Predictors of successful extubation in neurosurgical patients

A respiratory therapist-driven weaning protocol incorporating daily screens , spontaneous breathing trials (SBT), and prompts to caregivers has been as sociated with superior outcomes in mechanically ventilated medical patients . To determine the effectiveness of this approach in neurosurgical (NSY) pa tients, we conducted a randomized controlled trial involving 100 patients o ver a 14-mo period. All had daily screens of weaning parameters. if these w ere passed, a 2-h SET was performed in the Intervention group. Study physic ians communicated positive SET results, and the decision to extubate was ma de by the primary NSY team. Patients in the Intervention (n = 49) and Contr ol (n = 51) groups had similar demographic characteristics, illness severit y, and neurologic injuries. Among all patients, 87 (45 in the Control and 4 2 in the Intervention group) passed at least one daily screen. Forty (82%) patients in the Intervention group passed SBT, but a median of 2 d passed b efore attempted extubation, primarily because of concerns about the patient 's sensorium (84%). Of 167 successful SBT, 126 (75%) did not lead to attemp ted extubation on the same day. The median time of mechanical ventilation w as 6 d in both study groups, and there were no differences in outcomes. Ove rall complications included death (36%), reintubation (16%), and pneumonia (9%). Tracheostomies were created in 29% of patients. Multivariate analysis showed that Glasgow Coma Scale (GCS) score (p < 0.0001) and partial pressu re of arterial oxygen/fraction of inspired oxygen ratio (p < 0.0001) were a ssociated with extubation success. The odds of successful extubation increa sed by 39% with each CCS score increment. A CCS score greater than or equal to 8 at extubation was associated with success in 75% of cases, versus 33% for a GCS store < 8 (p < 0.0001). implementation of a weaning protocol bas ed on traditional respiratory physiologic parameters had practical limitati ons in NSY patients, owing to concerns about neurologic impairment. Whether protocols combining respiratory parameters with neurologic measures lead t o superior outcomes in this population requires further investigation.