Weaning Trial Research Articles

Outcomes of Weaning Trial from Veno-Arterial Extracorporeal Membrane Oxygenation Using Inflow-Outflow Bridging

Purpose The use of veno-arterial extracorporeal membrane oxygenation (ECMO) for cardiogenic shock support is increasing. Because the recovery period differs from patient to patient, a standard protocol for the timing and strategy of ECMO weaning-off is not well established. Inadequate length of ECMO support can critically affect a patient's outcome, so the evaluation of proper ECMO weaning-off is warranted. A longer weaning trial is preferred to rule out delayed cardiogenic shock, however a long low-flow ECMO wean presents the risk of ECMO thrombosis . At our center, an inflow-outflow bridging technique is aggressively used to evaluate hemodynamics and respiratory status while weaning patients off of ECMO. It allows us to simulate an off-ECMO status for an extended period of time, but is reversible and does not require ECMO discontinuation. Here, we analyzed the outcomes of our inflow-outflow bridging technique for ECMO weaning. Methods This is a single-center retrospective study of patients on veno-arterial ECMO from May 2016 to August 2018. 14 patients on whom we used the inflow-outflow bridging technique were analyzed. The pre-ECMO demographics, ECMO weaning success vs. abortion rates, post-ECMO survival to discharge and complications were analyzed. Figure 1 displays the technique. The outflow cannula is clamped, and then intermittently un-clamped to flash the cannula under proper anticoagulation . Results 14 weaning trials were performed on 14 patients. 12 patients had ECMO weaning-off and decannulation (85.7%). 2 patients underwent a weaning trial, but were deemed unsuitable for ECMO discontinuation (14.3%). 0 patients had stroke/distal embolism or bleeding complications due to ECMO weaning trial. Successful wean sensitivity was 100.0%. Conclusion Our ECMO weaning-off trial highlighted satisfactory rates of screening for ECMO wean. Further larger research will help to clarify our weaning sensitivity and develop an adequate protocol.

Tremendous Increase of Home Care in Ventilated and Tracheostomized Patients - Reasons, Consequences, Solutions

Seit 2005 gibt es in Deutschland eine deutliche Steigerung der invasiven häuslichen Langzeitbeatmung von ca. 1000 auf mittlerweile ca.20 000 Patienten. Die häusliche Krankenpflege ist aufwendig und teuer: ca. 4 Mrd. Euro jährlich zahlt die Solidargemeinschaft dafür. Zudem werden in den letzten 2 – 3 Jahren auch zunehmend tracheotomierte Patienten (meist nach Apoplex) ohne Beatmung nach Hause entlassen.

Tremendous Increase of Home Care in Ventilated andTracheostomized Patients - Reasons, Consequences, Solutions

Since 2005, invasive long-term ventilation in Germany has increased significantly from around 1000 to 20 000 patients in Germany. Due to complex home care, the health care system incurs additional costs of around 4 billion euros per year. In addition, in the last 2 - 3 years more tracheostomized patients have been discharged home without ventilation (usually after stroke), and they receive the same complex home care. These patients have almost never been given the chance of a professional weaning trial by a weaning center. They are discharged from hospitals directly into the care. As a result, the quality of care is significantly worse than traditional care with structured discharge management via a weaning center. The solutions are difficult to find due to the interface problems between inpatient and outpatient care and the different organizational structures with different delivery systems. Possible solutions are shown, but most of them require a change in the law.

Prospective Observational Study on Evaluation of Cardiac Dysfunction Induced during the Weaning Process.

ABSTRACTContextWeaning induced cardiac dysfunction can occur without underlying heart disease. Changes in intrathoracic pressure, systemic vascular resistance, preload and afterload leading to heart-lung interactions are the possible explanatory mechanismsAimsThe aim of the current study was whether the assessment and identification of cardiac dysfunction induced during the weaning process could predict the outcome of extubation.Settings and designA prospective observational study with convenience sampling method was conducted from May 2015 to April 2016 after institutional ethical committee approval (ref 161/2015).Materials and methodsPatients over eighteen and planned for extubation were included. Weaning method used was a spontaneous breathing trial (SBT) by pressure support-positive end-expiratory pressure (PS-PEEP). Baseline characteristics, weaning, and echocardiography parameters were collected pre extubation. Post-extubation echocardiographic parameters were collected within six hours as per the protocol. The primary outcome was extubation failure (reintubation within 48 hours). Secondary outcomes were ICU length of stay and ICU mortality.Statistical analysisStatistical method used is STATA™ (Version14, College Station TX).ResultsOut of one hundred and sixty-one patients, twenty-one failed extubation (13.04 %). Pre-extubation echocardiographic parameters were similar in two groups except for preexisting LV systolic dysfunction. Post-extubation E/e` (9.30 vs. 7.71 p = 0.018) was higher in the extubation failure group. Extubation failure group had higher intensive care unit (ICU) length of stay and ICU mortality.ConclusionIn our study E/e` during a weaning trial did not predict extubation success. Cardiac dysfunction induced during weaning may get masked during weaning and manifests postextubation. This needs to be verified in subsequent studies.Key messagesCardiac dysfunction induced during the weaning process may get masked and manifests post-extubation. Echocardiographic assessment during the weaning process and post-extubation helps to evaluate and identify the patients at risk of reintubation.How to cite this articleAmarja H, Bhuvana K, Sriram S. Prospective Observational Study on Evaluation of Cardiac Dysfunction Induced during the Weaning Process. Indian Journal of Critical Care Medicine, January 2019;23(1):15-19.

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.

Duration of sweep gas off trial for weaning from venovenous extracorporeal membrane oxygenation.

Background:No data are available on the duration of time needed to assess the adequacy of lung function after stopping sweep gas for weaning of venovenous extracorporeal membrane oxygenation (ECMO). The objective of this study was to investigate changes in arterial blood gases (ABGs) during sweep gas off trials in patients receiving venovenous ECMO.Methods:Data on patients receiving venovenous ECMO, with a weaning trial at least once, were collected prospectively from January 2012 through December 2017. Serial changes in ABGs during sweep gas off trial and clinical outcomes after weaning from venovenous ECMO were evaluated.Results:Over the study period, 192 sweep gas off trials occurred in 93 patients: 115 (60%) failed and 77 (40%) were successful. During the trial, significant changes in blood gases were observed within 1 h in all patients. When serial ABGs were compared according to trial off results, there were no significant differences in the pH, PaCO2, and HCO3− trends across time points between successful and failed trials. However, PaO2 (70.6 versus 93.4 mmHg), SaO2 (91.9 versus 95.2%), and PaO2/FiO2 ratio (164.0 versus 233.4) were significantly lower in failed trials than successful trials within 1 h after stopping sweep gas. After 2 h of trial off, no significant change in blood gases was observed until the end of the trial.Conclusions:No change in blood gases was observed 2 h after stopping sweep gas in patients receiving venovenous ECMO. Based on our institutional experience, however, we suggest monitoring for 2 h or more after stopping sweep gas flow to assess if patients are ready for decannulation. The reviews of this paper are available via the supplemental material section.

Role of assessment of the diaphragm by ultrasound during weaning from mechanical ventilation in patients with chronic obstructive pulmonary disease

Background Diaphragmatic rapid shallow breathing index (D-RSBI) is a new promising tool to predict weaning outcome. The D-RSBI is the ratio between respiratory rate (RR) and the ultrasonographic evaluation of diaphragmatic displacement (DD). Its accuracy in predicting weaning failure, in ready-to-wean mechanically ventilated (MV) patients with chronic obstructive pulmonary disease (COPD), needs to be evaluated. Aim To assess diaphragm using ultrasound during weaning from MV in patients with COPD and to compare the new D-RSBI with traditional RSBI. Patients and methods A prospective observational study was carried out on MV patients with COPD who were ready to wean. During spontaneous breathing trial, evaluation of the right hemi-DD and diaphragmatic thickness by using M-mode ultrasonography was done. Then calculation of D-RSBI (RR/DD), and RSBI (RR/tidal volume) was carried out simultaneously. Outcomes of the weaning trials were recorded. Receiver operating characteristic curves were used to evaluate the diagnostic accuracy of D-RSBI and RSBI. Results A total of 104 patients with acute exacerbation COPD who were ready to perform an spontaneous breathing trial from MV were included. Overall, 86 (82.7%) were successfully liberated from MV, and 18 (17.3%) patients had failure of weaning. The sensitivity and specificity of DD were 72.2 and 93.0%, respectively. The sensitivity and specificity of RSBI were 77.8 and 70.9%, respectively. However, the sensitivity and specificity of D-RSBI were 83.3 and 90.7%, respectively. Conclusion D-RSBI (RR/DD) is superior than the traditional RSBI (RR/tidal volume) in predicting weaning outcome in patients with acute exacerbation COPD.

Taking the baby out of the box: moving closer to evidence-based incubator weaning

Caring for infants in incubators to support thermoregulation was one of the first evidence-based strategies to improve survival of preterm infants (Pediatrics 1958; 22:876-86). Although this has been known for more than 60 years, in the intervening years there has been little evidence to guide the weaning of infants out of the incubator and practices vary considerably between hospitals. In this volume of The Journal, Shankaran et al report the results of a randomized trial of incubator weaning at weights of 1600 vs 1800 grams in 366 infants from 17 centers across the United States. Weight at weaning was not associated with the duration of hospitalization from birth to discharge (the primary study outcome). Fewer infants were able to wean from the incubator on the first attempt at 1600 grams (92%) than at 1800 grams (98%), but adverse events were not increased with earlier weaning, and weight gain was minimally better in infants weaned at 1600 grams. This study should help to dispel the notion that weaning the incubator when an infant weighs <1800 grams leads to poor weight gain and also shows that earlier weaning does not lead to earlier discharge of low birth weight infants. The results provide useful safety information and lead to the next set of questions about whether there is an optimal weight for weaning that supports infant state regulation and optimal auditory experiences as well as parental bonding and satisfaction. Studies of these outcomes would be welcome and helpful to neonatologists, nurses, and parents. Article page 96 ▶ Weaning of Moderately Preterm Infants from the Incubator to the Crib: A Randomized Clinical TrialThe Journal of PediatricsVol. 204PreviewTo assess whether length of hospital stay is decreased among moderately preterm infants weaned from incubator to crib at a lower vs higher weight. Full-Text PDF

Tracheobronchomalacia: An Unreported Pulmonary Complication of Acute Pancreatitis

Acute Pancreatitis(AP) is a common disease with a reported annual incidence ranging between 4.9 to 35 per 100,000 population. Multiple respiratory complications have been reported in AP including Acute Respiratory Distress Syndrome (ARDS). Here we present, to the best of our knowledge, the first reported case of Tracheobronchomalacia as a respiratory complication of AP.2900 Figure 1. CT scan showing tracheal diameter of 0.24 cm on expiration (A) and tracheal diameter of 2.9 cm on inspiration (B).A 54-year-old white male with history of Diabetes Mellitus, peripheral vascular disease (PVD) and no history of pulmonary disease was admitted for elective right Below-Knee Amputation(BKA) secondary to his PVD. Internal Medicine were asked to evaluate the patient for acute necrotizing pancreatitis (ANP) of undetermined etiology complicating his post-operative course. The patient was treated per protocol with hydration, Meropenem and pain management. Within one week of ANP onset, patient developed rapid respiratory distress. He was found to be in acute type II hypercapnic respiratory failure with PaO2/FiO2 <200. Chest radiography and arterial blood gase did not support the diagnosis of ARDS. Computed tomography (CT) with angiography ruled out pulmonary embolism but showed significant narrowing of the trachea on expiration with tracheal diameter less than 0.27 cm. When compared to a previous CT scan done 3 months earlier for a pulmonary nodule follow up, trahceal diameter was 2.8 cm. Diagnosis was confirmed by performing a dynamic CT scan with drop in tracheal diameter from 2.9 cm on inspiration to 0.24 cm on expiration (Image 1). The patient's respiratory status continued to deteriorate requiring endotracheal intubation and mechanical ventilation with weaning trials proving to be futile. The patient eventually developed Fungemia and expired after the patient's family opted for palliative extubation. Airway collapse related to Tracheobronchomalacia is an under-recognized diagnosis which should be suspected in patients with AP who develop acute respiratory distress in whom no specific etiology has been determined.

The impact of heart, lung and diaphragmatic ultrasound on prediction of failed extubation from mechanical ventilation in critically ill patients: a prospective observational pilot study

BackgroundFailed extubation from mechanical ventilation in critically ill patients is multifactorial, complex and not well understood. We aimed to identify whether combined transthoracic echocardiography, lung and diaphragmatic ultrasound can predict extubation failure in critically ill patients.ResultsFifty-three participants who were intubated > 48 h and deemed by the treating intensivist ready for extubation underwent a 60-min pre-extubation weaning trial (pressure support ≤ 10 cmH2O and positive end expiratory pressure 5 cmH2O). Prior to extubation, data collected included ultrasound assessment of left ventricular ejection fraction, left atrial area, early diastolic trans-mitral flow velocity wave (E), early diastolic trans-mitral flow velocity wave/late diastolic trans-mitral flow velocity wave (E/A), early diastolic trans-mitral flow velocity wave/early diastolic mitral annulus velocity (E/E′), interatrial septal motion, lung loss of aeration score and diaphragm movement. At the end of the weaning trial, the rapid shallow breathing index and serum B-type natriuretic peptide concentration were measured. Success and failure of weaning was assessed by defined criteria. Decision to extubate was at the discretion of the treating intensivist. Failure of extubation was defined as re-intubation, non-invasive ventilation or death within 48 h after extubation. Of 53 extubated participants, 11 failed extubation. Failed extubation was associated with diabetes, ischaemic heart disease, higher E/E′ (OR 1.27, 95% CI 1.05–1.54), left atrial area (OR 1.14, CI 1.02–1.28), fixed rightward curvature of the interatrial septum (OR 12.95, CI 2.73–61.41), and higher loss of aeration score of anterior and lateral regions of the lungs (OR 1.41, CI 1.01–1.82).ConclusionsFailed extubation in mechanically ventilated patients is more prevalent if markers of left ventricular diastolic dysfunction and loss of lung aeration are present.

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

Dexmedetomidine facilitates extubation in children who require intubation and respiratory support after airway foreign body retrieval: a case-cohort analysis of 57 cases.

This study aimed to investigate whether dexmedetomidine had sedative weaning advantage for extubation after airway foreign body (FB) removal in children. A retrospective case-cohort comparison study with total of 57 critical children who required mechanical ventilation after rigid bronchoscopy was performed. After tracheal intubation, group D (received dexmedetomidine 1µg/kg over 10min, followed by an infusion of 0.8µg/kg/h), and group RP (received remifentanil-propofol 6-10µg/kg/h and 1-3mg/kg/h, respectively). The primary outcome was successful extubation rate on first weaning trial. The minor outcomes included weaning time, emergency agitation, coughing score and the incidence of respiratory adverse complications on emergency. All 57 patients were included in the analysis, with 30 patients in group D and 27 controlled cases in group RP. The success rate of first weaning trial in the D group was 96.7 vs 77.8% in the RP group, risk ratio (RR) 1.56, 95% CI [0.78-1.98]. Time for resuming spontaneous breathing after termination infusion was shorter in the D group (median 8min, IQR 15min) vs RP group (median 12min, IQR 19min, P = 0.02, RR 0.56, 95% CI 0.14-6.57). In mechanical ventilation of pediatric patients following rigid bronchoscopy, in comparison to remifentanil-propofol, dexmedetomidine is proved to have high success rate for weaning strategy. WHAT IS ALREADY KNOWN?: Remifentanil is proved to be effective for weaning in ICU patients. Dexmedetomedine can provide similar rates of smooth extubation for pediatric patients who underwent airway surgery. WHAT THIS ARTICLE ADDS?: Invasive ventilation is used for patients with severe comorbidity after airway surgery, but the correct strategy for pediatric extubation after removal of airway foreign body remains unclear. For these patients with short-term mechanical ventilation, dexmedetomedine may improve the extubation rate, when compared with remifentanil-propofol.

Successful Wean Despite Emergence of Ictal-Interictal EEG Patterns During the Weaning of Prolonged Burst-Suppression Therapy for Super-Refractory Status Epilepticus.

Management of refractory status epilepticus (SE) commonly involves the induction of burst suppression using intravenous anesthetic agents. However, the endpoints of these therapies are not well defined. Weaning anesthetic agents are complicated by the emergence of electroencephalogram (EEG) patterns along the ictal-interictal continuum (IIC), which have uncertain significance given that IIC patterns may worsen cerebral metabolism and oxygenation, have a dissociation between scalp and depth EEG recordings, or may indicate a late stage of SE itself. Determining the significance of IIC patterns in the unique context of anesthetic weaning is important to prevent the potential for unnecessarily prolonging anesthetic coma. Among 118 individuals with SE, we retrospectively identified a series of patients who underwent at least 24h of burst-suppression therapy, experienced two or more weaning trials, and developed IIC patterns during anesthetic weaning. Anesthetic titration strategies during the emergence of these patterns were examined. Each of the six individuals who met inclusion criteria experienced aggressive weaning despite the emergence of IIC patterns. The IIC patterns that were encountered during anesthetic weaning (including generalized and lateralized periodic discharges) are described in detail. Favorable outcomes were reported in each subject. IIC patterns encountered during anesthetic weaning may be transitional and warrant observation, allowing for the emergence of more definitive clinical or electrographic results. The metabolic impact of these IIC patterns on brain activity is uncertain, but weaning strategies that treat IIC as a surrogate of recurrent SE risk further prolonging anesthetic management and its known toxicity. We speculate that these patterns may have a context-specific association with SE relapse, with less-risk conferred when these patterns are observed during the weaning of anesthetic agents after prolonged burst-suppression therapy. Other electrographic features aside from this clinical context may discriminate the risk of SE relapse, such as EEG background activity.

Ultrasound-Guided Laryngeal Air Column Width Difference as a New Predictor for Postextubation Stridor in Children

To assess the efficacy of ultrasound-guided laryngeal air column width difference in predicting postextubation stridor in children. Prospective observational study. Single, tertiary care pediatric hospital. This study was carried out at PICU and surgical ICU, Tanta University Hospital on 400 ventilated children between January 2015 and May 2017. Patients who received mechanical ventilation and met criteria for a weaning trial were included. Laryngeal ultrasound and cuff leak test. Ultrasound-guided laryngeal air column width and cuff leak test were measured before extubation. Laryngeal air column width is the width of air between the vocal cords seen by laryngeal ultrasonography. Laryngeal air column width difference is the width difference of air column passed through vocal cords with the balloon cuff inflated and deflated. Three-hundred fifty six patients (89%) had no postextubation stridor, whereas 44 patients (11%) developed postextubation stridor. Postextubation stridor was associated with younger age, less weight, female gender, prolonged duration of intubation, and ICU stay (p < 0.05). Both laryngeal air column width difference and cuff leak test showed significant decrease (p < 0.05) in patients with postextubation stridor in comparison with no postextubation stridor patients. Receiver operating characteristics curve analysis showed that laryngeal air column width difference at cutoff point of less than 0.8 mm gave a sensitivity of 93%, specificity of 86%, and accuracy of 91%, whereas cuff leak test at less than 11% yielded a sensitivity of (61%), specificity of (53%), and accuracy of (59%) for predicting postextubation stridor. Laryngeal air column width difference measurement may serve as a simple reliable noninvasive method for predicting postextubation stridor in children.

Role of diaphragmatic rapid shallow breathing index in predicting weaning outcome in patients with acute exacerbation of COPD.

BackgroundThe diaphragmatic rapid shallow breathing index (D-RSBI), which is the ratio between respiratory rate (RR) and the ultrasonographic evaluation of diaphragmatic displacement (DD), is a new and promising tool to predict weaning outcome. Its accuracy in predicting weaning failure, in ready-to-wean acute exacerbation COPD (AECOPD) patients, needs to be evaluated.Patients and methodsA prospective observational study was carried out on ready-to-wean AECOPD patients. During a T-tube spontaneous breathing trial (SBT) evaluation of the right hemidiaphragm displacement (ie, DD), M-mode ultrasonography to calculate the D-RSBI, as well as the RSBI (RR/tidal volume [VT]) were carried out simultaneously. Outcome of the weaning trial was recorded. Receiver operating characteristic (ROC) curves were used to evaluate the diagnostic accuracy of D-RSBI and RSBI.ResultsA total of 50 AECOPD patients requiring mechanical ventilation for more than 48 h who were ready to perform a SBT were included. Of these, 37 (74%) were successfully liberated from mechanical ventilation. Among the 13 patients who failed the weaning trial, 8 (62%) failed the SBT and reconnected to the ventilator, 2 (15%) were reintubated within 48 h of extubation and 3 (23%) required NIV support within 48 h of extubation. The areas under the ROC curves for D-RSBI and RSBI were 0.97 (p<0.001) and 0.67 (p<0.06), respectively.ConclusionD-RSBI (RR/DD) is superior to the traditional RSBI (RR/VT) in predicting weaning outcome in AECOPD patients.

Neurophysiological study of critical illness polyneuropathy and myopathy in mechanically ventilated children; additional aspects in paediatric critical illness comorbidities.

Critical illness polyneuropathy and myopathy (CIP/CIM) is being increasingly recognized as a significant clinical problem in critically ill children especially if they have spent long periods in the intensive care unit. So the aim was to determine the frequency of CIP/CIM amongst mechanically ventilated children and to analyse the associated risk factors and drawbacks frequently encountered in this cohort. The study included 105 patients admitted to the paediatric intensive care unit who underwent mechanical ventilation for ≥7 days. These patients were screened daily for awakening. Patients with severe muscle weakness on day 7 post-awakening underwent nerve conduction studies and electromyography. Accordingly, the patients were classified as CIP/CIM patients if they had abnormal neurophysiology studies or control patients if normal neurophysiology studies were obtained. Their clinical and laboratory profiles had been recorded as well. Overall, of 105 patients who achieved satisfactory awakening, 34 patients (32.4%) developed CIP/CIM mostly of the axonal polyneuropathy pattern (27.6%) whilst 71 control patients (67.6%) showed normal electrophysiological studies. The mean duration of mechanical ventilation was significantly longer in patients with CIP/CIM compared to control patients (P = 0.001). The study also revealed that 62.1% of our CIP/CIM patients failed weaning trials and finally died. CIP/CIM was significantly associated with decreased platelets, elevated liver enzymes and prolonged prothrombin time. Acidosis, low serum calcium and albumin levels and higher blood glucose were also found to be more significant in CIP/CIM patients compared to control patients. Critically ill children frequently develop CIP/CIM, mostly of axonal polyneuropathy pattern, which compromises rehabilitation and recovery and is associated with a number of comorbidities.

Education on invasive mechanical ventilation involving intensive care nurses: a systematic review.

Intensive care unit nurses are critical for managing mechanical ventilation. Continuing education is essential in building and maintaining nurses' knowledge and skills, potentially improving patient outcomes. The aim of this study was to determine whether continuing education programmes on invasive mechanical ventilation involving intensive care unit nurses are effective in improving patient outcomes. Five electronic databases were searched from 2001 to 2016 using keywords such as mechanical ventilation, nursing and education. Inclusion criteria were invasive mechanical ventilation continuing education programmes that involved nurses and measured patient outcomes. Primary outcomes were intensive care unit mortality and in-hospital mortality. Secondary outcomes included hospital and intensive care unit length of stay, length of intubation, failed weaning trials, re-intubation incidence, ventilation-associated pneumonia rate and lung-protective ventilator strategies. Studies were excluded if they excluded nurses, patients were ventilated for less than 24 h, the education content focused on protocol implementation or oral care exclusively or the outcomes were participant satisfaction. Quality was assessed by two reviewers using an education intervention critical appraisal worksheet and a risk of bias assessment tool. Data were extracted independently by two reviewers and analysed narratively due to heterogeneity. Twelve studies met the inclusion criteria for full review: 11 pre- and post-intervention observational and 1 quasi-experimental design. Studies reported statistically significant reductions in hospital length of stay, length of intubation, ventilator-associated pneumonia rates, failed weaning trials and improvements in lung-protective ventilation compliance. Non-statistically significant results were reported for in-hospital and intensive care unit mortality, re-intubation and intensive care unit length of stay. Limited evidence of the effectiveness of continuing education programmes on mechanical ventilation involving nurses in improving patient outcomes exists. Comprehensive continuing education is required. Well-designed trials are required to confirm that comprehensive continuing education involving intensive care nurses about mechanical ventilation improves patient outcomes.

Cardiac function during weaning failure: the role of diastolic dysfunction

BackgroundCardiac dysfunction is a common cause of weaning failure. Weaning shares some similarities with a cardiac stress test and may challenge active phases of the cardiac cycle-like ventricular contractility and relaxation. This study aimed at assessing systolic and diastolic function during the weaning process and scrutinizing their dynamics during weaning trials.MethodsEchocardiography was performed during baseline ventilator settings to assess cardiac function at the initiation of the weaning process and at the start and the end of consecutive weaning trials (performed at day-1, day-2, and before extubation if applicable) to explore the evolution of left ventricle contractility and relaxation in a subset of patients.ResultsAmong 67 patients included, weaning was prolonged (≥ 7 days) in 18 (27%) patients and short (< 7 days) in 49 (73%). Prevalence of systolic dysfunction and isolated diastolic dysfunction before the initiation of weaning process were 37 and 17%, respectively. Isolated diastolic dysfunction was more frequent in patients with prolonged weaning as compared to their counterparts. Thirty-one patients were explored by echocardiography during consecutive weaning trials. An increase in filling pressures with an alteration of ventricular relaxation (as assessed by a decrease in tissue Doppler early mitral diastolic wave velocity) was found during failed weaning trials.ConclusionsIsolated diastolic dysfunction was associated with a prolongation of weaning. Increased filling pressures with left ventricle relaxation impairment may be a key mechanism of weaning trial failure.

Outcome of Early Mobilization of Critically Ill Patients: A Propensity Score Matching Trial

Critically ill patients are frequently immobilized which exposes them to multiple hazards particularly muscle weakness. Early mobilization of those patients was proposed few years ago and may be associated with improvement of patient’s outcomes, especially reduction of ICU length of stay. Aim: To report the results of a quality improvement project of early mobilization in a tertiary center ICU. Method: A full detailed protocol was developed for the intervention and applied in the ICU as of January 2017. Outcomes of enrolled patients were compared to that of un-enrolled patients. The impact of the program on ICU LOS was evaluated by propensity score matching, using un-enrolled patients as controls. Results: Propensity score matching yielded a significant impact on LOS in the form of average reduction of 8.6 days (95% CI: 3.4-13.8, p=0.001), the average ICU LOS of enrolled patients was significantly lower than that of un-enrolled (15.8±8.2 vs. 21±9, p=0.04), as well as the duration of weaning trials duration (4.1±2.6 vs. 7.6±5.2, p=0.03), there was no difference in ICU mortality (p=0.07). Conclusion: Early mobilization of critically ill patients may be associated with reduced ICU LOS and weaning trial period.

Noninvasive ventilation in the intensive care unit of a university hospital: Success and failure related aspects

A commercially available decision support system (DSS) provides guidance for setting inspiratory pressure support (PS) to maintain work of breathing (WOB/min), breathing frequency (f), and tidal volume (VT) in proper clinical ranges (VentAssist™). If these values are outside the proper clinical range patients may suffer fatigue, atrophy, hypoventilation, hyperventilation, volutrauma, or VT deficiency. The purpose of our study was to evaluate the increase of the percentage of breaths in the targeted clinical ranges when the DSS guidance for setting the PS was followed.The study included 43 intubated adults with respiratory failure in an academic medical intensive care unit. Each of the patients had received ventilatory support for > 24 h with no weaning trials attempted. Clinicians switched the ventilator to PS then proceeded to utilize the guidance recommended by the DSS for setting PS for 21 patients (intervention group); while the clinicians caring for the remaining 23 patients did not have access to the DSS (control group).The use of a DSS to set PS level increased the percentage of breaths in the targeted clinical range [28% to 48%, p value < 0.0001]. An unexpected result was that while following the DSS 18 of the 21 patients were rapidly weaned to minimal ventilator settings within 46 ± 38 min; however, when the DSS was not available weaning to minimal ventilator settings lasted 21 ± 12 h [p value < 0.0001].The DSS is successful at assisting clinicians on how to set PS specific to a patient's individual demands (VT and f) while accounting for their breathing effort (WOB/min). The DSS appears to promote rapid weaning of PS to minimal ventilator settings when appropriate.