Decision making of tracheostomy and extubation outcomes in mechanically ventilated patients evaluated by logistic regression and decision tree analyses


Background: Most studies determining the predictors of extubation outcomes in patients with mechanical ventilation have not included high-risk populations who avoid extubation and undergo tracheostomy.

Objective: To evaluate predictors of extubation intolerance by analyzing patients regardless of whether extubation was attempted or not.

Design: Retrospective cohort study.

Settings: Mixed intensive care unit (ICU) of Kumamoto University Hospital.

Patients and participants: Medical data of 288 consecutive mechanically ventilated adults were collected. Initial outcomes of endotracheal tube treatment were classified as 1) successful extubation, 2) extubation failure, and 3) tracheostomy without attempting extubation. Clinical variables responsible for those outcomes were determined by logistic regression and decision tree analyses. We defined combined outcome of extubation failure and tracheostomy as extubation intolerance in the present study.

Results: Of 288 patients, 17 failed extubation and 37 opted for tracheostomy without extubation. Logistic regression analysis revealed that the significant predictors of extubation failure were weak cough strength, poor consciousness, and excessive airway secretion. The propensity score of extubation failure calculated by logistic regression analysis in the tracheostomy group was as high as that of extubation failure group. A decision tree to predict the outcomes was described by branching with consciousness, style of ICU admission, and volume of airway secretion.

Conclusions: The principle predictors of extubation intolerance were related to instability of airway patency, and the decision making of tracheostomy was shown to be appropriate. These statistical methods could reduce the selection bias of study subjects.

Authors: Susumu Hirosako, Hirotsugu Kohrogi, Katsuyuki Sagishima, Keisuke Sakai, Yohei Migiyama, Hidenobu Kamohara, Hiroaki Kawano, Yoshihiro Kinoshita

Malignant pericardial effusion presenting as a wheeze- case report


Slow growing pericardial effusion is detected less commonly than acute pericardial tamponade. However, it is equally life threatening if it is more than 250 to 300 ml and can contribute to a similar picture of a fix cardiac output obstructive shock. We would like to report a case of malignant pericardial effusion that was detected in the ICU when the patient presented to the hospital with shortness of breath and generalized wheezes suggestive of respiratory failure from chronic obstructive lung disease (COPD).

Authors: Eng Kiang Lee

Case report: central venous pressure-guided de-resuscitation in sepsis patients with fluid overload induced acute kidney injury


Background: Aggressive fluid resuscitation is commonly administered in septic patients as recommended by Surviving Sepsis Campaign. However, positive fluid cumulative balance resulting in fluid overload is correlated with various complications such as acute kidney injury, acute respiratory distress and delayed wound healing.

Case report: This report presents four septic patients with fluid overload and acute kidney injury who underwent active de-resuscitation aiming central venous pressure between zero and two mmHg.

Discussion: In all patients, central venous pressure guided de-resuscitation was associated with systemic oxygenation improvement (arterial lactate dropped from 8.3 to 0.8 mmol/l, from 5.3 to 0.3 mmol/l, from 3.5 to 0.5 mmol/l, and from 3.3 to 0.7 mmol/l) and acute kidney injury resolution without hemodynamic instability and elevated lactate level. Negative cumulative balance is associated with a significant reduction of norepinephrine dose.

Conclusion: A de-resuscitation strategy based on the target of central venous pressure 0-2 mmHg is a safe and effective procedure that resulted in improvement in hemodynamics, serum lactate, renal function and also systemic oxygenation.

Authors: Ni Luh Kusuma Dewi, Yohanes WH George

Status epilepticus caused by cerebral venous thrombosis in the puerperal period: case report and literature review


Status epilepticus (SE) caused by cerebral venous thrombosis (CVT) is rare in pregnancy and puerperium, with few cases described in literature. Seizures in pregnancy are usually due to previous epilepsy or pregnancy related disease, such as eclampsia, posterior reversible encephalopathy syndrome (PRES), reversible cerebral vasoconstriction syndrome (RCVS), eclampsia and thrombotic thrombocytopenic purpura (TTP). Due to its high mortality, the SE and the underlying disease must be promptly managed. In this article, we present a case of SE in postpartum due to cerebral venous thrombosis and we reviewed the cases described on the topic.

Authors: Orivaldo Alves Barbosa, João Filho Araujo Ribeiro, Paola Lima Lemos

Role of hemofilter with endotoxin adsorption capacity in management of septic shock


We reported an adolescent male with acute lymphoblastic leukemia who developed septic shock due to Klebsiella pneumoniae. Continuous renal replacement therapy using a hemofilter with endotoxin adsorption capacity was used to remove endotoxin and cytokines. The promising result suggested that this technique may be applied as an adjuvant therapy for treatment of septic shock.

Authors: Wun Fung Hui, Winnie Kwai Yu Chan