Predictors Of Weaning Research Articles

Electrographic Predictors of Successful Weaning from IV Anesthetics in Refractory Status Epilepticus

Electrographic Predictors of Successful Weaning from IV Anesthetics in Refractory Status Epilepticus

Sonographic measurement of lung aeration versus rapid shallow breathing index as a predictor of successful weaning from mechanical ventilation

BackgroundLung ultrasonography is a beneficial tool for evaluation of the extent of lung aeration through measurement of the amount of extravascular lung water. Lung ultrasonography offers some advantages over other methods of assessment of lung aeration including the lack of ionizing radiation and the possibility of use at patient’s bedside. It facilitates dynamic assessment of the lung during mechanical ventilation and during weaning.AimTo assess lung aeration by lung ultrasonography in patients ready for weaning and to validate the significance of its use as a predictor of weaning outcome in comparison with rapid shallow breathing index.Patients and methodsA prospective observational study was conducted on 30 critically ill mechanically ventilated patients for 48 h or more, and ready to undergo spontaneous breathing trial (SBT), according to the readiness criteria. It was conducted in Beni-Suef University Hospital from October 2017 to May 2018. Rapid shallow breathing index was measured before initiation of SBT, and lung ultrasound was done, before, during, and after SBT [lung ultrasound score (LUS) 1, 2, and 3] and were used as predictors for SBT outcome. Patients were divided, according to outcome, into successful weaning group (group A) and failed weaning group (group B).ResultsIn the failed weaning group, LUS1, LUS2, and LUS3 were significantly higher than those of the successful weaning group. At cutoff value of 8.5, LUS3 could be used for prediction of weaning failure with sensitivity 85% and specificity 100%. Moreover, there was a statistically significant relation between LUS and the other variables including hospital stay, mechanical ventilation duration, and mortality.ConclusionLung ultrasound is useful as a bedside tool that can help physicians in their weaning decisions.

Ventilatory equivalent for oxygen as an extubation outcome predictor: A pilot study.

IntroductionWeaning predictors can help liberate patients in a timely manner from mechanical ventilation. Ventilatory equivalent for oxygen (VEqO2), a surrogate for work of breathing and a measure of the efficiency of breathing, may be an important noninvasive alternative to other weaning predictors. Our study’s purpose was to observe any differences in VEqO2 between extubation outcome groups.MethodsEmploying a metabolic cart, oxygen consumption (V˙O2), minute volume (VE), tidal volume (VT), and breathing frequency were recorded during a spontaneous breathing trial (SBT) to calculate VEqO2 and the rapid shallow breathing index (RSBI) in 34 adult participants in the intensive care unit. Five-breath means of VEqO2 and the RSBI collected throughout the SBT were examined between SBT pass and fail groups and extubation pass and fail groups using the Mann–Whitney U test with p < 0.05.ResultsData from 31 participants were analyzed between SBT outcome groups. Data from 20 participants were examined for extubation outcome after a successful SBT. Median (interquartile range) VEqO2 was not different between extubation groups. Participants who passed the SBT had a higher median VEqO2 than those who did not at the midpoint (25.3 L/L V˙O2 [22–33 L/L V˙O2] vs. 23.7 L/L V˙O2 [18–24 L/L V˙O2], p = 0.035) and at the end (25.5 L/L V˙O2 [23–34 L/L V˙O2] vs. 21.3 L/L V˙O2 [20–24 L/L V˙O2], p = 0.017) of the SBT.DiscussionVEqO2 may show differences in SBT outcomes, but not differences between extubation outcomes. VEqO2 may be able to detect differences in work during an SBT, but may not be able to predict change in workload in the respiratory system after extubation. The small sample size may also have prevented any differences in extubation outcomes to be shown.ConclusionVEqO2 was higher in patients that passed their SBT. VEqO2 was not useful in identifying extubation success or failure in adult mechanically ventilated patients.

P1.56: Colonic continuity and Incidence of weaning from PN by 5 years of age in children with onset of intestinal failure(IF) related to short bowel syndrome(SBS) by 3 months of age with chronic persistent dependence on parenteral nutrition(PN) at one year of age

Objectives: To review 5-year outcome of children presenting in infancy with chronic intestinal failure (IF) associated with short bowel syndrome (SBS) who were still on parenteral nutrition (PN) treatment at 12 months of age. Method: Medical records of patients with SBS related IF presenting in neonatal period and up to 3 months of age from 2007–2017 who were still on PN at 12 months of age were reviewed. Data obtained included small intestinal length at time of resection, aetiology, presence/absence of ileo-caecal (I-C) valve and/or colon and number of patients still on PN at 5 years. Results: Twenty patients were identified. Eleven were male and 9 female. 14/20 were born prematurely. Diagnoses were necrotising enterocolitis (NEC) in 9, volvulus in 4, long segment Hirschsprung’s disease in 3, gastroschisis in 2, and intestinal atresia in 2. The remaining small intestinal length at time of surgery ranged from 4.5cm - 120cm (median 18cm) in 19 cases (not measured in 1). Four patients had ultra SBS (length <10cm). Eleven patients weaned from PN by 5 years of age and 9 were still on PN. The median age at time of weaning (corrected for gestational age in premature infants) was 2 years 4 months (range 1 year 6 months - 5 years 9 months). Small intestinal length ranged from 7–120 cm (median 30cm) in the weaned group and from 4–90 cm (median 20cm) in the persistent IF group. Seven/11 patients who weaned and 2/9 still on PN were female (p=0.09 not significant). 8/11 who weaned and 2/9 still on PN had NEC (p=0.068, not significant). 7/11 who weaned had an intact I-C valve compared to 3/9 on PN (p=0.6 not significant). All 11 children who weaned had a colon present compared to 5/9 who remained on PN (p=0.026, significant). 11/16 or 68% with colon in continuity weaned. Conclusion: Over 50% (11/20) infants with SBS and PN dependence for >12 months weaned from PN by or at 5 years of age. There was a statistically significant association with presence of colon with 68% with a colon weaning and even with some cases of ultra-SBS. Larger studies are needed to gain other predictors of weaning in this diverse group of patients.

Efficacy of echocardiography during spontaneous breathing trial with low-level pressure support for predicting weaning failure among medical critically ill patients.

Echocardiography was reported to be a good predictor of weaning failure when using T-piece method, but information about its efficacy in a pressure support setting is scarce. This study aimed to investigate the efficacy of echocardiography during spontaneous breathing trial with low-level pressure support for predicting weaning failure among medical critically ill patients. This prospective cohort study was conducted in adult respiratory failure patients that tolerated low pressure support weaning for 30minutes. Echocardiogram was performed during pressure support ventilation before extubation. Weaning failure was defined as reintubation within 48hours. Of the 52 included patients (mean age 65.9±17.8years), 14 experienced weaning failure. Severe pneumonia, metabolic acidosis, and septic shock were the leading causes of respiratory failure. Univariate analysis identified BMI>24, peak A wave<100cm/s, E/Ea>14, and inferior vena cava maximum diameter (IVCmax )>17mm as factors associated with reintubation. Multivariate analysis revealed E/Ea>14 and IVCmax >17mm to be independent predictors of weaning failure. Inferior vena cava maximum diameter>17 and E/Ea ratio≥14 independently predict weaning failure in patients with preserved left ventricular systolic function. This finding confirms that preload status of both ventricles plays a major role in weaning failure.

Effects of amount of milk fed, and starter intake, on performance of group-housed dairy heifers during the weaning transition

ABSTRACT To determine the effect of the amount of milk fed on performance of dairy calves during weaning, 55 female Holstein calves were randomly assigned to either a high (10 L/d) or low (5 L/d) amount of whole milk on d 3 of life. Calves were assigned to 1 of 2 milk treatments until d 48 when a 10-d weaning transition began, and all calves were weaned at d 58. Calves were housed individually for the first 21 ± 3 d of life and fed with an automated individual calf feeder, before being moved to a group pen where they were fed through an automated calf feeder. Calf starter and water were provided ad libitum from d 3, and hay was provided once they moved to the group pen. Milk and starter intake was automatically recorded daily, and BW was recorded weekly. Calves fed a high amount of whole milk had increased ADG during the preweaning period, greater BW before weaning (75.5 vs. 64.6 kg), but reduced starter intake during weaning (722 vs. 1,074 g/d). Starter intake was highly correlated with weight gain during weaning (r = 0.73), and regardless of treatment, there was large variation in starter intake during the weaning transition. The findings indicate that there is benefit to feeding an increased amount of whole milk on animal performance and that starter intake preweaning is a predictor of a successful weaning, particularly for calves fed a low amount of milk.

Predictors of prolonged weaning among mechanically ventilated patients in respiratory intensive care unit

Background Weaning has been classified into simple, difficult, and prolonged. Objective The aim of this study was to assess predictors of prolonged weaning (PW) and survival in the respiratory ICU (RICU). Patients and methods Fifty-three patients admitted to RICU and requiring mechanical ventilation (MV) were included in the study. According to the classification of weaning, patients were categorized into simple [20 (37.7%)], difficult [20 (37.7%)], and PW [13 (24.5%)]. Factors associated with PW and outcomes were assessed. Results Multiple factors were associated with PW: decreased serum Ca2+ (P Conclusion PW was associated with multiple factors; when subjected to multivariate analysis, only serum Mg2+ and SaO2% change (between baseline and first weaning trial) significantly predict PW. Increased ICU stay and mortality were significantly associated with PW. Clinical implications Prolonged MV is associated with higher frequency of tracheostomy, reintubation, longer ICU stay, and poor outcome. Detection and correction of PW associated factors may improve the outcome.

Diaphragmatic ultrasound as a predictor for successful weaning from mechanical ventilation

Diaphragmatic ultrasound as a predictor for successful weaning from mechanical ventilation

Comparing Ultrasound-based Diaphragmatic Excursion with Rapid Shallow Breathing Index as a Weaning Predictor.

BackgroundA challenging task in the intensive care unit is weaning intubated patients from mechanical ventilation. The most commonly used weaning parameter, the rapid shallow breathing index (RSBI), gives thorough guidance on extubation timing with spontaneous breathing trials. Diaphragm plays vital role in tidal volume generation. The main objective of the study was to compare ultrasound-based diaphragmatic excursion (DE) with RSBI as weaning predictors.MethodsWe conducted an observational prospective cohort study on patients on mechanical ventilation. During a spontaneous breathing trial (SBT) we simultaneously evaluated right hemidiaphragm excursion by using M-mode ultrasonography as well as the RSBI. To be included, patients must have been on mechanical ventilation for longer than 48 hours, have no excessive tracheobronchial secretions, and their underlying critical illness (for which they were intubated) must be resolved. Patients younger than 14 years, patients with neuromuscular disorder, patients with pneumothorax, and patients with cervical spine injury were excluded from the study. We analyzed the data to determine the significance of DE and RSBI.ResultsA total of 90 patients were included in our study; 54 (60%) were men, and 36 (40%) were women. The average age of all the participants was 55 ± 16 years (range, 19 to 83 years). Sixty-two patients (68.9%) were successfully weaned. The mean DE was 1.44 ± 0.26 cm, and the mean RSBI was 56.88 ± 8.30 in all patients. Successful weaning patients had a mean DE of 1.51 ± 0.26 cm and a mean RSBI of 54.05 ± 7.00. The greater the DE value, the greater the weaning success rate, and the lesser the RSBI value, the greater the weaning success rate. The area under the receiver operator curve for DE and RSBI was 0.795 and 0.815, respectively (p < 0.0001).ConclusionRSBI is an optimized clinical predictor in classifying weaning outcomes for intubated patients, but DE is also helpful in extubation assurance and reintubation prevention.

Diaphragmatic parameters by ultrasonography for predicting weaning outcomes

BackgroundDiaphragmatic dysfunction remains the main cause of weaning difficulty or failure. Ultrasonographic measurement of diaphragmatic function can be used to predict the outcomes of weaning from mechanical ventilation. Our primary objective was to investigate the performance of various sonographic parameters of diaphragmatic function for predicting the success of weaning from mechanical ventilation.MethodsWe prospectively enrolled 68 adult patients requiring mechanical ventilation who were admitted to the intensive care unit from June 2013 to November 2013. The diaphragmatic inspiratory excursion, time to peak inspiratory amplitude of the diaphragm (TPIAdia), diaphragmatic thickness (DT), DT difference (DTD), and diaphragm thickening fraction (TFdi) were determined by bedside ultrasonography performed at the end of a spontaneous breathing trial. A receiver operating characteristic curve was used for analysis.ResultsIn total, 62 patients were analyzed. The mean TPIAdia was significantly higher in the weaning success group (right, 1.27 ± 0.38 s; left, 1.14 ± 0.37 s) than in the weaning failure group (right, 0.97 ± 0.43 s; left, 0.85 ± 0.39 s) (P < 0.05). The sensitivity, specificity, positive predictive value, and negative predictive value of a TPIAdia of > 0.8 s in predicting weaning success were 92, 46, 89, and 56%, respectively. The diaphragmatic inspiratory excursion, DTD, and TFdi were associated with reintubation within 48 h. The P values were 0.047, 0.021, and 0.028, and the areas under the receiver operating characteristic curve were 0.716, 0.805, and 0.784, respectively.ConclusionAmong diaphragmatic parameters, TPIAdia exhibits good performance in predicting the success of weaning from mechanical ventilation. This study demonstrated a trend toward successful use of TPIAdia rather than diaphragmatic inspiratory excursion as a predictor of weaning from mechanical ventilation.

ACCURACY OF GAS EXCHANGE MEASUREMENTS AS A PREDICTORS OF EARLY SUCCESSFUL WEANING AMONG ICU PATIENTS OF PHILIPPINE HEART CENTER: A PROSPECTIVE COHORT STUDY

SESSION TITLE: Critical Care and Pediatrics SESSION TYPE: Global Case Reports PRESENTED ON: 10/10/2018 01:00 PM - 02:00 PM PURPOSE: Weaning is an important clinical issue between clinicians and patients that comprises 40% of mechanical ventilation. Rapid weaning and extubation is essential to fast-track recovery of the critically-ill patients. Gas exchange measurements such as Inspired – Expired oxygen concentration difference (I–E)O2 and end-tidal carbon dioxide concentration (PETCO2) are useful in identifying patients who are likely to succeed in liberation from mechanical ventilation. By being able to determine the accuracy of gas exchange measurements, it will greatly aid the physicians in the ventilator management and weaning of the patients which would affect both morbidity and mortality. METHODS: This prospective cohort study done at the intensive care unit of Philippine Heart Center. Patients who were intubated and mechanically ventilated were included in the study. Both standard and study weaning assessment protocols were done on a daily basis. Weaning were classified as successful if the patient was able to maintain spontaneous breathing for 48 hours after extubation. Sensitivity, Specificity, Positive Predictive Value (PPV) and Negative Predictive Value (NPV) were used to determine the diagnostic accuracy of gas exchange measurement in predicting optimal outcome. RESULTS: There were 290 patients enrolled in the study. A total of 210 patients who were successfully weaned from the mechanical ventilator, 142 (67.6%) males and 68 (32.3%) females. The mean age for both groups ranges from 48-51 years old. The probability of detecting weaning success using (I–E)O2 and PETCO2 is 92.92% and 90.35% respectively, while the probability of detecting weaning failure is 100% and 93.55% respectively. The ability of these measurements to detect weaning success in the general population were 80% in (I–E)O2 and 72.5% in PETCO2. Based on the sensitivity and specificity of these gas exchange measurements, a cut-off value of ≥ 4.6% in (I–E)O2 and ≥ 4 kPa in PETCO2 were deteremined. CONCLUSIONS: Capnographys is a non-invasive monitoring technique that allows fast and reliable insight into ventilation and it is useful in the weaning of patients from mechanical ventilation. According to our results, (I-E)O2 and PETCO2 measurement provides an accurate predictor of weaning in mechanically ventilated patients when the best cut-off values were applied. CLINICAL IMPLICATIONS: The process of weaning from mechanical ventilation is central to the management of critically ill patients. Delayed or unnecessarily prolonged weaning increases intensive care unit (ICU) length of stay, increases the cost of ICU care, decreases the availability of ICU beds, and can adversely affect patient outcome. Gas exchange measurements such as (I–E)O2 and PETCO2 greatly aid physicians in the ventilator management and weaning of the patients from the mechanical ventilator which affects both morbidity and mortality DISCLOSURES: no disclosure on file for Fernando Ayuyao; no disclosure on file for Teresita DeGuia; No relevant relationships by John Ray Galamay, source=Web Response no disclosure on file for Maria Encarnita Limpin

Ultrasound assessment of diaphragmatic dysfunction as a predictor of weaning outcome from mechanical ventilation: a systematic review and meta-analysis

ObjectiveThe aim of this systematic review was to assess the diaphragmatic dysfunction (DD) as a predictor of weaning outcome.BackgroundSuccessful weaning depends on several factors: muscle strength, cardiac, respiratory and metabolic....

PREDICTION OF WEANING FAILURE OF MECHANICAL VENTILATION USING CLINICAL PARAMETERS IN PICU

ABSTRACT Background: Mechanical ventilation is a life support intervention that is used for a large number of patients in Pediatric intensive care units. The current pediatric literature shows that the science of ventilator weaning and extubation remains undetermined. No optimal weaning method has been described for a more rapid and successful extubation. Objective: Weaning predictors are used as a decision point in protocols to determine whether a patient may advance to a spontaneous breathing trial. We designed a study to determine the effect of including a weaning predictor (clinical weaning parameters) in a weaning protocol. Subjects & Methods:  Cross section study was conducted on 53 children who admitted to PICU. All patients should be eligible for weaning from mechanical ventilation. Clinical data and laboratory investigations were obtained on admission. Patients underwent a spontaneous breathing trial (SBT) after reversal of the underlying cause for respiratory failure and when they met all the weaning criteria. Then Rapid shallow breathing index (RSBI) was performed. As RSBI ≤ 8 breath/min/ml/kg, PaO 2 > 60 mmHg , Pa CO 2 200 mg , Tidal volume (V T ) > 5 ml/kg, V e >200 ml/min/kg, PEEP < 5 CmH 2 O and RR < 45 breath/min.  Weaning failure is defined as the inability to sustain spontaneous breathing without any form of ventilator support, for at least 48 h. The results were tabulated and analyzed with SPSS. Results: RSBI differed significantly between patients who succeeded weaning from mechanical ventilation and those who failed (3.12±1 vs. 9.5±1.04 breath/min/ml/kg; P < 0.001). A cutoff value ≥3.5 breath/min/ml/kg on were associated with a prediction of failure of weaning from mechanical ventilation with a 100%sensitivity, 75% specificity,0.724 positive predictive value (PPV), 1 negative predictive value (NPV) and 84.91% accuracy. Conclusion and key messages: Clinical weaning parameter could be considered a sensitive and specific marker for prediction of weaning failure. Keywords Weaning; extubation; mechanical ventilation; pediatric Intensive Care Unit; weaning criteria; spontaneous breathing.

Predictors of prolonged weaning among mechanically ventilated patients in respiratory intensive care unit

Background: Weaning is an essential part of critically ill patients who are on mechanical ventilation. Weaning was classified into simple, difficult and prolonged. Some patients are easily weaned off and others require a more prolonged duration. Methods: 52 patients admitted to the respiratory intensive care unit (RICU) and requiring mechanical ventilation were successfully weaned and classified into simple (20, 37.7%), difficult (20, 37.7%) and prolonged weaning (13, 24.5%). Factors associated with prolonged weaning and outcomes were determined. Results: A total of 53 intubated patients admitted to the RICU (30 (56.6%) males), aged (59.8±14.3) years were included. The following factors are associated with prolonged weaning: ↓ed serum mg++(P< 0.0001) & CA++(P< 0.0001) , ↑ed BUN level (P= 0.001), ↑ed PaCO2 (P0.04), ↓ed SaO2% (P0.0001),presence of ≥2 co-morbidities (P0.02), prolonged duration of MV (P<0.0001) and long ICU stay (P<0.0001). There was no significant relation between prolonged weaning and Modes of MV (p0.2), also A-a gradient ↓ed in patients with prolonged weaning but not significant (P=0.5). In multivariate analysis, prolonged weaning was independently associated with serum Mg+ (OR 0.03, 95% CI 0.003–0.24, P <0.001), and SaO2% change (the beginning- the end of weaning trial) OR 0.91, 95%CI 0.83–0.99, P < 0.04). Regarding baseline serum Mg++ & tidal volume, the cutoff point for predicting prolonged weaning was (≤1.5 .mmol/l & ≤450 ml) with, sensitivity, specificity, PPV NPV and accuracy (61.5%, 92.5%, 72.7%, 88.1%, 77%, P ˂0.0001 and77%,55%, 36% 88%, 66%, P ˂ 0.02, respectively).The cutoff points of PaCO2 ≥49 mmHg & SaO2% ≤91 at first weaning trial & SaO2% change ≥5 (between the beginning and the end of a weaning trial) were strongly associated with prolonged weaning (P ˂0.02, ˂ 0.0001& ˂0.003, respectively). Prolonged weaning was significantly associated with high mortality rate (P˂ 0.0001). Conclusions: Several factors were associated with prolonged weaning, however, when subjected to multivariate analysis, only serum Mg++& SaO2% change significantly predict prolonged weaning. Prolonged weaning is associated with increased ICU stay and higher rate of tracheostomy. Clinical Implications: Prolonged mechanical ventilation is associated with higher rate of reintubation, tracheostomy rate, longer ICU stay and higher mortality. Identification and correction of factors associated with prolonged weaning may change the outcome and prognosis of these patients. In addition, early intervention such as tracheostomy is likely to benefit these patients

Clinical experience with temporary right ventricular mechanical circulatory support

ObjectivesThis study sought to determine if indication for support affects the outcomes after temporary right ventricular mechanical circulatory support after postcardiotomy cardiogenic shock, cardiac transplant, or left ventricular assist device placement. MethodsA retrospective review was performed on 80 patients receiving a right ventricular assist device. Data were collected from a prospectively maintained database. Kaplan–Meier survival analysis was performed to compare survival between groups. Multivariate regression analysis was performed to identify risk factors for failure to wean from support. ResultsThe indication for support was postcardiotomy cardiogenic shock in 13 patients (16%), cardiac transplant in 25 patients (31%), and left ventricular assist device in 42 patients (53%). Median support time was 6 days. Device was successfully weaned in 6 postcardiotomy cardiogenic shock cases (46%), 21 cardiac transplant cases (84%), and 35 left ventricular assist device cases (83%). Survival was worse for patients with postcardiotomy cardiogenic shock compared with patients with a left ventricular assist device. Survival up to 3 months was better for patients who received immediate (n = 43) versus delayed (n = 37) support (79% vs 46%, P = .003). Weaning and survival remained static across implant era. Risk factor analysis identified postcardiotomy cardiogenic shock indication (odds ratio, 0.161; P = .007; confidence interval, 0.043-0.600) as an independent negative predictor of weaning from mechanical support. ConclusionsTemporary right ventricular mechanical support remains an effective treatment strategy after left ventricular assist device placement with immediate support resulting in superior short-term survival. Caution should be applied in postcardiotomy cardiogenic shock when weaning and survival are poor. Overall survival outcomes have remained relatively static over time.

Physiologic Basis of Mechanical Ventilation.

The primary purpose of mechanical ventilation is to decrease work of breathing. Achieving this goal requires that cycling of the ventilator be carefully aligned with the intrinsic rhythm of a patient's respiratory center output. Problems arise at the point of ventilator triggering, post-trigger inflation, and inspiration-expiration switchover. Careful, iterative adjustments of ventilator settings are required to minimize work of breathing. Use of protocols for the selection of ventilator settings can lead to complications (including alveolar overdistention) and risk of death. Because complications are axiomatic to mechanical ventilation, it should be discontinued at the earliest possible time. To shorten ventilator time, the critical step is to screen for weanability through use of weaning predictor tests. Use of T-tube trials circumvents the impossibility of estimating patient work of breathing during pressure support. Before extubation, patients should demonstrate the ability to breathe successfully in the absence of pressure support and positive end-expiratory pressure.

A Prospective Observational Study on the Predictive Value of Serum Cystatin C for Successful Weaning from Continuous Renal Replacement Therapy

Background/Aims: There is a paucity of literature that investigates a biomarker associated with successful renal recovery following continuous renal replacement therapy (CRRT). Our study aimed to identify potential renal biomarkers or clinical indicators that could predict the successful weaning from CRRT. Methods: We conducted a prospective, observational study of 110 patients who had received CRRT and were weaned after renal recovery. Patients were considered to have successfully weaned from CRRT once there was no need for renal replacement therapy (RRT) for at least 14 days. For patients who had to restart dialysis within 14 days were considered unsuccessful. Results: Of the 110 patients evaluated, 89 (80.9%) were successfully weaned from CRRT. These patients had lower serum cystatin C (CysC) levels and higher urine output than the group that restarted RRT at the time of CRRT cessation. However, the levels of serum creatinine and neutrophil gelatinase-associated lipocalin were not significantly lower in the successful group compared to the restart-RRT group. A multivariable logistic regression showed that serum CysC was an independent predictor for the successful weaning from CRRT. Furthermore, in a multivariable Cox proportional hazards analysis, the group that was successfully weaned from CRRT had a lower in-hospital mortality compared to the restarted RRT group. Conclusion: Serum CysC, at the time of CRRT cessation, is an independent predictor of the successful weaning from CRRT in critically ill patients with acute kidney injury.

Use of ultrasound-guided preoperative diaphragmatic thickness as a predictor of postoperative weaning failure in recipients and donors scheduled for living donor liver transplant surgery.

Background and Objectives:The present study was designed to explore the utility of ultrasound-guided diaphragmatic thickness in the preoperative period in healthy controls scheduled for live-related donor hepatectomy and patients suffering from chronic liver disease scheduled for liver transplantation (LT) and its use as a predictor of postoperative weaning failure.Materials and Methods:This prospective observational study was conducted in a tertiary health care center and 65 adult (18–70 years) participants (30 healthy liver donors and 35 liver transplant recipients) were enrolled for this study. Right diaphragmatic thickness of both donors and recipients was measured by B-mode ultrasound using a 10 MHz linear array transducer in the supine position in the operation theater just before induction of anesthesia. For subgroup analysis of the recipients, we further divided them into two groups – Group 1 (diaphragmatic thickness < 2 mm) and Group 2 (diaphragmatic thickness > 2 mm), and comparison was done for duration of mechanical ventilation. Intergroup comparison was made for duration of mechanical ventilation and various other parameters.Results:The sonographic measurement of diaphragm revealed that its thickness is decreased in patients with chronic liver disease patients (2.12 ± 0.54 mm) as compared to healthy donors (3.70 ± 0. 58 mm). On multiple logistic regression, higher duration of mechanical ventilation was associated with diaphragmatic thickness < 2 mm (Group 1 of recipients) (adjusted odds ratio 0.86; 95% confidence interval: 0.75–0.99; P = 0.013) after adjusting for age, gender, and body mass index.Conclusions:Diaphragmatic thickness is decreased in patients with chronic liver disease as compared to healthy liver donors. Preoperative measurement of ultrasound-guided right hemidiaphragm thickness can be used to predict weaning failure in patients undergoing LT. Other studies are needed to confirm these finding on different group of patients.

Diaphragm and Lung Ultrasound to Predict Weaning Outcome: Systematic Review and Meta-Analysis

Deciding the optimal timing for extubation in patients who are mechanically ventilated can be challenging, and traditional weaning predictor tools are not very accurate. The aim of this systematic review and meta-analysis was to assess the accuracy of lung and diaphragm ultrasound for predicting weaning outcomes in critically ill adults. MEDLINE, the Cochrane Library, Web of Science, Scopus, LILACS, Teseo, Tesis Doctorales en Red, and OpenGrey were searched, and the bibliographies of relevant studies were reviewed. Two researchers independently selected studies that met the inclusion criteria and assessed study quality in accordance with the Quality Assessment of Diagnostic Accuracy Studies-2 tool. The summary receiver-operating characteristic curve and pooled diagnostic OR (DOR) were estimated by using a bivariate random effects analysis. Sources of heterogeneity were explored by using predefined subgroup analyses and bivariate meta-regression. Nineteen studies involving 1,071 people were included in the study. For diaphragm thickening fraction, the area under the summary receiver-operating characteristic curve was 0.87, and DOR was 21 (95%CI, 11-40). Regarding diaphragmatic excursion, pooled sensitivity was 75%(95%CI, 65-85); pooled specificity, 75%(95%CI, 60-85); and DOR, 10 (95%CI, 4-24). For lung ultrasound, the area under the summary receiver-operating characteristic curve was 0.77, and DOR was 38 (95%CI, 7-198). Based on bivariate meta-regression analysis, a significantly higher specificity for diaphragm thickening fraction and higher sensitivity for diaphragmatic excursion was detected in studies with applicability concerns. Lung and diaphragm ultrasound can help predict weaning outcome, but its accuracy may vary depending on the patient subpopulation.

Mechanical ventilation weaning protocol improves medical adherence and results

IntroductionImplementation of a weaning protocol is related to better patient prognosis. However, new approaches may take several years to become the standard of care in daily practice. We conducted a prospective cohort study to investigate the effectiveness of a multifaceted strategy to implement a protocol to wean patients from mechanical ventilation (MV) and to evaluate the weaning success rate as well as practitioner adherence to the protocol. MethodsWe investigated all consecutive MV-dependent subjects admitted to a medical-surgical intensive care unit (ICU) for >24h over 7years. The multifaceted strategy consisted of continuing education of attending physicians and ICU staff and regular feedback regarding patient outcomes. The study was conducted in three phases: protocol development, protocol and multifaceted strategy implementation, and protocol monitoring. Data regarding weaning outcomes and physician adherence to the weaning protocol were collected during all phases. ResultsWe enrolled 2469 subjects over 7years, with 1,943 subjects (78.7%) experiencing weaning success. Physician adherence to the protocol increased during the years of protocol and multifaceted strategy implementation (from 38% to 86%, p<0.01) and decreased in the protocol monitoring phase (from 73.9% to 50.0%, p<0.01). However, during the study years, the weaning success of all subjects increased (from 73.1% to 85.4%, p<0.001). When the weaning protocol was evaluated step-by-step, we found high adherence for noninvasive ventilation use (95%) and weaning predictor measurement (91%) and lower adherence for control of fluid balance (57%) and daily interruption of sedation (24%). Weaning success was higher in patients who had undergone the weaning protocol compared to those who had undergone weaning based in clinical practice (85.6% vs. 67.7%, p<0.001). ConclusionsA multifaceted strategy consisting of continuing education and regular feedback can increase physician adherence to a weaning protocol for mechanical ventilation.