Withdrawal Of Mechanical Ventilation Research Articles

Withdrawal of Life-Sustaining Mechanical Ventilation for a Patient With Amyotrophic Lateral Sclerosis in Locked-In Syndrome.

Withdrawal of Life-Sustaining Mechanical Ventilation for a Patient With Amyotrophic Lateral Sclerosis in Locked-In Syndrome.

Diaphragmatic excursion time index as a predictor of extubation in intensive therapy

Extubation is a critical process in the ICU. Pulmonary USG has different applications, those that predict success in extubation, such as the diaphragmatic excursion time index (DEIT). To determine the diaphragmatic excursion time index is a predictor of the success of weaning off mechanical ventilation in patients in the intensive care unit. Diagnostic performance study in patients in the ICU and in the extubation protocol. Diaphragmatic measurement by USG, evaluating DEIT; cut-off point of 2.42 ± 1.55 cm/s. In the hypothesis test, a JI square was carried out between the two qualitative variables, in order to accept or reject H0, with a statistical significance of p < 0.05 to determine if there is dependence between the dependent and independent variables. Total of 200 patients from the population, with successful extubation in 52.5% and extubation failure in 47.5%. Prognostic values of the DEIT were: S: 77.1% (68.2-84.1%), E: 56.8% (46.8-66.3%). ROC curve for ITED, AUC of 0.665 (0.58-0.74; p = 0.001). In secondary objectives, a correlation was made between ventilatory and demographic variables for successful extubation; with FvT (Rho: 0.680, p = 0.0001). The DEIT for withdrawal of mechanical ventilation has low sensitivity and specificity as a result of successful extubation. The finding that DEIT is not an adequate predictor determining the outcome of successful extubation.

Innovative Strategies for Palliative Care in the Intensive Care Unit.

Palliative care is interdisciplinary care that addresses suffering and improves the quality of care for patients and families when patients are facing a life-threatening illness. Palliative care needs in the intensive care unit include communication regarding diagnosis and prognosis, goals-of-care conversations, multidimensional pain and symptom management, and end-of-life care that may include withdrawal of mechanical ventilation and life support. Registered nurses spend the greatest amount of time with patients and families who are facing death and serious illness, so nurses must be armed with adequate training, knowledge, and necessary tools to address patient and caregiver needs and deliver high-quality, patient-centered palliative care. Innovative approaches to integrating palliative care are important components of care for intensive care nurses. This article reviews 2 evidence-based practice projects, a serious illness support tool and the 3 Wishes Project, to add to the palliative care toolkit for registered nurses and other team members.

Diagnostic value of bedside lung ultrasound and 12-zone score in the 65 cases of neonatal respiratory distress syndrome and its severity

ObjectiveTo explore the predictive value of bedside lung ultrasound score in the severity of neonatal respiratory distress syndrome (NRDS) and mechanical ventilation and extubation.MethodsThe clinical data of 65 neonates with NRDS and invasive mechanical ventilation diagnosed in the neonatal intensive care unit of our hospital from July 2021 to July 2022 were retrospectively analyzed. 65 neonates were included in the NRDS group, and 40 neonates with other common lung diseases were selected as the other lung disease groups. All neonates underwent lung ultrasound and X-ray examination. The correlation between lung ultrasound scores and arterial blood gas indexes was analyzed by Pearson. The efficacy of successful evacuation of mechanical ventilation was evaluated by lung ultrasound analysis by ROC curve analysis.ResultsThe positive rates of lung consolidation and white lung in NRDS group were higher than the other lung disease groups (P < 0.05). The positive rates of bronchial inflation sign and double lung points were lower than these in the other lung disease groups (P < 0.05). The ultrasound scores of both lungs, left lung, right lung, bilateral lung and double basal lung in the NRDS group were significantly higher than those in the other lung disease groups (P < 0.05). There was a significant positive correlation between lung ultrasound score and X-ray grade (r = 0.841, P < 0.001). The area under the curve (AUC) of lung ultrasound score for the differential diagnosis of NRDS and common lung diseases was 0.907. The AUC of lung ultrasound score in the differential diagnosis of mild and moderate, and moderate and severe NRDS were 0.914 and 0.933, respectively, which had high clinical value. The lung ultrasound score was positively correlated with the level of PaCO2 (r = 0.254, P = 0.041), and negatively correlated with the levels of SpO2 and PaO2 (r = − 0.459, − 0.362, P = 0.001, 0.003). The AUC of successful mechanical ventilation withdrawal predicted by the pulmonary ultrasound score before extubation was 0.954 (95% CI 0.907–1.000). The predictive value of successful extubation was 10 points of the pulmonary ultrasound score, with a sensitivity of 93.33% and a specificity of 88.00%.ConclusionThe bedside lung ultrasound score can intuitively reflect the respiratory status of neonates, which provides clinicians with an important basis for disease evaluation.

Process of Withdrawal of Mechanical Ventilation at End of Life in the ICU: Clinician Perceptions

BackgroundNearly a quarter of all Americans die in the intensive care unit (ICU). Many of their deaths are anticipated and occur after withdrawal of mechanical ventilation (WMV). Yet, there are few data on which to base best practices for interdisciplinary ICU teams to conduct WMV. Research QuestionTo investigate the perceptions of current WMV practices among ICU clinicians, and gain their opinions of processes that might improve the practice of WMV at end of life in the ICU. Study Design and MethodsWe conducted a prospective two-center observational study in Boston, MA of the withdrawal of mechanical ventilation (OBSERVE-WMV) designed to better understand the perspectives of clinicians and experience of patients undergoing WMV. This report focuses on analyses of qualitative data obtained from in-person surveys administered to the ICU clinicians (nurses, respiratory therapists, physicians) caring for these patients. Surveys assessed a broad range of clinician perspectives on planning, and key processes required for WMV. This analysis utilized independent open, inductive coding of responses to open-ended questions. Initial codes were reconciled iteratively, and then organized and interpreted using a thematic analysis approach. We assessed opinions on how WMV could be improved for individual patients and the ICU as a whole. ResultsAmong 456 eligible clinicians, 312 in-person surveys were completed by clinicians caring for 152 patients who underwent WMV. Qualitative analyses identified two main themes characterizing high quality WMV processes: good communication (e.g. mutual understanding of family preferences) between the ICU team and family, and medical management (e.g. planning, availability of ICU team) that minimizes patient distress. Team member support was identified as an essential process component in both themes. InterpretationClinician perceptions of the appropriateness or success of WMV prioritize the quality of team and family communication and patient symptom management. Both are modifiable targets of interventions aimed at optimizing overall WMV.

Beyond Legal Boundaries: Public and Clinician Perspectives on Treatment Withdrawal in Infants With Poor Neurological Prognosis.

Despite medical advancements in neonatal survival rates, many children have poor neurological outcomes. Because the law in Korea restricts the withdrawal of life-sustaining treatment to only cases of imminent death, treatment discontinuation may not be an option, even in patients with poor neurological prognosis. This study investigated the opinions of the general population and clinicians regarding life-sustaining treatment withdrawal in such cases using hypothetical scenarios. We conducted a cross-sectional study on the general population and clinicians using a web-based questionnaire. The sample of the general population from an online panel comprised 500 individuals aged 20-69 years selected by quota sampling. The clinician sample comprised 200 clinicians from a tertiary university hospital. We created hypothetical vignettes and questionnaire items to assess attitudes regarding mechanical ventilation withdrawal for an infant at risk of poor neurological prognosis due to birth asphyxia at 2 months and 3 years after the incidence. Overall, 73% of the general population and 74% of clinicians had positive attitudes toward mechanical ventilator withdrawal at 2 months after birth asphyxia. The proportion of positive attitudes toward mechanical ventilator withdrawal was increased in the general population (84%, P < 0.001) and clinicians (80.5%, P = 0.02) at 3 years after birth asphyxia. Religion, spirituality, the presence of a person with a disability in the household, and household income were associated with the attitudes of the general population. In the multivariable logistic regression analysis of the general population, respondents living with a person with a disability or having a disability were more likely to find the withdrawal of the ventilator at 2 months and 3 years after birth asphyxia not permissible. Regarding religion, respondents who identified as Christians were more likely to find the ventilator withdrawal at 2 months after birth asphyxia unacceptable. The general population and clinicians shared the perspective that the decision to withdraw life-sustaining treatment in infants with a poor neurological prognosis should be considered before the end of life. A societal discussion about making decisions centered around the best interest of pediatric patients is warranted.

Evidence Guiding Withdrawal of Mechanical Ventilation at the End of Life: A Review.

Distress at the end of life in the intensive care unit (ICU) is common. We reviewed the evidence guiding symptom assessment, withdrawal of mechanical ventilation (WMV) process, support for the ICU team, and symptom management among adults, and specifically older adults, at end of life in the ICU. Systematic search of published literature (January 1990-December 2021) pertaining to WMV at end of life among adults in the ICU setting using PubMed, Embase, and Web of Science. Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were followed. Adults (age 18 and over) undergoing WMV in the ICU. Study quality was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Out of 574 articles screened, 130 underwent full text review, and 74 were reviewed and assessed for quality. The highest quality studies pertained to use of validated symptom scales during WMV. Studies of the WMV process itself were generally lower quality. Support for the ICU team best occurs via structured communication and social supports. Dyspnea is the most distressing symptom, and while high quality evidence supports the use of opiates, there is limited evidence to guide implementation of their use for specific patients. High quality studies support some practices in palliative WMV, while gaps in evidence remain for the WMV process, supporting the ICU team, and medical management of distress. Future studies should rigorously compare WMV processes and symptom management to reduce distress at end of life.

Effect of a Japanese Version of the Burns Wean Assessment Program e-Learning Materials on Ventilator Withdrawal for Intensive Care Unit Nurses.

No assessment tool for predicting ventilator withdrawal success is currently available in Japan. Thus, an accessible and valid assessment tool to address this issue is needed. The Burns Wean Assessment Program (BWAP) has been validated as a reliable predictor of ventilator withdrawal outcomes. However, nurses must be familiar with this tool to ensure its efficient utilization in clinical settings. This study was designed to examine the effect of a 26-item Japanese version of BWAP (J-BWAP) e-learning materials on ventilator withdrawal in a sample of intensive care unit nurses in Japan. The BWAP was translated into Japanese, checked, and verified as the J-BWAP. Nonrandomized intensive care unit nurses from six hospitals were assigned to three groups, including Intervention Group 1 (e-learning in one session), Intervention Group 2 (e-learning over three sessions during 1 week), and the control group. The participants underwent pretests and posttests using web-based, simulated patients. The primary outcome measure was the difference in online pretest and posttest total scores among the two intervention groups and the control group. The feasibility of the J-BWAP and its e-learning materials was evaluated using four frameworks: acceptability, demand, implementation, and adaptation. Of the 48 participants in the study, 32 completed the posttest and were included in the analysis (dropout rate: 33.3%). The difference between pretest and posttest scores was significantly higher in the intervention groups than the control group (2 vs. -1, p = .0191) and in Intervention Group 2 than the control group (2.0 vs. -0.5, p = .049). The feasibility frameworks for the J-BWAP and its e-learning materials were mostly positive. The development of the J-BWAP and training nurses using e-learning were shown to be feasible in this study. The J-BWAP contents are appropriate for predicting the outcome of mechanical ventilation withdrawal. The J-BWAP has the potential to become a common tool among Japanese medical professionals after the contents are further simplified for daily application in clinical practice. Subsequent studies should verify the reliability and validity of this tool and test the real-world utility of the J-BWAP using randomized controlled trials in Japanese clinical settings.

Withdrawal of mechanical ventilation in amyotrophic lateral sclerosis patients: a multicenter Italian survey

BackgroundLaw 219/2017 was approved in Italy in December 2017, after a years-long debate on the autonomy of healthcare choices. This Law, for the first time in Italian legislation, guarantees the patient’s right to request for withdrawal of life-sustaining treatments, including mechanical ventilation (MV).ObjectiveTo investigate the current status of MV withdrawal in amyotrophic lateral sclerosis (ALS) patients in Italy and to assess the impact of Law 219/2017 on this practice.MethodsWe conducted a Web-based survey, addressed to Italian neurologists with expertise in ALS care, and members of the Motor Neuron Disease Study Group of the Italian Society of Neurology.ResultsOut of 40 ALS Italian centers, 34 (85.0%) responded to the survey. Law 219/2017 was followed by an increasing trend in MV withdrawals, and a significant increase of neurologists involved in this procedure (p 0.004). However, variations across Italian ALS centers were observed, regarding the inconsistent involvement of community health services and palliative care (PC) services, and the intervention and composition of the multidisciplinary team.ConclusionsLaw 219/2017 has had a positive impact on the practice of MV withdrawal in ALS patients in Italy. The recent growing public attention on end-of-life care choices, along with the cultural and social changes in Italy, requires further regulatory frameworks that strengthen tools for self-determination, increased investment of resources in community and PC health services, and practical recommendations and guidelines for health workers involved.

Terminal Withdrawal of Mechanical Ventilation in a PICU

AbstractData regarding a terminal withdrawal of mechanical ventilation (TWMV) in pediatric patients, in particular the time to death, would be helpful to family and hospital staff. This retrospective case series will review the TWMV in pediatric intensive care unit (PICU) patients at our hospital between 2015 and 2020. There were 222 PICU deaths and 53 of these patients died following a TWMV. The time to death was &lt;1 hour in 37 patients, from 1 to 24 hours in 12 patients, and &gt;24 hours in 4 patients. Neither age nor the duration of mechanical ventilation prior to TWMV was associated with time to death. TWMV was complicated by concurrent withdrawal of cardiac support devices in 9 patients and by a recent cardiac arrest in 3 patients (1 of whom also had a cardiac support device withdrawal), and the time to death for these 11 patients was less than 1 hour (p = 0.01 vs. all others). The time to death for those without concurrent withdrawal of cardiac support devices or recent cardiac arrest was shorter in those with a higher fraction of inspired oxygen but was not associated with positive end expiratory pressure. Time to death following a TWMV was less than a day in more than 90% of our patients and was not associated with patient age or the duration of mechanical ventilation. However, in patients without a recent cardiac arrest or concurrent withdrawal of cardiac support devices, nearly 1 in 10 survived a TWMV for more than a day, while those with a recent cardiac arrest or concurrent withdrawal of cardiac support devices survived for less than an hour.

Sedation With Dexmedetomidine in Critically Ill Burn Patients Reduced Delirium During Weaning From Mechanical Ventilation.

Weaning of mechanical ventilation while maintaining appropriate pain control and preventing delirium is one of the most challenging aspects of burn care.Dexmedetomidine, an α2-adrenergic receptor agonist used for sedation may improve intensive care unit (ICU) patients' arousal status and enhance patient comfort. To determine the efficacy of dexmedetomidine vs. standardized usual care (midazolam or propofol) in maintaining sedation and reducing delirium in burn patients while weaning off mechanical ventilation. A total of 56 mechanically ventilated patients who fulfilled the criteria for weaning were enrolled in the study. Group 1 (26 patients) received dexmedetomidine 1 mcg/kg over 15 minutes as a loading dose, followed by 0.4-0.1 mcg/kg/h. Group 2 (30 patients) received usual sedation with midazolam 0.08 mg/kg/h or propofol 15- 30 mcg /kg/min). Dexmedetomidine was not associated with a significantly shorter duration of mechanical ventilation (Mean {IQR}: 9.3 {4,12} versus 7.5 {4,10}, p=0.3).Patients who received dexmedetomidine had a lower delirium rate (38,4% on Day 1 to 7,7% on Day 5) in comparison with patients from the usual care group (53,3% on Day 1 to 20% on Day 5) during the five days after the onset of weaning process (p=0.02)and had less need for supplemental use of analgesia (23.1% versus 53.3%, p=0.045) and antipsychotic agents (15.4% versus 53.3%, p=0.01). The most notable adverse effect of dexmedetomidine was bradycardia. Dexmedetomidine may provide effective light sedation and is associated with fewer sedation-related adverse effects in burn patients. Sedation with dexmedetomidine during the weaning process in adult burn patients was associated with lower delirium rates, a trend towards the earlier withdrawal of mechanical ventilation but did not seem to improve the total duration of mechanical ventilation.

The Use of Mechanical Ventilation Support at the End of Life in Motor Neurone Disease/Amyotrophic Lateral Sclerosis: A Scoping Review.

There has been an increase in the use of mechanical ventilation (MV) in motor neurone disease (MND) to alleviate symptoms related to hypoventilation. Little is known about its use at the end of life, and the withdrawal of MV is a challenging topic. A scoping review was conducted to map the existing evidence of ventilation use at the end of life in MND. The Joanna Briggs Institute methodological framework was used, and a total of 31 documents were included in the data extraction. Boarder themes around place, planning, cause and comments on death were identified. Our findings show that the focus of the literature has been on the process of the withdrawal of ventilation, creating the subthemes of timing and reason for withdrawal, along with ethical, emotional, and practical issues, medications used and the time until death. There is a foundation of evidence to guide the process and discuss the ethical and emotional issues of withdrawing ventilation. However, there remains limited evidence from patient and family member perspectives. Importantly, there is almost no evidence exploring dying with ventilation in place, the active or passive decisions around this process, how the interface might impact the dying process, or what families think about this.

Survey of critical care practices for alcohol withdrawal syndrome in the intensive care unit

AbstractIntroductionAlcohol use disorder affects up to 60% of intensive care unit (ICU) patients. Alcohol withdrawal syndrome (AWS) is associated with increased length of stay, mechanical ventilation, and mortality. The lack of clinical practice guidelines specific to ICU patients leads to ambiguity about the standard management of AWS in this population.ObjectivesThe aim of this study was to describe current practice patterns employed for AWS management in ICU settings across the United States.MethodsThis was a cross‐sectional survey of practicing critical care pharmacists identified via a pharmacy professional organization critical care listserv. Emails were sent four times to the recipient list from May 14, 2021 to June 25, 2021. Retired pharmacists and trainees on the listserv were excluded. The survey was conducted by REDCap and descriptive statistics were performed.ResultsThere were a total of 144/1534 (9.4%) responses. Predominant characteristics included university hospital settings (n = 71/143, 49.7%) with greater than 75 ICU beds (n = 54/144, 37.5%), and medical (n = 53/144, 36.8%) or mixed (n = 52/144, 36.1%) ICU populations. The majority reported having an institutional AWS guideline (n = 96/140, 68.6%). A total of 139/143 (97.2%) preferred benzodiazepines, with lorazepam (n = 136/143, 97.8%) as the primary benzodiazepine agent. Most preferred lorazepam as needed, rather than preemptively (n = 137/138, 99.3%). Phenobarbital use was reported by 82.6% (n = 119/144) of respondents, primarily for treatment of benzodiazepine‐refractory withdrawal (n = 96/117, 82.1%). Similarly, dexmedetomidine use was reported by 86.1% (n = 124/144) of respondents, primarily for refractory withdrawal (n = 48/121, 39.7%). Propofol was primarily preferred for patients on mechanical ventilation (n = 56/98, 57.1%) or refractory withdrawal (n = 51/98, 52.0%). Clonidine was preferred by 45.8% (n = 66/144) and atypical antipsychotics by 33.6% (n = 48/143) of respondents.ConclusionsMost ICU pharmacists prefer symptom‐triggered benzodiazepines first line, followed by propofol in intubated patients and dexmedetomidine and/or phenobarbital for refractory cases. Clinical practice guidelines may help provide guidance for the management of these patients.

Quantitative EEG may predict weaning failure in ventilated patients on the neurological intensive care unit

Neurocritical patients suffer from a substantial risk of extubation failure. The aim of this prospective study was to analyze if quantitative EEG (qEEG) monitoring is able to predict successful extubation in these patients. We analyzed EEG-monitoring for at least six hours before extubation in patients receiving mechanical ventilation (MV) on our neurological intensive care unit (NICU) between November 2017 and May 2019. Patients were divided in 2 groups: patients with successful extubation (SE) versus patients with complications after MV withdrawal (failed extubation; FE), including reintubation, need for non-invasive ventilation (NIV) or death. Bipolar six channel EEG was applied. Unselected raw EEG signal underwent automated artefact rejection and Short Time Fast Fourier Transformation. The following relative proportions of global EEG spectrum were analyzed: relative beta (RB), alpha (RA), theta (RT), delta (RD) as well as the alpha delta ratio (ADR). Coefficient of variation (CV) was calculated as a measure of fluctuations in the different power bands. Mann–Whitney U test and logistic regression were applied to analyze group differences. 52 patients were included (26 male, mean age 65 ± 17 years, diagnosis: 40% seizures/status epilepticus, 37% ischemia, 13% intracranial hemorrhage, 10% others). Successful extubation was possible in 40 patients (77%), reintubation was necessary in 6 patients (12%), 5 patients (10%) required NIV, one patient died. In contrast to FE patients, SE patients showed more stable EEG power values (lower CV) considering all EEG channels (RB: p < 0.0005; RA: p = 0.045; RT: p = 0.045) with RB as an independent predictor of weaning success in logistic regression (p = 0.004). The proportion of the EEG frequency bands (RB, RA RT, RD) of the entire EEG power spectrum was not significantly different between SE and FE patients. Higher fluctuations in qEEG frequency bands, reflecting greater fluctuation in alertness, during the hours before cessation of MV were associated with a higher rate of complications after extubation in this cohort. The stability of qEEG power values may represent a non-invasive, examiner-independent parameter to facilitate weaning assessment in neurocritical patients.

Peri-Operative Desensitization for Highly Sensitized Lung Transplant Recipients Following COVID-19 Acute Respiratory Distress Syndrome (ARDS) - Report of Two Cases

IntroductionSensitized lung transplant (LTx) candidates have longer waiting times, decreased likelihood of transplant, and increased risk of death while on the waitlist. Patients with SARS-Cov-2 ARDS on ECMO support due to end-stage lung disease have a short window of opportunity for LTx. We report two cases in which the Toronto LTx peri-operative strategy was performed with good outcomes in highly sensitized Covid-19 patients.Case ReportCase 1: 31-yo female patient with Covid-19 ARDS, transferred for LTx evaluation after 46 days on VV-ECMO. She was pregnant when she presented with Covid -19 acute respiratory failure, and underwent an urgent C-section due to fetal distress. She required blood transfusions during ICU stay. At LTx assessment: PRA class I: 95%; class II: 0%. A decision to proceed with LTx with perioperative desensitization was made considering the low probability of finding a suitable donor. After seven days on the waiting list, she underwent bilateral LTx. Virtual crossmatch (XM) positive (B35); CDC-XM negative. Desensitization protocol was performed with perioperative plasma exchange (PLEX) without basiliximab induction, followed by five sessions of PLEX and intravenous immunoglobulin 1 mg/kg. Due to postoperative acute cholecystitis with positive cultures after biliary drainage, anti thymocyte globulin (ATG) infusion (3 mg/kg) was held, and infusion postponed until four weeks post LTx. Tacrolimus, mycophenolate, and prednisone were used as maintenance immunosuppression. The patient was discharged home on PO day 53 with excellent graft function. Case 2: 35-yo female patient with Covid-19 ARDS, transferred for LTx after 69 days on VV-ECMO. History of 3 previous pregnancies and multiple blood transfusions due to transitory coagulopathy during her ICU stay. PRA class I: 83%; class II: 94%. VCM positive (B7, Cw7, DRB1*11:01, DR52, DQA1*05/DQB1*03). Desensitization protocol was performed, but ATG infusion was held due to C. albicans bloodstream infection and colonization with pan-resistant K. pneumoniae. DSAs at six weeks were negative. She remains hospitalized for mechanical ventilation withdrawal and inpatient rehabilitation.SummaryIn selected cases, peri-operative desensitization is feasible and can be safely implemented in highly sensitized patients with Covid-19 ARDS.

Nurses' involvement in end-of-life decisions in neonatal intensive care units.

End-of-life decision-making for terminally ill neonates raises important legal and ethical issues. In Greece, no recent data on nurses' attitudes and involvement in end-of-life decisions are available. To investigate neonatal nurses' attitudes and involvement in end-of-life decisions and the relation to their socio-demographic and work-related background data. A survey was carried out in 28 neonatal intensive care units between September 2018 and January 2019. A structured questionnaire was distributed by post. The questionnaire was answered anonymously by 312 nurses (response rate, 71.1%) and returned to the investigators. The study was approved by the Bioethics and Research Committee of Aretaieio Hospital in accordance with the Helsinki Declaration. Nurses more often reported involvement in various end-of-life decisions, such as continuation of treatment without adding further therapeutic interventions for terminally ill neonates, while less reported were mechanical ventilation withdrawal and drug administration to end life. Nurses with a high attitude score, reflecting a more quality-of-life approach, were more likely to be involved in setting limits to intensive care. α low score was consistent with life preservation. Nurses' religiousness (p = 0.097), parenthood (p = 0.093), involvement in daily practice (p = 0.03), and position on the existing legal framework (p < 0.002) influenced their attitude score. The likelihood of nurses to support interventions in neonates with poor prognosis in neonatal intensive care units was related to their attitudes. After adjusting for potential confounders, the most important predictors for nurses' attitudes were parenthood, involvement in daily practice, and position supporting current legislation reform. Variability in involvement in end-of-life decisions among nurses exists on a national level.

ICU Clinicians’ Experiences of Terminal Weaning and Extubation

ContextAside from spontaneous death, a majority of ICU deaths occur after a decision to either withhold or withdraw life-sustaining measures, including withdrawal of ventilatory support. While terminal weaning or terminal extubation are both used, the lack of evidence on the superiority of one method over the other can create challenges for ICU clinicians. There is a need to explore clinicians’ experiences related to terminal weaning/extubation to understand their decision-making processes as well as the context and mechanisms that guide this process. ObjectivesThis study aimed to explore ICU clinicians'experiences of Terminal Weaning of Mechanical Ventilation (TWMV) in order to better understand the process, and clinicians’ feelings about the process. MethodsThis study used an exploratory descriptive qualitative design. Data were collected via semi-structured, face-to-face interviews with 20 ICU clinicians. An inductive, data driven thematic analysis approach was used for data analysis. ResultsAnalysis of the data resulted in four themes: Fine-tuning the Process of TWMV; Focusing on the Family; Ensuring Patient-Centered Care; and Impact on Health care Clinicians and Support Needs. ConclusionThe identified themes provide insight into the complexity of the withdrawal of mechanical ventilation within the context of end-of-life care in the ICU. The themes highlight the need for clear communication of a TWMV plan between clinicians to avoid conflict during the process, ensuring medication is in place for potential distressing symptoms, incorporating patient and family wishes in planning, supporting the family during the process, and training and support for clinicians.

Polysomnography in pre-operative screening for obstructive sleep apnea in patients undergoing bariatric surgery: a retrospective cohort study.

To assess the impact of obstructive sleep apnea (OSA) screening with polysomnography on preventing cardiovascular and pulmonary complications in the postoperative period of bariatric surgery. This was a single-center retrospective cohort study, including 522 adults who underwent bariatric surgery between August 2010 and May 2019. Electronic medical records were accessed to obtain variables of interest. Screening for OSA was performed as a medical indication and registered as positive if apnea-hypopnea index was ≥5 events/hour in patients who did not have previous OSA diagnosis. The primary outcome was the presence of cardiac or pulmonary events in the 30-day postoperative period. Secondary outcomes included length of stay (days), need for an intensive care unit (ICU) after surgery, length of mechanical ventilation, and time from mechanical ventilation withdrawal. Statistical analyses were performed with χ2, Fisher's exact test, Student's t-test, Mann-Whitney U test, and Poisson regression. Most participants (n = 326) did not have OSA screening with polysomnography, while 196 had performed this screening. There was no difference in cardiopulmonary events between the screening and non-screening groups (4.2% vs. 2.8%; P = 0.45). Polysomnography screening could not reduce cardiovascular or pulmonary complications in the postoperative period, RR = 1.73 (95% CI: 0.68-4.14). There was no difference in ICU admission, length of stay, and time from mechanical ventilation between groups in secondary outcomes. Our study suggests that OSA screening with polysomnography in the pre-operative care of bariatric surgery is a dispensable procedure, as it does not change postoperative cardiopulmonary outcomes. Indications for polysomnography should be made at the individual level.

A new protocol to compare successful versus failed patients using the electromyographic diaphragm signal in extubation process.

In clinical practice, when a patient is undergoing mechanical ventilation, it is important to identify the optimal moment for extubation, minimizing the risk of failure. However, this prediction remains a challenge in the clinical process. In this work, we propose a new protocol to study the extubation process, including the electromyographic diaphragm signal (diaEMG) recorded through 5-channels with surface electrodes around the diaphragm muscle. First channel corresponds to the electrode on the right. A total of 40 patients in process of withdrawal of mechanical ventilation, undergoing spontaneous breathing tests (SBT), were studied. According to the outcome of the SBT, the patients were classified into two groups: successful (SG: 19 patients) and failure (FG: 21 patients) groups. Parameters extracted from the envelope of each channel of diaEMG in time and frequency domain were studied. After analyzing all channels, the second presented maximum differences when comparing the two groups of patients, with parameters related to root mean square (p = 0.005), moving average (p = 0.001), and upward slope (p = 0.017). The third channel also presented maximum differences in parameters as the time between maximum peak (p = 0.004), and the skewness (p = 0.027). These results suggest that diaphragm EMG signal could contribute to increase the knowledge of the behaviour of respiratory system in these patients and improve the extubation process.Clinical Relevance-This establishes the characterization of success and failure patients in the extubation process.

Variation in COVID-19 Resource Allocation Protocols and Potential Implementation in the Chicago Metropolitan Area

Background Scarce resource allocation policies vary across the United States. Little is known about regional variation in resource allocation protocols and variation in their application. We sought to evaluate how Covid-19 scarce resource allocation policies vary throughout the Chicago metropolitan area and whether there are differences in policy application within hospitals when prioritizing hypothetical patients who need critical care resources. Methods Two cross-sectional surveys were distributed to Chicago metropolitan area hospital representatives and triage officers. Survey responses and categorical variables are described by frequency of occurrence. Intra- and interhospital variation in ranking of hypothetical patients was assessed using Fleiss’s Kappa coefficients. Results Eight Chicago-area hospitals responded to the survey assessing scarce resource allocation protocols (N = 8/18, response rate 44%). For hospitals willing to describe their ventilator allocation protocol (N = 7), most used the sequential organ failure assessment (SOFA) score (N = 6/7, 86%) and medical comorbidities (N = 4/7, 57%) for initial scoring of patients. A majority gave priority in initial scoring to pre-defined groups (N = 5/7, 71%), all discussed withdrawal of mechanical ventilation for adult patients (N = 7/7, 100%), and a minority had exclusion criteria (N = 3/7, 43%). Forty-nine triage officers from nine hospitals responded to the second survey (N = 9/10 hospitals, response rate 90%). Their rankings of hypothetical patients showed only slight agreement amongst all hospitals (Kappa 0.158) and fair agreement within two hospitals with the most respondents (Kappa 0.21 and 0.25). Almost half used tiebreakers to rank patients (N = 23/49, 47%). Conclusions Although most respondents from Chicago-area hospitals described policies for resource allocation during the COVID-19 pandemic, the substance and application of these protocols varied. There was little agreement when prioritizing hypothetical patients to receive scarce resources, even among people from the same hospital. Variations in resource allocation protocols and their application could lead to inequitable distribution of resources, further exacerbating community distrust and disparities in health. Supplemental data for this article is available online at https://doi.org/10.1080/23294515.2021.1983667