Weaning Trial Research Articles

Development of a core predictor set of weaning in critically ill patients: a Delphi-based study protocol.

Prolonged mechanical ventilation in intensive care units (ICUs) leads to increased morbidity, higher mortality rates, and elevated healthcare costs. Predicting successful weaning from mechanical ventilation with accuracy is essential for optimizing resource use and improving patient outcomes. The International Classification of Functioning, Disability and Health (ICF) framework offers a holistic perspective on health conditions and can be adapted to identify key predictors of weaning readiness. This study aims to develop a Delphi-based core predictor set for weaning in critically ill patients, utilizing the ICF model. The core predictor set development comprises three steps: (1) Literature review and expert consultation to gather weaning predictors, (2) Predictor alignment with ICF categories per established rules, and (3) Three-round Delphi survey with a multidisciplinary team. A systematic review across major databases will be conducted to identify predictors related to weaning predictors in critically ill adults from cohort studies, trials, and reviews. Predictors will then be categorized within ICF domains. A multidisciplinary expert panel will evaluate the relevance of each predictor using a 9-point Likert scale to achieve consensus. This study will contribute to the development of a standardized, evidence-based predictor set for weaning readiness in critically ill patients. Using the ICF framework, this study aims to encompass the complex factors that influence weaning, thereby enabling personalized care plans and improving weaning outcomes. The Delphi methodology guarantees a thorough, iterative process for building consensus by integrating diverse clinical perspectives. The proposed Delphi-based study protocol aims to establish a core set of predictors for weaning in the ICU setting, guided by the ICF model. Successful implementation of this predictor set could enhance decision-making around weaning trials, reduce unnecessary ventilation days, and ultimately improve patient outcomes and healthcare efficiency. Future validation and implementation studies will be essential to confirm the utility and generalizability of this predictor set in clinical practice.

Echocardiographic evaluation of ventricular performance in VA-ECMO weaning: results from a observational monocentric prospective study

Abstract Background Although temporary mechanical circulatory support (MCS) devices are increasingly used in the management of cardiogenic shock (CS), several open question regarding the kind of support and timing of institution/weaning remains open. Echocardiography is widely applied to drive the weaning process and decision although there are no standardized protocols for the trial nor accordance on the parameters to apply. Purpose We sought to evaluate the overall accuracy of echocardiographic indices in predicting successful weaning from VA ECMO in patients with CS. Specifically, we tested total isovolumic time (tIVT), an index of ventricular performance, and longitudinal function (MAPSE) on top of the commonly used parameters (left ventricular ejection fraction, LVEF; left ventricular velocity time integral, LV VTI; TAPSE; right ventricular S’ at tissue Doppler imaging, RV S’). Methods Monocentric prospective study on adults receiving VA-ECMO due to refractory CS and/or cardiac arrest (CA) from 2012 to 2020. Echocardiography was performed at VA-ECMO placement and during the weaning trials. Weaning trials were performed daily, starting 48 hours after VA-ECMO institution, when patients were hemodynamically stable: mean arterial pressure >65 mmHg, no or minimum adrenergic support (vasoactive inotropic score <10), heart rate <110 bpm, lactate <2 mmol/L, and no signs of respiratory distress. Weaning trials were performed with a stepwise decrease of VA-ECMO blood flow until reaching 1 or 1.5 L/min under adequate anticoagulation. Successful weaning was defined as removal of VA-ECMO with no requirement for further MCS in the following 30 days. Results 76 patients were enrolled (23.8% female, 54.2±10.6 years-old), 52.6% due to CA. Median duration of VA-ECMO was 58 hours; 47 (61.8%) had intra-aortic balloon pump (IABP) inserted upfront. In-hospital mortality was 62.4% overall, 40% for CS without CA. 6 of the 32 weaned patients died for multiorgan failure due to septic shock. The baseline echocardiographic parameters associated with successful weaning were (table): stroke volume >13.9 mL (p 0.002), tIVT >23.6 min/sec (p 0.053), LV VTI >6.6 cm (p<0.001), MAPSE >6.15 mm (p 0.001), TAPSE >11 mm (p 0.023), RV S’ >10 cm/s (p 0.012). LVEF did not reach the statistical significance. Figure shows Kaplan-Meier analysis on echocardiographic indices collected at time of cannulation (panel A) and during the last weaning trial (panel B). Conclusions Echocardiography is pivotal in defining cardiac recovery and monitoring the weaning trial. Indices reflecting ventricular performance and delivered flow from LV were associated with weaning success both at VA-ECMO institution and throughout the weaning trials. Considering the known limitations of LVEF (heart rate, loading and left ventricular dyssynchrony dependence), tIVT and MAPSE should be introduced in the standard evaluation of patients in the acute setting.TableFigure

Hemodynamic monitoring during weaning from mechanical ventilation in critically ill pediatric patients: a prospective observational study

BackgroundCardiovascular dysfunction is a significant factor contributing to weaning failure in mechanically ventilated children. Understanding the cardiopulmonary pathophysiological changes that occur during weaning is a prerequisite for the early recognition of weaning failure of cardiovascular origin. This study aimed to assess the effect of weaning trials on central hemodynamics and to identify the indices predictive of cardiac-related weaning failure.MethodsThis prospective observational study was conducted in the Pediatric Intensive Care Unit (PICU) and included mechanically ventilated patients aged between 2 and 30 months who were on minimal ventilatory settings and ready for weaning. Patients who were hemodynamically unstable, diagnosed with neuromuscular diseases, or diagnosed with cardiac diseases were excluded. Hemodynamic parameters were evaluated during weaning from ventilation via echocardiography and noninvasive cardiometry during pressure support (PS) ventilation and at the end of the spontaneous breathing trial (SBT).ResultsThe study included 50 patients, comprising 30 males (60%) and 20 females (40%) with ages ranging from 2 to 30 months. Echocardiography revealed a significant increase in the cardiac index (CI), tricuspid annular plane systolic excursion (TAPSE), and the E/A ratio at the end of SBT. Moreover, right ventricular systolic pressure (RVSP) significantly decreased. Noninvasive cardiometry revealed a significant increase in the index of contractility (ICON) and CI at the end of SBT (p-value = 0.023 and < 0.001, respectively). Of the 12 (25%) patients who failed their first extubation trial, they exhibited a significantly lower CI and TAPSE (p values = 0.001 and 0.001, respectively).ConclusionThis study identified that weaning from mechanical ventilation in children is associated with hemodynamic changes, which can impact weaning success and reveal potential ventricular dysfunction. Bedside echocardiography was found to detect cardiac dysfunctions during weaning, and noninvasive cardiometry was considered a reliable tool that supports echocardiography for detecting changing trends in CI in PICUs. However, accurate values should be confirmed by echocardiography.

Echocardiographic parameters for weaning from Extracorporeal Membrane Oxygenation - the role of longitudinal function and cardiac time intervals.

Limited data exist on echocardiographic predictors of weaning from veno-arterial extracorporeal membrane oxygenation (V-A ECMO). We aimed to test the performance of different echocardiographic indices to predict weaning from V-A ECMO. and free survival after weaning. Observational study including patients with cardiogenic shock submitted to V-AECMO. Echocardiography was performed after V-AECMO placement and daily during the weaning trial to assess cardiac recovery. Echocardiography data after V-A ECMO implantation and during the last weaning-trial before V-A ECMO removal were analyzed. Besides traditional parameters, total isovolumic time (t-IVT, a left ventricular performance index) and mitral annular plane systolic excursion (MAPSE) were also tested.76 patients were included. A greater ventricular velocity-time integral (LVOT VTI) at baseline was associated with a 5-fold increase in weaning success (p < 0.001) as MAPSE lateral >6.15 mm (p 0.001) did. TAPSE and S' at tricuspid annulus showed an analogous association. During the weaning trial t-IVT, LVEF, MAPSE, LVOT VTI and TAPSE all improved significantly (p <0.001 for all). At regression analysis t-IVT <14.4second/minute (<0.001), LVOT VTI >12.3cm (p <0.001), MAPSE >8.9mm (p < 0.001), TAPSE> 16mm (<0.001) and E/e' <15.5 (p 0.001) were associated with weaning success and free survival after weaning. LVEF did not predict the weaning success and survival at any time-point (p 0.230). Longitudinal function, t-IVT and native ejection, measured with LVOT VTI, are reliable parameters to predict weaning success in V-A ECMO whereas the LVEF, although dynamically changing during weaning trial, it is not.

Occurrence of Dysrhythmias During Ventilatory Weaning and Its Association With Length of Mechanical Ventilation and In-hospital Complications.

The occurrence of cardiac dysrhythmias during ventilatory weaning and its impact on the length of ventilation and occurrence of complications have not been systematically investigated. The aim of this study was to evaluate the association between cardiac dysrhythmias during weaning and the duration of ventilation and complications during ventilator weaning. Data on the length of ventilation and complications were collected from the medical records of 30 mechanically ventilated patients. Continuous electrocardiographic recordings were collected at baseline and during the initial weaning trial. Multiple regression analysis was used to evaluate the association between dysrhythmias and length of ventilation. The relationship between prolonged ventilation and complications was assessed using the χ2 analysis. Supraventricular ectopic beats during weaning positively predicted the length of ventilation (P < .01). Prolonged ventilation (>7 days) is associated with the occurrence of renal insufficiency and septicemia. The association between the occurrence of supraventricular ectopic beats during ventilator weaning and the length of ventilation requires further evaluation and tailored management to improve patient outcomes.

Hypophosphatemia in Chronic Obstructive Pulmonary Disease Patients Requiring Mechanical Ventilation and Its Impact on Weaning in an Intensive Care Unit of a Tertiary Care Hospital in Eastern India.

Background Hypophosphatemia, defined as a serum phosphate level less than 2.5 mg/dL, is a frequent finding in patients with chronic obstructive pulmonary disease (COPD) and has been speculated to negatively affect weaning outcomes. This study aimed to determine the incidence of hypophosphatemia in COPD patients requiring mechanical ventilation and evaluate the predictive role of hypophosphatemia as an indicator of successful weaning from mechanical ventilation in such patients admitted to the intensive care unit (ICU) in a tertiary care hospital in eastern India. Methodology This prospective observational study included 60 adult patients aged 18 to 75 years with acute exacerbations of COPD on mechanical ventilation in the ICU who were planned to undergo a weaning trial. Serum phosphate levels were assessed at the time of admission and before each weaning attempt. Weaning outcomes at each attempt, length of ventilator and ICU stay, and mortality were recorded. Data collection was initiated after approval of the Institutional Ethics Committee. Receiver operating curve (ROC) analysis was done to identify the cut-off value of serum phosphate which predicted successful weaning. Results Of 60 participants, hypophosphatemia on admission was present in 15 (25%) patients. Despite the correction, 13 (21.7%) patients had hypophosphatemia before the first weaning attempt. Only 22 patients out of 60 were successfully weaned off from mechanical ventilation in the first trial, accounting for a success rate of 36.7%, of whom 20 were normophosphatemic (90.9%). In the second and third weaning trials, hypophosphatemia was significantly associated with weaning failure. Overall differences in mean serum phosphate levels among those who failed to wean in each weaning trial and the successful attempt were statistically significant (p < 0.001). On ROC analysis of serum phosphate level before the first weaning trial, a cut-off value of ≥3.0 mg/dL was identified to have 86.4% sensitivity, 55.3% specificity, 52.8% positive predictive value, 87.5% negative predictive value, and 66.7% diagnostic accuracy in predicting weaning success. Five patients died, accounting for a mortality rate of 8.3%. Lower mean serum phosphate levels before the first weaning trial, higher mean age, and longer ventilator and ICU days were significantly associated with mortality among our study participants (p < 0.05). Conclusions Our findings suggest that maintaining normal serum phosphate levels is critical to successfully weaning off patients with COPD from ventilator support.

Echocardiographic evaluation of ventricular performance in VA-ECMO weaning: results from a observational multicentric prospective study

Abstract Funding Acknowledgements None. Background Although temporary mechanical circulatory support devices are increasingly used in the management of cardiogenic shock (CS), several open question regarding the kind of support and timing of institution/weaning remains open. Echocardiography is widely applied to drive the weaning process from VA-ECMO although there are no standardized protocols. Purpose We sought to evaluate the accuracy of echocardiographic indices in predicting successful weaning from VA-ECMO in CS patients. We tested total isovolumic time (tIVT), an index of ventricular performance(1,2), and longitudinal function (MAPSE) on top of the commonly used parameters (left ventricular ejection fraction, LVEF; E/e’ at mitral valve; left ventricular velocity time integral, LV VTI; TAPSE; right ventricular S’ at tissue Doppler imaging, RV S’). Methods Multicentric prospective study on adults receiving VA-ECMO due to refractory CS and/or cardiac arrest (CA) from 2012 to 2020. Echocardiography was performed at VA-ECMO placement and during the weaning trials. Waning trials were performed daily starting from 48 hours after VA-ECMO institution. A stepwise decrease of VA-ECMO blood flow was applied, until reaching 1 or 1.5 L/min. Successful weaning was defined as removal of VA-ECMO with no requirement for further MCS in the following 30 days. Results 76 patients were enrolled (23.8% female, 54.2±10.6 years-old), 52.6% due to CA. Median duration of VA-ECMO was 58 hours; 47 (61.8%) had intra-aortic balloon pump (IABP) inserted upfront. In-hospital mortality was 62.4% overall, 40% for CS without CA. 6 of the 32 weaned patients died in hospital for multiorgan failure due to septic shock. The baseline echocardiographic parameters associated with successful weaning were (Figure 1-A): stroke volume (SV) &amp;gt;13.2 ml (HR 4.12 [1.71-9.95], p 0.002), tIVT &amp;gt;23.6 min/sec (HR 0.14 [0.02-1.03], p 0.053), LV VTI &amp;gt;6.6 cm (HR 4.99 [1.94-12.87], p&amp;lt;0.001), MAPSE &amp;gt;6.15 mm (HR 4.42 [1.90-10.24], p 0.001), TAPSE &amp;gt;11 mm (HR 10.13 [1.37-7.02], p 0.023), RV S’ &amp;gt;7 cm (HR 5.40 [1.45-20.12], p 0.012). LVEF, E/e’ and S’ at mitral valve did not reach the statistical significance. Figure 1-B shows Kaplan-Meier analysis on echocardiographic indices collected during the last weaning trial; figure 2 details HR of all these parameters. Conclusions Echocardiography is pivotal in defining cardiac recovery and monitoring the weaning trial. Indices reflecting ventricular performance and delivered flow from LV were associated with weaning success both at VA-ECMO institution and throughout the weaning trials. Parameters reflecting ventricular activation and systo-diastolic interaction already demonstrated superiority in defining ventricular performance. Considering the known limitations of LVEF (HR, loading and LV dyssynchrony dependence), tIVT and MAPSE should be introduced in the standard evaluation in the acute setting.

Developing efficient feeding and weaning protocols for Betta splendens informed by larval digestive physiology

Betta splendens, also known as the Siamese fighting fish, is an anabantoid native to Southeast Asia and is among the top ten freshwater ornamental fish species imported into the USA for the aquarium trade. Although B. splendens is a staple in the ornamental aquaculture industry, larval production continues to rely heavily on the use of Artemia spp. nauplii. Digestive physiology data can be used to minimize the use of costly live feeds during larval production by indicating when larvae can digest complex feeds like microdiets (MDs). A 30-day trial was conducted to determine the timing of the maturation of the digestive tract. Standard microplate assays were conducted to quantify pepsin, trypsin, and lipase activities and histology was used to describe digestive tract morphology. Pepsin activity and the development of gastric glands indicated the presence of a functional stomach between 15 and 18 DPH (days post-hatch). Next, a 42-day dietetics trial was conducted to determine which of three commercially available MDs best promoted growth and survival in larval B. splendens compared to an Artemia spp. reference diet. Survival was statistically similar for larvae fed Gemma Micro compared to the Artemia spp. reference diet and all MD treatments yielded significantly higher growth compared with the reference diet. Finally, a 25-day weaning trial was conducted where MD was introduced at three timepoints surrounding the development of the digestive tract. Larvae were subjected to one of five treatments: Artemia spp. reference diet, MD from first-feeding, or MD introduction at 12, 15, or 18 DPH. MD introduction at 15 and 18 DPH yielded similar survival and growth compared to the Artemia spp. reference diet. MD from first-feeding yielded statistically lower survival and growth compared to all other treatments. These results suggest that B. splendens can transition to a MD as early as 15 DPH without reducing growth or survival.

A Deep Learning Framework for Predicting Patient Decannulation on Extracorporeal Membrane Oxygenation Devices: Development and Model Analysis Study.

Venovenous extracorporeal membrane oxygenation (VV-ECMO) is a therapy for patients with refractory respiratory failure. The decision to decannulate someone from extracorporeal membrane oxygenation (ECMO) often involves weaning trials and clinical intuition. To date, there are limited prognostication metrics to guide clinical decision-making to determine which patients will be successfully weaned and decannulated. This study aims to assist clinicians with the decision to decannulate a patient from ECMO, using Continuous Evaluation of VV-ECMO Outcomes (CEVVO), a deep learning-based model for predicting success of decannulation in patients supported on VV-ECMO. The running metric may be applied daily to categorize patients into high-risk and low-risk groups. Using these data, providers may consider initiating a weaning trial based on their expertise and CEVVO. Data were collected from 118 patients supported with VV-ECMO at the Columbia University Irving Medical Center. Using a long short-term memory-based network, CEVVO is the first model capable of integrating discrete clinical information with continuous data collected from an ECMO device. A total of 12 sets of 5-fold cross validations were conducted to assess the performance, which was measured using the area under the receiver operating characteristic curve (AUROC) and average precision (AP). To translate the predicted values into a clinically useful metric, the model results were calibrated and stratified into risk groups, ranging from 0 (high risk) to 3 (low risk). To further investigate the performance edge of CEVVO, 2 synthetic data sets were generated using Gaussian process regression. The first data set preserved the long-term dependency of the patient data set, whereas the second did not. CEVVO demonstrated consistently superior classification performance compared with contemporary models (P<.001 and P=.04 compared with the next highest AUROC and AP). Although the model's patient-by-patient predictive power may be too low to be integrated into a clinical setting (AUROC 95% CI 0.6822-0.7055; AP 95% CI 0.8515-0.8682), the patient risk classification system displayed greater potential. When measured at 72 hours, the high-risk group had a successful decannulation rate of 58% (7/12), whereas the low-risk group had a successful decannulation rate of 92% (11/12; P=.04). When measured at 96 hours, the high- and low-risk groups had a successful decannulation rate of 54% (6/11) and 100% (9/9), respectively (P=.01). We hypothesized that the improved performance of CEVVO was owing to its ability to efficiently capture transient temporal patterns. Indeed, CEVVO exhibited improved performance on synthetic data with inherent temporal dependencies (P<.001) compared with logistic regression and a dense neural network. The ability to interpret and integrate large data sets is paramount for creating accurate models capable of assisting clinicians in risk stratifying patients supported on VV-ECMO. Our framework may guide future incorporation of CEVVO into more comprehensive intensive care monitoring systems.

Using digestive physiology to develop larval culture protocols for the Blackbanded Sunfish, a threatened centrarchid native to the United States

AbstractObjectiveThe Blackbanded Sunfish Enneacanthus chaetodon is a small centrarchid that is endemic to slow‐moving waters from New Jersey to central Florida, United States. The distribution of this species has been increasingly fragmented, primarily due to habitat degradation. The development of larval culture protocols is essential to produce this species for the aquarium trade and for potential restoration efforts. To streamline the production process, larvae should be transitioned from live feeds to inert diets as early as possible without sacrificing larval growth or survival.MethodsA developmental trial was conducted to determine the timing of digestive tract maturation, which indicates the ability of larvae to better digest inert microdiets (MDs). Blackbanded Sunfish larvae were sampled 12 times from 2 days posthatch (dph; notochord length [mean ± SD] = 4.38 ± 0.22 mm) to 50 dph (total length [TL] = 9.89 ± 1.64 mm) for subsequent analysis of digestive enzyme activity (via microplate assays) and digestive system morphology (via histology). A dietetics trial was conducted to determine the most appropriate commercial MD for this species at early life stages by testing the efficacy of three different MDs against a reference diet of brine shrimp Artemia nauplii. Lastly, a weaning trial was conducted to determine the earliest time point at which MDs should be introduced during the larval period.ResultBlackbanded Sunfish larvae transitioned from agastric to gastric digestion at approximately 40 dph (7.95 ± 0.86 mm TL), as determined by the presence of gastric glands and pepsin activity. In the dietetics trial, certain MDs yielded higher survival than others; however, all diets performed equally when considering the TL of the larvae. In the weaning trial, the highest survival was found when larvae were fed Artemia nauplii exclusively or when an MD was introduced at 48 dph (10.62 ± 1.88 mm TL).ConclusionLarval Blackbanded Sunfish may require up to 48 days of live feeds before introducing MDs but can be successfully transitioned to MDs after 48 dph without significantly affecting survival or growth.

Psychosocial Predictors of Ventilator weaning Outcomes among patients in intensive care units

BackgroundVentilator weaning is a process of discontinuing mechanical ventilation and transitioning patients to independent breathing after a period of mechanical support. Weaning outcomes among the critically ill in intensive care units (ICUs) vary significantly among individuals, leading to considerable variation in healthcare costs, length of hospital stay, morbidity and mortality. Addressing psychosocial aspects of care can improve weaning outcomes. ObjectiveThis study aimed to determine the effect of psychosocial factors (social support, family/significant other support, ability to communicate) on weaning outcome within intensive care patients. This research hypothesized that psychological and social factors play a role in determining ventilator weaning outcomes among ICU patients. MethodsThis study used a longitudinal, retrospective research design to analyze positive and negative psychosocial predictors of ventilator weaning outcomes. Data collection methods include interviews and questionnaires with patients and their families, as well as clinical data from the patient's medical records. Resultspresence of anxiety, depression, and hallucinations, have a negative relationship with weaning outcomes regarding a patient's psychological characteristics (rs = −0.207, −0.163, −0.158), while communication with a patient during mechanical ventilation have a positive relationship with weaning outcomes regarding a patient's psychological characteristics (rs = 0.152; p ≤ 0.05). Moreover patients who have fear during weaning trials, feeling neglected, and feeling insecurity have a negative relationship with weaning outcomes while gaining family support during mechanical ventilation have a positive relationship with weaning outcomes (rs = 0.144; p ≤ 0.05).Significance of results, the findings suggests that psychosocial factors, such as anxiety, depression, patient's perception of their illness, motivation to wean, and family involvement can influence the success of ventilator weaning among patients in ICUs.

Predictors of respiratory failure in Guillain-Barré syndrome: a 22 year cohort study from a single Italian centre.

The study aimed to identify predictors of respiratory failure leading to mechanical ventilation (MV) and tracheostomy in Guillain-Barré syndrome (GBS). Two hundred and thirty adult cases admitted to the Neurology Unit of Modena, Italy, between January 2000 and December 2021 were studied. A cut-off of MV starting within 8 weeks from onset of weakness was used. Univariable, multivariable logistic and Cox regression analyses were used to determine which pre-specified clinical and diagnostic characteristics were capable of predicting MV and tracheostomy, due to weaning failure. The model was internally validated within the full cohort. The Erasmus GBS Respiratory Insufficiency Score was retrospectively applied. One hundred and seventy-six cases (76.5%) were classified as classical sensorimotor GBS and 54 (23.4%) as variants. Thirty-two patients (13.9%) needed MV: 84.3% required respiratory support within 7 days. Independent predictors of respiratory failure and MV were older age, facial, bulbar, neck flexor weakness, dysautonomia, axonal electrophysiological subtype, cardiovascular comorbidities and higher disability score at entry. There was no association with abnormal spinal fluid parameters nor with positive serology for recent infections. Twenty-two patients (68.7%) were ventilated for more than 7 days; 4.7% died within 8 weeks. The patients who required MV were treated more often with plasma exchange. Independent predictors of tracheostomy due to weaning trial failure were facial, bulbar, neck flexor weakness, autonomic dysfunction, associated cardiovascular morbidities and axonal electrophysiological subtype on nerve conduction study. Our study indicates distinct predictors of MV and tracheostomy in GBS patients.

A RARE CASE OF BILATERAL SPONTANEOUS TENSION PNEUMOTHORAX IN A PATIENT WITH MUCORMYCOSIS

Mucormycosis is an invasive fungal infection seen in immunocompromised hosts. Here a rare case of mucormycosis with pulmonary involvement followed by bilateral spontaneous tension pneumothorax is described. Bilateral spontaneous tension pneumothorax is a rare and fatal condition. We present a case of 3 years old child, diagnosed case of acute Leukemia. During the course of induction chemotherapy, he was hospitalized with fever and diarrhea. He was being managed on lines of neutropenic colitis. During the hospital stay, the child developed sudden respiratory distress and seizures. Chest X-ray showed bilateral spontaneous tension pneumothorax. Immediate bilateral chest tubes insertions were done. He was also electively intubated. After successful lung expansion, the trial of weaning off the ventilator was given and patient was successfully extubated. CT Thorax after lung re-expansion showed few pneumatoceles with no bronchopleural fistulous communication. CT Brain and para nasal sinuses showed fungal rhinosinusitis with intracranial extension. Nasal endoscopy and debridement of necrotic tissue was done. Tissue cultures showed the growth of mucor species. The patient was also started on amphotericin B that was later changed to Posaconazole. He responded well to anti-fungal treatment and there was no recurrence of pneumothorax. Keywords: Mucormycosis, Tension pneumothorax, Bronchopulmonary fistula

Lung ultrasound score for monitoring the withdrawal of extracorporeal membrane oxygenation on neonatal acute respiratory distress syndrome

BackgroundExtracorporeal membrane oxygenation (ECMO) is considered an efficient and life-saving treatment for neonatal severe acute respiratory distress syndrome (ARDS). Bedside lung ultrasound (LUS) is an attractive and feasible method for evaluating neonatal ARDS. ObjectiveTo evaluate the value of LUS score at veno-arterial (V-A) ECMO withdrawal in neonatal patients with severe acute ARDS. MethodsA retrospective preliminary study was conducted in our cardiac intensive care unit from June 2021 to June 2022. Eight severe ARDS neonates who received V-A ECMO were enroled in this study. LUS was measured daily during ECMO and when weaning off ECMO. The relationships between the LUS score and ECMO parameters (blood flow and the sweep gas of FiO2) were assessed. Results(1) There was a significant improvement in LUS score by ECMO treatment. And, various diagnostic signs of lung ultrasound were detected during ECMO, including pulmonary edema (7 neonates) and lung consolidation (4 neonates), followed by pleural effusion (1 neonate) and bilateral white lung (1 neonate). (2) A total of 12 trials for weaning off ECMO were carried out, of which four failed, but all eight neonates finally succeeded in passing the weaning trial. LUS score of 21 or less was defined as a cut-off value for predicting ECMO weaning success. During ECMO treatment, LUS score was positively correlated with ECMO blood flow (r = 0.866, P < 0.05). ConclusionsLUS can be used to evaluate the various lung diagnostic signs in ARDS neonatal patients during ECMO treatment, and the LUS score under ECMO treatment decreases over time. The reduction in LUS score is associated with lower ECMO blood flow. LUS score is regarded as a predictor of ECMO weaning success.

Cough Augmentation Techniques for Weaning in Critically Ill Patients from Mechanical Ventilation

Abstract Background Retained sputum conflicts the weaning trial, as well as increase the risk of chest infection and prolong the time on mechanical ventilation Objective To evaluate the impact of using mechanical exsufflators insufflators as cough augmentation technique on outcome of weaning, in addition to assessing the rate of successful weaning using NIV and T-tube mode. Methods A randomizes control trial that included 30 patients divided into 2 groups; the first weaned by NIV mode, the second by T-tube mode. All patients prepared equally for spontaneous breathing trial (SBT), and using ME-I frequently just before SBT. Results The rate of successful weaning in all cases was 66.6% (20 patients of 30), the rate was higher in groups that weaned by T-tube than NIV mode (86.67% versus 46.67%), P = 0.01. Moreover, the number of ME-I cycle was significantly higher in group with successful weaning than other group, P = 0.02.In addition, the ventilation support time was significantly longer in failed group than the successful one, P &amp;lt; 0.001. Conclusion The use of MI-E just before the weaning trial enhance the outcome of weaning, moreover, the weaning trial by T-tube mode gave a higher successful rate during spontaneous breathing trial (SBT).

Pragmatic, randomized, blinded trial to shorten pharmacologic treatment of newborns with neonatal opioid withdrawal syndrome (NOWS)

BackgroundThe incidence of maternal opioid use in the USA has increased substantially since 2000. As a consequence of opioid use during pregnancy, the incidence of neonatal opioid withdrawal syndrome (NOWS) has increased fivefold between 2002 and 2012. Pharmacological therapy is indicated when signs of NOWS cannot be controlled, and the objective of pharmacological therapy is to control NOWS signs. Once pharmacologic therapy has started, there is great variability in strategies to wean infants. An important rationale for studying weaning of pharmacological treatment for NOWS is that weaning represents the longest time interval of drug treatment. Stopping medications too early may not completely treat NOWS symptoms.MethodsThis will be a pragmatic, randomized, blinded trial of opioid weaning to determine whether more rapid weaning, compared to slow wean, will reduce the number of days of opioid treatment in infants receiving morphine or methadone as the primary treatment for NOWS.DiscussionThe proposed study is a pragmatic trial to determine whether a rapid-weaning intervention reduces the number of days of opioid treatment, compared to a slow-weaning intervention, and we powered the proposed study to detect a 2-day difference in the length of treatment. Hospitals will be able to use either morphine or methadone with the knowledge that we may find a positive treatment effect for both, one, or neither drugs.Trial registrationNCT04214834. Registered January 2, 2020.

Factors associated with 30-day in-hospital mortality in critically ill adult patients receiving extracorporeal membrane oxygenation: A retrospective cohort study

ObjectiveTo identify factors associated with the 30-day in-hospital mortality rate among adult patients requiring extracorporeal membrane oxygenation (ECMO) in intensive care units. Research MethodologyRetrospective cohort study including 148 patients who underwent ECMO for at least 48 h between March 2010 and August 2021. The patients were divided into survivors and non-survivors based on their 30-day in-hospital survival. We obtained the sociodemographic information and pre- and post-ECMO data from electronic medical records. Kaplan–Meier survival curves and Multivariate Cox proportional hazards regression were used to analyse the data. SettingA tertiary-care university hospital in South Korea. Main Outcome MeasuresThe 30-day in-hospital mortality rate was the principal outcome measure. ResultsThe 30-day in-hospital mortality rate was 49.3% (n = 73). Kaplan–Meier analysis demonstrated that the duration of ECMO support in the 50th percentile of surviving patients was 13 days. Multivariable Cox regression analysis showed that new-onset renal failure, lower mean arterial pressure, and ECMO weaning failure were associated with an increased 30-day in-hospital mortality risk among patients who received ECMO. Subgroup analysis also revealed a significant association between weaning failure and 30-day in-hospital mortality after adjusting for covariates in patients undergoing veno-arterial ECMO. ConclusionClose monitoring of post-ECMO renal function and mean arterial pressure is required to minimize the risk of 30-day in-hospital mortality, especially in adults within the first two weeks of ECMO initiation. Moreover, the success of ECMO weaning should be optimized by collaboration within the ECMO team. Implications for Clinical PracticeCritical care nurses should pay close attention to patients’ response to weaning trials as well as alternations in renal function and mean arterial pressure during ECMO support. Furthermore, developing nursing care guidelines for adult patients receiving ECMO and standardized training programs for nurses in intensive care, are required in Korea.

Assessment of cardiac load-responsiveness in veno-arterial extracorporeal life support: A case series.

Well-timed explant of veno-arterial extracorporeal life support (V-A ECLS) depends on adequate assessment of cardiac recovery. Often, evaluation of cardiac recovery consists of reducing support flow while visualizing cardiac response using transoesophageal echocardiography (TEE). This method, however, is time consuming and based on subjective findings. The dynamic filling index (DFI) may aid in the quantitative assessment of cardiac load-responsiveness. The dynamic filling index is based on the relationship of support flow and pump speed, which varies with varying hemodynamic conditions. This case series intends to investigate whether the DFI may support TEE in facilitating the assessment of cardiac load-responsiveness. Measurements for DFI-determination were performed in seven patients while simultaneously assessing ventricular function by measuring the aortic velocity time integral (VTI) using TEE. Measurements consisted of multiple consecutive transient speed manipulations (∼100r/min) during weaning trials, both at full support and during cardiac reloading at reduced support. The VTI increased between full and reduced support in six weaning trials. In five of these trials DFI decreased or remained equal, and in one case DFI increased. Of the three trials in which VTI decreased between full and reduced support, DFI increased in two cases and decreased in one case. Changes in DFI, however, are mostly smaller than the detection threshold of 0.4mL/rotation. Even though current level of accuracy of the parameter requires further investigation to increase reliability and possibly predictability, DFI seems likely to be a potential parameter in supporting TEE for the assessment of cardiac load-responsiveness.

P92: Arterio-Venous Bridge for Peripheral Veno-Arterial Extracorporeal Membrane Oxygenation Weaning in Adults

Background: The timing for liberation of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) can be challenging. Various ECMO weaning strategies have been described in the literature. Arterio-venous (AV) bridge has been deployed successfully in the pediatric population but remains underutilized in adults. This case study illustrates the usefulness of AV bridge technique in adult VA-ECMO weaning trial. Method: Arterio-venous bridge is a weaning modality that allows the patient to be temporarily fully removed from VA-ECMO therapy while maintaining the ECMO circuit integrity and enabling the immediate resumption of ECMO therapy. The technique of AV bridge is described in Picture 1 and clinical data, including diagnosis, hemodynamics, biomarkers, are included in Table 1. We present two cases of adult VA-ECMO weaning trial utilizing AV bridge. Result: One patient who had previously undergone a failed VA-ECMO weaning trial initially was subsequently weaned and successfully decannulated utilizing the AV bridge technique. The second patient was able to tolerate AV bridge off pump trial up for two hours but became hypoxic and acidotic, and eventually placed back on VA-ECMO. With no evidence of recovery and poor candidacy for advanced therapies, patients was transitioned to comfort care. Conclusion: Arterio-venous bridge is a safe and effective method to wean from VA-ECMO in adult patients. It not only allows clinicians to monitor patient’s hemodynamics when patient is fully off VA-ECMO support, but also retains the capability of immediate therapy resumption if patient fails the wean.Figure 1. The technique of AV bridge Table 1. - Patients’ Characteristics, Hemodynamics and Biomarkers when off ECMO Patient Diagnosis Hemodynamics Biomarkers Pressor Requirement MAP CVP PA Lactate PaO2 PaCO2 58 yo M Hemorrhagic Shock s/p OHT 71 12 34/25 =0.9 111 38 = 60 yo F Cardiogenic shock 2/2 CTEPH 70 10 88/49 ↑2.9 57 55 ↑↑↑

Predictors of successful weaning from VA-ECMO: the role of CS etiology and related treatment

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a short-term mechanical circulatory support for refractory cardiogenic shock (CS). Successful weaning from VA ECMO is defined as device removal without further requirement for re-cannulation over the following 30 days. Few data exist regarding timing and reliable parameters for weaning from VA-ECMO: most study focused on echocardiographic and invasively monitored parameters during weaning trial(1,2). No data exist concerning pharmacological support and standard haemodynamic parameters in the first 24 hours since VA-ECMO implantation. Purpose We sought to evaluate hemodynamic predictors of VA-ECMO weaning. Methods Single-center retrospective observational study of patients with refractory CS who underwent VA-ECMO insertion from 2013 to 2020 in Intensive Care Unit (ICU). Primary endpoint was successful weaning from VA ECMO. Demographic, clinical, hemodynamic data within the first 24 hours and outcome were collected. We also recorded maximum dose of each vasoactive medication, Vasoactive Inotropic Score (VIS)(3) after VA-ECMO implantation and the total amount of time exposition to vasoactive drugs. Results 100 patients (26% female; 52,6±12,6 y.o.) who underwent VA-ECMO cannulation were enrolled (Table 1). 31 were successfully weaned (31%) at a median time of 140,0 [74,3-229,0] hours; 30-days mortality was 47%. 79 (79%) patients were admitted for cardiac arrest (CA); 48 (48%) had acute myocardial infarction (AMI)-CS. CA patients were less likely to be weaned: 20,3% of CA patients had successful VA-ECMO removal while 79,4% was not weaned (p &amp;lt;0,001). In the weaned group, mean blood pressure was significantly higher (75,3±18,2 vs 61,4±18,3 mmHg; p &amp;lt;0,01).Patients who successfully removed VA-ECMO had lower serum lactate (8,8±5,2 vs 11,3±5,0 mmol/L; p &amp;lt;0,05), lower fluid balance (+2,3 [0,5-5,5] vs +4,1 [1,7-8,3] L/die; p &amp;lt;0,05) and lower Sequential Organ Failure Assessment (SOFA) score (11,2±2,6 vs 13,2±3,4; p &amp;lt;0,01). Lower doses of norepinephrine was administered in patient successfully weaned (0,27±0,17 vs 0,44±0,25 mcg/kg/min; p &amp;lt;0,01). Despite not significant, lower VIS and time to exposition to vasoactive drugs amongst weaned patients were observed (p=0,08 and p=0,09, respectively). Stepwise logistic regression confirmed the worst outcome of CA patients (OR 0,64; p &amp;lt;0,001), SOFA score (OR 0,81; p &amp;lt;0,05) and time to exposition to vasoactive drugs (OR 0,81; p &amp;lt;0,05) on successful weaning from VA-ECMO. Conclusions Mortality of patients undertaking VA-ECMO still remains high. Amongst the data in the model, the strongest negative association with successful weaning from VA-ECMO was found for CA, according to the latest classification entailing CA as CS severity modifier(4). Other results show higher requirement of norepinephrine and fluid administration for vasoplegia mostly related to hypoxic organ injury and related infection (i.e. bowel translocation).