Leveron&Nexovas
Neurology India
menu-bar5 Open access journal indexed with Index Medicus
  Users online: 1082  
 Home | Login 
About Editorial board Articlesmenu-bullet NSI Publicationsmenu-bullet Search Instructions Online Submission Subscribe Videos Etcetera Contact
  Navigate Here 
 Search
 
  
 Resource Links
  »  Similar in PUBMED
 »  Search Pubmed for
 »  Search in Google Scholar for
 »Related articles
  »  Article in PDF (1,288 KB)
  »  Citation Manager
  »  Access Statistics
  »  Reader Comments
  »  Email Alert *
  »  Add to My List *
* Registration required (free)  

 
  In this Article
 »  Abstract
 »  Materials and Me...
 » Results
 » Discussion
 » Conclusion
 »  References
 »  Article Tables

 Article Access Statistics
    Viewed284    
    Printed14    
    Emailed0    
    PDF Downloaded10    
    Comments [Add]    

Recommend this journal

 


 
Table of Contents    
ORIGINAL ARTICLE
Year : 2022  |  Volume : 70  |  Issue : 4  |  Page : 1540-1547

Impact of Postoperative ABG Analysis and ICU Weaning Protocol in Surgical Outcome of Atlanto-Axial Dislocation: It's not the Towering Sail, but the Unseen Wind that Moves the Ship


1 Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
2 Department of Anaesthesia, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
3 Department of Biostatistics and Health Informatics, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Date of Submission17-Mar-2019
Date of Decision17-Mar-2019
Date of Acceptance17-Mar-2019
Date of Web Publication30-Aug-2022

Correspondence Address:
Sanjay Behari
Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences (SGPGI), Lucknow, Uttar Pradesh
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.355113

Rights and Permissions

 » Abstract 


Background: The outcome in patients of atlanto-axial dislocation (AAD) depends on multiple factors like preoperative optimization, intraoperative distractio and cord manipulation. Certain unfocussed factors such as respiratory reserve and compensatory acclimatization to hypoxia warrant consideration.
Aims: The purpose of this study is to find the association of postoperative arterial blood gas (ABG) analysis and respiratory reserve in patients of AAD with clinical outcome.
Study Design: We retrospectively analyzed the available records of patients, operated for AAD, at our institute (n = 66), from January 2014 to November 2018.
Materials and Methods: Preoperative pulmonary function test (PFT) and the postoperative ABG analysis was noted. Timing of extubation, duration of intensive care unit (ICU) stays, and clinical outcomes (Nurick grade) were noted from the inpatient record and the last outpatient follow up. An independent t-test and analysis of variance were used to find significance.
Results: In total, 41% (n = 27) patients had body mass index of less than 18.5, and 50% (n = 33) had breath holding time of less than 20 minutes. There was improvement in mean Nurick grade from 3.17 ± 0.8 to 2.76 ± 0.7 in follow up. A trend suggesting that patients with poor preoperative PFT has more ICU duration and worse outcome. In patients with mild acid-base disorders, extubation was possible within 24 hours. Out of 26 patients with ICU duration less than 2 days, 23 patients had “good” outcome, whereas ten out of 40 patients with ICU duration of more than or equal to 2 days had “bad” outcome (P = 0.00).
Conclusion: Patients having moderate to severe primary or mixed acid-base disorder have a probability of re-intubation or delayed extubation. A strong correlation was seen with the novel grading system (grade >6 had worse outcome).


Keywords: Arterial blood gas, atlanto-axial dislocation, intensive care unit weaning protocol, pulmonary function test
Key Message: 1. Patients having moderate to severe primary or mixed acid-base disorder have a higher probability of reintubation or delayed extubation. 2. In a well-optimized patient, preoperative respiratory reserve does not affect intensive care unit (ICU) duration, timing of extubation, or even outcome. 3. Independent breathing effort or arterial blood gas values may not be significant, but a strong correlation was seen with the novel grading system (grade >6 had worse outcome). 4. An algorithm for the postoperative ICU protocol has been proposed depending upon parameters used in our grading system.


How to cite this article:
Marutirao R, Singh S, Shamshery C, Sardhara J, Mishra P, Mehrotra A, Srivastava AK, Jasiwal AK, Srivastava S, Behari S. Impact of Postoperative ABG Analysis and ICU Weaning Protocol in Surgical Outcome of Atlanto-Axial Dislocation: It's not the Towering Sail, but the Unseen Wind that Moves the Ship. Neurol India 2022;70:1540-7

How to cite this URL:
Marutirao R, Singh S, Shamshery C, Sardhara J, Mishra P, Mehrotra A, Srivastava AK, Jasiwal AK, Srivastava S, Behari S. Impact of Postoperative ABG Analysis and ICU Weaning Protocol in Surgical Outcome of Atlanto-Axial Dislocation: It's not the Towering Sail, but the Unseen Wind that Moves the Ship. Neurol India [serial online] 2022 [cited 2022 Oct 2];70:1540-7. Available from: https://www.neurologyindia.com/text.asp?2022/70/4/1540/355113




The Surgical nuances of various approaches for atlanto-axial dislocation (AAD) have been discussed in the literature a lot. Different school of thoughts propose their own modification and advantages. In our experience of operating more than 500 cases of AAD, we feel that surgical outcome depends on other unexplored factors. These factors, including preoperative respiratory reserve, body mass index (BMI), adequate preoperative respiratory optimization, postoperative intensive care protocol and physiotherapy, should be considered more important rather than surgical corridor and small technical alterations. In this study, we intend to analyze the preoperative spirometry and postoperative arterial blood gas (ABG) values in an operated patient of AAD; and find its correlation with intensive care unit (ICU) stay or surgical outcome. We herein propose our postoperative extubation protocol highlighting the importance of interpretation of blood gas values.


 » Materials and Methods Top


In this retrospective study, 66 patients of AAD, operated in our institute (January 2014 to November 2018), were analysed. Individual consent from the patient to use clinical and radiological details for publication was taken. Institutional ethical clearance was obtained, and there was no conflict of interest. Data analysis included, demographic data, clinical features, BMI, and radiological parameters were recorded from hospital case records, outpatient files, and the hospital information system.

Patient spectrum

We included all patients of AAD irrespective of the presence or absence of basilar invagination or Chiari-malformation. Patients were operated by posterior fusion ± distraction. The technical aspect was similar in all patients, and there is no difference in level of expertise among surgeons. Patients with Revanappa's modified Nurick grade 5 (chair-bound or bedridden) [n = 35] and traumatic AAD were excluded from study [n = 20].[1] Being a retrospective study, a majority of ABG [n = 145] could not be retrieved so these patients were excluded. None of the patients underwent isolated transoral decompression.

Study parameters

Preoperative pulmonary function assessment (PFT) and the ABG analysis were conducted on the first postoperative day were studied in our study. The PFT was conducted as part of the routine workup of AAD patients in our institute. The PFT was conducted in the Pulmonary Medicine Department by a qualified doctor. The laboratory had normative data for age and sex-matched subjects [Supplement 1]. The percentage of predicted values of the PFT parameters (based on the patient's height, age, and sex) was used for comparison.



The following parameters in the PFT were assessed:

  1. Inspiratory vital capacity (IVC): The maximum volume of air inspired from the maximum expiratory level. It is the sum of the tidal volume (TV) and inspiratory reserve volume (IRV). Average TV in healthy adults being 0.5 litres, and average IRV being 3 litres in males and 1.9 litres in females. The total vital capacity decreases in both obstructive and restrictive lung disease, and exhalation from TLC to RV is better marker for patients with obstructive lung disease than inhalation form RV to TLC, which better represents expansible nature of lung, i.e., better represents restrictive lung disease.[2]
  2. Forced vital capacity (FVC) - It is defined as the amount of air that can be forcibly exhaled from the lungs after taking the deepest breath possible. The average FVC in healthy adults is 3-5 litres. FVC and vital capacity record similar information, but FVC refers to the amount of air you can exhale forcefully, while VC records the maximum amount of air that can be exhaled when breathing normally. FVC decreases in both obstructive diseases (chronic obstructive pulmonary disease (COPD), including chronic bronchitis, emphysema, and bronchiectasis) and restrictive diseases (idiopathic pulmonary fibrosis, scoliosis and chest scarring, sarcoidosis, inflammatory lung diseases, such as asbestosis, silicosis, lung cancer). Normal predictive FVC is 80-120.[3]
  3. Forced expiratory volume at first second (FEV1) and the ratio of FEV1 to FVC: The time indicating the volume of air exhaled forcefully in the first second. FEV1 from 80 to 100% is usually considered normal; FEV1 between 60 and 79% of predicted indicates a mild obstruction; FEV1 between 40 and 59% indicates a moderate obstruction; and FEV of less than 40% is considered severe obstruction. A normal FEV1/FVC ratio is 70–80% or higher in adults; and 85% or higher in children. In restrictive lung diseases, the inhalation is limited but people can generally exhale with the same extra force. Contrarily, in the obstructive lung diseases, it is difficult to exhale, leading to short and rapid breathing. In the restrictive lung diseases, such as pulmonary fibrosis, the FEV1 and FVC both decreases proportionally, so that the ratio of FEV1/FVC is not affected; while in the obstructive diseases, such as COPD, the FEV1/FVC ratio will be less than 70%. Normal predictive FEV1 is above 80.[2],[3]
  4. Mid expiratory flow (MEF25-75): The mid expiratory flow between 25% and 75% of vital capacity reflects small airway patency. The current practice guidelines recommend only FEV1, VC, and FEV1/VC as indicators of obstructive disease, and not MEF25-75, but it may be a more sensitive parameter than FEV1 in the detection of obstructive small airway disease. Reductions in MEF25-75, in the absence of classically defined airways obstruction, may also result from reduced lung volume rather than from airway disease.[3]


In the ABG, we focussed at pH, pCO2, pHCO3, and base excess (BE).

  1. Primary acid-base disorders: A change in pCO2 when responsible for a change in hydrogen ion concentration [H+], the condition is called respiratory acid-base disorders; an increase in pCO2 (more than 45 mmHg) is a respiratory acidosis, and a decrease in pCO2 (less than 35 mmHg) is a respiratory alkalosis. When a change in HCO3 (bicarbonate ion) is responsible for a change in [H+], the condition is called metabolic acid-base disorders; an increase in HCO3 (more than 26 mEq/L) is a metabolic alkalosis (less than 22 mEq/L), and a decrease in HCO3 is a metabolic acidosis.
  2. Mixed acid-base disturbances are combinations of two or more primary acid-base disturbances at the same time.[4]
  3. Base deficit: It is defined as the amount of acid required to restore a litre of blood to its normal pH at a PaCO2 of 40 mmHg. The BE increases in metabolic alkalosis and decreases (or becomes more negative) in metabolic acidosis. BE of +/-3 mEq/L is normal. Severe metabolic acidosis is p H < 7.2. Base deficit denotes nonrespiratory acid base disorder, thereby indirectly represents those patients who suffer from subclinical hypoxia; but may or may not be compensated.


Subgroup analysis

The following outcomes were assessed in terms of PFT and ABG parameters:

  1. Timing of extubation: The patients in our study were grouped on the basis of the time of extubation, i.e., whether the extubation is done within 24 hours (Group A), and more than 24 hours (Group B).
  2. Duration of ICU stay: The patients were also grouped on the basis of the duration of ICU stays [less than 48 hours (Group 1) and more than 48 hours (Group 2)].
  3. Surgical outcome: Patients with improvement in modified Nurick grade and discontinuation of baclofen was considered as “good outcome”; patients with either improvement in above grades or discontinuation of baclofen was labelled as “better outcome”; and patients with neither improvement in above grades nor discontinuation of baclofen was labelled as “worse outcome”. The patients who died (n = 4) were also included in “worse outcomes”.


Postoperative analysis

The surgical outcome was assessed by Revanappa's modified Nurick grade (Grade 0 – signs or symptoms of root involvement but without evidence of spinal cord disease; Grade 1 – signs of spinal cord disease but no difficulty in walking; Grade 2 – slight difficulty in walking but can get up from squatting or sitting on ground without vertical support; Grade 3 – difficulty in walking and requires vertical support to get up from squatting or sitting on ground; Grade 4 – able to walk only with someone else's help or with the aid of a frame; and Grade 5 – chair-bound or bedridden).[1]

Surgery

All the patients underwent high cervical neural decompression and fusion surgery (anterior (transoral odontoidectomy or posterior C1-2 distraction followed by occipito – C1 − C2 fusion/C1 − C2 fusion) depend upon their radiological and clinical sign of cervical myelopathy.

Statistical analysis

The Statistical Package for the Social Sciences version 22.00, International Business Machines (IBM, New York, NY, USA) was used for statistical analysis. For comparison of mean distribution of PFT parameters, among groups, an independent t-test analysis and analysis of variance were conducted. ABG analysis was conducted on an individual basis depending on interquartile range. Chi-square test was used to find a correlation between outcome or study parameters. A P value less than 0.05 was considered significant.


 » Results Top


Demography and clinical characteristics

The mean age was 25.7 ± 11.8 years [M:F = 49:17], ranging from 8 years to 58 years [Table 1]. In total, 89.4% of patients were below 40 years, and 42.4% even below 20 years. Patients with chronic progressive myelopathy (nearly 59% presented after 1-5 years) underwent AAD anomalies by Dynamic CT CVJ and MRI cervical spine. Nearly 41% (n = 27) of patients had BMI of less than 18.5, and 50% (n = 33) had their breath holding time of less than 20 minutes. The majority of our patients had spinal cord intensity changes in T2 weighted MRI images (80%) and basilar invagination (82%) on CT CVJ. There was improvement in mean Nurick grade from 3.17 ± 0.8 to 2.76 ± 0.7 in the last follow up after surgery. Therefore, in spite of the fact that we deal with a complex subset of patients, 80% of our patients had “better” or “good” outcome. There were 4 deaths in our study.
Table 1: Clinical characteristics of patients in our study (n=66)

Click here to view


In total, 63.6% (n = 42) patients were extubated within 24 hours (Group A), and 36.45 patients (n = 24) were extubated after 24 hours. In total, 39.4% patients (n =26) had ICU duration of less than 48 hours (Group 1), and 60.6% patients (n = 40) had ICU duration of more than 48 hours (Group 2).

Effect of preoperative pulmonary reserve

The majority of the patients had moderate restriction [Supplement 2] preoperatively (FVC = 50-69 and FEV1 = 60-69). The mean IVC of 66 patients was 53.47 ± 20.0 (13-93), mean FVC was 59.98 ± 21.6 (11-111), mean FEV1 was 61.7 ± 21.9 (11-118), mean FEV1/FVC ratio was 104.1 ± 13.1 (43-121), and mean MEF25-75 54.9 ± 22.1 (9-122). On further subgroups analyses, the preoperative respiratory parameters were not statistical significant with either timing of extubation, ICU duration, nor surgical outcome. On analysing the patients, we found a trend showing patients with poor preoperative parameters have comparatively more ICU duration and worse outcome. The timing of extubation, however, does not correlate with the PFT parameters. Actually, all the patients (n = 66) were operated in elective settings, and were well optimized before taking them for surgery. Therefore, importance of optimizing the preoperative PFT is substantiated.



Effect of postoperative blood gas parameters

Mean pH of patients in our study was 7.36 ± 0.08 (7.0-8.0), mean pCO2 was 37.93 ± 7.9 (14-67), HCO3 20.98 ± 4.7 (10-34), and mean BE -3.87 ± 5.5 (-14 to 9). Most common arterial base gas disorder in our study is metabolic acidosis. [Table 2] shows a comparison of blood gas parameters among Group 1 and 2. The mean of parameters was not statistically significant (because these parameters have a normal range); both the extreme values are considered abnormal. There is a clinical trend. In patients with mild acid-base disorders (pH between 7.31 and 7.45), extubation was possible within 24 hours, whereas patients with moderate acid-base disorders or mild mixed disorders took more than 24 hours for extubation. Patients with BE more than -9 were extubated after 1 day. The similar trend was seen for surgical outcome also; patients with moderate acid-base disorders or mild mixed disorders have worse outcomes. On comparing the mean distribution of ABG parameters, we found a significant outcome for pCO2 (mean pCO2 of “good outcome group” was 37.8 ± 5.49 compared to 41.02 ± 16.36 of “worse outcome group”).
Table 2: Comparison of blood gas parameters among Group 1 and 2

Click here to view


Out of 26 patients with ICU duration less than 2 days, 23 patients had “good” outcome, whereas ten out of 40 patients with ICU duration of more than or equal to 2 days had “bad” outcome (Pearson's Chi-square P = 0.00) [Table 3]. There was a positive correlation between timing of extubation and outcome (r = 0.2), extubation and ICU duration (r = 0.5), ICU duration and outcome (r = 0.3). There was no correlation between preoperative IVC and timing of extubation (r = 0.1), between BE and timing of extubation (r = 0.01), and between outcome and blood gas values (r = -0.1).
Table 3: Relation of arterial blood gas parameters with surgical outcome

Click here to view


Analysis of all patients who had delayed extubation (more than 48 hours)

In our study, 16 patients were extubated after 48 hours. These patients needed prolonged postoperative ventilator support and optimization. [Table 4] shows ABG and PFT values of the 16 patients who had delayed extubation in our study group. Individual PFT analysis of these patients showed that 3 patients had normal PFT and 3 had a mild restrictive pattern, only 4 patients had a severed restrictive pattern, and 6 patients had a moderate restrictive pattern on preoperative PFT. The retrospective analysis of ABG also showed similar varied result; 4 patients had normal range ABG, 5 had a mild acid-base disorder, and only 2 patients had a severe metabolic acidosis. In addition, 3 patients had a mixed acid-base disorder, and 2 patients had moderate metabolic acidosis. There was an interesting pattern in our study, suggesting that 10 patients (in delayed extubation group) had BMI less than 10. Therefore, in a well-optimized patient, planned for elective surgery for AAD, independent preoperative PFT, ABG, or BMI may not affect the outcomes, may be because of the physiological compensatory reserve. However, when two or more of these parameters are affected, then the above compensation fails, and either outcome becomes worse or patients needed reintubation.
Table 4: Factors (PFT, ABG, BMI) associated with delayed extubation patients

Click here to view


A novel grading system is advocated [Table 5] to predict the outcome in AAD patients including preoperative PFT, postoperative ABG, and BMI values. In our study, the number of patients with score 1-6 had good (n = 19) and better (n = 15) outcome; compared to patients with score 7-10 respectively. This grading system correlation showed a strong correlation with outcome (r = 1).
Table 5: Novel ABP scoring system to predict the outcome in AAD patients

Click here to view


The above grading system was applied retrospectively on the 6 patients who needed re-intubation, because physiological compensation failed. [Table 6] shows that all these patients had poor predictive grade; with more than two parameters deranged.
Table 6: Frequency distribution of surgical outcome according to the ABP scoring system

Click here to view



 » Discussion Top


The surgical outcome of patients operated for AAD is variably reported in the literature.[3],[4],[5],[6],[7],[8] Apart from nonmodifiable factors such as preoperative disability or medical co-morbidity, other factors like preoperative respiratory capacity and postoperative intensive care management have convincing effects on patient outcome. It is evident from our study that these under focussed factors are the foretellers of a need for re-intubation, duration of ICU-stay, and the probable outcome. However, these factors need to be interpreted in the background of preoperative PFT, BMI, and renal status; not ignoring intraoperative variables such as duration of surgery, blood loss, type of surgery, and surgical complications.

In patients of AAD, an occult respiratory dysfunction may occur, due to direct compression of neural tissue (poor drive) or due to weak respiratory muscles (poor effort).[5] As our departmental protocol, all patients underwent pulmonary function test in preoperative period. We found that these patients of AAD showed a restrictive pattern of PFT. A low preoperative IVC and FVC values were seen in these patients, which may explain longer ICU stay in these patients, although the results were statistically insignificant. In a similar study by Bhagavatula et al., there was a significant preoperative decrease in FVC and FEV1 which was responsible for intra- and postoperative respiratory insufficiency.[3] They also observed that FVC was lower in patients with worse neurological grading and proposed some possible mechanisms for the same. The variously explained pathogenesis is being repetitive cord trauma, stagnant hypoxia secondary to venous stasis or vertebral, and spinal artery occlusion and preexisting microscopic intraaxial abnormalities.[9] The discordant in our result may be due to our preoperative policy. We optimize the patients in ward and gradually build up IRV by incentive spirometry, and once sufficient capacity is achieved, then only post these patients for surgery. Uppar et al. concluded that preoperative FVC, FEV1, MVV, and PEFR are significantly reduced with AAD, most common being the AAD; and objective evaluation of respiratory dysfunction is necessary to improve postoperative pulmonary rehabilitation and thus ICU stay.[5] There are no studies till date to establish the significance of preoperative PFT to ICU stay.

Comparing ABG is not possible by analysing any central statistical value. Rather we preferred to compare range, although mean partial pressure of carbon dioxide was significantly lower in patients with poor outcome group. The patients with ICU duration of more than 24 hours (Group 2) had carbon dioxide retention (respiratory acidosis). We also found that base deficit of more than 9-10 is an independent parameter for longer ICU duration and poor outcome. To the best of our knowledge, this is the first study to highlight the importance of postoperative blood gas analysis in patients with AAD. We would like to propose that immediate postoperative ABG reflect may guide the intensives to make a wise decision. We noted that there is a strong correlation between the three parameters (BMI + PFT + ABG) influencing the timing of extubation and the duration if ICU stays collectively.

One-third of our patients had either mixed acid-base disorder and/or moderate acidosis/alkalosis. These patients formed a group of delayed extubation. These patients remained uncompensated, either due to poor pulmonary reserve, blood loss during surgery, prolonged surgical duration, or prolonged persistent cervico-medullary compression. These all correlated with prolonged ICU stay and worse outcome.

A majority of our study patients (63.6%, n = 42) had mild metabolic acidosis or normal ABG study in the first day of ICU and were extubated uneventfully within the first 24 hours of ICU stay. This leads us to the finding that mild metabolic acidosis is well tolerated/well compensated and has minimal if at all effect on reintubation or worse outcome. The most common causes of metabolic acidosis in the immediate postoperative period could be attributed to hemodynamic instability, renal failure, hyperchlorinemia due to rapid saline infusion, and cation-exchange resins. Gunnerson et al. also showed that metabolic acidosis is the main ABG disorder of patients admitted in ICU setting and had a positive correlation for poor outcome with respect to progressive worsening of metabolic acidosis.[10] Patients with severe metabolic acidosis had worse outcomes and vice versa.[11] We also noticed that patients with mild metabolic alkalosis also had uneventful extubation within the first 24 hours of ICU stay. In a similar study by Cain et al., it was concluded that the patients with an ICU stay >5 days had significantly decreased PFT parameters (FVC, FEV1, FEF25-75, and PEFR) compared to those who stayed less than 5 days but the study was done in patients undergoing cardiac surgery.[12]

Base deficit is the amount of base required to neutralize to titrate 1 litre of whole arterial blood to a pH 7.4 with a sample fully saturated with oxygen at 27°C and PaCO2 of 40 mmHg. It is an indirect marker of intravenous fluid deficit and is shown to be superior to pH for evaluating reversal of metabolic acidosis.[13] Davis et al. defined 3 categories of BE: mild, moderate, and severe and said it to be an equally good marker as lactate in predicting the outcome/resuscitation of the patient. With moderate to severe base deficit, patient had bad outcomes.[14] In our study, all patients with BE of less than 10, in the immediate postoperative setting had a poor outcome. More so, if the patient had a poor pulmonary/renal reserve, the patient can be doomed to have a poor outcome and calls for immediate intervention for its correction. Or else patients were seeming to have prolonged ICU stay, delayed extubation, worsened neurological outcome, tracheostomy, and ventilator dependence.

In a study by Smith et al., BE was more negative than 4 mmmol/L and had a mortality of 57.1% compared to 17.6% with BE more than -4 mmol/L.[13] Santi et al. also showed that patients with BE less than -4 mmol/L had higher mortality than the contrary.[15] Both these studies were defined in critically ill patients admitted to ICU due to different reasons. In our study, we have defined BE in AAD-operated patients in deciding the outcome in the form of the timing of extubation, and also -10 was the critical level deciding the outcome.

BE in AAD patients can occur due to excessive blood loss, persistent compression over the cord, hypovolemia, sepsis, neuromuscular weakness, renal pathology, and loss of carbon dioxide respiratory drive. In a study by Epstein et al., the failure rate in ICU ranged between 2% and 20%.[16] These failed extubation pertain greater hospital morbidity and mortality and thereby increasing hospital duration.[17] The patient is first subjected to spontaneous breathing trial, following sedation-off, and is reassessed for response frequently (Weaning protocol – [Annexure 1]). The patient should be evaluated for ABG before extubation. This ABG further guides the clinician, as to the decision for extubation. An abnormal ABG parameter is gradually compensated in-vivo by buffers viz. blood, lungs, and kidneys. An abnormal ABG is an indirect marker of inadequate buffer systems in the body; it could be either acidosis or alkalosis both of which when moderate to severe or of when present together would lead to delayed extubation. We would suggest to notice the alarming signs of moderate to severe ABG disorder, BE, and mixed disorders and to treat them appropriately. It also averts the cost of reintubation.



Nutrition is another factor which has been deceived of a spotlight. BMI is an indirect measure of the body's nutritional status and has become one of the factors of discussion in the present topic. In total, 40.9% of our patients were malnourished. We found that patients with poor nutrition (BMI < 20) had a poor outcome, respiratory compromise due to reduced muscle tone, and power of the respiratory muscles overlapped with the inability to bare surgical stress in view of a poor nutritional reserve.


 » Conclusion Top


Patients having moderate to severe primary or mixed acid-base disorder have a probability of reintubation or delayed extubation; hence, they should be optimized before the trial of extubation. In a well-optimized patient, posted for elective surgery, preoperative spirometry values do not effect ICU duration, timing of extubation, or even outcome. Physiological compensations of these patients crumble in situations of severe metabolic acidosis with a base deficit of more than -9 or even with mild mixed-acid base disorders. Independent breathing effort or ABG values may not be significant, but a strong correlation was seen with the novel grading system (grade > 6 had worse outcome). An algorithm for postoperative ICU protocol has been proposed depending upon parameters used in our grading system.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
Revanappa KK, Moorthy RK, Jeyaseelan V, Rajshekhar V. Modification of Nurick scale and Japanese Orthopedic Association score for Indian population with cervical spondylotic myelopathy. Neurol India 2015;63:24-9.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Bencowitz HZ. Inspiratory and expiratory vital capacity. Chest 1984;85:834-5. PubMed PMID: 6723401.  Back to cited text no. 2
    
3.
Bhagavatula ID, Bhat DI, Sasidharan GM, Mishra RK, Maste PS, Vilanilam GC, et al. Subclinical respiratory dysfunction in chronic cervical cord compression: A pulmonary function test correlation. Neurosurg Focus 2016;40:E3. doi: 10.3171/2016.3.FOCUS1647. PubMed PMID: 27246486.  Back to cited text no. 3
    
4.
Adams LG, Polzin DJ. Mixed acid-base disorders. Vet Clin North Am Small Anim Pract 1989;19:307-26. Review. PubMed PMID: 2494782.  Back to cited text no. 4
    
5.
Uppar AM, Vilanilam GC. Respiratory dysfunction in craniovertebral junction pathology: A pulmonary function test correlation. J Spinal Surg 2017;4:164-70.  Back to cited text no. 5
  [Full text]  
6.
Sindgikar P, Das KK, Sardhara J, Bhaisora KS, Srivastava AK, Mehrotra A, et al. Craniovertebral junction anomalies: When is resurgery required? Neurol India 2016;64:1220-32.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Bollo RJ, Riva-Cambrin J, Brockmeyer MM, Brockmeyer DL. Complex Chiari malformations in children: An analysis of preoperative risk factors for occipitocervical fusion. J Neurosurg Pediatr 2012;10:134-41.  Back to cited text no. 7
    
8.
Sardhara J, Behari S, Mohan BM, Jaiswal AK, Sahu RN, Srivastava A, et al. Risk stratification of vertebral artery vulnerability during surgery for congenital atlanto-axial dislocation with or without an occipitalized atlas. Neurol India 2015;63:382-91.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Jain VK, Behari S. Management of congenital atlanto-axial dislocation: Some lessons learnt. Neurol India 2002;50:386-97.  Back to cited text no. 9
    
10.
Gunnerson KJ, Saul M, He S, Kellum JA. Lactate versus non-lactate metabolic acidosis: A retrospective outcome evaluation of critically ill patients. Crit Care 2006;10:R22.  Back to cited text no. 10
    
11.
Maciel AT, Park M. Differences in acid-base behavior between intensive care unit survivors and nonsurvivors using both a physicochemical and a standard base excess approach: A prospective, observational study. J Crit Care 2009;24:477-83.  Back to cited text no. 11
    
12.
Cain HD, Stevens PM, Adaniya R. Preoperative pulmonary function and complications after cardiovascular surgery. Chest 1979;76:130-5.  Back to cited text no. 12
    
13.
Smith I, Kumar P, Molloy S, Rhodes A, Newman PJ, Grounds RM, et al. Base excess and lactate as prognostic indicators for patients admitted to intensive care. Intensive Care Med 2001;27:74-83.  Back to cited text no. 13
    
14.
Davis JW, Shackford SR, Mackersie RC, Hoyt DB. Base deficit as a guide to volume resuscitation. J Trauma 1988;28:1464-7.  Back to cited text no. 14
    
15.
Santi M, Mcanulty G, Grounds M. Base excess and lactate as prognostic indicators for patients admitted to intensive care - 15 years later. Intensive Care Med Exp 2015;3(Suppl 1):A341.  Back to cited text no. 15
    
16.
Epstein SK, Ciubotaru RL, Wong JB. Effect of failed extubation on the outcome of mechanical ventilation. Chest 1997;112:186-92.  Back to cited text no. 16
    
17.
Rath GP, Bithal PK, Guleria R, Chaturvedi A, Kale SS, Gupta V, Dash HH. A comparative study between preoperative and postoperative pulmonary functions and diaphragmatic movements in congenital craniovertebral junct ion anomalies. J Neurosurg Anesthesiol 2006;18:256-61.  Back to cited text no. 17
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

Top
Print this article  Email this article
   
Online since 20th March '04
Published by Wolters Kluwer - Medknow