Weaning Trial Research Articles

Rare Case of Miller-Fischer Syndrome Linked to COVID-19 Infection (P6-10.004)

<h3>Objective:</h3> <h3>Introduction:</h3> A plethora of neurological deficits, with an incidence of 35–80%, have been found to be associated with the novel coronavirus (COVID-19) infection. Though several reports of Guillain-Barré syndrome, encephalitis, acute stroke, and anosmia have been established, Miller-Fisher syndrome has few cases linked to COVID 19 infection. <h3>Background:</h3> <h3>Case Description:</h3> A 58-year-old male with a past medical history of hypertension, coronary artery disease, and diagnosed with COVID-19 two weeks prior, presented with hand and feet paresthesia’s, dysphagia, and difficulty walking. Initial evaluation demonstrated rapidly progressive ptosis, external ophthalmoplegia, facial weakness, tongue weakness, quadriparesis, areflexia, and bulbar dysfunction. A head and neck MR angiogram and brain MRI were unremarkable. Due to worsening hypoxia and respiratory failure, he was intubated. He underwent lumbar puncture with no evidence of infectious etiology on CSF analysis. He failed multiple weaning trials, and therefore underwent tracheostomy and PEG-tube placement. Further laboratory evaluation revealed elevated CK, ESR, and CRP. Serology included acetylcholine receptor blocking antibody &lt;15, acetylcholine binding antibody of 0.00, MuSK antibody of 0.00, ganglioside GD1B antibody &lt;1:100, ganglioside GQIB antibody titer 1:12800. He was diagnosed with Miller Fisher syndrome. He was given 5 days of IVIG, but also completed 5 sessions of plasmapheresis for persistent neurological symptoms. He returned to baseline functional status afterwards and was discharged to a rehabilitation center. <h3>Design/Methods:</h3> NA <h3>Results:</h3> NA <h3>Conclusions:</h3> <h3>Discussion:</h3> MFS is an acute, autoimmune peripheral neuropathy that is characterized by a triad of ophthalmoplegia, gait ataxia, and areflexia, and is also associated with anti-GQ1b antibodies. With few and sporadic known cases of COVID-19 associated MFS, it is difficult to draw a conclusion regarding the linkage between the two and if COVID-19 predisposes patients to MFS. As clinicians, it is imperative that we pay close attention to the neurologic symptoms associated with COVID-19 given the wide and clinically unestablished range of symptoms. <b>Disclosure:</b> Ms. Shareef has nothing to disclose. Dr. Khan has nothing to disclose. Dr. Shahid has nothing to disclose.

A comparison of ventricular volume and linear indices in predicting shunt dependence in aneurysmal subarachnoid hemorrhage

BackgroundGuidelines for determining shunt dependence after aneurysmal subarachnoid hemorrhage (aSAH) remain unclear. We previously demonstrated change in ventricular volume (VV) between head CT scans taken pre- and post-EVD clamping was predictive of shunt dependence in aSAH. We sought to compare the predictive value of this measure to more commonly used linear indices. MethodsWe retrospectively analyzed images of 68 patients treated for aSAH who required EVD placement and underwent one EVD weaning trial, 34 of whom underwent shunt placement. We utilized an in-house MATLAB program to analyze VV and supratentorial VV (sVV) in head CT scans obtained before and after EVD clamping. Evans' index (EI), frontal and occipital horn ratio (FOHR), Huckman's measurement, minimum lateral ventricular width (LV-Min.), and lateral ventricle body span (LV-Body) were measured using digital calipers in PACS. Receiver operating curves (ROC) were generated. ResultsArea under the ROC curves (AUC) for the change in VV, sVV, EI, FOHR, Huckman's, LV-Min., and LV-Body with clamping were 0.84, 0.84, 0.65, 0.71.0.69, 0.67, and 0.66, respectively. AUC for post-clamp scan measurements were 0.75, 0.75, 0.74, 0.72, 0.72, 0.70, and 0.75, respectively. ConclusionVV change with EVD clamping was more predictive of shunt dependence in aSAH than change in linear measurements with clamping and all post-clamp measurements. Measurement of ventricular size on serial imaging with volumetrics or linear indices utilizing multidimensional data points may therefore be a more robust metric than unidimensional linear indices in predicting shunt dependence in this cohort. Prospective studies are needed for validation.

Factors Affecting Mechanical Ventilator Weaning Success and 28-Day Survival Among Patients With Acute Respiratory Distress Syndrome Secondary to COVID-19.

The process of weaning patients off mechanical ventilation (MV) is difficult and complex. Critical care nurses must maintain continuity of care for patients undergoing MV weaning, assess patients' overall condition, and meet patients' needs. The study aimed to explore clinical factors of MV weaning success and 28-day survival among patients with acute respiratory distress syndrome secondary to COVID-19. This prospective observational study was conducted on 90 newly admitted patients in the general intensive care unit Assiut Univeristy Main Hospital in Egypt from October 2021 to March 2022. The researchers applied a standard weaning protocol for all of the patients in this study and then assessed the outcome variables: success or failure of weaning trials from a mechanical ventilator, and 28-day survival. In total, 50 (55.6%) patients were successfully weaned from MV, and 45 (50%) patients survived at 28 days. In a multivariate regression analysis, dynamic compliance (OR, 1.115; 95% CI, 1.010-1.230, p = .031*), lymphocyte count (OR, 3.025; 95% CI, 1.322-6.923, p = .009*), urine output (OR, 1.002; 95% CI, 1.001-1.004, p = .002*), and alanine aminotransferase (ALT; OR, 0.993; 95% CI, 0.988-0.999, p = .017*) were significantly associated with weaning success. In addition, age (OR, 1.058; 95% CI, 1.015-1.102; p = .007*), lymphocyte count (OR, 3.304; 95% CI, 1.348-8.100; p = .009*), urine output (OR, 1.003; 95% CI, 1.001-1.004; p = .001*), and ALT (OR, 0.994; 95% CI, 0.989-0.99, p = .015*) were significantly associated with survival at 28 days. Dynamic lung compliance, lymphocyte count, urine output, and ALT were found to be predictive parameters that may affect the success of weaning off MV. Additionally, it was found that age, lymphocyte count, urine output, and ALT are predictors of survival at 28 days. We recommend further studies with larger, more systematic samples and complete follow-up, focusing on pulmonary function and quality of life in postweaning patients with acute respiratory distress syndrome.

Weaning from mechanical ventilation: a narrative review

The “weaning” from mechanical ventilation is a process that involves several assessments and steps to aid a patient to reach a “liberation” from the ventilator and allow for breathing autonomy.The process of “weaning” from mechanical ventilation involves several assessments and steps to support a patient in reaching a “liberation” from the ventilator and allow for spontaneous breathing. The weaning process consists of evaluating if the patient is able to breathe with minimal or no ventilation support. This assessment is performed by a diagnostic test named spontaneous breathing trial (SBT), repeated every 24 hours to ensure extubation success. Even though many patients do not meet the eligibility criteria for starting the weaning process, they can still be weaned. For this reason, these criteria should be evaluated in order to assess a possible weaning, rather than adopting absolute standards which have to be met simultaneously. The SBT helps the healthcare professionals to understand the patient’s capacity to sustain physiological breathing once they are extubated (or on spontaneous breathing if a tracheostomy tube is maintained in place). Several patients fail to meet the weaning criteria after less than 20 minutes of the SBT. Therefore, a 30-minute trial is enough to estimate the patient’s capacity to withhold spontaneous breathing. Even if the SBT is currently the gold standard method to conduct the weaning trial, it does not prevent the occurrence of complications after extubation such as upper airways obstruction, increased resistance, loss of airway protective reflexes, cough efficiency, and drainage of tracheobronchial secretions. The preventive use of NIV or High Flow Nasal Cannula is strongly recommended for patients experiencing extubation failure and mechanically ventilated for more than 24 hours after an SBT. A well-performed SBT usually leads to definitive extubation; on the other hand, SBT failure requires a comprehensive investigation on potentially reversible conditions. Prolonged weaning is highly wasteful in terms of time and resources due to the need for a systematic and multidisciplinary approach to successfully face the weaning process.

Echocardiographic Prediction of Successful Weaning From Venoarterial Extracorporeal Membrane Oxygenation.

Weaning from venoarterial extracorporeal membrane oxygenation (VA-ECMO) support fails in 30% to 70% of patients. To explore the utility of echocardiographic parameters in predicting successful disconnection from VA-ECMO. Patients receiving VA-ECMO in a referral hospital were included. The relationships between echocardiographic parameters during the weaning trial and weaning success (survival > 24 hours after VA-ECMO explant and no death from cardiogenic shock, heart failure, or cardiac arrest during the hospital stay) and survival were evaluated. Of 85 patients included, 61% had successful weaning. Parameters significantly related to weaning success were higher left ventricular ejection fraction (LVEF; 40% in patients with weaning success vs 30% in patients with weaning failure, P = .01), left ventricular outflow tract velocity time integral (15 cm vs 11 cm, P = .01), aortic valve opening in every cycle (98% vs 91% of patients, P = .01), and normal qualitative right ventricular function (60% vs 42% of patients, P = .02). The LVEF remained as an independent predictor of weaning success (hazard ratio, 0.938; 95% CI, 0.888-0.991; P = .02). An LVEF >33.4% was the optimal cutoff value to discriminate patients with successful weaning (area under the curve, 0.808; sensitivity, 93%; specificity, 72%) and was related to higher survival at discharge (60% vs 20%, P < .001). Among weaning trial echocardiographic parameters, LVEF was the only independent predictor of successful VA-ECMO weaning. An LVEF >33.4% was the optimal cutoff value to discriminate patients with successful weaning and was related to final survival.

Two Birds, One Stone: Awake Extracorporeal Life Support.

Case A 55 year old female, no previous medical history, underwent out-of-hospital cardiac arrest. Advanced cardiac life support (ACLS) was initiated, with return of spontaneous circulation after 30’ of conventional resuscitation efforts. At first hospital arrival coronary angiography and successful percutaneous transluminal angioplasty were performed to treat right coronary artery stenosis. Incidentally, lung computed tomography (CT) revealed signs of aspiration pneumonia (Figure 1). Moreover, as a result of improper out-of-hospital endotracheal tube (ETT) positioning (ID 7.5/OD 10.7 mm) during ACLS, the patient suffered iatrogenic airway injury, as confirmed by bronchoscopy (12 x 19 mm respectively sagittal and longitudinal axis, Figures 1 and 2).Figure 1.: Tracheal injury (white arrow) and aspiration pneumonia at CT scan performed at hospital admission: distal end of the endotracheal tube in the main right bronchus (white arrow); retrocarinal pneumomediastinum (black arrow); evidence of basal consolidation in the left lung. CT, computed tomography.Figure 2.: Evolution of tracheal injury (white arrows) at fiberoptic bronchoscopy. A: day 1 large tear in the pars membranacea (posterior wall) of the trachea, extended to the emergence of the main right bronchus (white arrow), with hyperemic peripheral area; (B) day 7: partial re-epithelialization of the posterior wall, and decreased mucosal hyperemia; (C) day 24 evidence of resolution of the injury, with a residual linear scar. ECMO, extracorporeal membrane oxygenation; LMB, left main bronchus; RMB, right main bronchus.Pneumonia worsened rapidly to acute respiratory distress syndrome (ARDS) over subsequent days, and the presence of tracheal injury complicated mechanical ventilation management, so femoro-femoral veno-venous extracorporeal membrane oxygenation (V-V ECMO) was initiated in referring hospital (details in online supplement, Supplemental Digital Content 1, https://links.lww.com/ASAIO/A876). After cannulation the patient was transferred to referral center. For the first 2 days deep sedation and neuromuscular blockade were deemed necessary to provide lung protective ventilation (settings detailed in online supplement, Supplemental Digital Content 1, https://links.lww.com/ASAIO/A876). Due to the location of the distal end of the ETT cuff tube, the intracuff pressure was strictly monitored and maintained at 20 mm Hg. On minimal ECMO support gas exchange rapidly improved. To improve tracheal tear healing the patient was extubated on third day of ECMO, and high flow nasal oxygen (HFNO) initiated. After 8 days successful weaning trial was attempted, and decannulation performed. Follow up CTs demonstrated progressive resolution of lung disease and airway injury, with reabsorption of pneumodediastinum. Since ECMO weaning the patient remained eupneic; she was discharged home with almost complete lung recovery and intact tracheal wall (evolution of injury and clinical course are depicted in supplementary figures 1 and 2, Supplemental Digital Content 1, https://links.lww.com/ASAIO/A876). Full neurologic recovery was achieved, with no signs of physical impairment.

WHEN FLU LEADS THE WAY: A CASE OF PARVIMONAS MICRA POLYMICROBIAL EMPYEMA IN A PATIENT WITH INFLUENZA A INFECTION

WHEN FLU LEADS THE WAY: A CASE OF PARVIMONAS MICRA POLYMICROBIAL EMPYEMA IN A PATIENT WITH INFLUENZA A INFECTION

EFFECT OF MODAFINIL ON TIME TO WEAN FROM MECHANICAL VENTILATION

SESSION TITLE: Late Breaking Posters in Critical CareSESSION TYPE: Original Investigation PostersPRESENTED ON: 10/18/2022 01:30 pm - 02:30 pmPURPOSE: Modafinil is a wake promoting agent commonly used in sleep disorders. Sedation during mechanical ventilation in the ICU disrupts circadian rhythms and results in sleep disturbances and delirium. Wakefulness and ability to follow commands is a key component of successful extubation. This study evaluates the effect of modafinil on time to wean from mechanical intubation.METHODS: This study was a retrospective study conducted at a single urban center. Chart review was performed on 511 patients. Exclusion criteria included patients who expired, were transferred to hospice for terminal extubation or those who required tracheostomy (n=256). Sub-group analysis was done on patients intubated at least 5 days prior to initiation of weaning trials (n=81). Data was analyzed with medcalc statistical software.RESULTS: Patients who were treated with Modafinil had an overall longer time to wean from the ventilator as compared to patients who were not treated with Modafinil. Further evaluation showed patients who received Modafinil were intubated at least 5 days or more prior to initiation of the weaning process. Sub-group analysis of these patients intubated at least 5 days or more showed a decrease in mean time to wean from ventilation by 1 day (4 days with Modafinil and 5 days without Modafinil) with findings not statistically significant (p=0.673).CONCLUSIONS: Although our study showed reduction in mean number of days to wean from ventilation with Modafinil, these results were not statistically significant due to reduction in the power of the study after further exclusion of patients intubated less than 5 days during sub-group analysis. Future studies should involve a higher number of patients for increased power and assess other variables such as dosage effect of Modafinil, RASS score, GCS score, presence of other sedating medications, and reason for failure of pressure support trial.CLINICAL IMPLICATIONS: This research may serve as the basis for future studies regarding the effect of Modafinil on time to wean from ventilation. Implications include potentially decreasing time to wean from the ventilator and may serve as a strategy to decrease total time of intubation in patients by promoting wakefullness and restoring circadian rhythms. Decreasing time of intubation is beneficial to shorten ICU stay and minimize risks associated with prolonged mechanical ventilation.DISCLOSURES:No relevant relationships by AdeYinka AdeniyiNo relevant relationships by Chelsae Keeney SESSION TITLE: Late Breaking Posters in Critical Care SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/18/2022 01:30 pm - 02:30 pm PURPOSE: Modafinil is a wake promoting agent commonly used in sleep disorders. Sedation during mechanical ventilation in the ICU disrupts circadian rhythms and results in sleep disturbances and delirium. Wakefulness and ability to follow commands is a key component of successful extubation. This study evaluates the effect of modafinil on time to wean from mechanical intubation. METHODS: This study was a retrospective study conducted at a single urban center. Chart review was performed on 511 patients. Exclusion criteria included patients who expired, were transferred to hospice for terminal extubation or those who required tracheostomy (n=256). Sub-group analysis was done on patients intubated at least 5 days prior to initiation of weaning trials (n=81). Data was analyzed with medcalc statistical software. RESULTS: Patients who were treated with Modafinil had an overall longer time to wean from the ventilator as compared to patients who were not treated with Modafinil. Further evaluation showed patients who received Modafinil were intubated at least 5 days or more prior to initiation of the weaning process. Sub-group analysis of these patients intubated at least 5 days or more showed a decrease in mean time to wean from ventilation by 1 day (4 days with Modafinil and 5 days without Modafinil) with findings not statistically significant (p=0.673). CONCLUSIONS: Although our study showed reduction in mean number of days to wean from ventilation with Modafinil, these results were not statistically significant due to reduction in the power of the study after further exclusion of patients intubated less than 5 days during sub-group analysis. Future studies should involve a higher number of patients for increased power and assess other variables such as dosage effect of Modafinil, RASS score, GCS score, presence of other sedating medications, and reason for failure of pressure support trial. CLINICAL IMPLICATIONS: This research may serve as the basis for future studies regarding the effect of Modafinil on time to wean from ventilation. Implications include potentially decreasing time to wean from the ventilator and may serve as a strategy to decrease total time of intubation in patients by promoting wakefullness and restoring circadian rhythms. Decreasing time of intubation is beneficial to shorten ICU stay and minimize risks associated with prolonged mechanical ventilation. DISCLOSURES: No relevant relationships by AdeYinka Adeniyi No relevant relationships by Chelsae Keeney

A Prospective Comparative study between the Tobin Index and Integrative Weaning Index to predict the outcome of trials of weaning from mechanical ventilation

Weaning indices that are simple to derive and apply have been developed for predicting the likeliness of a patient to tolerate weaning. This study compared the Tobin Index and Integrative Weaning Index (IWI) to determine the better predictor for a successful weaning. This was a prospective observational study done on 60 patients on mechanical ventilation meeting the defined criteria whose physicians considered clinically stable to be given a weaning trial. Pre-determined threshold values of the Tobin index and IWI for determining a successful or unsuccessful weaning were used. A daily assessment was made with calculation of the Tobin index in GroupTI for extubation when Tobin Index≤105 breaths/min/L and IWI in GroupIWI when IWI&gt;25 ml/min/cm H2O, with each group having 30 patients. A spontaneous breathing trial of 2 hours was given. The variables compared between the two groups were the outcome of weaning, duration of mechanical ventilation, ICU stay and hospital stay in days, and mortality. Comparison was done using Chi square test / Fisher’s exact test and Mann Whitney test. There was no significant comparison in terms of weaning success or failure, durations of mechanical ventilation, hospital stay and mortality. The duration of ICU stay was less and of statistical significance in the IWI group. However, the percentage of successful weanings while using the indices, both considered separately, was higher than the failures. Both the predictive indices studied did not successfully predict weaning outcomes in all the cases thus limiting their use in clinical practice. Key words: successful weaning, mechanical ventilation, weaning predictors, Tobin index, integrated weaning index

Using the TIDieR checklist to describe the intervention of the Sedation and Weaning in Children (SANDWICH) trial.

Published reports of complex interventions in randomized controlled trials often lack sufficient detail to allow trial replication and adoption into practice. The aim of this paper is to describe our experience of using the Template for Intervention Description and Replication (TIDieR) checklist in reporting a recent trial of sedation and ventilation weaning in critically ill children (the Sedation and Weaning in Children [SANDWICH] trial). The TIDieR 12-point checklist has been used to detail and describe the specific SANDWICH trial intervention and methods of implementation. Overall, we found the checklist a useful tool to direct and ensure consistency of reporting of our complex intervention used in a multi-centre clinical trial. We experienced some minor limitations in classifying training materials and delivery mode into one item because of the overlapping nature of this component. Using the TIDieR checklist to report complex interventions tested in trials provides a structured, systematic way of describing necessary detail. This allows clinicians to understand the theory behind the intervention, how it should be delivered, and the resources required. The SANDWICH intervention had a significant beneficial effect on reducing time on ventilation for children. The detailed description of the team-based intervention will aid replication, implementation and monitoring of fidelity in other paediatric intensive care units.

Prediction of weaning readiness off nasal CPAP in preterm infants using point-of-care lung ultrasound.

This study's primary aim was to assess whether end-expiratory lung ultrasound severity score(expLUSsc) at Day 3 of life, the second week of life, and before weaning off nasal continuous positive airway pressure (nCPAP) can predict the weaning readiness off nCPAP trial in preterm infants. The secondary aim was to evaluate the value of adding lung tidal recruitment(LTR) to expLUSsc (expLUSsc-plus-LTR) to improve predictability. We conducted a prospective study on premature infants <33 weeks of gestation. Point-of-care lung ultrasound(POC-LUS) was performed on Day 3, the second week of life, before and after the trial off nCPAP. expLUSsc, pleural thickness, and LTR were assessed. A receiver operator curve was constructed to evaluate the ability of POC-LUS to predict the weaning readiness off nCPAP. A total of 148 studies were performed on 39 infants, of them 12 weaned off nCPAP from the first trialand 27 infants failed attempts off nCPAP. An expLUSsc cut-off 8 before the first trial of weaning off nCPAP has a sensitivity and specificity of 88% and 90%, and positive and negative predictive values of 87% and 92%, respectively, with area under the curve (AUC) was 0.87 (CI: 0.8-0.93), p < .0001. If LTR is added to an expLUSsc cut-off 8 (expLUSsc-plus-LTR) before the first trial of weaning, then sensitivity and specificity of 95% and 90%, and positive and negative predictive values of 88% and 90%, respectively, with AUC was 0.95 (CI: 0.91-0.99), p < .0001. In conclusion, this study demonstrated the ability of POC-LUS to predict the weaning readiness off nCPAP in premature infants. The use of this simple bedside noninvasive test can potentially avoid the exposure of premature infants to multiple unsuccessful weaning cycles.

End-Tidal to Arterial Pco2 Ratio as Guide to Weaning from Venovenous Extracorporeal Membrane Oxygenation.

Rationale: Weaning from venovenous extracorporeal membrane oxygenation (VV-ECMO) is based on oxygenation and not on carbon dioxide elimination. Objectives: To predict readiness to wean from VV-ECMO. Methods: In this multicenter study of mechanically ventilated adults with severe acute respiratory distress syndrome receiving VV-ECMO, we investigated a variable based on CO2 elimination. The study included a prospective interventional study of a physiological cohort (n = 26) and a retrospective clinical cohort (n = 638). Measurements and Main Results: Weaning failure in the clinical and physiological cohorts were 37% and 42%, respectively. The main cause of failure in the physiological cohort was high inspiratory effort or respiratory rate. All patients exhaled similar amounts of CO2, but in patients who failed the weaning trial, [Formula: see text]e was higher to maintain the PaCO2 unchanged. The effort to eliminate one unit-volume of CO2, was double in patients who failed (68.9 [42.4-123] vs. 39 [20.1-57] cm H2O/[L/min]; P = 0.007), owing to the higher physiological Vd (68 [58.73] % vs. 54 [41.64] %; P = 0.012). End-tidal partial carbon dioxide pressure (PetCO2)/PaCO2 ratio was a clinical variable strongly associated with weaning outcome at baseline, with area under the receiver operating characteristic curve of 0.87 (95% confidence interval [CI], 0.71-1). Similarly, the PetCO2/PaCO2 ratio was associated with weaning outcome in the clinical cohort both before the weaning trial (odds ratio, 4.14; 95% CI, 1.32-12.2; P = 0.015) and at a sweep gas flow of zero (odds ratio, 13.1; 95% CI, 4-44.4; P < 0.001). Conclusions: The primary reason for weaning failure from VV-ECMO is high effort to eliminate CO2. A higher PetCO2/PaCO2 ratio was associated with greater likelihood of weaning from VV-ECMO.

Old and new echocardiographic parameters to predict successful VA ECMO weaning

Abstract Funding Acknowledgements Type of funding sources: Other. Main funding source(s): ESC Research Grant 2018, App000021138. Introduction Venoarterial extracorporeal membrane oxygenation (VA ECMO) is a type of temporary mechanical circulatory support (MCS) for acute cardiovascular failure. The population of VA ECMO patients is characterised by high mortality rates. No protocol for weaning from VA ECMO has been validated worldwide. The decision to wean a patient from VA ECMO is challenging because it is necessary to understand whether the patient can tolerate VA ECMO removal, but it is also important to avoid any delay to avoid complications. Purpose the aim of this pilot study was to assess whether strain by speckle tracking could give additional information to haemodynamic, and conventional echocardiographic parameters in identifying patients who develop adverse outcomes within 3 (± 1) months from VA ECMO removal. Methods observational prospective pilot study delivered over 3 years in 2 ECMO centres. The VA ECMO patients who underwent VA ECMO removal (not for palliation) after a weaning trial have been recruited and followed up. Conventional echocardiographic, haemodynamic and strain parameters (recorded during the VA ECMO weaning trial) of patients developing a composite clinical outcome (ClO) within 3 (± 1) months post VA ECMO removal (death for any reason, new necessity of high dose of ino-vasopressors or MCS after VA ECMO removal, new hospitalisation for heart failure) have been compared with those of patients free from ClO. A sub-analysis on composite cardiac outcome (CaO) development and an exploratory ROC analysis have been performed. Results Over 3 years of recruitment, 92 VA ECMO patients have been screened. 21 patients met the eligibility criteria for the study and 19 patients could be analysed. 5 patients experienced ClO (3 had CaO, 2 were complicated by septic shock necessiting high dose of ino-vasopressors). As reported in Figure 1, there were no differences between ClO+ and ClO– patients apart from indexed end diastolic volume (iEDV). iEDV was significantly lower in ClO– patients compared to the others (respectively 44.7 ml m-2 IQR 17.9; 70.4 ml m-2 IQR 43.0, p &amp;lt; 0.01). Focusing on CaO development, the median iEDV remained significantly higher in CaO+ (112.5 ml min-1m-2 IQR 47.1; p = 0.01). Furthermore, the median circumferential strain (absolute value) and the ejection fraction (EF) were significantly lower in CaO+ (Figure 2). At the ROC analysis, the best cut point to discriminate ClO+ and ClO- patients was: for EF 26.32% (AUC 0.79), for cardiac index 2.5ml min-1 m-2 (AUC 0.71) and for right ventricle (RV) free wall longitudinal strain -12.0%. (AUC 0.75). Conclusions VA ECMO weaning procedure is complex and requires the assessment of multiple variables. According to our analysis, large iEDV and low EF predispose to the development of CaO. Furthermore, low absolute values of circumferential strain and RV free wall longitudinal strain may be indicative of development of CaO and ClO respectively. The study is limited by the small number of events.

Weaning success among COPD patients following ventilator care bundle application

Objective: Several studies evaluated the effectiveness of the ventilator care bundle in reducing the occurrence of ventilatorassociated pneumonia. The ventilator care bundle efficacy in early mechanical ventilation weaning has not been adequately assessed. The study aimed to investigate the weaning success among chronic obstructive pulmonary disease (COPD) patients following ventilator care bundle application.Methods: This study is quasi-experimental, recruiting 80 mechanically ventilated COPD patients (40 patients for each bundle and control group). It was conducted at the respiratory intensive care units (ICUs) at Mansoura University Hospital, Egypt. Data were collected using a mechanically ventilated patient (MVP) assessment tool, a ventilator care bundle compliance checklist, and MVP evaluation tools based on the Burns’ Wean Assessment Program (BWAP) checklist and the patient’s ventilation indicators.Results: The results revealed that almost 75% of the bundle group was successfully weaned from invasive mechanical ventilation at the first attempt of the spontaneous breathing trial compared with 32.5% of the control group. The ventilation duration and length of ICU stay were reduced in the bundle compared with the control group.Conclusions: The bundle group demonstrated higher weaning scores than the control group. Therefore, we recommend the integration of the ventilator care bundle in the weaning trial of MVPs to accelerate weaning and reduce the duration of mechanical ventilation.

Novel Use of Catheter Mount as an Alternative to T-piece.

ABSTRACTCatheter mounts with swivel connectors are used to attach the endotracheal tube to the ventilator circuit, dampening jerks and drags and increasing patient comfort. We suggest a unique application of catheter mount as T-piece for weaning, eliminating the need for a single inventory purchase and repurposing a previously used item for a new use, lowering the financial burden on patients. In our ICU, catheter mounts are being used as an alternative to T-piece for 30-minute weaning trials following successful SBT trials to evaluate patients’ response to Zero PEEP (ZEEP) and therefore the probable occurrence of alveolar derecruitment to decrease extubation failure.How to cite this articleAnand A, Panda R, Kodamanchili S, Saigal S, Gowthaman TB, Bhardwaj K. Novel Use of Catheter Mount as an Alternative to T-piece. Indian J Crit Care Med 2022;26(2):246–247.

Extubation Failure Prediction by Echography of the Diaphragm After Cardiothoracic Surgery: The EXPEDIA Study.

Successful extubation is difficult to predict. Ultrasound measurement of the diaphragm thickening fraction (DTF) might help predict weaning failure after cardiothoracic surgery. We assessed the predictive performance of diaphragm ultrasound in a derivation cohort of 50 prospectively included cardiothoracic surgery subjects ready for a weaning trial and in a validation cohort of 39 subjects ventilated for ≥ 48 h. DTF was assessed by ultrasound during pressure support ventilation (PSV) then during a T-piece spontaneous breathing trial (SBT). DTF was the percentage change in diaphragm thickness between expiration and inspiration and DTFmax, the higher DTF value of the 2 hemidiaphragms. DTFmax during SBT (static study) and the difference in DTFmax between PSV and SBT (dynamic study) were analyzed. In the derivation cohort, DTFmax during SBT was 25.6 ± 17.3% in subjects with successful extubation and 65.2 ± 17.3% in those with weaning failure (difference 39.7 [95% CI 27.4-51.9], P < .01). During SBT, DTFmax ≥ 50% was associated with weaning failure (area under the receiver operating characteristic curve [AUC] 0.94 ± 0.05). In the dynamic study, a ≥ 40% DTFmax increase was associated with weaning failure (AUC 0.91 ± 0.06). In the validation cohort, DTFmax during SBT was 20.3 ± 17.1% in subjects with successful extubation and 82.0 ± 51.6% in those with weaning failure (difference 61.8 [95% CI 41.6-82.0], P < .01). During SBT, DTFmax ≥ 50% predicted weaning failure (AUC 0.99 ± 0.02). In the dynamic study, a ≥ 40% increase in DTFmax predicted weaning failure (AUC 0.81 ± 0.09). Measuring DTFmax during SBT and the DTFmax change when switching from PSV to SBT may help predict weaning failure after cardiothoracic surgery. The study was registered on ANZCTR. U1111-1180-1999.

Handgrip strength to predict extubation outcome: a prospective multicenter trial

BackgroundICU-acquired weakness (ICUAW) has been shown to be associated with prolonged duration of mechanical ventilation and extubation failure. It is usually assessed through Medical Research Council (MRC) score, a time-consuming score performed by physiotherapists. Handgrip strength (HG) can be monitored very easily at the bedside. It has been shown to be a reproducible and reliable marker of global muscular strength in critical care patients. We sought to test if muscular weakness, as assessed by handgrip strength, was associated with extubation outcome.MethodsProspective multicenter trial over an 18 months period in six mixed ICUs. Adults receiving mechanical ventilation for at least 48 h were eligible. Just before weaning trial, HG, Maximal Inspiratory Pressure (MIP), Peak Cough Expiratory Flow (PCEF) and Medical Research Council (MRC) score were registered. The attending physicians were unaware of the tests results and weaning procedures were conducted according to guidelines. Occurrence of unscheduled reintubation, non-invasive ventilation (NIV) or high-flow nasal continuous oxygen (HFNC) because of respiratory failure within 7 days after extubation defined extubation failure. The main outcome was the link between HG and extubation outcome.Results233 patients were included. Extubation failure occurred in 51 (22.5%) patients, 39 (17.2%) required reintubation. Handgrip strength was 12 [6–20] kg and 12 [8–20] kg, respectively, in extubation success and failure (p = 0.85). There was no association between extubation outcome and MRC score, MIP or PCEF. Handgrip strength was well correlated with MRC score (r = 0.718, p < 0.0001). ICU and hospital length of stay were significantly higher in the subset of patients harboring muscular weakness as defined by handgrip performed at the first weaning trial (respectively, 15 [10–25] days vs. 11 [7–17] days, p = 0.001 and 34 [19–66] days vs. 22 [15–43] days, p = 0.002).ConclusionNo association was found between handgrip strength and extubation outcome. Whether this was explained by the appropriateness of the tool in this specific setting, or by the precise impact of ICUAW on extubation outcome deserves to be further evaluated.Trial registration Clinical Trials; NCT02946502, 10/27/2016, URL: https://clinicaltrials.gov/ct2/results?cond=&term=gripwean&cntry=&state=&city=&dist=

Role of Capnograghy during weaning from mechanical ventilation in patients with chronic obstructive pulmonary disease

Abstract Background Chronic obstructive pulmonary disease (COPD) is characterized by persistent airflow limitation associated with an enhanced chronic inflammatory response in the airway, acute exacerbations of COPD can lead to progressive respiratory failure necessitating mechanical ventilation. Weaning of these patients may prove difficult and a spontaneous breath trial should be provided before the decision of extubation. Aim To evaluate the role of capnograghy in COPD patients during weaning from mechanical ventilation. Subject and methods This was a cross sectional prospective study conducted on 50 patients who were admitted at the Respiratory Intensive Care Unit of Abbassia Chest hospital and diagnosed as COPD and on mechanical ventilation. During the weaning trial, the role of capnography device evaluated considering the ability of Pet CO2 parameter in predicting hypercapnia and subsequently weaning outcome Results The changes in ABG reading before and after the SBT, PaCO2 and Pet CO2 showed significant elevation at the end of SBT,P=0.001 for both, while O2 saturation was significantly decrease at the end of SBT, P0.001. Conclusion The study found that Pa CO2 and PetCO2 are correlated to each other before, during and after SBT. Most of the studies that was found reported that PetCO2 is highly correlated with Paco2 and that PetCO2 may be a rapid and reliable predictor of arterial PaCO2 in respiratory distress.

Lung Ultrasonography as Tool for Follow Up of Ventilated Neonates for Prediction of Weaning Readiness

Abstract Background Timing is crucial when deciding if a patient can be successfully extubated. Both premature discontinuation and unnecessary delay of mechanical ventilation weaning have been associated with poor outcome. There are no enough guidelines for the assessment of readiness of newborns for extubation. The degree of lung aeration loss in different clinical conditions can be quantified via lung ultrasound (LUS). Objectives To evaluate the lung ultrasound score as a follow up tool in ventilated neonates and its validity as predictor of extubation. Subjects and Methods Prospective study done on 39 mechanically ventilated neonates 27-42 weeks’ gestation. Lung ultrasound was done daily for each patient till the day of weaning and lung ultrasound (LUS) score was calculated. Patients were divided into 2 groups according to trial of weaning; Success “S” group: in which weaning succeeded and Failure “F” group: in which weaning failed. Results The “F” group had significantly higher LUS score at time of intubation, pre- extubation and post-extubation compared with the “S” group (P- value= 0.002, 0.003 and 0.001 respectively). A cut off value of ≤ 10 for LUS score pre-extubation predict successful weaning with sensitivity 76% and specificity 64.3%. Conclusion LUS is an indicator for lung aeration and can be used as a tool to predict success of weaning of ventilated neonates.

A CASE OF DEXMEDETOMIDINE-INDUCED DRUG FEVER: AN IMPORTANT AND PRESS-EDEX-ING ISSUE

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Dexmedetomidine has revolutionized the field of critical care medicine, providing clinicians a short-acting, well-tolerated sedative. Cardiovascular adverse effects are well described with this agent (1). Less common adverse effects such as fever are increasingly being reported (2). Previous studies demonstrated no appreciable rate of dexmedetomidine-related fever (1, 3). Here we report a case of high-grade fever in the intensive care unit (ICU) after initiation of dexmedetomidine, with resolution after discontinuation. CASE PRESENTATION: A 34-year-old male with a past medical history of alcohol abuse and asthma was admitted to the general ward with Coronavirus disease 2019 (COVID-19) pneumonia. His course was complicated by severe hypoxia and subsequent pulseless electrical activity (PEA) arrest, requiring ICU transfer after achieving return of circulation and undergoing mechanical ventilation. On hospital day 7, after improvement in respiratory status with COVID-19 management including corticosteroids, as well as treatment with ceftriaxone and azithromycin given concern for superimposed bacterial pneumonia, he was transitioned to dexmedetomidine in preparation for a ventilator weaning trial. He developed fevers over the following 12 hours, initially to 39.4 C (102.9 F) prompting empiric sepsis management with intravenous fluids and broad-spectrum antibiotics (see figure-1). Despite this, he continued to have fevers to a maximum core temperature of 41.1 C (106 F). Blood, fungal, and respiratory cultures were unremarkable. With no clear infectious source or alternative explanation for severe hyperthermia, the decision was made to wean off dexmedetomidine given suspicion for drug-induced fever, upon which core temperature returned to 37.8 C (100.1 F). He remained afebrile, and eventually extubated and discharged in stable condition. DISCUSSION: We present a case of severe hyperthermia corresponding to, with a probable association using the Naranjo Adverse Drug Reaction Probability Scale, dexmedetomidine initiation, followed by resolution of fever after discontinuation. Antimicrobial therapy had no observable effect on the fever, and extensive infectious work-up was unremarkable. Completely attributing a febrile episode in the ICU setting to a medication is a difficult task. Furthermore, adequately powering studies to identify rare medication adverse effects in the ICU is a challenge, which may explain the absence of fever as a documented adverse effect of dexmedetomidine (1,2,4). In this case, no alternate diagnoses were evident, thus management was focused on discontinuing the presumed inciting agent. CONCLUSIONS: Recognizing dexmedetomidine as an etiology of severe hyperthermia in the ICU may help mitigate excessive therapies and improve outcomes. Further research is warranted to describe risk factors and proper recognition for when fevers occur with dexmedetomidine. REFERENCE #1: Hospira (2014) Precedex® (dexmedetomidine hydrochloride) [package insert]. Lake Forest, IL: Hospira, Inc. REFERENCE #2: Peterson J, Thomas W, Michaud C, et al. Incidence of Fever Associated With Dexmedetomidine in the Adult Intensive Care Unit. J Pharm Pract. 2021 Apr 5:8971900211004828. REFERENCE #3: Jakob SM, Ruokonen E, Grounds RM, et al. Dexmedetomidine for Long-Term Sedation Investigators. JAMA. 2012 Mar 21;307(11):1151-60. DISCLOSURES: No relevant relationships by Raef Fadel, source=Web Response No relevant relationships by Sara Hegab, source=Web Response No relevant relationships by Michael Reaume, source=Web Response No relevant relationships by Zachary Smith, source=Web Response