the airway postextubation via an AEC can be an important component of an extubation strategy in selected difficult airway patients. The indwelling AEC appears to increase the first-pass success rate in patients with known or suspected difficult airways and decrease the incidence of complications in patients intolerant of extubation and requiring tracheal reintubation. |
| La extubacion de la via aerea dificil |
C. M. de la Linde Valverde
Servicio de Anestesiologia y Reanimacion. Hospital Universitario Virgen de las Nieves. Granada.
Rev. Esp. Anestesiol. Reanim. 2005; 52: 557-570
Resumen
La extubación es, junto con la intubación, uno de los momentos críticos del desarrollo de la anestesia general. No existen algoritmos o secuencias ordenadas de procedimientos diseñados para la extubación, sin embargo, la estrategia de actuación ha de enfocarse hacia la observación
estrecha del paciente en un entorno donde se disponga de monitorización, equipamiento o material adecuado para manejo de la vía aérea difícil, de personal experimentado para lograr el acceso inmediato a la vía respiratoria y capaz de facilitar el aporte e intercambio de oxígeno, manteniendo permeable y protegida la vía aérea, aún cuando la extubación haya sido fallida. En este artículo revisaremos las condiciones clínicas y hallazgos fisiopatológicos que se asocian a una extubación de alto riesgo de complicaciones y describiremos diferentes estrategias de extubación en pacientes con vía aérea difícil conocida o sospechada.
Palabras clave: Extubacion. Via aerea dificil, manejo, reintubacion, complicaciones.
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