Having a good death in our ICU

 

family_about_bed_landscape-mr

What is a good death?

(Andrej Michalsen)

‘Decent farewell’

  • End of life without pain (not force-fed but without thirst; medication for pain, anxiety, dyspnoea; comfortable positioning)
  • Comforted, peaceful (secure as to personal cultural, spiritual and religious values)
  • With dignity and respect
  • Closeness to family (potentially difficult if absent / estranged/ also feelings of guilt or pressure in relatives for contributing to medical decisions)

 

Challenges and pitfalls

  • Blurred language used around death / dying
  • Cultural negligence
  • Irresoluteness of healthcare team and burden of unnecessary suffering (by not making a decision on extent of treatment)

 

There is often conflict between doctors and nurses about a dignified death, and also between family and medical team about what treatment is / isn’t indicated (any treatment given has to be given willingly by a healthcare professional)

 

Good end-of-life care for patient and family

(Dominique Benoit)

 

More aggressive ICU care at EOL over last decades (associated with guilt and depressive symptoms in family afterwards); 10-30% pts on ICU are receiving excessive care and will not be alive in 1 year

Outcome in patients perceived as receiving excessive care across different ethical climates: a prospective study in 68 intensive care units in Europe and the USA

 

Goals of good EOL care:

  • Shift from cure to care, holistic, dignified, responsive to spiritual/emotional needs
  • Sensitive, timely, open communication
  • Interdisciplinary collaboration
  • Being able to spend time with family / die at home if possible
  • Overall is protective of patient AND the family

 

CAESAR (CAESAR: a new tool to assess relatives’ experience of dying and death in the ICU.)

  • tool to assess relatives’ experience of death and dying in the ICU
  • 3/6/12 mths
  • Anxiety / depression / complicated grief / PTSD

 

 

Quality of death affected by timeliness of clinical decisions, this should be part of the aim of treatment!

 

Up to 80% pts wish to die at home

  • palliative care referral to facilitate when feasible
  • Very Uncommon occurrence in reality
  • Advanced directive helpful
  • Also responsibility of referring team PRIOR to ICU admission

 

Which conflicts to expect at the end-of-life?

(Hanne Irene Jensen)

 

Good ICU death is possible. Conflicts:

  • No psychological support
  • Suboptimal decision-making process
  • Suboptimal symptom control
  • Patient +/- Family preferences disregarded
  • Futile treatment
  • EOL decision made too early or late

Prevalence and factors of intensive care unit conflicts: the conflicus study.

 

Majority of conflicts believed to be preventable

 

Most common conflict between doctors and nurses: both acting to different goals, but think it is in the patient’s best interests – effect of personal perceptions and preferences

 

Conflict between pt and family – pt with capacity may need help mediating with family if different views; pt without capacity but with advance directive (when was it written and is it still in keeping with family’s perceived wishes of the pt?)

 

Consequences of conflicts

In practice:

  • Communication and shared decision-making
  • In complex situations, discuss between referring team + ICU, agree on best management then speak to pt /family (avoid presenting conflicting views)
  • Conflicts can escalate – seek communication early +/- mediation if necessary

 

Withholding therapies: Ethical and legal aspects

(Andrej Michalsen)

 

Epidemiology of withholding and withdrawing treatment:

 

A treatment is appropriate when it is both INDICATED and CONSENTED

Indicated Consented Appropriate
Yes Yes Yes
Yes No No
No Yes / No No
Indicated Demanded Appropriate
No Yes No

 

Ethically, withholding is equivalent to withdrawing treatment, as supported by many critical care societies and regulatory bodies

  • psychologically it may be harder to withdraw than withhold
  • if treatment no longer needed, stop giving it
  • if significant doubt about prognosis, treatment trial may be helpful (look for improvement / deterioration within relatively short period, not a prolonged number of days)
  • helpful to discuss Morbidity and QOL with pt and family in specific terms e.g. being able to sit down at table for dinner / engage in hobby

 

Global variability regarding limitation of life-sustaining therapy i.e. No withdrawal bundles as such – depends on individual and on team

 

No common morality – there will always be some tension between what we think is ethical and what someone else believes

 

Legal stipulations vary across and within countries

  • prioritising pt-related clinical factors over stipulations can have severe consequences

 

Everything is easier with a more human environment

(Maria Cruz Martin Delgado)

 

Pts often experience depersonalisation during prolonged admission

IMG_0661

 

Early assessment for Palliative care needs can alleviate suffering in critically ill pts

  • ideally, if unfit for aggressive treatments – transfer to acute palliative care units / hospice / home

 

A mixed model combining primary care of ICU physicians with specialist palliative care physician input can help, although this rarely occurs in practice

IMG_0663

Palliative care in intensive care units: why, where, what, who, when, how

 

Humanising ICU care

‘Open’ ICU

  • flexible hours / open-doors policy
  • also removal of unnecessary barriers (masks, gowns, gloves)
  • visits from children with appropriate support and supervision by psychologist if available

Communications

  • New media tools to allow long-distance communication with empathy, compassion and intimacy
  • Augmentative and assistive communication strategies for those who cannot speak / write
  • Family conferences with medical team (often fragmented and limited by time)

Wellbeing of pt

  • At the least, need to address the basics of pain / thirst / temperature / noise / rest / positioning comfort / speech / isolation / vulnerability / privacy / lack of information
  • Reassess as situation progresses – dynamic

Presence and participation of family

Caring for the healthcare professionals

Caring for pt and family after ICU

Education in ICU Palliative Care

 

Nutrition in Challenging Conditions

Continuing Professional Education Session

 

Nutrition in patients with CRRT

(Pierre Singer)

 

AKI – metabolic modifications, hypercatabolism, hyperglycaemia

Nutrients and solutes levels affected by haemodialysis/haemofiltration

IMG_0432 IMG_0434

Equations to calculate energy expenditure (EE) can be misleading in CRRT, likely to result in overfeeding – measure EE by indirect calorimetry after 6 hours stabilisation

 

Pts use more fat than carbohydrates, therefore give 50% fat + 50% carbs

 

Amino acids lost through convection and ultrafiltration: 8g/day, total loss including catabolism: 10-15g/day, therefore give at least 1.3g/kg/day protein and more to compensate for losses

 

Loss of micronutrients in effluent: Selenium, Copper, Zinc –replace with trace element solutions

IMG_0451

 

Hypophosphataemia in AKI treated with haemodialysis is associated with adverse events

 

Nutrition of obese patients

(Mette Berger)

 

BMI poor indicator of body composition / obesity, doesn’t account for muscle loss in ageing and disease, and does not detect sarcopenia (measured on cross sectional CT imaging at Lumbar L3 level)

IMG_0458

 

Obesity associated with increased all-cause mortality in hospitalised pts (increased prevalence of hypertension, Type 2 DM, hypercholesterolaemia)

 

High rates of central obesity and sarcopenia in CKD irrespective of RRT

 

Obesity and trauma:

  • Relative block on lipolysis and fat oxidation
  • Shift to preferential use of proteins and carbohydrates
  • Resultant catabolism

 

Glucose handling in obesity:

  • Relative insulin resistance and risk of Type 2 DM
  • Sepsis/trauma induces post-receptor insulin resistance
  • Significant risk of hyperglycaemia (conventional feeds use carbohydrates as predominant energy source)

 

Obesity can co-occur with malnutrition – MDT approach to handle various aspects of obesity

 

How much to feed obese pts?

  • Penn State Equations: 80% validity in predicting resting metabolic rate in critically ill pts at extremes of BMI

(Prediction of resting metabolic rate in critically ill patients at the extremes of body mass index.)

 

Simple guide:

  • Assess nutritional need and develop plan within 48hrs of ICU admission (pt usually has little reserves)
  • Will need Indirect Calorimetry or Penn State Equations for more accurate calculation of energy expenditure
  • Feeding should not be hypocaloric, but rather Aim for Iso-caloric for lean mass
  • Ideal body weight used to calculate protein needs (2-2.5 g/kg)
  • Careful attention to micronutrients, B12, Cu, Fe to avoid anaemia / neurological problems
  • Convert to Enteral feeding as soon as pt is stabilised

 

 

Nutrition during non-invasive ventilation

(Steffen Weber-Carstens)

 

Reasons NOT to feed enterally during NIV:

  • Potential need for intubation
  • NGT presence may cause air leakage, compromising effectiveness of NIV
  • Gastric distension associated diaphragmatic splinting
  • Removal of mask to consume oral diet may cause deterioration

IMG_0480

 

In this group of pts, TPN is in fact preferred to EN – no increase in mortality / gastrointestinal infection rate with TPN compared to EN; EN associated with significantly more GI infections

Enteral versus parenteral early nutrition in ventilated adults with shock: a randomised, controlled, multicentre, open-label, parallel-group study (NUTRIREA-2).

 

Nutrition in necrotising pancreatitis

(Valentin Fuhrmann)

 

Severe acute pancreatitis

  • shock, respiratory failure, AKI, delirium, abdominal compartment syndrome
  • mortality 20%
  • Early enteral nutrition (EN) important in the multimodal therapy

 

Recommendations:

Mild- oral feed once pain / vomiting resolved

Severe- Early EN – ESPEN 2018; Parenteral nutrition only when EN route not available / not tolerated / not meeting energy requirements (ACG 2013)

 

NG tube feeding safe and well-tolerated compared to NJ feeding

Nasogastric or nasojejunal feeding in predicted severe acute pancreatitis: a meta-analysis

 

Feeding intolerance is common in acute pancreatitis (nausea, vomiting, ileus, diarrhoea)

Early versus on-demand nasoenteric tube feeding in acute pancreatitis.

 

Managing feeding intolerance:

  • Start EN early to avoid extended ileus
  • Re-assess GI function early
  • Slow start, do not aim for full energy needs
  • Prokinetics
  • Post-pyloric feeding is an option if prokinetics not helping
  • Diagnose and manage of intraabdominal hypertension
  • Consider parenteral route

 

IMG_0497

 

ESICM guidelines:  DELAY enteral feeding in cases of

  • Uncontrolled shock
  • Uncontrolled hypoxia / hypercapnoea / acidosis
  • Abdominal compartment syndrome
  • Gastric aspirates > 500mls / 6hrs

 

 

 

Nutrition in elderly frail patients

(Jean-Charles Preiser)

IMG_0503

IMG_0514

Nutritional management in frailty:

  • Acute phase: refeeding risk
  • Recovery phase: Need adequate calories, high protein intake, exercise, selected pharmaconutrients

 

ESPEN Recommendations for refeeding hypophosphataemia

  • Measure electrolytes 2-3x/day, supplement if needed
  • Restrict energy supply for 48hrs then gradually increase

 

Positive energy balance is associated with accelerated muscle atrophy (Positive energy balance is associated with accelerated muscle atrophy and increased erythrocyte glutathione turnover during 5 wk of bed rest)

 

Burden of critical illness in frail pts lasts for long period after d/c from ICU and hospital

  • huge task of rebuilding
  • Vit D deficiency associated with muscle loss (type 2 myocytes), supplementation increases muscle protein synthesis in non-critically ill
  • Selected amino acids, in particular leucine, can stimulate muscle protein synthesis
  • Combination of increased protein intake, amino acid supplementation and exercise

 

 

Nutrition in malnourished patients

(Michael Hiesmayr)

 

Risk factors for malnutrition include:

  • Unintentional weight loss >5% in 1 month
  • Starvation >7days
  • Prolonged hypocaloric feeding / chronic swallowing difficulties
  • Idiosyncratic diets (qualitative malnutrition)
  • Nutrient losses / reduced absorption e.g. GI condition, chronic pancreatitis, chronic antacid use (by binding minerals), chronic high-dose diuretics, post bariatric surgery

 

Malnourished pts do not always look thin (e.g. bariatric surgery); low BMI does not mean malnourishment (e.g. endurance sports)

 

Those who tend to eat less in hospital are either the elderly or pts <39 yrs of age: ? related to unusual situation of being hospitalised at this age / history of chronic illness

 

Measurements:

  • BMI – fluctuates with fluid resuscitation
  • Muscle mass – visualisation by CT / Ultrasound (degree of subjectivity)
  • Muscle function – MRC grading of strength, Dynamometer
  • Bioimpedance

 

Muscle layer thickness is dynamic and fluid-sensitive

  • up to 15% apparent increase in muscle mass after 8-hr surgical procedure
  • reflects lean tissue, but also fluid, impaired venous return and inflammation

IMG_0528

IMG_0529

 

 

Nutrition risk assessment:

 

Estimate body weight if unknown

Investigate nutrition history

  • history from pt / family
  • If malnourished, start slow feed and increase progressively
  • Prophylactic thiamine
  • Supplement K+, Mg++, PO4- (measure)

Observe pt for GI tolerance, cardio/pulmonary tolerance

 

Sensible take home messages:

  • Due to loss of autonomy, ICU pts are often dependent on nutrition care
  • Always consider malnutrition once the pt has been on ICU >7 days even if body size appears fine
  • Look at the patient, not just the numbers – muscle bulk, hands, overall appearance
  • NO reason not to feed early once condition stabilised
  • If the pt is ‘eating independently’ on ICU, always monitor intake to avoid false reassurances of adequate nutrition
  • Aim to retrain pt to eat while on ICU + swallowing test before discharge to the ward, where there is less direct nursing care and risk of further malnutrition

How do I humanise patient care?

Image result for Humanising

(Nancy Kentish-Barnes)

Critical illness and ICU environment (culture, priorities and architecture) have significant impact on patient and relatives

IMG_0404

Arriving in ICU

  • Signs / way-finding systems (Davidson Crit Care Med 2007)
  • Waiting: initial communication and reassurance, estimating time before pt is ready for visit
  • Seeing pt: touching / talking to pt – encourages togetherness
  • ICU team: introduction, name badges
  • Place: privacy, natural lighting, furniture, positive distractions (art or photos to personalise room), clock (visible to pt)

Patient experience

  • Discomforts: question pt, noise from alarms and verbal communications
  • Thirst bundle (oral swab, cold water spray, lip moisturiser (Thirst Bundle – Puntillo ICM 2014)
  • Restraint alternatives (bed net, sleeper bag, surveillance)
  • Psychological distress: music, 5-minute foot massage, relaxation / hypnosis
  • Technology: look at patient before machines, eye contact, empathy

 

  • Lack of agency: encourage pt choice to promote sense of control over decisions and own body
  • Lack of memory: Post ICU burden include nightmares, memories
  • ICU diary: multiple contributors, factual narrative, written messages of caring, transparency

 

  • Vulnerable relatives: anxiety, depression common, understand 50% of medical info
  • Visiting policy: prolonged time in waiting room prevents relatives from leaving ICU to self-care, worry re pt welfare / transparency when they can’t see pt
  • Child visits: Adapted leaflets for children, also to guide ICU team, child psychologist

 

  • Communication: by far non-verbal cues are picked up over words; family-support pathway (daily nurse communication and at least 2 multidisciplinary team-family meetings)

 

  • Relatives participation in care: listen to pt, relatives

 

Leaving ICU

  • Ward transfer: positive indicator of progress but anxiety/stress due to reduced presence of healthcare team
  • Information in anticipation of ward environment: written, family conference, video

 

End-of-life in ICU:

  • Pt’s wishes, spiritual support, family needs
  • Acknowledge emotions, elicit questions, understand pt as a person
  • Discontinue unnecessary monitoring, tests and treatments
  • Increases satisfaction and trust
  • Decreases risk of PTSD, anxiety and depression following death

 

In practice, for units that have not specifically adopted ‘humanising care approach’, start by creating an ICU workgroup to create a dynamic around humanisation – this allows addressing of staff concerns e.g. visiting policies / timing of EOL care etc.

Posters on #POCUS

POCUSPOSTERS

 

Once again, the recently concluded ESICM #LIVES2018  was a myriad of #POCUS goodness performed by colleagues across the world. In addition to the usual pre-congress Echo courses and State-of-the-Art sessions, the posters presented were equally impressive and educational. Here I’ve summarised just some of the posters that caught my eye (particularly the TDi of diaphragm and the UltraNurses study)

ps. don’t forget to listen to our podcast with Prof McLean and the amazing SICS group

 

EVALUATION OF DIAPHRAGMATIC FUNCTION USING TISSUE DOPPLER IMAGING (TDI) – CORRELATION WITH TRANSDIAPHRAGMATIC (Pdi) DERIVED PARAMETERS

Soilemezi et al (Greece)

Since TDI measures the velocity of moving tissue……why not use it to measure the velocity of the diaphragm???

INTRODUCTION. Tissue Doppler Imaging (TDI) is an ultrasonographic technique extensively used in cardiology to evaluate cardiac systolic and diastolic function. It uses Doppler to quantify the velocity of tissue rather than blood, and it, therefore, allows direct measurement of the velocity of moving tissue. TDI of the diaphragm has never being used so far to assess the characteristics of diaphragmatic contraction and relaxation.

OBJECTIVES. This study attempts to correlate TDI-derived parameters with transdiaphragmatic (Pdi)-derived parameters, which are already evaluated and used in clinical practice.

METHODS. In twelve patients undergoing a T-piece weaning trial (9 weaning success and 3 weaning failures) a TDI examination of the diaphragm was performed. High quality images of diaphragmatic TDI were very easily obtained in all patients with a cardiac 4 MHz sector transducer. In all patients a nasogastric tube, equipped with two balloons for measuring esophageal and gastric pressures, was previously inserted for feeding purposes allowing for Pdi recording. Simultaneous Pdi and TDI tracings were recorded for 207 breaths in total (approximately 15 breaths/patient). For every breath, the Pdi signal was analyzed to measure the following parameters (fig 1): maximum Pdi (Pdi max), pressure time product (PTP), and the slope of the initial steepest part of the descending part of the Pdi curve, ie the diaphragmatic Maximum Relaxation Rate (Pdi-MRR). These Pdi-derived parameters were respectively correlated with the following TDI-derived parameters (fig.2): TDI peak contraction velocity, the velocity-time integral during inspiration (VTI), and the slope of the initial steepest part of the velocity curve of diaphragmatic motion during relaxation, ie, the TDI-derived maximum relaxation rate. The level of significance and the correlation coefficient were calculated for each comparison.

RESULTS. A highly significant correlation was found between the Pdi-MRR and the TDI-derived maximum relaxation rate (r=0.93, y=1.7x+30, p< 0.001). Furthermore, TDI peak contraction velocity was also highly correlated with PTP and Pdi max, (r=0.91 and r=0.89 respectively, p< 0.001). On the contrary, a weak but significant correlation (r=0,54, y=2x+3.2, p< 0.01) was found between the PTP and the VTI.

CONCLUSIONS. Our results suggest that TDI represents an ultrasonographic technique that can be used to assess features of the contraction and relaxation of the diaphragm, until now thought to be acquired only with Pdi recordings; it bears the additional advantages of all ultrasonographic techniques, ie, it is non-invasively performed on the bedside, compared to the cumbersome method of acquiring and interpreting Pdi tracings. Further studies are needed to demonstrate the potential utilities of this new ultrasonographic examination of the diaphragm in the everyday ICU practice.

 

Screenshot 2018-10-28 at 08.56.40

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Screenshot 2018-10-28 at 08.56.57

 

UltraNurse: Bedside Ultrasound by ICU nurses

Morreale et al. (Netherlands)

INTRODUCTION. Bedside ultrasound is now extensively used by intensivists worldwide to optimize patient management at the bedside [1]. However, monitoring is discontinuous and relies on intensivist availability. Therefore, teaching bedside ultrasound to ICU nurses holds great promise, as they typically spend far more time at the bedside.

OBJECTIVES. To assess the feasibility of teaching bedside ultrasound to ICU nurses.

METHODS. We enrolled 8 ICU nurses into our UltraNurse training program that relied on a focused 3-phase approach [2] within our 24-bed university hospital ICU. First, these UltraNurses attended two 4-hour theory and practice sessions led by an ultrasound-certified intensivist. Our UltraNurse scanning protocol consisted of anterior and posterolateral lung ultrasound (LUS) imaging as well as measuring the left ventricular outflow tract flow velocity time integral (LVOT-VTI) using pulsed wave Doppler as a proxy for stroke volume. UltraNurses then performed 5 bedside ultrasound examinations under direct supervision. Finally, they continued performing bedside ultrasound examinations until full proficiency was reached. Every examination was supervised by ultrasound-certified intensivists and graded on dexterity, image quality and accuracy of interpretation, using Likert scales. A priori, full proficiency was defined as 5 consecutive examinations performed without assistance and interpreted correctly. Using structured questionnaires, UltraNurses were interviewed frequently to identify barriers and facilitators for our program. Data are given as medians and interquartile range.

RESULTS. All UltraNurses reached full proficiency status. This required 13 [12-18] examinations for LUS and 13 [11-16] for LVOT-VTI. Total time required to become fully proficient was 21 [14-26] weeks for LUS and 26 [19-29] weeks for LVOT-VTI. Figures 1 and 2 depict UltraNurse progress. Table 1 shows UltraNurse characteristics. Total duration of the program was 7 months in which 123 patients underwent 230 examinations. Varying support from intensivists and perceived high workload were barriers for our program while facilitators included intensivist enthusiasm, increased work satisfaction and improved perceived valuable contribution to the treatment team.

Screenshot 2018-10-28 at 09.28.59

Screenshot 2018-10-28 at 09.29.07

CONCLUSION. This is the first report to show that teaching bedside ultrasound to ICU nurses is feasible. The number of examinations to reach full proficiency for our UltraNurse protocol was small, although this took many weeks. Teaching bedside ultrasound to ICU nurses deserves widespread consideration. It holds great promise for increasing ICU nurse work satisfaction but most importantly for further improving management of our critically ill patients. We are currently evaluating the clinical impact of our UltraNurse program.

Comparison of bedside ultrasound with chest X-ray to detect CVC related mechanical complications; a prospective observational study (COMBUX-study)

Smit et al. (Netherlands)

Could bedside ultrasound replace chest x-ray as the standard to detect complications and malpositioning of CVC lines?

INTRODUCTION. Complications arising from central venous catheter (CVC) placement are mostly due to pneumothorax or malposition . Correct position is currently confirmed by chest X-ray (CXR), while ultrasound (US) might be a more suitable option.

OBJECTIVES. We investigated whether CVC malposition and iatrogenic pneumothorax could be accurately detected by US compared to CXR.

METHODS. Design – Single-center prospective, observational study conducted at the VU University Medical Center in the Netherlands. The study population consisted of critically ill adult patients who underwent central venous cannulation of the internal jugular vein (IJV) or subclavian vein (SV). The US evaluation of pneumothorax and CVC malposition consisted of three parts; vascular US of the IJV and SV bilaterally, lung-US to detect pneumothorax and a cardiac US examination combined with contrast enhanced ultrasound. Primary outcome was the feasibility and accuracy of bedside ultrasound in detecting CVC misplacement. Regarding pneumothorax, the overall agreement percentage and Cohen’s kappa coefficient between US and CXR were secondary outcomes.

RESULTS. Between April 2016 and June 2017, 450 CVCs in 427 patients were included, with a median age of 68.5 (±IQR: 13.0). 70.2% of the population was male. Malposition occurred in 2.3% of all central line placements and pneumothorax in 0.9% – 2.2%. Vascular ultrasound of the IJV and SV bilaterally and lung-US were feasible in 100% of the cases, whereas cardiac US examination was feasible in 88.9% of the cases. Sensitivity of US to detect CVC malposition was 0.727 (95% CI: 0.435 – 0.924) and specificity was 0.995 (95% CI: 0.984 – 0.999). In 442 out of 450 cases (98.2%) US and CXR showed agreement for pneumothorax with a Cohen’s κ-coefficient of 0.421 (95% CI: 0.255 – 0.587).

Screenshot 2018-10-28 at 09.06.01 Screenshot 2018-10-28 at 09.05.53

CONCLUSIONS. To our knowledge this is the largest study so far investigating the feasibility and accuracy of US to detect CVC malposition and associated pneumothorax. In conclusion, US is a suitable diagnostic modality to detect CVC malposition and iatrogenic pneumothorax with an excellent specificity and moderate sensitivity. Furthermore, US has multiple advantages over CXR in the critical care setting; it is performed faster and does not subject patients to radiation.

REFERENCE(S).
– Parienti, J.J., et al., Intravascular Complications of Central Venous Catheterization by Insertion Site. N Engl J Med, 2015. 373(13): p. 1220-9.
– Zanobetti, M., et al., Verification of correct central venous catheter placement in the emergency department: comparison between ultrasonography and chest radiography. Intern Emerg Med, 2013. 8(2): p. 173-80.
– Hourmozdi, J.J., et al., Routine Chest Radiography Is Not Necessary After Ultrasound-Guided Right Internal Jugular Vein Catheterization. Crit Care Med, 2016. 44(9): p. e804-8.

 

Goal Directed Integrated Ultrasound Protocol in predicting Weaning Success and Extubation Failure: A Prospective Observational Study

Kundu et al. (India)

INTRODUCTION. Difficulty in weaning from mechanical ventilation is encountered in approximately 20% of patients in the intensive care unit.Recent investigations focusing on lung, diaphragmatic and cardiac ultrasound highlights the potential role of ultrasonography in prediction of outcome following extubation. The present study attempted to assess the ability of a combined lung, diaphragmatic and cardiac ultrasound protocol to predict weaning success and failure following extubation.

OBJECTIVES.
Primary:
1.To assess the ability of an Integrated USG protocol during weaning to predict weaning success or failure.
Secondary:
2. To assess the role of lung, diaphragmatic and cardiovascular dysfunction to failed weaning.
3.To assess the changes in Lung ultrasound Score (LUS) following SBT.

METHODS. All patients scheduled to undergo SBT were evaluated by USG to measure LUS, Diaphragmatic Thickness fraction(DTF) and changes in Velocity Time Integral (VTI) to passive leg raise at the beginning of SBT. Changes in LUS following SBT was recorded. Patients extubated following SBT were classified as weaning success if non invasive or invasive mechanical ventilator support was not required in the next 48 hours.

Screenshot 2018-10-28 at 09.11.25

RESULTS. 60 patients who underwent extubation following a successful SBT were included in the study.27 patients(45%) required either non invasive or invasive mechanical ventilator support during the next 48 hours and were classified as weaning failure (Group F). Rest 33 patients were designated as weaning success (Group S).Patients in Group F had significantly longer ICU length of stay, higher LUS change during SBT(p< 0.001),lower DTF (p< 0.05) and showed lower VTI increment to PLR(p< 0.001).Using a binary logistic regression model,DTF< 26% (odds ratio 6.20,95% CI 1.06-36.04) and VTI change to PLR< 10.2% (odds ratio 6.16,95%CI 1.14-33.13) were found to be significant predictors of weaning failure(p< 0.05).The AUROC for VTI and DTF for predicting weaning failure were 0.79 and 0.64 respectively(Figure 1).

Screenshot 2018-10-28 at 09.12.19

CONCLUSIONS. An integrated Ultrasound protocol using a combination of ultrasonographic parameters of lung, diaphragm and cardiac sonography was a reliable predictor of weaning failure. This study highlights the role of diaphragmatic dysfunction and preload independence of the heart in contributing to failed weaning, earlier detection of which may lead to better tailoring of therapy.

Lung and diaphragm ultrasound in post-surgical patients to predict weaning failure

Colombo (Italy)

INTRODUCTION. Weaning failure (WF) in post-surgical patients may be due to lung and diaphragm dysfunction; they can both be assessed by ultrasound (LUS and DUS), helping in predicting WF.1

OBJECTIVES. To assess lung aeration and diaphragm activity in post-surgical patients to early identify those at risk of WF.

METHODS. Prospective observational monocentric study. We enrolled ICU post-surgical adult patients within 24 hours after extubation. They were in spontaneous breathing and had no neuromuscular diseases. LUS score for aeration assessment was computed: sternum, anterior and posterior axillary lines define anterior, lateral and posterior regions, each divided in superior and inferior to have 12 areas per side; in each area a score from 0 (normal aeration) to 3 (complete loss of aeration) was given.2 Global and anterolateral scores corresponded to the sum of all and anterolateral areas’ score respectively. DUS analyzed right thickening fraction (TF=(expiratory – inspiratory)/inspiratory thickness*100) and caudal displacement (CD).1 WF was defined as NIV/reintubation within 48 hours after extubation.

RESULTS. We enrolled 74 patients (60 males, age 69.0±10.0yrs, BMI 26.4±5.1, mechanical ventilation length in ICU 272.0±125.6 mins, ICU stay 2[1.0-3.0] days). Surgery was performed by laparotomy (17), sternotomy (47) and right thoracotomy (10). WF occurred in 21 patients (28.4%); WF patients differed by BMI only (30.3±5.4 vs. 24.9±4.1; p< 0.0001). WF wasn’t significantly different among surgical approaches; a trend in higher WF is observed in thoracotomies (50% vs. laparotomy 23.5% and sternotomy 25.5%, p=0.284). Overall global and anterolateral LUS scores were 11.0[8.0-14.0] and 3.0[1.0-6.0] respectively. No significant differences were remarked among surgical approaches. WF patients had higher scores (global 13.0[11.0-17.0] vs. 10.5 [7.5-13-0], p=0.0089; anterolateral 5.0[3.0-8.0] vs. 3.0[1.0-4.0], p=0.0019). Relative risk of WF if anterolateral LUS≥8 was 2.9 (95% CI 1.5-5.5; p=0.0341). Anterolateral LUS alone predicted WF with AUC 0.7405 [95%CI 0.60519-0.87572] (fig. 1). Overall CD was 1.5[1.1-1.74] and 2.5[1.7-3.1] cm and TF was 17.7[8.5-29.6] and 23.1[11.0-37.3] in normal and forced inspiration respectively. No significant differences were remarked among different surgical approaches and in patients with/without WF.

Screenshot 2018-10-28 at 09.17.26

CONCLUSIONS. Preliminary data suggests LUS score, but not DUS, is useful to predict WF in post-surgical extubated patients. Data need to be confirmed in a wider population.

Using ultrasound of heart, lungs and diaphragm to predict weaning success

Haaksma et al. (Netherland)

BACKGROUND. In ICU patients deciding the optimal timing for extubation is challenging and clinical predictors are not very accurate. Ultrasonographic assessment of the diaphragm function has been used to predict successful extubation.1 However, cardiorespiratory function also greatly impacts a patient’s ability to wean from mechanical ventilation.

OBJECTIVE. To assess if a combination ultrasound measurements of the diaphragm, heart and lungs could predict extubation success more accurately than using single-organ ultrasonography assessment.

METHODS. This prospective observational study in the Intensive Care Unit of a tertiary academic hospital included adult patients who were invasively ventilated for > 72 hrs. Exclusion criteria included paraplegia, tracheostomy or planned non-invasive ventilation (NIV) after extubation. Ultrasound measurements of heart (left ventricular function (LVF)), lungs (number of B-lines) and diaphragm (thickening fraction (TFdi%)) were performed within 6 hours before extubation during spontaneous breathing trial. Patients not needing reintubation or NIV within 48 hrs after extubation were recorded as successful extubation. A logistic regression prediction model using backward selection was made.

RESULTS. In this interim analysis, 39 patients were included of which 77% were male, with a mean age of 61 (±17) years and a median of 126 [95-207] and 96 [84-185] hours on mechanical ventilation in the successful and failed group, respectively. Of these patients, 7 (18%) required reintubation within 48 hours. Patients in need of reintubation compared to patients who were extubated successfully had no significant difference in TFdi% (21.2% vs. 25.5%; p=0.36), left ventricular function (72% good vs. 71% good, p=.94) or B- lines (17 [9-24] vs. 7 [3-15] p=.072), although a trend for more B-lines was observed in the extubation failure group. Multivariable regression analysis showed that addition of B- lines and classic parameters such as PaO2 and FiO2 to the thickening fraction has added value in predicting extubation (Table 1). This was not the case for LVF.

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CONCLUSION. The results of this study suggest that addition of lung ultrasound to diaphragm ultrasound might have added benefit in predicting extubation success, while for LVF this does not seem to be the case.

Diagnostic performance of the BLUE-lung ultrasound protocol in critically ill patients undergoing thoracic CT

Haaksma et al. (Netherlands)

BACKGROUND. The BLUE protocol was developed to match artifacts of lung ultrasound (LUS) with the final diagnosis in patients in respiratory distress presenting to the emergency department. Since then, it has found its way into routine use on the intensive care unit (ICU) to assess respiratory failure [1]. However, the diagnostic accuracy of this protocol has never been verified in an ICU setting.

OBJECTIVE. We set out to determine diagnostic performance of the BLUE protocol in ICU patients undergoing thoracic CT-scan.

METHODS. This prospective single center observational study included patients admitted to our 24-bed university hospital ICU who underwent thoracic CT scan. LUS was performed within 3 hours of the CT scan according to the BLUE protocol without venous analysis [1]. The ultrasound operator was blinded for the result of the CT scan. Additionally, an intensivist, blinded for the result of the CT scan, provided a BLUE-protocol diagnosis (pulmonary edema, pneumothorax, obstructive lung disease and pneumonia) based on the LUS findings in combination with clinical information. The reference test was the diagnosis made by one radiologist based on the CT scan.

RESULTS. 61 patients, of which 41 were male, were included with a median age of 61 (IQR 25). Of all diagnoses, signs for pneumothorax yielded the highest effective accuracy with 89%. Overall diagnostic accuracy of the BLUE protocol was 48%. Intensivists diagnosis based on LUS and clinical findings yielded an accuracy of 62%. Sensitivity, specificity, PPV and NPV for the four final diagnoses are shown in Table 1.

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CONCLUSION. In ICU patients undergoing thoracic CT, the highest accuracy of the BLUE protocol without venous analysis is 89% for pneumothorax, while overall accuracy is 48%. When LUS findings are combined with clinical findings its accuracy increases to 62%.