Faktor-Faktor yang Berhubungan dengan Pengetahuan Perawat Tentang Penyapihan Ventilasi Mekanik Di Ruang Perawatan Intensif Rumah Sakit Panti Rapih Yogyakarta

Background: Mechanical ventilation weaningis a collaborative action of multidisciplines. The nurse's knowledge plays an important role in assessing the readiness of the patient and observing it during the weaning process to support the success of the patient escaping from mechanical ventilation. Objective: The purpose of this study was to determine the factors related to the knowledge of nurses about mechanical ventilation weaning in the Intensive Care Room at Panti Rapih Hospital. Methods:This research is adescriptive analytic study with a cross sectional approach. The population of this study were all nurses who worked in the Intensive Care Room at Panti Rapih Hospital, Yogyakarta. The sample in this study was the total population, namely nurses in the Intensive Care Room, amounting to 48 respondents. The research instrument was avalid and reliable questionnaire on the level of knpwledge and influencing factors with a calculated r value of morethan 0.482 and cronbach alpha 0.75. Analysis using independent T-test and Spearman Results: The mean level of knowledge of respondents about mechanical ventilation weaning averaged 31.52 with CI7.458. Factors related to mechanical ventilation weaning knowledgein this studywereage (p-value:0.024), education (p-value:0.000), experience (p-value: 0.003), social and cultural (p-value: 0.009).), and sources of information (p-value:0.001). Meanwhile, the factors that were not related to knowledge of mechanical ventilation in this study were environment (p-value:0.115) and economy (p-value:0.231).

Lung Ultrasonography as Tool for Follow Up of Ventilated Neonates for Prediction of Weaning Readiness

Background Timing is crucial when deciding if a patient can be successfully extubated. Both premature discontinuation and unnecessary delay of mechanical ventilation weaning have been associated with poor outcome. There are no enough guidelines for the assessment of readiness of newborns for extubation. The degree of lung aeration loss in different clinical conditions can be quantified via lung ultrasound (LUS). Objectives To evaluate the lung ultrasound score as a follow up tool in ventilated neonates and its validity as predictor of extubation. Subjects and Methods Prospective study done on 39 mechanically ventilated neonates 27-42 weeks’ gestation. Lung ultrasound was done daily for each patient till the day of weaning and lung ultrasound (LUS) score was calculated. Patients were divided into 2 groups according to trial of weaning; Success “S” group: in which weaning succeeded and Failure “F” group: in which weaning failed. Results The “F” group had significantly higher LUS score at time of intubation, pre- extubation and post-extubation compared with the “S” group (P- value= 0.002, 0.003 and 0.001 respectively). A cut off value of ≤ 10 for LUS score pre-extubation predict successful weaning with sensitivity 76% and specificity 64.3%. Conclusion LUS is an indicator for lung aeration and can be used as a tool to predict success of weaning of ventilated neonates.

A Survey of Mechanical Ventilation Weaning Practices in ICUs of Bangladesh

Objective : To determine mechanical ventilation discontinuation (weaning) practices in Bangladesh as there is currently no data available on this issue. Method : Analyzing the Survey on Bangladeshi respondents using questionnaire developed by and used by a pan Asian study where Bangladesh critical care physicians participated. Result : 40 physicians from 10 ICUs of Bangladesh participated. Majority of our participating doctors (62.5%) came from private for profit hospital. 19 out of 40 respondents were certified in critical care medicine. In our study spontaneous breathing trial (SBT) was liberally used with pressure support being used by 30% respondents. Most of the extubation trial took place during day. As criteria for extubation, respondents mainly considered consciousness and cooperation and along with gag reflex, cough strength, suction frequency and cuff leak at different times. Noninvasive ventilation (NIV) was commonly used for early extubation in cases of COPD, cardiogenic pulmonary edema, neuromuscular disorders, post-operative cases and obesity. Slightly less than half of respondents did not follow any sedation protocol and 42.5% followed weaning protocol. Protocolized weaning by nurses are not known to be practiced in Bangladesh. Conclusion : Weaning practices are diverse in Bangladeshi ICUs. Protoclized weaning is rarely practiced in Bangladesh. Bangladesh Crit Care J March 2021; 9(1): 4-11

Clinical and neurophysiological characterization of muscular weakness in severe COVID-19

Objective To report clinical and electroneuromyographic (ENMG) characteristics of patients affected by severe COVID-19 infection, evaluated for muscular weakness. Materials and methods ENMGs performed for evaluation of diffuse weakness in patients who could not be discharged from semi-intensive care COVID unit because of difficulties in ventilation weaning were reviewed. Patients with severe COVID-19 infection who had undergone endotracheal intubation and able to co-operate were considered. ENMG protocol was focused on neurophysiological items that excluded or confirmed critical illness polyneuropathy (CIP), myopathy (CIM), or polyneuromyopathy (CIPM). Standardized clinical evaluation was performed using Medical Research Council (MRC) sum score. Results Eight patients were included in the study. All presented known risk factors for intensive care unit-acquired weakness (ICU-AW), and none of them had history of underlying neuromuscular disorders. ENMG findings were normal in two patients, while only two patients had an altered MRC sum score (< 48). Neuromuscular involvement was diagnosed in 6/8 patients (75%): 2 had CIP, 1 had possible CIM, 1 had CIPM, while 1 patient, with clinically evident weakness but equivocal ENMG findings, was classified as ICU-AW. Finally, 1 patient was diagnosed with acute demyelinating neuropathy. Patients with neuromuscular involvement were those with longer intubation duration and higher levels of IL-6 at admission. Conclusion Neuromuscular complications are frequent in severe COVID-19 and cannot be excluded by MRC sum scores above 48. Standardized ENMG is helpful in guiding diagnosis when clinical evaluation is not reliable or possible. Elevated IL-6 at admission may be a predictor biomarker of ICU-AW in COVID-19.

Phrenic Nerve Stimulator Placement via the Cervical Approach: Technique and Anatomic Considerations

BACKGROUND Diaphragmatic pacing via phrenic nerve stimulation can help improve breathing and facilitate mechanical ventilation weaning in patients with respiratory failure secondary to brainstem injury, high cervical spinal cord injury, or congenital central hypoventilation. Devices can be placed utilizing several techniques; however, nuances regarding placement are not well published. OBJECTIVE To describe our experience with phrenic nerve stimulator placement via the cervical approach with a focus on surgical anatomy, variations, and technique. METHODS Placement of phrenic nerve stimulator via a cervical approach is described in detail. RESULTS Successful placement of phrenic nerve stimulator without complication. CONCLUSION The cervical approach for the placement of a phrenic nerve stimulator is a safe and effective option for patients. Detailed knowledge of anatomy and anatomic variations is required. Potential advantages and disadvantages are discussed.

Implementation and evaluation of a nurse-driven noninvasive ventilation weaning protocol in infants with severe bronchiolitis

Rationale: Noninvasive ventilation (NIV) is the first-line therapy in infants with bronchiolitis-related acute respiratory failure. However, there is a lack of data regarding weaning from NIV in this setting. Working hypothesis: This study aims to evaluate a nurse-driven weaning protocol in this homogenous population. Study design: A retrospective single-center study with pre-versus-post comparative design in a tertiary center. Methodology: Data from all infants aged ≤ 6 months admitted to the PICU during 2 seasons with a clinical diagnosis of bronchiolitis and requiring any type of noninvasive ventilatory support on admission, were analyzed. Main results: In total, 187 infants (95 with standard and 92 with nurse-driven protocols) were included; the median age was 47 (IQR 24-75) and 31 days (19-58) in patients at baseline and after the protocol implementation, respectively. There was no difference in terms of weaning failure between the two periods (11 (12%) versus 14 (15%), p=0.46). At baseline, the ventilatory support duration was 70 hours (IQR 54-104) versus 56 hours (IQR 29-83) during the nurse-driven protocol period (p=0.29). The PICU and hospital lengths of stay did not differ between the two periods. No complication related to NIV occurred in the two periods. Conclusions: In patients with bronchiolitis supported by NIV, the nurse-driven weaning management - as opposed to physician-driven - was not associated with a significantly higher proportion of weaning failure cases.