Weaning Group Research Articles

PSI-24 Acute and chronic stress response following weaning and transportation in the average piglet

Abstract The American swine industry relies on a model where facilities for farrowing are often geographically isolated from those used later for wean-finish, which necessitates multiple coincident stressors including weaning, mixing, transportation and feed/water restriction. Previous studies indicate this combined stress reduces subsequent growth performance; however, the specific impact of each stressor on an average, objectively healthy piglet is not well understood, nor is the acute physiological response to this life event. The objective of this study was to determine the effect these stressors on thyroid function, intestinal health, and body weight (BW) in average, healthy pigs. In this study, a total population of 588 piglets were weighed the day prior to weaning and 230 piglets with the lowest Z-scores for BW were selected (5.74 ± 0.70 kg). Piglets (n = 70) were weaned directly into nursery pens and provided with feed and water, 70 were transported for 10 h with no access to feed and water, and 70 were grouped together into 2 large pens with no access to feed and water for an equivalent 8 h period. The remaining 20 piglets were not weaned and served as an unstressed control group. A total of 10 pigs from each group were euthanized at 32 and 56 h post-weaning for tissue sampling. Ileal villi height, crypt depth, and goblet cell numbers were measured, and no treatment effects observed (P > 0.05). Serum triiodothyronine (T3) concentrations were measured pre-treatment (t = 0), 24 h (t = 24), 48 h (t = 48), and immediately following euthanasia (t = 32 or 56 d). There were no significant differences in serum T3 among treatments at t = 0. At all-time points post stress event, control piglets had greater T3 concentrations compared with feed restricted (P < 0.05) and transported (P < 0.05) pigs. Weaned pigs at t = 32, t = 48, and t = 56 had decreased T3 concentrations (P < 0.05) and weaned pigs tended (P = 0.0584) to have decreased t = 24 T3 concentrations compared with pigs remaining with the sow. The remaining pigs (n = 50) per weaning group were weighed weekly throughout the nursery phase and every 3 wk in the grow-finish phase to determine the impact of each stressor on growth. There was no significant effect of weaning treatment on BW at any time point (P > 0.10). Carcass data including carcass weight, loin and backfat depths, and lean percentage were measured at time of slaughter with no significant differences found among groups (P > 0.60). As no effect on growth weight or carcass characteristics were observed between treatment groups in average pigs, this suggests that it may be beneficial to transport average pigs the longest distance, while minimizing transport for pigs on either end of the weaning weight spectrum. Further research is needed to compare effects of weaning and transportation stressors on average and weight extremes of weaned pigs.

Venovenous extracorporeal membrane oxygenation (VV-ECMO) for severe acute respiratory distress syndrome (ARDS) in adults—a single-center experience

BackgroundThe survival benefit of venovenous extracorporeal membrane oxygenation (VV-ECMO) in adult patients with severe acute respiratory distress syndrome (ARDS) remains controversial. This study aimed to investigate the efficiency and potential prognostic factors of VV-ECMO for severe ARDS in adults by evaluating our institutional experience and results.Materials and methodsThis research studied ARDS patients receiving VV-ECMO between June 2011 and May 2023. The inclusion criteria were PaO2/FiO2 < 100 mmHg at FiO2 of 1.0. Retrospective data was analyzed to identify factors associated with successful ECMO weaning and hospital discharge survival.ResultsA total of 18 patients were included in this study, with 7 cases (38.9%) successfully weaned from ECMO and 5 cases (27.8%) surviving hospital discharge. The overall complication rate was 77.8%. After treatment with VV ECMO, there were statistically significant improvements in both PaO2 and PaCO2 (P < 0.05). Patients in the successful weaning group had a lower pTB value, less accumulative volume of sodium bicarbonate during ECMO, and lower accumulative volume of intravenous immunoglobulin in the hospital compared to the unsuccessful weaning group (all P < 0.05). Furthermore, compared to the non-survivors, the survivors had less severe acidosis, higher mean arterial pressure before ECMO, a lower level of pCr, and a lower pTB value during ECMO (all P < 0.05).ConclusionECMO can effectively promote oxygenation and carbon dioxide (CO2) removal in patients with severe ARDS. Early initiation of ECMO with appropriate management could benefit in reducing comorbidities and mortality.

Prompt closure versus gradual weaning of external ventricular drain for hydrocephalus following aneurysmal subarachnoid haemorrhage: a statistical analysis plan for the DRAIN randomised clinical trial

BackgroundInsertion of an external ventricular drain (EVD) is a first-line treatment of acute hydrocephalus caused by aneurysmal subarachnoid haemorrhage (aSAH). Once the patient is clinically stable, the EVD is either removed or replaced by a permanent internal shunt. The optimal strategy for cessation of the EVD is unknown. Prompt closure carries a risk of acute hydrocephalus or redundant shunt implantations, whereas gradual weaning may increase the risk of EVD-related infections.MethodsDRAIN (Danish RAndomised Trial of External Ventricular Drainage Cessation IN Aneurysmal Subarachnoid Haemorrhage) is an international multicentre randomised clinical trial comparing prompt closure versus gradual weaning of the EVD after aSAH. The primary outcome is a composite of VP-shunt implantation, all-cause mortality, or EVD-related infection. Secondary outcomes are serious adverse events excluding mortality and health-related quality of life (EQ-5D-5L). Exploratory outcomes are modified Rankin Scale, Fatigue Severity Scale, Glasgow Outcome Scale Extended, and length of stay in the neurointensive care unit and hospital. Outcome assessment will be performed 6 months after ictus. Based on the sample size calculation (event proportion 80% in the gradual weaning group, relative risk reduction 20%, alpha 5%, power 80%), 122 participants are required in each intervention group. Outcome assessment for the primary outcome, statistical analyses, and conclusion drawing will be blinded. Two independent statistical analyses and reports will be tracked using a version control system, and both will be published. Based on the final statistical report, the blinded steering group will formulate two abstracts.ConclusionWe present a pre-defined statistical analysis plan for the randomised DRAIN trial, which limits bias, p-hacking, and data-driven interpretations. This statistical analysis plan is accompanied by tables with simulated data, which increases transparency and reproducibility.Trial registrationClinicalTrials.gov identifier: NCT03948256. Registered on May 13, 2019.

Management of external ventricular drain: to wean or not to wean?

PurposeExternal ventricular drain (EVD) is one of the most frequent procedures in neurosurgery and around 15 to 30% of these patients require a permanent cerebrospinal fluid (CSF) diversion. The optimal EVD weaning strategy is still unclear. Whether gradual weaning compared to rapid closure, reduces the rate of permanent CSF diversion remains controversial. The aim of this trial is to compare the rates of permanent CSF diversion between gradual weaning and rapid closure of an EVD.MethodsThis was a single-center, retrospective cohort study including patients between 2010 to 2020. Patients were divided into a weaning (WG) and non-weaning (NWG) group. The primary outcome was permanent CSF diversion rates, secondary outcomes included hospitalization time, EVD-related morbidity, and clinical outcome.ResultsOut of 412 patients, 123 (29.9%) patients were excluded due to early death or palliative treatment. We registered 178 (61.6%) patients in the WG and 111 (38.4%) in the NWG. Baseline characteristics were comparable between groups. The VPS rate was comparable in both groups (NWG 37.8%; WG 39.9%, p = 0.728). EVD related infection (13.5% vs 1.8%, p < 0.001), as well as non-EVD related infection rates (2.8% vs 0%, p < 0.001), were significantly higher in the WG. Hospitalization time was significantly shorter in the NWG (WG 24.93 ± 9.50 days; NWG 23.66 ± 14.51 days, p = 0.039).ConclusionGradual EVD weaning does not seem to reduce the need for permanent CSF diversion, while infection rates and hospitalization time were significantly higher/longer. Therefore, direct closure should be considered in the clinical setting.

Role of diaphragmatic ultrasound in predicting weaning success from mechanical ventilation in pediatric intensive care unit

BackgroundWeaning off mechanical ventilation (MV) is a critical step in pediatric ICU; however, it lacks standardized criteria. Diaphragmatic ultrasound parameters like diaphragm thickening fraction (DTF), diaphragmatic excursion (DE) and time to peak inspiratory amplitude (TPIA) can be used to assess diaphragmatic muscle strength and to predict weaning success.Aim of studyIs to assess the validity of diaphragmatic ultrasonography as a predictor of weaning outcome from mechanical ventilation in pediatric age group.MethodsProspective cohort study including 30 pediatric patients aged 0–18 years on mechanical ventilation. Ultrasound measurements of diaphragmatic thickening fraction, diaphragmatic excursion and time to peak inspiratory amplitude were taken during the spontaneous breathing trial (SBT) and compared between successful and failed weaning groups.ResultsOut of the included 30 patients (50% male), 19 patients (63.3%) were successfully weaned. Mechanical ventilation duration was significantly longer in the failed weaning group (P = 0.017). There was significant difference between both groups regarding right DE (P = 0.032) and left DE (P = 0.022) with cutoff values of > 4.1 mm and > 5.5 mm with AUC (Area under curve) of 0.737 and 0.831, respectively. There was no statistically significant difference between both groups regarding DTF or TPIA.ConclusionWe have found that DE is a predictor of weaning success, while DTF and diaphragmatic TPIA had no correlation with weaning outcome.

Immediate vs Gradual Brace Weaning Protocols in Adolescent Idiopathic Scoliosis

Lack of evidence and consensus for brace weaning protocol in adolescent idiopathic scoliosis (AIS) results in clinicians prescribing gradual weaning in the hope of avoiding curve deterioration after weaning. However, gradual weaning contributes to prolonged brace wear, which can affect spinal stiffness and health-related quality of life (HRQoL). To determine whether gradual weaning results in better curve magnitude and truncal balance maintenance after brace weaning vs immediate brace removal for patients with AIS. This was an open-labeled randomized clinical trial commenced in April 2017 with 24-month follow-up completed in January 2023. Outcome assessors were masked to weaning protocol assigned. The study took place at a territory-wide tertiary scoliosis clinic serving the largest number of referrals in the local population. Patients with AIS ready to wean off of brace wear were eligible (402 were screened; 33 were excluded [15 for <18 hours/day of brace-wear compliance before weaning, 11 were treated with Milwaukee brace, and 7 declined to participate]; and 369 were included), and those who were treated with a custom molded thoracolumbosacral orthosis and had reached skeletal maturity were consecutively recruited. Patients were randomized to gradual weaning protocol (n = 176) with an additional 6 months of nighttime wear before completely stopping or immediate weaning protocol (n = 193) with immediate brace removal at recruitment. Changes in major curve Cobb angle and truncal balance from the time of weaning to 6-month, 12-month, and 24-month follow-up. HRQoL was also assessed using the refined Scoliosis Research Society 22-item and EuroQol 5-dimension questionnaires. A total of 369 patients (mean [SD] age, 14.9 [1.1] years; 304 [83.4%] girls) were randomized with 284 (77.0%) completing 24-month longitudinal follow-up. Immediate and gradual weaning groups had no significant differences in change of major Cobb angle at postweaning 6-month (difference, -0.6°; 95% CI, -1.4 to 0.2; P = .17), 12-month (difference, -0.3°; 95% CI, -1.2 to 0.6; P = .47), and 24-month (difference, -0.3°; 95% CI, -1.2 to 0.7; P = .60) follow-up. The number of curve progression, nonprogression, and rebound cases were comparable (χ22 = 2.123; P = .35). Postweaning changes in truncal balance and HRQoL demonstrated no significant differences between groups. Gradual weaning did not demonstrate superiority to immediate weaning with predefined criteria of Cobb angle and truncal balance maintenance and HRQoL after brace weaning. Gradual and immediate weaning achieved very similar maintenance of brace outcomes in AIS. We therefore recommend the consideration of immediate brace weaning, which aims to benefit patients with earlier time for increased exercises and activity level. ClinicalTrials.gov Identifier: NCT03329716.

Comparison of the effect of Sunset yellow on the stomach and small intestine of developmental period of mice

Sunset Yellow (SY), a synthetic food dye, is widely used in the food industry worldwide. The acceptable daily dosage for SY is 2.5 mg/kg/bw in humans. If SY is consumed in overdosage, it may cause histopathological effects in several organs. Studies in the literature about the effects of SY on growth and development in mammals are contradictory, and there are not enough of them. The investigation aims to determine SY's effects on the stomach and small intestine in different age groups of mice using histological methods. Control and treatment groups were created via mice aged 4, 8, and 10 weeks (n = 6). SY was administered by gavage at a level of 30 mg/kg/bw for 28 days to treatment groups. On the last day of the study, the mice were weighed and sacrificed by cervical dislocation. Stomach and small intestine tissues were removed from mice and transferred to 10 % formaldehyde. After passing through alcohol and xylene series and staining with Hematoxylin-Eosin, the tissues were evaluated under light and electron microscopy. The mean body weight (p = 0.01), mean stomach weight (p = 0.03), and mean small intestine weight were increased (p = 0.02) in treatment groups. In these groups, ruptures, fractures, and hemorrhage were detected in the small intestine tissue. In the stomach tissue, necrotic areas and hemorrhage were detected among the epithelial cells. The degenerations were more advanced in the weaning group. SY may be more harmful during weaning and puberty, but additional long-term studies are needed on the subject.

VA-ECMO weaning strategy using adjusted pulse pressure by vasoactive inotropic score in AMI complicated by cardiogenic shock.

This study evaluated how well serial pulse pressure (PP) and PP adjusted by the vasoactive inotropic score (VIS) predicted venoarterial extracorporeal membrane oxygenation (VA-ECMO) weaning success and clinical outcomes in acute myocardial infarction complicated by cardiogenic shock (AMI-CS) patients. A total of 213 patients with AMI-CS who received VA-ECMO between January 2010 and August 2021 were enrolled in the institutional ECMO registry. Serial PP and VIS were measured immediately, 12, 24, and 48h after VA-ECMO insertion. PP adjusted by VIS was defined as PP/√VIS. The primary outcome was successful VA-ECMO weaning. Successful weaning from VA-ECMO was observed in 151 patients (70.9%). Immediately after VA-ECMO insertion, PP [successful vs. failed weaning, 26.0 (15.5-46.0) vs. 21.0 (12.5-33.0), P=0.386] and PP/√VIS [11.1 (5.1-25.0) vs. 6.0 (3.1-14.2), P=0.118] did not differ between the successful and failed weaning groups. Serial PP and PP adjusted by VIS at 12, 24, and 48h after VA-ECMO insertion were significantly higher in patients with successful weaning than those with failed weaning [successful vs. failed weaning, 24.0 (4.0-38.0) vs. 12.5 (6.0-25.5), P=0.007 for 12h PP, and 10.1 (5.7-22.0) vs. 2.9 (1.7-5.9), P<0.001 for 12h PP/√VIS]. The 12h PP/√VIS showed better discriminative function for successful weaning than 12h PP alone [area under the curve (AUC) 0.80, 95% confidence interval (CI) 0.72-0.88, P<0.001 vs. AUC 0.67, 95% CI 0.57-0.77, P=0.002]. Patients with a low 12h PP/√VIS (≤7) had higher rates of in-hospital mortality (44.4% vs. 19.8%, P<0.001) and 6month follow-up mortality (hazard ratio 2.41, 95% CI 1.49-3.90, P<0.001) than those with a high 12h PP/√VIS (>7). PP adjusted by VIS taken 12h following VA-ECMO initiation can predict weaning from VA-ECMO more successfully than PP alone, and its low value was associated with a higher risk of mortality in AMI-CS patients.

Tissue Doppler imaging of the diaphragm and outcome of weaning from mechanical ventilation.

This study aimed to employ tissue Doppler imaging to monitor diaphragmatic peak velocity and acceleration during contraction and relaxation in mechanically ventilated patients, with the objective of assessing the potential utility of this technique in predicting weaning outcomes. A total of 89 adult subjects were recruited in this study. After 30 min of spontaneous breathing trial, the diaphragm motion parameters, including peak contraction velocity, peak relaxation velocity, contraction acceleration and relaxation acceleration, were measured in real time using tissue Doppler imaging. According to the results of weaning, the patients were divided into successful weaning group and failed weaning group. The differences of diaphragmatic tissue Doppler imaging monitoring indicators between the two groups were analysed, and the receiver operating characteristic curve was drawn to analyse the value of each ultrasound parameter in predicting weaning. In the successful weaning group, there were 61 subjects, while in the failed weaning group, there were 28 subjects. The peak contraction velocity, peak relaxation velocity, contraction acceleration and relaxation acceleration of the diaphragm were significantly higher in the failed weaning group compared to the successful weaning group (P < 0.05). The area under the curve of diaphragmatic peak contraction velocity, peak relaxation velocity, diaphragmatic contraction acceleration and diaphragmatic relaxation acceleration were 0.81 (0.72-0.91), 0.85 (0.77-0.93), 0.74 (0.63-0.86) and 0.86 (0.78-0.94), respectively. The diaphragm ultrasonic tissue Doppler imaging variables can serve as predictive indicators for weaning mechanical ventilation in patients, thus providing an effective tool to assist critical care physicians in determining the optimal timing for weaning mechanical ventilation.

47 Application of a ‘high’ or ‘low’ energy matrix to a nutrient-reduced diet supplemented with a novel phytase maintained growth performance and conferred production and sustainability benefit

Abstract This study assessed the capacity of a novel consensus bacterial 6-phytase variant (PhyG) to maintain growth performance of weaned pigs when added to a nutrient-reduced mixed cereal diet with two levels of dietary net energy (NE) reduction applied. A total of 360 newly weaned pigs [Greater York × Norsvin Landrace; initial body weight (BW) 8.4 ± 0.78 kg] were assigned to 60 floor-pens and 5 dietary treatments in a randomized complete block design. There were 2 blocks (weaning group), 6 replicate pens per block, and 6 pigs/pen (3 male, 3 female), in total of 12 replications per treatment. Diets were based on wheat, corn, barley, and soybean meal and were offered to pigs in 2 phases in pelleted form (0–14 and 14–35 d post-weaning). Treatments comprised a nutritionally adequate positive control (PC) and 4 negative control (NC) diets supplemented with PhyG. The NC diets were reduced in digestible P, Ca, Na, and digestible amino acids vs. PC, according to the expected contribution of PhyG added at 1,000 phytase units (FTU)/kg (NC1) or 2,000 FTU/kg (NC2), respectively. Each NC1 and NC2 was formulated at two NE reduction levels, designated ‘low’ and ‘high’ (‘low’: -53 to -65 kcal/kg and ‘high’: -73 to -86 kcal/kg, vs. PC at 1,000 and 2,000 FTU/kg PhyG, respectively). Data were analyzed by ANOVA. Means separation was by Tukey’s HSD test. During both phases and overall (0–35 d), average BW, average daily gain (ADG), average daily feed intake (ADFI), and feed conversion ratio (FCR) in all PhyG-supplemented, nutrient- and NE-reduced treatments, were either not different or were improved compared with the PC. Overall ADG, ADFI, and final BW (d 35) were greater in NC2+PhyG 2,000 FTU/kg ‘low’ vs. PC (466 vs. 424 g, 9.9%, 622 vs. 567 g, 9.7%, and 24.7 vs. 23.1 kg, 6.9%, respectively; P &amp;lt; 0.05). Total feed costs (ingredients price, February 2023) and estimated carbon footprint (CFP; FeedPrint, WUR, The Netherland) per kilogram of BW gain (BWG) were reduced in all PhyG-supplemented, nutrient- and NE-reduced treatments vs. PC. Feed costs saving per kg BWG were greater with ‘high’ than ‘low’ NE reduction applied (-0.013 vs. -0.007 €, respectively, vs. PC) with PhyG at 1,000 FTU/kg, and it was greatest in NC2+PhyG 2,000 FTU/kg with ‘low’ NE reduction (-0.036 € vs. PC). Similarly, the CFP was reduced from 2,068 to 1,840 g CO2 eq/kg BWG (-11 %) by NC2+PhyG 2,000 FTU/kg with ‘low’ NE reduction vs. PC. In conclusion, the application of a full nutrient matrix with ‘high’ or ‘low’ NE reduction combined with supplementation of PhyG maintained growth performance of weaned pigs and reduced the total feed costs and carbon footprint per kg BW gain, lead to production and sustainability benefits.

Determination of the effects of sunset yellow on mouse liver and pancreas using histological methods.

Sunset Yellow (SY) is an azo synthetic food dye. Although the amount of SY consumed varies in different periods of life, it increases especially in children and adolescents. It may cause pathologic effects in organs at early ages. The aim of this study was to determine the effects of SY on the liver and pancreas of mice of different age groups using histological methods. The study included Swiss albino mice that were divided into three treatment groups and three control groups based on age (4, 8, and 10weeks old), with six mice in each group (n=6/group). SY was administered at 30mg/kg/bw/week orally for 28days to treatment groups. The liver and pancreas tissues were kept in 10% formaldehyde, then passed through alcohol and xylene series and stained with Hematoxylin-Eosin. They were evaluated using light and electron microscopy. In SY groups, the mean body weight (p: 0.026) and the mean liver weight (p: 0.013) of the mice increased, and their mean pancreas weight decreased (p: 0.045).The numbers of degenerative cells in the liver tissues of the mice in the SY groups were high. Severe dilation in the sinusoids and haemorrhages focused around the Vena Cava were detected. In the pancreatic tissues of the SY groups, increases in fibroblasts and lymphocytic infiltration were observed. Pathologies interpreted as chronic pancreatitis were more intense in the weaning group (4weeks old). SY may be more harmful at an early age, and it may be beneficial to limit its use during this period.

A historical cohort study on predictors for successful weaning from prolonged mechanical ventilation and up to 3-year survival follow-up in a rehabilitation center

BackgroundWe followed prolonged mechanically ventilated (PMV) patients for weaning attempts and explored factors associated with successful weaning and long-term survival. MethodsThis historical cohort study included all adult PMV patients admitted to a single rehabilitation hospital during 2015–2018 and followed for survival according to weaning success up to 3 years or the end of 2021. ResultsThe study included 223 PMV patients. Of them, 124 (55.6 %) underwent weaning attempts, with 69 (55.6 %) successfully weaned, 55 (44.4 %) unsuccessfully weaned, and 99 patients with no weaning attempts.The mean age was 67 ± 20 years, with 39 % female patients. Age, sex distributions and albumin levels at admission were not significantly different among the groups. The successful weaning group had a 6 % higher proportion of conscious patients than the failed weaning group (55 % vs. 49 %, respectively, p = 0.45). Patients successfully weaned were less frequently treated with antibiotics for 5 days or more than those unsuccessfully weaned (74 % vs 80 %, respectively, p = 0.07). They also had a lower proportion of time from intubation to tracheostomy greater than 14 days (45 % vs 66 %, p = 0.02). The age, sex, antibiotic treatment, time to tracheostomy exceeding 14 days and time from admission to first weaning attempt adjusted one-year mortality risk of successful vs. failed weaning was somewhat lower, HR = 0.75, 95%CI: 0.33–1.60, p = 0.45, with the same trend by the end of 3 years, HR = 0.77, 95%CI: 0.42–1.39, p = 0.38. ConclusionSuccessful weaning from PMV may be associated with better survival and allows chronically ventilated patients to become independent on a ventilator. A larger study is needed to further validate our findings.

Spontaneous breathing trial with pressure support on positive end-expiratory pressure and extensive use of non-invasive ventilation versus T-piece in difficult-to-wean patients from mechanical ventilation: a randomized controlled trial

BackgroundThe aim of this study is to assess whether a strategy combining spontaneous breathing trial (SBT) with both pressure support (PS) and positive end-expiratory pressure (PEEP) and extended use of post-extubation non-invasive ventilation (NIV) (extensively-assisted weaning) would shorten the time until successful extubation as compared with SBT with T-piece (TP) and post-extubation NIV performed in selected patients as advocated by guidelines (standard weaning), in difficult-to-wean patients from mechanical ventilation.MethodsThe study is a single-center prospective open label, randomized controlled superiority trial with two parallel groups and balanced randomization with a 1:1 ratio. Eligible patients were intubated patients mechanically ventilated for more than 24 h who failed their first SBT using TP. In the extensively-assisted weaning group, SBT was performed with PS (7 cmH2O) and PEEP (5 cmH2O). In case of SBT success, an additional SBT with TP was performed. Failure of this SBT-TP was an additional criterion for post-extubation NIV in this group in addition to other recommended criteria. In the standard weaning group, SBT was performed with TP, and NIV was performed according to international guidelines. The primary outcome criterion was the time between inclusion and successful extubation evaluated with a Cox model with adjustment on randomization strata.ResultsFrom May 2019 to March 2023, 98 patients were included and randomized in the study (49 in each group). Four patients were excluded from the intention-to-treat population (2 in both groups); therefore, 47 patients were analyzed in each group. The extensively-assisted weaning group had a higher median age (68 [58–73] vs. 62 [55–71] yrs.) and similar sex ratio (62% male vs. 57%). Time until successful extubation was not significantly different between extensively-assisted and standard weaning groups (median, 172 [50–436] vs. 95 [47–232] hours, Cox hazard ratio for successful extubation, 0.88 [95% confidence interval: 0.55–1.42] using the standard weaning group as a reference; p = 0.60). All secondary outcomes were not significantly different between groups.ConclusionAn extensively-assisted weaning strategy did not lead to a shorter time to successful extubation than a standard weaning strategy.Trial registration The trial was registered on ClinicalTrials.gov (NCT03861117), on March 1, 2019, before the inclusion of the first patient. https://clinicaltrials.gov/study/NCT03861117.

Establishment and transfer management of veno-arterial extracorporeal membrane oxygenation in patients with difficult downtime during cardiopulmonary bypass surgery

To investigate the establishment method, coordination points and safe transport management strategy of vena-arterial extracorporeal membrane oxygenation (VA-ECMO) in patients with downtime difficulties during cardiopulmonary bypass (CPB). A observation study was conducted. The patients admitted to the department of critical care medicine of the First Affiliated Hospital of Wannan Medical College (Yijishan Hospital) from January 2020 to October 2022 were enrolled. These patients could not be separated from CPB and received VA-ECMO-assisted CPB surgery. The clinical data of the patients were recorded, including the basic information of the patients, the data of VA-ECMO establishment and transport process, the clinical indicators before and after VA-ECMO installation, the operation data of VA-ECMO and clinical outcomes. The experience was summarized from the aspects of extracorporeal membrane oxygenation (ECMO) establishment, transport process, team cooperation, and adverse events during transport. The clinical indicators before and after ECMO operation were compared. According to whether ECMO was successfully weaned, the patients were divided into a successful weaning group and a failure weaning group, and the clinical data between the two groups were compared. Eighteen patients who underwent VA-ECMO-assisted CPB were enrolled, including 10 males and 8 females. The average age was (56.7±12.3) years old. Preoperative left ventricular ejection fraction (LVEF) was 0.46±0.10, and the main reasons for switching to VA-ECMO assistance included right ventricular systolic weakness in 6 cases, total cardiac systolic weakness in 5 cases, left ventricular systolic weakness in 4 cases, high pulmonary arterial pressure in 2 cases, and intractable ventricular fibrillation in 1 case. Among the 18 patients transferred from CPB to VA-ECMO, 10 cases were successfully weaned and 8 cases failed. In ICU, 8 cases survived, 5 cases died, and 5 cases gave up treatment and discharged. The average time for successful CPB to VA-ECMO establishment was (24.6±7.4) minutes, initial blood flow was (3.3±0.4) L/min, and transit time was (8.4±1.5) minutes. ECMO-assisted duration averaged (82.0±69.3) hours. Adverse events occurred in 9 patients during ECMO establishment and transfer. Post-ECMO onboarding for 4 hours, significant improvements were noted in blood lactic acid (Lac), pH value, mean arterial pressure (MAP), central venous oxygen saturation (ScvO2) as compared with pre-ECMO onboarding [Lac (mmol/L): 10.5±7.0 vs. 15.2±6.8, pH value: 7.38±0.92 vs. 7.26±0.87, MAP (mmHg, 1 mmHg ≈ 0.133 kPa): 74.9±13.7 vs. 58.4±17.0, ScvO2: 0.678±0.065 vs. 0.611±0.061, all P < 0.01], and vasoactive-inotropic score (VIS) was also decreased (39.8±29.8 vs. 68.9±64.4, P < 0.01). Compared with successful weaning group, the patients in the failed weaning group exhibited higher pre-machine Lac (mmol/L: 18.8±7.8 vs. 12.3±4.3, P < 0.05), longer CPB time [minutes: 238.0 (208.8, 351.2) vs. 200.0 (185.8, 217.0), P < 0.05], and shorter ECMO-assisted time [hours: 19.5 (11.0, 58.8) vs. 94.5 (65.8, 179.8), P < 0.01]. However, there was no statistically significant difference in pre-machine pH value, ScvO2, MAP, VIS score, and initial blood flow and establishment time of ECMO between the two groups. VA-ECMO is an effective circulatory aid for CPB surgery that cannot be weaned after CPB. The establishment and transfer of CPB "bridge" to ECMO aid depends on multi-disciplinary treatment (MDT) cooperation. The success rate of ECMO weaning is related to the Lac and CPB duration. If it is not possible to detach from the CPB successfully, VA-ECMO should be initiated as early as possible.

Lung and diaphragm ultrasound as predictors of successful weaning from nasal continuous positive airway pressure in preterm infants.

Assessment of the utility of lung and diaphragm ultrasound in the prediction of successful weaning from nasal continuous positive airway pressure (NCPAP) in preterm infants. This prospective cohort study was conducted on preterm infants who were considered ready for weaning off NCPAP. Lung and diaphragm ultrasound were performed just before and 3 h after weaning off NCPAP. The primary outcome was to evaluate the accuracy of lung ultrasound (LUS) in predicting successful weaning from NCPAP. Out of 65 enrolled preterm infants, 30 (46.2%) were successfully weaned from NCPAP to room air. The successful weaning group had higher gestational ages, lower incidences of previous invasive mechanical ventilation, and treated hemodynamically significant patent ductus arteriosus before the trial weaning. A LUS score of ≤6, measured before discontinuation of NCPAP, exhibited a predictive sensitivity of 80% and specificity of 75% for successful weaning (Area under the curve (AUC) = 0.865, ≤.001). When the LUS score was assessed 3 h after weaning from NCPAP, a cutoff point of ≤7 predicted successful weaning with a sensitivity and specificity of 90% and 60% respectively (AUC = 0.838, p ≤ .001). The diaphragmatic thickness fraction (DTF) was significantly lower in the successful weaning group. After adjustment for various factors, LUS score remained the only independent predictor of successful weaning. LUS score before weaning from NCPAP has a good sensitivity and specificity for predicting successful weaning from NCPAP in preterm infants. Diaphragmatic excursion and DTF were not good predictors.

Prediction of ventilator weaning failure in postoperative cardiac surgery patients using vasoactive-ventilation-renal score and nomogram analysis.

This study evaluated the predictive value of the vasoactive-ventilation-renal (VVR) score in identifying the risk of weaning failure after cardiac surgery and developing a nomogram model to help physicians improve the success rate of weaning from mechanical ventilation in adult patients undergoing postoperative cardiac surgery. Clinical data were retrospectively collected from adult patients who underwent extracorporeal circulation cardiac surgery at the First Affiliated Hospital of Nanjing Medical University between August 2022 and April 2023 and who were subsequently transferred to the Intensive Care Unit (ICU) and treated with vasoactive drugs. Patients were divided into successful and unsuccessful weaning groups based on first-attempt weaning success. Variable selection was regularized using univariate logistic regression and Least absolute shrinkage and selection operator (LASSO) regularization. Multivariate logistic regression was performed to identify predictors and a nomogram was created to predict the risk of weaning failure. A total of 519 patients were included in the study. After selecting multiple stepwise variables, the VVR score before weaning, the modified Sequential Organ Failure Assessment (mSOFA) score on weaning day, and mechanical ventilation duration before weaning were determined as predictive indicators of weaning failure in adult patients after cardiac surgery. The optimal cut-off values for these indicators were 18.46 points, 4.33 points, and 20.50 h, respectively. The predictive model constructed using these three factors demonstrated good predictive performance. The VVR score before weaning accurately predicts the probability of weaning failure in adult patients after cardiac surgery. The weaning risk-predictive nomogram model, established based on the VVR score, mSOFA score, and mechanical ventilation duration before weaning, demonstrated robust predictive ability.

Anti-tumor necrosis factor (aTNF) weaning strategy in juvenile idiopathic arthritis (JIA): does duration matter?

To compare outcomes of a short and long weaning strategy of anti-tumor necrosis factor (aTNF) in our prospective juvenile idiopathic arthritis (JIA) cohort. JIA patients on subcutaneous adalimumab with at least 6months of follow-up were recruited (May 2010-Jan 2022). Once clinical remission on medication (CRM) was achieved, adalimumab was weaned according to two protocols-short (every 4-weekly for 6months and stopped) and long (extending dosing interval by 2weeks for three cycles until 12-weekly intervals and thereafter stopped) protocols. Outcomes assessed were flare rates, time to flare, and predictors. Of 110 JIA patients, 77 (83% male, 78% Chinese; 82% enthesitis-related arthritis) underwent aTNF weaning with 53% on short and 47% on long weaning protocol. The total flare rate during and after stopping aTNF was not different between the two groups. The time to flare after stopping aTNF was not different (p = 0.639). Positive anti-nuclear antibody increased flare risk during weaning in long weaning group (OR 7.0, 95%CI: 1.2-40.8). Positive HLA-B27 (OR 6.5, 95%CI: 1.1-30.4) increased flare risks after stopping aTNF. Duration of weaning aTNF may not minimize flare rate or delay time to flare after stopping treatment in JIA patients. Recapture rates for inactive disease at 6months remained high for patients who flared after weaning or discontinuing medication.

Comparison of the Recent ExPreS Score, WEANSNOW Score, and the Parsimonious HACOR Score as the Best Predictor of Weaning: An Externally Validated Prospective Observational Study.

Since weaning failure is multifactorial, comprehensive weaning scores encompassing not only the respiratory component but also nonrespiratory aspects are quintessential for successful weaning prediction. This was a single-center prospective observational study on 128 intensive care unit (ICU) patients undergoing spontaneous breathing trials (SBT). The extubation prediction score (ExPreS), heart rate, acidosis, consciousness, oxygenation, respiratory rate (HACOR), and weaning parameters, endotracheal tube size, arterial blood gas analysis, nutrition, secretions, neuromuscular affecting agents, obstructive airway problems and wakefulness (WEANSNOW) scores were compared for their diagnostic accuracy for successful weaning prediction. Out of 128 patients, 49 (38.3%) patients had weaning failure, and 79 (61.7%) had weaning success. The patients in the weaning failure group had significantly higher APACHE II scores, WEANSNOW scores, HACOR scores, MV days, and significantly lower ExPreS scores as compared to the successful weaning group. Multivariable regression analysis showed that ExPreS score p = 0.015, adjusted OR 0.960, 95% CI (0.929-0.992) and HACOR score p < 0.001, adjusted OR 1.357, 95% CI (1.176-1.567) were independent predictors of weaning failure. The HACOR score had an AUC of 0.830, cut-off ≥5, p < 0.001, sensitivity 76%, specificity 68%, diagnostic accuracy 70% to predict weaning failure. The ExPreS score had an AUC of 0.735, cut-off ≥69, p < 0.001, sensitivity of 70.9%, specificity of 69.4%, and diagnostic accuracy of 70.3% to predict weaning success. Both the HACOR and ExPreS scores were good models for predicting weaning outcomes (model quality 0.76 and 0.64 respectively). The parsimonious HACOR score is comparable to the ExPreS score for the prediction of weaning outcomes in critically ill patients. Nayak G, Chaudhuri S, Ravindranath S, Todur P. Comparison of the Recent ExPreS Score, WEANSNOW Score, and the Parsimonious HACOR Score as the Best Predictor of Weaning: An Externally Validated Prospective Observational Study. Indian J Crit Care Med 2024;28(3):273-279.

Weaning buprenorphine in pregnant patients#

Objective Evaluate maternal and neonatal outcomes after buprenorphine wean compared to patients maintained on buprenorphine throughout pregnancy. Methods Prospective cohort study of pregnant patients with opioid use disorder enrolled in a multidisciplinary treatment program between 2015 and 2022. All patients were offered Medications to treat Opioid Use Disorder (MOUD) primarily with buprenorphine. Patients had at least 2 prenatal visits and negative urine drug tests (UDT) prior to weaning. The experimental group underwent a buprenorphine wean greater than 20% of their baseline dose. The control group was maintained on buprenorphine throughout the pregnancy. Relapse was defined as patient reported use or positive UDT during weekly assessments. Mass spectrophotometer was used for detection of drugs in samples. Fisher’s exact tests were used to compare outcomes in weaned and control groups. Results 334 of 456 (73%) patients were treated with buprenorphine during pregnancy, with 39 in the experimental group and 295 in the control group. The mean dose for buprenorphine was similar between the groups (wean: 10.6 mg ± 5.6 vs. control: 10.3 mg ± 4.6, p = 0.76) but was significantly lower at delivery (wean: 4.4 ± 4.6 mg vs. control: 13.0 ± 4.7, p < 0.0001). Mean gestational age at initiation of the buprenorphine wean was 22.7 weeks. 10 of 39 (26%) who weaned were able to completely discontinue buprenorphine prior to delivery. Demographic data was similar between the groups, including overdose history. Overdose history at time of enrollment had a higher trend in the non-weaning group. neonatal opioid withdrawal syndrome (NOWS) treatment was significantly lower in the wean group (23 vs. 47%, p = 0.006), as was highest Finnegan score (9.6 ± 4.5 vs. 12.3 ± 4.0, p = 0.0003). Birthweight percentile was significantly higher in the wean group (44.3 ± 29.9 vs. 34.8 ± 24.4, p = 0.03). Gestational age at delivery, mode of delivery, and complications (HTN, DM, preterm labor, or short cervix) at delivery did not significantly differ between the groups. Conclusion Despite counseling to stay on buprenorphine, there are patients who desire to wean. The NOWS rate in the weaned cohort was significantly lower than the controls with no observed increase in maternal or neonatal morbidity. There were no maternal overdoses or deaths during the pregnancy. Larger studies are needed to evaluate this approach.

Weaning causes imbalanced T lymphocyte distribution and impaired intestinal immune barrier function in piglets

Context The immune system of piglets is not fully developed at weaning. The immature adaptive immune system along with the change in the feed types and the living conditions make piglets susceptible to pathogenic infections, and result in diarrhoea and decreased growth. However, the underlying mechanisms require further research. Aims This study was conducted to investigate the effects of weaning on the growth performance and intestinal immune function of piglets. Methods In total, 40 piglets with similar bodyweights were selected in pairs at 21 days old and divided into the suckling group (SG, breastfed by their mothers) and weaning group (WG, weaned at 21 days old). Eight piglets from each group were randomly selected and sacrificed at 24 days (SG3 and WG3) and 28 days of age (SG7 and WG7). The growth performance, T lymphocyte subpopulations, the concentration of cytokines and immunoglobulins, and the expression of Notch2 signalling proteins were determined. Key results The weaning caused a decrease in bodyweight (P &lt; 0.01) and the ratio of CD3+CD4+/CD3+CD8+ T cells in the thymus (P &lt; 0.05). Compared with SG3, the concentration of secretory immunoglobulin A (sIgA) in the jejunum was decreased, and that of interleukin 2 (IL-2) in serum and ileum, IL-1β and IL-2 in jejunum were upregulated (P &lt; 0.01), while IL-10 in the small intestine was downregulated (P &lt; 0.05) in WG3. Weaning downregulated gene expression of IL-4 and upregulated gene expression of IL-1β, IL-12, and interferon γ (IFN-γ) in small intestine (P &lt; 0.05). Weaning downregulated protein expression of Notch2 and Hes1 but upregulated Jagged1 expression in small intestine of piglets (P &lt; 0.05). Conclusions Weaning caused an imbalance in T lymphocyte distribution, thus impairing the intestinal immune function of piglets, which might be associated with the Notch2 signalling. Furthermore, weaning caused adverse effects on piglets especially on the first 3 days, which were partly recovered after 3 days, but still existed at 7 days after weaning. Implications The results of this study may guide the pig-raising industry, especially for the management of piglets shortly after weaning.