Ventilator Liberation Research Articles

Directed Hypercapnia for Weaning From ECMO to Mechanical Ventilation—Progress or Just a Process?

In this issue of The Annals of Thoracic Surgery, Kluis and colleagues1Kluis A. Shih E. Squiers J.J. et al.Directed hypercapnia as a strategy to wean extracorporeal membrane oxygenation in COVID-19 pneumonia.Ann Thorac Surg. 2022; 114: e307-e309Abstract Full Text Full Text PDF Scopus (1) Google Scholar report a single-institution experience with 5 cases of severe COVID-19 acute respiratory distress syndrome (ARDS) with hypercarbic respiratory failure using directed hypercapnia as a strategy to wean patients from venovenous extracorporeal membrane oxygenation (ECMO). The authors instituted a directed hypercapnia approach in combination with metabolically compensated respiratory acidosis to terminate long-term ECMO support and to reduce associated morbidity and mortality. Five patients were successfully weaned off ECMO. One patient with preexisting kidney disease requiring renal replacement therapy ultimately died of refractory acidosis and sepsis. ECMO duration ranged from 56 to 167 days, highlighting the extended duration of support. More than 13,000 cases of COVID-19 requiring ECMO have been reported to the Extracorporeal Life Support Organization registry with a 47% in-hospital mortality.2Extracorporeal Life Support OrganizationELSO live registry dashboard of ECMO patient data.https://www.elso.org/Registry/ELSOLiveRegistryDashboard.aspxDate accessed: March 20, 2022Google Scholar Early use of ECMO for COVID-19 resulted in poor outcomes, with many clinicians discouraging this application.3Henry B.M. Lippi G. Poor survival with extracorporeal membrane oxygenation in acute respiratory distress syndrome (ARDS) due to coronavirus disease 2019 (COVID-19): pooled analysis of early reports.J Crit Care. 2020; 58: 27-28Crossref PubMed Scopus (144) Google Scholar As the pandemic progressed, ECMO use increased rapidly, and more recent data suggest similar outcomes to non-COVID ARDS.4Barbaro R.P. MacLaren G. Boonstra P.S. et al.Extracorporeal membrane oxygenation support in COVID-19: an international cohort study of the Extracorporeal Life Support Organization registry.Lancet. 2020; 396: 1071-1078Abstract Full Text Full Text PDF PubMed Scopus (420) Google Scholar Much of the management of ECMO and mechanical ventilation has been extrapolated from non-COVID ARDS populations. Whereas most centers use lung-protective ventilation, there are no standard guidelines for ventilator management in this setting. Institutional demands and experiences often dictate the pathway of care. The authors report an ECMO weaning protocol that successfully liberated patients from this high-risk, resource-intensive therapy, allowing discharge from a tertiary center to long-term acute rehabilitation facilities. At the individual patient level, this may translate into decreases in the morbidity and mortality associated with prolonged ECMO. At the health system level, the economic and resource allocation benefits associated with freeing up intensive care beds, staff, and resources could be immense. This protocol could be particularly valuable during high infectivity periods when the health system is significantly strained. Certain considerations temper enthusiasm for widespread adoption of this protocol. Individualized care is essential, and recovery is the primary aim. As reported, all survivors remain on assist-control ventilation, and long-term outcomes, including prospects for eventual ventilator liberation, are unknown. Patients may have been better served with sedative reduction, extubation, and ambulation on ECMO. In addition, proponents of directed hypercapnia must ensure that protocols do not restrict evaluation for lung transplantation. Outcomes from ECMO bridging to transplantation have improved because of better patient selection and protocolized management approaches. As highlighted in a recent US nationwide analysis published in the New England Journal of Medicine, lung transplantation is an important option for refractory COVID-19 ARDS or post-COVID fibrosis, with promising early outcomes including 95% 3-month survival in more than 200 recipients.5Roach A. Chikwe J. Catarino P. et al.Lung transplantation for Covid-19–related respiratory failure in the United States.N Engl J Med. 2022; 386: 1187-1188Crossref PubMed Scopus (24) Google Scholar Notwithstanding, there will likely be a role for directed hypercapnia in this population, which will be further delineated as more research is performed. Directed Hypercapnia as a Strategy to Wean Extracorporeal Membrane Oxygenation in COVID-19 PneumoniaThe Annals of Thoracic SurgeryVol. 114Issue 5PreviewCoronavirus disease 2019 pneumonia with respiratory failure refractory to maximum medical therapy has been successfully managed with venovenous extracorporeal membrane oxygenation. This report describes a process of using directed hypercapnia in 5 patients to wean them from prolonged extracorporeal support secondary to refractory hypercarbic respiratory failure. Full-Text PDF

Association between early cumulative fluid balance and successful liberation from invasive ventilation in COVID-19 ARDS patients — insights from the PRoVENT-COVID study: a national, multicenter, observational cohort analysis

BackgroundIncreasing evidence indicates the potential benefits of restricted fluid management in critically ill patients. Evidence lacks on the optimal fluid management strategy for invasively ventilated COVID-19 patients. We hypothesized that the cumulative fluid balance would affect the successful liberation of invasive ventilation in COVID-19 patients with acute respiratory distress syndrome (ARDS).MethodsWe analyzed data from the multicenter observational ‘PRactice of VENTilation in COVID-19 patients’ study. Patients with confirmed COVID-19 and ARDS who required invasive ventilation during the first 3 months of the international outbreak (March 1, 2020, to June 2020) across 22 hospitals in the Netherlands were included. The primary outcome was successful liberation of invasive ventilation, modeled as a function of day 3 cumulative fluid balance using Cox proportional hazards models, using the crude and the adjusted association. Sensitivity analyses without missing data and modeling ARDS severity were performed.ResultsAmong 650 patients, three groups were identified. Patients in the higher, intermediate, and lower groups had a median cumulative fluid balance of 1.98 L (1.27–7.72 L), 0.78 L (0.26–1.27 L), and − 0.35 L (− 6.52–0.26 L), respectively. Higher day 3 cumulative fluid balance was significantly associated with a lower probability of successful ventilation liberation (adjusted hazard ratio 0.86, 95% CI 0.77–0.95, P = 0.0047). Sensitivity analyses showed similar results.ConclusionsIn a cohort of invasively ventilated patients with COVID-19 and ARDS, a higher cumulative fluid balance was associated with a longer ventilation duration, indicating that restricted fluid management in these patients may be beneficial.Trial registration Clinicaltrials.gov (NCT04346342); Date of registration: April 15, 2020.Graphical abstract

Ventilation Liberation Practices Among 380 International PICUs.

OBJECTIVES:1) Characterize the prevalence of ventilator liberation protocol use in international PICUs, 2) identify the most commonly used protocol elements, and 3) estimate an international extubation failure rate and use of postextubation noninvasive respiratory support modes.DESIGN:International cross-sectional study.SUBJECTS:Nontrainee pediatric medical and cardiac critical care physicians.SETTING:Electronic survey.INTERVENTION:None.MEASUREMENTS AND MAIN RESULTS:Responses represented 380 unique PICUs from 47 different countries. Protocols for Spontaneous Breathing Trial (SBT) practice (50%) and endotracheal tube cuff management (55.8%) were the only protocols used by greater than or equal to 50% of PICUs. Among PICUs screening for SBT eligibility, physicians were most commonly screened (62.7%) with daily frequency (64.2%). Among those with an SBT practice protocol, SBTs were most commonly performed by respiratory therapists/physiotherapists (49.2%) and least commonly by nurses (4.9%). Postextubation respiratory support protocols were not prevalent (28.7%). International practice variation was significant for most practices surveyed. The estimated median international extubation failure was 5% (interquartile range, 2.3–10%). A majority of respondents self-reported use of planned high-flow nasal cannula in less than or equal to 50% (84.2%) and planned noninvasive ventilation in less than or equal to 20% of extubations (81.6%).CONCLUSIONS:Variability in international pediatric ventilation liberation practice is high, and prevalence of protocol implementation is generally low. There is a need to better understand elements that drive clinical outcomes and opportunity to work on standardizing pediatric ventilation liberation practices worldwide.

Pediatric ventilation liberation: evaluating the role of endotracheal secretions in an extubation readiness bundle.

An evidence gap exists regarding the role of endotracheal secretions in pediatric extubation decisions. This study aims to evaluate whether endotracheal secretion burden independently correlates with pediatric extubation failure. This is a single-center, prospective cohort study of children aged <19 years requiring intubation. Nurses (RN) and respiratory therapists (RT) independently used a novel secretion assessment score focusing on secretion volume, character, and trend. We hypothesized that the RN and RT secretion scores would not correlate with extubation outcome and inter-rater reliabilitywould be poor. RN secretion character sub-score (OR 3.3, 95% CI 1.1-11.1, p = 0.048) was independently associated with extubation failure. RN and RT inter-rater reliability was poor (correlation 0.385, 95% CI 0.339-0.429, p < 0.001). A failure prediction model incorporating the RN secretion character sub-score as well as indication for mechanical ventilation and spontaneous breathing trial result demonstrated an area under the receiver operating curve of 0.817 (95% CI 0.730-0.904, p < 0.001). In the general pediatric population, the RN assessment of endotracheal secretion character was independently associated with extubation failure. A model incorporating indication for mechanical ventilation, spontaneous breathing result, and RN assessment of endotracheal secretion character demonstrated reasonable accuracy in predicting failure in those clinically selected for extubation. Development of comprehensive and sensitive extubation readiness bundles are key to balancing the competing risks of prolonged invasive mechanical ventilation duration and extubation failure. Evidence for clinical factors linked to extubation outcomes in children are limited. Endotracheal secretion burden is a common factor considered but has not been studied. This study supports a role for endotracheal secretion burden, as assessed by the bedside nurse, in extubation readiness bundles. Inter-rater reliability with respiratory therapists was poor. A model incorporating other key factors showed good discrimination for extubation outcome and sets the stage for prospective evaluation in the general population and diagnosis-specific subgroups.

Tracheostomy Outcomes in Patients With COVID-19 at a New York City Hospital.

ObjectiveTracheostomies have been performed in patients with prolonged intubation due to COVID-19. Understanding outcomes in different populations is crucial to tackle future epidemics.Study DesignProspective cohort study.SettingTertiary academic medical center in New York City.MethodsA prospectively collected database of patients with COVID-19 undergoing open tracheostomy between March 2020 and April 2020 was reviewed. Primary endpoints were weaning from the ventilator and from sedation and time to decannulation.ResultsSixty-six patients underwent tracheostomy. There were 42 males (64%) with an average age of 62 years (range, 23-91). Patients were intubated for a median time of 26 days prior to tracheostomy (interquartile range [IQR], 23-30). The median time to weaning from ventilatory support after tracheostomy was 18 days (IQR, 10-29). Of those sedated at the time of tracheostomy, the median time to discontinuation of sedation was 5 days (IQR, 3-9). Of patients who survived, 39 (69%) were decannulated. Of those decannulated before discharge (n = 39), the median time to decannulation was 36 days (IQR, 27-49) following tracheostomy. The median time from ventilator liberation to decannulation was 14 days (IQR, 8-22). Thirteen patients (20.0%) had minor bleeding requiring packing. Two patients (3%) had bleeding requiring neck exploration. The all-cause mortality rate was 10.6%. No patients died of procedural causes, and no surgeons acquired COVID-19.ConclusionOpen tracheostomies were successfully and safely performed at our institution in the peak of the COVID-19 pandemic. The majority of patients were successfully weaned from the ventilator and sedation. Approximately 60% of patients were decannulated prior to hospital discharge.

Tracheostomy Is Associated With a Decrease in Delirium and Sedation for Intubated COVID-19 Patients.

Patients with coronavirus disease 2019 (COVID-19) acute respiratory distress syndrome can experience prolonged periods of ventilation, high incidence of delirium, and require high amounts of sedation. Tracheostomy has been associated with earlier ventilator liberation, decreased sedation needs, and lower rates of delirium but optimal timing of tracheostomy remains unknown. Is tracheostomy associated with lower sedation requirements and lower incidence of delirium in patients with COVID-19 that are intubated? We retrospectively reviewed the first 32 patients at a large urban tertiary referral center that underwent tracheostomy for prolonged respiratory failure. We obtained Richmond Agitation Sedation-Scale scores and Confusion Assessment Method for Intensive Care Unit data along with amount(s) and type(s) of sedating medications given, in the 7 days before and after tracheostomy. Proportion of days delirious and sedating medications were compared in the 7 days before and after tracheostomy. There was a significant decrease in the amount of opioids and benzodiazepines in the 7-day period following tracheostomy. Opioid dosing decreased by 157.5 morphine equivalents (SD=339, P =0.01) and benzodiazepine dosing decreased by 18 mg lorazepam equivalents (SD=34, P =0.01). There was no significant difference in antipsychotic or other sedative-hyponotic drug doses. There was a significant decrease in the proportion of days of coma or delirium (mean decrease in proportion=0.16, SD=0.32, P =0.008) following tracheostomy. Tracheostomy was associated with a significant decrease amount of sedating medications and with a decrease in proportion of days delirious following tracheostomy.

Co-ordinated multidisciplinary intervention to reduce time to successful extubation for children on mechanical ventilation: the SANDWICH cluster stepped-wedge RCT.

Daily assessment of patient readiness for liberation from invasive mechanical ventilation can reduce the duration of ventilation. However, there is uncertainty about the effectiveness of this in a paediatric population. To determine the effect of a ventilation liberation intervention in critically ill children who are anticipated to have a prolonged duration of mechanical ventilation (primary objective) and in all children (secondary objective). A pragmatic, stepped-wedge, cluster randomised trial with economic and process evaluations. Paediatric intensive care units in the UK. Invasively mechanically ventilated children (aged < 16 years). The intervention incorporated co-ordinated multidisciplinary care, patient-relevant sedation plans linked to sedation assessment, assessment of ventilation parameters with a higher than usual trigger for undertaking an extubation readiness test and a spontaneous breathing trial on low levels of respiratory support to test extubation readiness. The comparator was usual care. Hospital sites were randomised sequentially to transition from control to intervention and were non-blinded. The primary outcome measure was the duration of invasive mechanical ventilation until the first successful extubation. The secondary outcome measures were successful extubation, unplanned extubation and reintubation, post-extubation use of non-invasive ventilation, tracheostomy, post-extubation stridor, adverse events, length of intensive care and hospital stay, mortality and cost per respiratory complication avoided at 28 days. The trial included 10,495 patient admissions from 18 paediatric intensive care units from 5 February 2018 to 14 October 2019. In children with anticipated prolonged ventilation (n = 8843 admissions: control, n = 4155; intervention, n = 4688), the intervention resulted in a significantly shorter time to successful extubation [cluster and time-adjusted median difference -6.1 hours (interquartile range -8.2 to -5.3 hours); adjusted hazard ratio 1.11, 95% confidence interval 1.02 to 1.20; p = 0.02] and a higher incidence of successful extubation (adjusted relative risk 1.01, 95% confidence interval 1.00 to 1.02; p = 0.03) and unplanned extubation (adjusted relative risk 1.62, 95% confidence interval 1.05 to 2.51; p = 0.03), but not reintubation (adjusted relative risk 1.10, 95% confidence interval 0.89 to 1.36; p = 0.38). In the intervention period, the use of post-extubation non-invasive ventilation was significantly higher (adjusted relative risk 1.22, 95% confidence interval 1.01 to 1.49; p = 0.04), with no evidence of a difference in intensive care length of stay or other harms, but hospital length of stay was longer (adjusted hazard ratio 0.89, 95% confidence interval 0.81 to 0.97; p = 0.01). Findings for all children were broadly similar. The control period was associated with lower, but not statistically significantly lower, total costs (cost difference, mean £929.05, 95% confidence interval -£516.54 to £2374.64) and significantly fewer respiratory complications avoided (mean difference -0.10, 95% confidence interval -0.16 to -0.03). The unblinded intervention assignment may have resulted in performance or detection bias. It was not possible to determine which components were primarily responsible for the observed effect. Treatment effect in a more homogeneous group remains to be determined. The intervention resulted in a statistically significant small reduction in time to first successful extubation; thus, the clinical importance of the effect size is uncertain. Future work should explore intervention sustainability and effects of the intervention in other paediatric populations. This trial is registered as ISRCTN16998143. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 18. See the NIHR Journals Library website for further project information.

Mechanical Ventilator Liberation of Patients With COVID-19 in Long-term Acute Care Hospital

BackgroundMechanical ventilation (MV) via tracheostomy is performed commonly for patients who are in long-term acute care hospitals (LTACHs) after respiratory failure. However, the outcome of MV in COVID-19-associated respiratory failure in LTACHs is not known.Research QuestionWhat is the ventilator liberation rate of patients who have received tracheostomy with COVID-19-associated respiratory failure compared with those with respiratory failure unrelated to COVID-19 in LTACHs?Study Design and MethodsIn this retrospective cohort study, we examined mechanically ventilated patients discharged between June 2020 and March 2021. Of 242 discharges, 165 patients who had undergone tracheostomy arrived and were considered for ventilator liberation. One hundred twenty-eight patients did not have COVID-19 and 37 patients were admitted for COVID-19.ResultsThe primary outcome of the study was ventilator liberation; secondary outcomes were functional recovery, length of stay (LOS) at the LTACH, and discharge disposition. After controlling for demographics, the number of comorbidities, hemodialysis, vasopressor need, thrombocytopenia, and the LOS at the short-term acute care hospital, our results indicated that patients with COVID-19 showed a higher adjusted ventilator liberation rate of 91.4% vs 56.0% in those without COVID-19. Functional ability was assessed with the change of Functional Status Score for the Intensive Care Unit (FSS-ICU) between admission and discharge. The adjusted mean change in FSS-ICU was significantly higher in the COVID-19 group than in the non-COVID-19 group: 9.49 (95% CI, 7.38-11.6) vs 2.08 (95% CI, 1.05-3.11), respectively (P < .001). Patients with COVID-19 experienced a shorter adjusted LOS at the LTACH with an adjusted hazard ratio of 1.57 (95% CI, 1.0-2.46; P = .05) compared with patients without COVID-19. We did not observe significant differences between the two groups regarding discharge location, but a trend toward need for lower level of care was found in patients with COVID-19.InterpretationOur study suggests that patients with COVID-19 requiring MV and tracheostomy have a higher chance for recovery than those without COVID-19.

The Rapid Implementation of Ad Hoc Tele-Critical Care Respiratory Therapy (eRT) Service in the Wake of the COVID-19 Surge

A 24/7 telemedicine respiratory therapist (eRT) service was set up as part of the established University of Pennsylvania teleICU (PENN E-LERT®) service during the COVID-19 pandemic, serving five hospitals and 320 critical care beds to deliver effective remote care in lieu of a unit-based RT. The eRT interventions were components of an evidence-based care bundle and included ventilator liberation protocols, low tidal volume protocols, tube patency, and an extubation checklist. In addition, the proactive rounding of patients, including ventilator checks, was included. A standardized data collection sheet was used to facilitate the review of medical records, direct audio–visual inspection, or direct interactions with staff. In May 2020, a total of 1548 interventions took place, 93.86% of which were coded as “routine” based on established workflows, 4.71% as “urgent”, 0.26% “emergent”, and 1.17% were missing descriptors. Based on the number of coded interventions, we tracked the number of COVID-19 patients in the system. The average intervention took 6.1 ± 3.79 min. In 16% of all the interactions, no communication with the bedside team took place. The eRT connected with the in-house respiratory therapist (RT) in 66.6% of all the interventions, followed by house staff (9.8%), advanced practice providers (APP; 2.8%), and RN (2.6%). Most of the interaction took place over the telephone (88%), secure text message (16%), or audio-video telemedicine ICU platform (1.7%). A total of 5115 minutes were spent on tasks that a bedside clinician would have otherwise executed, reducing their exposure to COVID-19. The eRT service was instrumental in several emergent and urgent critical interventions. This study shows that an eRT service can support the bedside RT providers, effectively monitor best practice bundles, and carry out patient–ventilator assessments. It was effective in certain emergent situations and reduced the exposure of RTs to COVID-19. We plan to continue the service as part of an integrated RT service and hope to provide a framework for developing similar services in other facilities.

Effects of Aggressive and Conservative Strategies for Mechanical Ventilation Liberation

Effects of Aggressive and Conservative Strategies for Mechanical Ventilation Liberation

Percutaneous Dilational Tracheostomy at the Epicenter of the SARS-CoV-2 Pandemic: Impact on Critical Care Resource Utilization and Early Outcomes.

The COVID-19 pandemic overwhelmed New York City hospitals early in the pandemic. Shortages of ventilators and sedatives prompted tracheostomy earlier than recommended by professional societies. This study evaluates the impact of percutaneous dilational tracheostomy (PDT) in COVID+ patients on critical care capacity. This is a single-institution prospective case series of mechanically ventilated COVID-19 patients undergoing PDT from April 1 to June 4, 2020 at a public tertiary care center. Fifty-five patients met PDT criteria and underwent PDT at a median of 13days (IQR 10, 18) from intubation. Patient characteristics are found in Table 1. Intravenous midazolam, fentanyl, and cisatracurium equivalents were significantly reduced 48hours post-PDT (Table 2). Thirty-five patients were transferred from the ICU and liberated from the ventilator. Median time from PDT to ventilator liberation and ICU discharge was 10 (IQR 4, 14) and 12 (IQR 8, 17)days, respectively. Decannulation occurred in 45.5% and 52.7% were discharged from acute inpatient care (Figure 1). Median follow-up for the study was 62days. Four patients had bleeding complications postoperatively and 11 died during the study period. Older age was associated with increased odds of complication (OR 1.12, 95% CI 1.04, 1.23) and death (OR=1.15, 95% CI 1.05, 1.30). All operators tested negative for COVID-19 during the study period. These findings suggest COVID-19 patients undergoing tracheostomy within the standard time frame can improve critical care capacity in areas strained by the pandemic with low risk to operators. Long-term outcomes after PDT deserve further study.

Establishing Medicaid incentives for liberating nursing home patients from ventilators.

Chronic ventilator use in Tennessee nursing homes surged following 2010 increases in respiratory care payment rates. Tennessee's Medicaid program implemented multiple policies between 2014 and 2017 to promote ventilator liberation in 11 nursing homes, including quality reporting, on-site monitoring, and pay-for-performance incentives. Using repeated cross-sectional analysis of Medicare and Medicaid nursing home claims (2011-2017), hospital discharge records (2010-2017), and nursing home quality reports (2015-2017), we examined how service use changed as Tennessee implemented policies designed to promote ventilator liberation in nursing homes. We measured the annual number of nursing home patients with ventilator-related service use; discharge destination of ventilated inpatients and percent of nursing home patients liberated from ventilators. Between 2011 and 2014, the number of Medicare SNF and Medicaid nursing home patients with ventilator use increased more than sixfold. Among inpatients with prolonged mechanical ventilation, discharges to home decreased as discharges to nursing homes increased. As Tennessee implemented policy changes, ventilator-related service use moderately declined in nursing homes from a peak of 198 ventilated Medicare SNF patients in 2014 to 125 in 2017 and from 182 Medicaid patients with chronic ventilator use in 2014 to 145 patients in 2017. Nursing home weaning rates peaked at 49%-52% in 2015 and 2016, but declined to 26% by late 2017. Median number of days from admission to wean declined from 81 to 37 days. This value-based approach demonstrates the importance of designing payment models that target key patient outcomes like ventilator liberation.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

Surgical stabilization of severe chest wall injury following cardiopulmonary resuscitation.

Cardiopulmonary resuscitation (CPR) contributes to significant chest wall injury similar to blunt trauma. With benefits realized for surgical stabilization of rib fractures (SSRFs) for flail injuries and severely displaced fractures following trauma, SSRF for chest wall injury following CPR could be advantageous, provided good functional and neurologic outlook. Experience is limited. We present a review of patients treated with SSRF at our institution following CPR. A retrospective analysis of patients undergoing SSRF following CPR was performed between 2019 and 2020. Perioperative inpatient data were collected with outpatient follow-up as able. Five patients underwent SSRF over the course of the 2-year interval. All patients required invasive ventilation preoperatively or had impending respiratory. Mean age was 59 ± 12 years, with all patients being male. Inciting events for cardiac arrest included respiratory, ventricular tachycardia, ventricular fibrillation, pulseless electrical activity, and anaphylaxis. Time to operation was 6.6 ± 3 days. Four patients demonstrated anterior flail injury pattern with or without sternal fracture, with one patient having multiple severely displaced fractures. Surgical stabilization of rib fracture was performed appropriately to restore chest wall stability. Mean intensive care unit length of stay was 9.8 ± 6.4 days and overall hospital length of stay 24.6 ± 13.2 days. Median postoperative ventilation was 2 days (range, 1-15 days) with two patients developing pneumonia and one requiring tracheostomy. There were no mortalities at 30 days. One patient expired in hospice after a prolonged hospitalization. Disposition destination was variable. No hardware complications were noted on outpatient follow-up, and all surviving patients were home. Chest wall injuries are incurred frequently following CPR. Surgical stabilization of these injuries can be considered to promote ventilator liberation and rehabilitation. Careful patient selection is paramount, with surgery offered to those with reversible causes of arrest and good functional and neurologic outcome. Experience is early, with further investigation needed. Therapeutic, Level V.

HYPERCYTOKINEMIA AND DOXYCYCLINE DEFICIENCY: HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS SECONDARY TO ROCKY MOUNTAIN SPOTTED FEVER IN AN ADULT

TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: Hemophagocytic lymphohistiocytosis (HLH) is a syndrome characterized by cytokine storm and multi-organ failure with a mortality rate approaching 42% even when treated appropriately. HLH has a reported annual incidence of 1 in 800,000 with 90% being secondary HLH. Infections are the trigger in 20% of secondary HLH. Rickettsial triggers are limited to case reports in the pediatric population. We present a case of HLH secondary to Rickettsia rickettsii in a geriatric patient. CASE PRESENTATION: A 70-year-old diabetic male was admitted in the summer for 1 week of fevers, headaches, and progressing weakness. On admission, the patient had a waxing and waning mental status. He had anemia, thrombocytopenia, and kidney injury. CT abdomen showed mild splenomegaly. As part of an anemia work-up, a ferritin level was drawn and resulted at 7,044 ng/mL. At this time, HLH was added to the differential. A triglyceride level returned at 309 mg/dL.His mental status slowly deteriorated until he became unresponsive and intubated on hospital day 3. His platelet count dropped to 18,000/µL with a hemoglobin of 9 g/dL. Additionally, his creatinine increased to 9.28 mg/dL with a urea nitrogen of 120.7 mg/dL requiring renal replacement therapy. On day 5, IL-2 level returned at 21289 U/mL. However, the underlying etiology of his HLH was not clear. On day 6, the patient was started on doxycycline empirically as Rickettsial disease could not be ruled out. By day 7, the patient was interacting with caregivers. Following ventilator liberation, he confirmed that he frequently camps at a local lake with his last trip being 4 days prior to onset of fevers and headaches. The patient continued to gradually improve and was discharged to an acute rehab facility. Several days after his discharge, Rickettsia ricketssii IgM and IgG titers returned at 1:16384 and 1:2048, respectively. DISCUSSION: Rocky Mountain Spotted Fever (RMSF) has an incidence of 19-to-63 per million. Ricketsial infections rarely progress to HLH with variable outcomes depending on time of treatment. By our review, this complication has not been reported in adult patients. HLH secondary to infection has a favorable outcome compared to cases triggered by malignancy; however, mortality is heavily dependent on treatment of the underlying infection. Our patient's HLH resolved solely with treatment of the underlying infection and we suspect that this was due to early intervention. CONCLUSIONS: HLH carries a high mortality and has numerous triggers. While zoonotic triggers are a rare cause, the treatment can be simple and lifesaving. Early and aggressive diagnostic studies and treatment are imperative to surviving secondary HLH. REFERENCE #1: A. Hayden, S. Park, D. Giustini, A. Y. Y. Lee and L. Y. C. Chen, "Hemophagocytic syndromes (HPSs) including hemophagocytic lymphohistiocytosis (HLH) in adults: A sytematic scoping review," Blood Reviews, vol. 30, pp. 411-20, 2016. REFERENCE #2: M. R. George, "Hemophagocytic lymphohistiocytosis: review of etiologies and management," Journal of Blood Medicine, vol. 5, pp. 69-86, 2014. REFERENCE #3: S. C. Buckingham, G. S. Marshall, G. E. Schutze, L. E. R. Patterson and R. F. Jacobs, "Clinical and laboratory features, hospital course and outcome of rocky mountain spotted fever in children," The Journal of Pediatrics, vol. 150, no. 2, pp. 180-4, 2007. DISCLOSURES: No relevant relationships by Jason Thomas, source=Web Response No relevant relationships by Robert Walter, source=Web Response

Ventilator Weaning Outcomes in SARs-CoV-2 (+) Individuals in the LTACH Setting-A Retrospective Cohort Study

Research ObjectivesTo examine weaning outcomes of patients with a history of COVID-19 on prolonged mechanical ventilation (PMV) in the LTACH setting.DesignRetrospective cohort.SettingA long-term acute care facility.ParticipantsParticipants (N=25; mean±sd age, 58±13.2 yr) mostly consisted of overweight diabetic men with diaphragmatic dysfunction (DD) and no history of COPD or sleep apnea.InterventionsPulmonary function was determined using spirometry and arterial blood gas measurements. Diaphragmatic dysfunction was assessed using fluoroscopy; neuromuscular function measured via EMG.Main Outcome MeasuresThe primary outcome was weaned status at discharge. Weaning success was defined as MV liberation for over 48 hours at time of discharge. Variables included MIP, MEP, FVC, FEV1/FVC, DD (bilateral/unilateral/none) and PCO2.ResultsMost participants (57.7%) had either unilateral or bilateral diaphragmatic dysfunction. The proportion of participants with ventilator liberation success was 53.8% at time of discharge with a median [IQR] LOS of 41 [33-68] days. The mean (sd) FVC and PCO2 were 0.6 (±0.3)% and 51.4 (±9.7), respectively; the MEP and MIP were 43.9 (±16.7) and -36.5 (±15.9) cmH2O. Univariate logistic regression analyses found a significant association with MIP (OR 95% CI = (0.87-0.99); p-value = 0.0391) on wean status.ConclusionsLiberation from MV has been a challenge in the COVID-19 population with a large number of individuals subjected to PMV. Many studies have sought to examine the parameters for weaning in the ICU setting, but few have discussed weaning strategies in LTACHs. MIP may have the potential to help prognosticate weaning outcomes in the COVID-19 population. Further studies are needed to confirm and identify other parameters associated with successful weaning.Author(s) DisclosuresThe authors have no conflicts of interest.

Effect of a Sedation and Ventilator Liberation Protocol vs Usual Care on Duration of Invasive Mechanical Ventilation in Pediatric Intensive Care Units

There is limited evidence on the optimal strategy for liberating infants and children from invasive mechanical ventilation in the pediatric intensive care unit. To determine if a sedation and ventilator liberation protocol intervention reduces the duration of invasive mechanical ventilation in infants and children anticipated to require prolonged mechanical ventilation. A pragmatic multicenter, stepped-wedge, cluster randomized clinical trial was conducted that included 17 hospital sites (18 pediatric intensive care units) in the UK sequentially randomized from usual care to the protocol intervention. From February 2018 to October 2019, 8843 critically ill infants and children anticipated to require prolonged mechanical ventilation were recruited. The last date of follow-up was November 11, 2019. Pediatric intensive care units provided usual care (n = 4155 infants and children) or a sedation and ventilator liberation protocol intervention (n = 4688 infants and children) that consisted of assessment of sedation level, daily screening for readiness to undertake a spontaneous breathing trial, a spontaneous breathing trial to test ventilator liberation potential, and daily rounds to review sedation and readiness screening and set patient-relevant targets. The primary outcome was the duration of invasive mechanical ventilation from initiation of ventilation until the first successful extubation. The primary estimate of the treatment effect was a hazard ratio (with a 95% CI) adjusted for calendar time and cluster (hospital site) for infants and children anticipated to require prolonged mechanical ventilation. There were a total of 8843 infants and children (median age, 8 months [interquartile range, 1 to 46 months]; 42% were female) who completed the trial. There was a significantly shorter median time to successful extubation for the protocol intervention compared with usual care (64.8 hours vs 66.2 hours, respectively; adjusted median difference, -6.1 hours [interquartile range, -8.2 to -5.3 hours]; adjusted hazard ratio, 1.11 [95% CI, 1.02 to 1.20], P = .02). The serious adverse event of hypoxia occurred in 9 (0.2%) infants and children for the protocol intervention vs 11 (0.3%) for usual care; nonvascular device dislodgement occurred in 2 (0.04%) vs 7 (0.1%), respectively. Among infants and children anticipated to require prolonged mechanical ventilation, a sedation and ventilator liberation protocol intervention compared with usual care resulted in a statistically significant reduction in time to first successful extubation. However, the clinical importance of the effect size is uncertain. isrctn.org Identifier: ISRCTN16998143.

Assessment and Impact of Intravenous Medication Fluid Administration in Critically Ill Patients With Acute Respiratory Failure.

Positive fluid balance early in critical illness is associated with poor outcomes. Reducing intravenous medication volume may mitigate volume overload. Objective: Assessment of fluid and medication administration and clinical outcomes in acute respiratory failure. Single-center, prospective observational study of hemodynamically stable adult patients in a medical intensive care unit (MICU) with acute respiratory failure. Median cumulative total intake volume was 12 890 (interquartile range [IQR] = 8654-22 221) mL (n = 27), and median cumulative intravenous medication volume was 3563 (IQR = 2371-9412) mL over the first 7 days. Medication volume accounted for 27.6% of aggregate fluid volume. Median daily intravenous medication volume administered was 591 (IQR = 339-1082) mL. Cumulative fluid volume was associated with reduced ventilator-free days (r2 = -0.393; P = 0.043), and cumulative fluid volumes during the first 3 and 7 days were associated with increased MICU length of stay (LOS ± standard error 0.73 ± 0.35 d/L, P = 0.047, and 0.38 ± 0.16 d/L, P = 0.021, respectively). Cumulative medication volume administered significantly reduced the likelihood of mechanical ventilator liberation (hazard ratio [HR] = 0.917; 95% CI: 0.854, 0.984; P = 0.016) and MICU discharge (HR = 0.911; 95% CI: 0.843, 0.985; P = 0.019). Small-volume infusion may decrease cumulative intravenous medication volume by 38%. Intravenous medication diluent contributes substantially to total fluid intake in patients with acute respiratory failure and is associated with poor outcomes. Reduction of intravenous medication fluid volume to improve clinical outcomes should be further investigated.

Role of a successful spontaneous breathing trial in ventilator liberation in brain-injured patients.

Spontaneous breathing trials (SBTs) have been shown to improve outcomes in critically ill patients. However, in patients with brain injury, indications for intubation and mechanical ventilation are different from those of non-neurological patients, and the role of an SBT in patients with brain injury is less established. The aim of the present study was to compare key respiratory variables acquired during a successful SBT between patients with successful ventilator liberation versus failed ventilator liberation. In this prospective study, patients with brain injury (≥18 years of age), who completed a 30-min SBT, were enrolled. Airway pressure, flow, esophageal pressure, and diaphragm electrical activity (ΔEAdi) were recorded before (baseline) and during the SBT. Respiratory rate (RR), tidal volume, inspiratory muscle pressure (ΔPmus), ΔEAdi, and neuromechanical efficiency (ΔPmus/ΔEAdi) of the diaphragm were calculated breath by breath and compared between the liberation success and failure groups. Failed liberation was defined as the need for invasive ventilator assistance within 48 h after the SBT. In total, 46 patients (51.9±13.2 years, 67.4% male) completed the SBT. Seventeen (37%) patients failed ventilator liberation within 48 h. Another 11 patients required invasive ventilation within 7 days after completing the SBT. There were no differences in baseline characteristics between the success and failed groups. In-depth analysis showed similar changes in patterns and values of respiratory physiological parameters between the groups. In patients with brain injury, ventilator liberation failure was common after successful SBT. In-depth physiological analysis during the SBT did not provide data to predict successful liberation in these patients. The trial was registered at ClinicalTrials.gov (No. NCT02863237).

Liberation from Ventilation: An Intervention Study in Public Adult Intensive Care Units in the Eastern Cape Province of South Africa

Implementing evidence-based guidelines is one way of addressing the knowledge gap of critical care nurses regarding the ventilator liberation of critically ill adult patients in South Africa. A quasi-experimental intervention study using a pre-test/post-test design to measure critical care nurses’ knowledge on ventilator liberation of adult patients in intensive care units was conducted. The critical care nurses were purposively sampled into three groups and their knowledge was measured before an educational intervention, and three months after. Data was collected with pre/post-test questionnaires, n1=115 pre-test and n2=90 post-test, respectively. An educational intervention using a PowerPoint presentation, printed copies of the guidelines, posters as reminders, and informal monitoring visits (Intervention Group One) had an insignificant effect (p=0.371; Cohen’s d &lt;0.20) on the improvement of the respondents’ knowledge score (62,93 versus 65,22). Handing out printed copies of guidelines alone (Intervention Group Two) had a small effect (p=0.033; Cohen’s d=0.49 small) but did not improve respondents’ knowledge score (60,34 versus 53,41). The absence of an educational intervention (Control Group) had an insignificant effect (p=0.884; Cohen’s d &lt;0.20) on the improvement of respondents’ knowledge score (59,60 versus 60,33). Across the three groups, intensive care unit experience had a moderate effect (p=0,018; Cohen’s d=0.67 medium) on the way critical care nurses responded to the pre/post-test questionnaires. Respondents lacked knowledge of ventilator liberation practices in the study context, and this can be addressed using combined educational intervention methods. Sequel studies using different educational intervention methods are recommended that take into account the diversity within the study population.