Pediatric cardiac surgery poses significant challenges in developing countries, where a considerable number of children require intervention for congenital heart disease (CHD). The utilization of endotracheal intubation and anesthesia is pivotal in conducting surgical or angiography procedures on patients with CHD exhibiting diverse anatomical and hemodynamic characteristics. The decision to extubate pediatric patients following cardiac surgery remains a crucial element of postoperative care. This article explores the complexities surrounding extubation decision-making in this population, emphasizing the critical role of surgical, physiological, and postoperative factors. Various preoperative and intraoperative factors influence the timing of extubation. Early extubation is increasingly prevalent, offering benefits like reduced length of stay and minimized drug exposure. Multidisciplinary collaboration and protocol-driven strategies contribute to improved extubation outcomes, emphasizing the need for a comprehensive approach in pediatric cardiac surgery. Future research can focus on the implementation and efficacy of standardized extubation procedures involving collaboration among healthcare experts.

Remifentanil, characterized by its ultra-short action duration and nonorgan-dependent metabolism, is applied in postcardiac surgery settings worldwide. While previous studies have compared its efficacy with that of other opioids, it has never been compared to a single specific opioid. Here, we evaluated whether remifentanil shortens mechanical ventilation (MV) times in patients after cardiac surgery. We identified randomized controlled trials that compared various opioids in adults (≥18 years) admitted to the intensive care unit after cardiac surgery. The primary outcome was the duration of MV, expressed as the mean difference (MD) in minutes, with a 95% confidence interval (CI). A 60-min reduction was considered significant based on prior research. Data were sourced from MEDLINE, the Cochrane Central Register of Controlled Trials, EMBASE, the World Health Organization International Clinical Trials Platforms Search Portal, and ClinicalTrials.gov, and a frequentist network meta-analysis was conducted. The eight identified studies indicate no differences in the duration of MV between remifentanil and fentanyl (MD 0.09 min; 95%CI -36.89-37.08), morphine (MD -19 min; 95%CI -55.86-16.21), or sufentanil (MD -2.44 min; 95%CI -67.52-62.55). Our study revealed that remifentanil did not reduce MV times in patients after cardiac surgery. The study protocol was registered with the Open Science Forum (https://osf.io/) (DOI 10.17605/OSF.IO/YAHW2).

The occurrence of postoperative pulmonary complications (PPCs) is frequently observed and has been linked to elevated levels of morbidity and mortality, which have adverse effects on both clinical and financial outcomes in healthcare settings. This systematic review aims to present the evidence that supports our comprehension of PPCs and emphasize the circumstances that necessitate the use of postoperative noninvasive ventilation (PNIV) or re-intubation with postoperative mechanical ventilation (POMV). A search was conducted on the National Library of Medicine\'s Pubmed database and Cochrane Library until November 29, 2020, to find published reports of randomized control trials (RCTs) that assessed postoperative pulmonary complications. Data related to the prevalence of PPCs and the use of PNIV, POMV, and length of hospital stay were extracted from all the studies. For the analysis, a total of 13 studies involving 6,609 patients were included, and out of these, four RCTs reported statistically significant results. The use of protective lung ventilation (PLV) with low tidal volume and positive end-expiratory pressure (PEEP) during intraoperative ventilation, along with pressure-controlled (PCV) ventilation, as well as the postoperative ventilation strategy of continuous positive airway pressure (CPAP) combined with standard oxygen therapy were the only techniques that demonstrated a clear reduction in the incidence of PPCs. Furthermore, the use of PLV with low tidal volume and PEEP and intraoperative mechanical ventilation with a vital capacity maneuver followed by 10 cm H2O of PEEP were found to decrease the requirement for postoperative noninvasive ventilation. CPAP with standard oxygen therapy was the only intervention that reduced the need for reintubation. Various ventilation strategies are available for both intraoperative and postoperative periods with the goal of decreasing the need for postoperative noninvasive ventilation (PNIV) or re-intubation with postoperative mechanical ventilation (POMV).

Residual neuromuscular blockade is associated with increased postoperative pulmonary complications. This study aimed to evaluate the effect of an extubation protocol incorporating neuromuscular blockade reversal (NMBR) by train-of-four monitoring on \"fast-track\" cardiac surgery outcomes.
A retrospective cohort study.
At a university hospital.
Out of 1,843 cardiac surgery patients, from February 2, 2015, to March 31, 2017, 957 (52%) underwent cardiac surgery on or after February 29, 2016.
An extubation protocol, comprised of weaning from mechanical ventilation and NMBR guidelines, was implemented on February 29, 2016.
The associations of baseline characteristics with the postoperative duration of mechanical ventilation (primary outcome) and respiratory and/or adverse complications (secondary outcomes) were evaluated using regression and interrupted- time series models. The implementation of an extubation protocol was associated with an 18% decrease in the duration of mechanical ventilation (incident rate ratio [IRR] 0.82, 95% CI 0.72-0.94; p < 0.01), statistically insignificant 26% increase in patients extubated ≤6 hours (odds ratio [OR] 1.26, 95% CI 0.97-1.65; p = 0.09), and 13% shorter intensive care unit length of stay (LOS) (IRR 0.87, 95% CI 0.79-0.97; p < 0.01). Patients undergoing isolated coronary artery bypass graft or isolated valve procedures, on or after February 29, 2016, had decreased extubation times (IRR 0.82, p < 0.01 and IRR 0.80, p = 0.02). The protocol did not have a statistically significant association with hospital LOS (IRR 0.98, p = 0.57) or readmission (OR 1.22, p = 0.33), and differences in the occurrence of pulmonary complications and adverse outcomes between the pre- and postprotocol groups were clinically insignificant.
The application of an extubation protocol incorporating NMBR based on neuromuscular monitoring was associated with a decrease in postoperative duration of mechanical ventilation and facilitated more patients meeting the early extubation benchmark without an increased risk of respiratory complications or adverse outcomes.

OBJECTIVE: Open heart surgery (OHS) is frequently performed on elderly patients. We aimed to investigate the risk factors associated with prolonged intensive care unit (ICU) stay in elderly patients undergoing open heart surgery.
METHODS: Medical records of all patients ≥ 75 years who underwent OHS (coronary artery bypass grafting (CABG) and/or heart valve surgery) between June 1, 2013, and December 31, 2020, were retrospectively analyzed. Those staying in the ICU longer than five days were determined as prolonged ICU stay. Patients were divided into two groups, according to ICU stay <5 days and ≥5 days.
RESULTS: Out of the 198 patients included in the study, 130 (65.7%) were male. Seventy patients (35.4%) had prolonged ICU stay. The mean age was higher in patients within the prolonged ICU stay group when compared to the other group (79.9±3.5 years vs.78.1±2.7 years, p<0.001). The patients who used statins and angiotensin-converting enzyme inhibitors (ACEi)/angiotensin receptor blockers (ARBs) in the preoperative period had a shorter ICU stay compared to those who did not (45% vs 31.4%, p=0.04; 57% vs 42.9%, p=0.03). The history of previous thoracic surgery (2.3% vs 10% p=0.03), emergency surgery (12.5% vs 24.5% p=0.04), and preoperative pacemaker usage (0.8% vs 7%, 1 p=0.01) were higher in the group of patients with prolonged ICU stay compared to the other group. Preoperative ejection fraction (EF)% (47.7±11.3 vs 51.1±8.8, p<0.001) and hemoglobin level (11.8±1.9 mg/dL vs 12.9±1.6, p<0.001) were lower in the group with prolonged ICU stay compared to the other group. Incidence of cardiac arrest (3.9% vs 15.7% p=0.006), presence of arrhythmia (16.4% vs 41.6%,p<0.001), frequency of pacemaker and intra-aortic balloon pump (IABP) usage (0 vs 10% p=0.002; 1.6% vs 8.6% p=0.02), and need for renal replacement therapy (3.1% vs 12.9%,p=0.02) were higher in the group with prolonged ICU stay compared to the other group. According to the logistic regression analysis; higher age (OR: 1.225, 95%CI 1.104-1.360, p<0.001), preoperative pacemaker usage (OR: 0.100, 95%CI 0.01-0.969, p<0.04), preoperative statin non-use (OR: 2.056, 95%CI 1.040-4.066, p<0.03) and preoperative low EF (OR: 0.947, 95%CI 0.915-0.981, p=0.002) were determined as independent risk factors for prolonged ICU stay.
CONCLUSIONS: The incidence of prolonged ICU stay after OHS among patients ≥75 years was 35.4% in our cohort. Higher age, preoperative pacemaker usage, preoperative statin non-use, and low preoperative EF were associated with prolonged ICU stay.

BACKGROUND: Primary graft dysfunction (PGD) is still a major complication in patients undergoing lung transplantation (LTx). Much is unknown about the effect of postoperative mechanical ventilation on outcomes, with debate on the best approach to ventilation.
OBJECTIVE: The goal of this study was to generate hypotheses on the association between postoperative mechanical ventilation settings and allograft size matching in PGD development.
METHODS: This is a retrospective study of LTx patients between September 2011 and September 2018 (n = 116). PGD was assessed according to the International Society of Heart and Lung Transplantation (ISHLT) criteria. Data were collected from medical records, including chest x-ray assessments, blood gas analysis, mechanical ventilator parameters and spirometry.
RESULTS: Positive end-expiratory pressures (PEEP) of 5 cm H2 O were correlated with lower rates of grade 3 PGD. Graft size was important as tidal volumes calculated according to the recipient yielded greater rates of PGD when low volumes were used, a correlation that was lost when donor metrics were used.
CONCLUSIONS: Our results highlight a need for greater investigation of the role donor characteristics play in determining post-operative ventilation of a lung transplant recipient. The mechanical ventilation settings on postoperative LTx recipients may have an implication for the development of acute graft dysfunction. Severe PGD was associated with the use of a PEEP higher than 5 and lower tidal volumes and oversized lungs were associated with lower long-term mortality. Lack of association between ventilatory settings and survival may point to the importance of other variables than ventilation in the development of PGD.

UNASSIGNED: Acute kidney injury (AKI) is common in patients undergoing major surgeries, and leads to the need for renal replacement therapy and increased morbidity, intensive care unit (ICU) and hospital length of stay (LOS), cost, and mortality. We evaluated the incidence and predictors of postoperative AKI in patients undergoing hepatic resections and their short-term outcomes.
UNASSIGNED: This prospective observational study was conducted over a 3-year period in 180 patients undergoing elective hepatic resections for a variety of indications. We used the Acute Kidney Injury Network criteria to determine the incidence of AKI at 72 hours. Perioperative variables contributing to the development of AKI and the short-term postoperative outcomes of patients were evaluated.
UNASSIGNED: Postoperative AKI occurred in 29.4% of patients. Persistent renal dysfunction was seen in five patients. Development of AKI was associated with hepatic failure (18.5 vs 5.5%, p < 0.005), prolonged ICU (2 vs 1 days, p < 0.001) and hospital LOS (11 vs 8 days, p < 0.004), and increased ICU and hospital mortality (9.6 vs 1.4%, p < 0.02). Age [OR (odds ratio) 1.033, 95% CI (confidence interval) 1.003-1.065, p = 0.03], BMI (body mass index) (OR 1.131, 95% CI 1.043-1.227, p = 0.003), and need for postoperative ventilation (OR 3.456, 95% CI 1.593-7.495, p = 0.002) were independent predictors of AKI.
UNASSIGNED: AKI after elective hepatic resection occurred in nearly one-third of our patients. Persistent renal dysfunction was seen in five patients. Age, BMI, and need for postoperative ventilation were independent predictors of postoperative AKI. (CTRI reg. No.: CTRI/2016/06/007044).
UNASSIGNED: Joshi M, Milmile R, Dhakane P, Bhosale SJ, Kulkarni AP. Incidence and Predictors of Acute Kidney Injury in Patients Undergoing Elective Hepatic Resection for Malignant Tumors: A 3-year Prospective Observational Study. Indian J Crit Care Med 2021;25(4):398-404.

OBJECTIVE: To report on postoperative outcomes related to the administration of neostigmine for reversal of nondepolarizing neuromuscular blocking agents in cardiovascular surgery patients, with a specific focus on the duration of postoperative mechanical ventilation as the primary endpoint.
METHODS: A retrospective cohort study design was followed to achieve the study objectives.
METHODS: This was a single-center, chart review study conducted at a large academic medical center of adult patients post-cardiovascular surgery.
METHODS: Patients were included if they had received a bolus dose of perioperative nondepolarizing neuromuscular blocking agent and underwent one of the targeted cardiovascular surgeries.
METHODS: Final analysis comprised of 175 patients, 95 of whom received neostigmine and 80 who did not receive neostigmine.
RESULTS: The primary endpoint was the duration of postoperative mechanical ventilation. When controlling for all covariates, neostigmine use was associated with a 0.34-hour reduction (∼20.4 min) in duration of mechanical ventilation (parameter estimate: 0.66, 95% confidence interval 0.49-0.89; p = 0.0071). More patients who received neostigmine met the early extubation benchmark of less than 6 hours (55 v 34 patients; p = 0.04). Finally, neostigmine use was not found to be associated with increased risk of respiratory complications or postoperative nausea and/or vomiting.
CONCLUSIONS: The use of neostigmine was found to have a protective effect on the duration of postoperative mechanical ventilation without increasing the risk of adverse complications.

OBJECTIVE: To evaluate by meta-analysis the effects of dexmedetomidine versus midazolam on postoperative delirium in patients that received postoperative mechanical ventilation.
METHODS: The electronic databases of PubMed, Web of Science, EMbase, CNKI, CBM, Cochrane library and WanFang were searched by two reviewers. All the clinical studies related to dexmedetomidine versus midazolam on postoperative delirium were screened and collected in this meta-analysis. The combined postoperative delirium risk between dexmedetomidine and midazolam groups was pooled by random effect model. The publication bias was assessed by Begg\'s funnel plot and Egger\'s line regression test.
RESULTS: A total of six studies including 386 subjects (202 in the dexmedetomidine group and 184 in the midazolam group) were finally included in this meta-analysis. All six studies reported adequate sequence generation. Three studies used blindness methods and 2 publications were free of selective reporting. However, only 1 publication reported allocation concealment. Because of significant heterogeneity across the studies (I2=61.7%, p<0.05), the data were pooled by random effect model. Pooled data showed the postoperative delirium risk in the dexmedetomidine group was significantly lower than that of the midazolam group (RR=0.20 (095%CI:0.09~0.47, p<0.05)).The Begg\'s funnel plot showed obvious asymmetry at the bottom and Egger\'s line regression test also indicated significant publication bias (t=-6.51, p<0.05).
CONCLUSIONS: Compared with midazolam, patients that received dexmedetomidine for postoperative mechanical ventilation sedation had less risk of developing delirium.

Myasthenia gravis (MG) is an autoimmune disease with an incidence of 2-10/100,000 cases per year, characterized by muscle weakness secondary to destruction of postsynaptic acetylcholine receptors. In these patients, important perioperative issues remain unresolved, namely, optimal administration of cholinesterase inhibitors, risks of regional anesthesia, and prediction of need of postoperative mechanical ventilation. We describe the use of a low-dose spinal anesthesia in a patient with MG who was submitted for emergence exploratory laparotomy. The utilization of low-dose spinal anesthesia allowed us to perform surgery with no adverse respiratory or cardiovascular events in this patient.