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Burns KEA, Sadeghirad B, Ghadimi M, Khan J, Phoophiboon V, Trivedi V, Gomez Builes C, Giammarioli B, Lewis K, Chaudhuri D, Desai K, Friedrich JO. Comparative effectiveness of alternative spontaneous breathing trial techniques: a systematic review and network meta-analysis of randomized trials. Crit Care 2024; 28:194. [PMID: 38849936 PMCID: PMC11162018 DOI: 10.1186/s13054-024-04958-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Accepted: 05/17/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND The spontaneous breathing trial (SBT) technique that best balance successful extubation with the risk for reintubation is unknown. We sought to determine the comparative efficacy and safety of alternative SBT techniques. METHODS We searched Medline, EMBASE, and the Cochrane Central Register of Controlled Trials from inception to February 2023 for randomized or quasi-randomized trials comparing SBT techniques in critically ill adults and children and reported initial SBT success, successful extubation, reintubation (primary outcomes) and mortality (ICU, hospital, most protracted; secondary outcome) rates. Two reviewers screened, reviewed full-texts, and abstracted data. We performed frequentist random-effects network meta-analysis. RESULTS We included 40 RCTs (6716 patients). Pressure Support (PS) versus T-piece SBTs was the most common comparison. Initial successful SBT rates were increased with PS [risk ratio (RR) 1.08, 95% confidence interval (CI) (1.05-1.11)], PS/automatic tube compensation (ATC) [1.12 (1.01 -1.25), high flow nasal cannulae (HFNC) [1.07 (1.00-1.13) (all moderate certainty), and ATC [RR 1.11, (1.03-1.20); low certainty] SBTs compared to T-piece SBTs. Similarly, initial successful SBT rates were increased with PS, ATC, and PS/ATC SBTs compared to continuous positive airway pressure (CPAP) SBTs. Successful extubation rates were increased with PS [RR 1.06, (1.03-1.09); high certainty], ATC [RR 1.13, (1.05-1.21); moderate certainty], and HFNC [RR 1.06, (1.02-1.11); high certainty] SBTs, compared to T-piece SBTs. There was little to no difference in reintubation rates with PS (vs. T-piece) SBTs [RR 1.05, (0.91-1.21); low certainty], but increased reintubation rates with PS [RR 2.84, (1.61-5.03); moderate certainty] and ATC [RR 2.95 (1.57-5.56); moderate certainty] SBTs compared to HFNC SBTs. CONCLUSIONS SBTs conducted with pressure augmentation (PS, ATC, PS/ATC) versus without (T-piece, CPAP) increased initial successful SBT and successful extubation rates. Although SBTs conducted with PS or ATC versus HFNC increased reintubation rates, this was not the case for PS versus T-piece SBTs.
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Affiliation(s)
- Karen E A Burns
- Departments of Critical Care Medicine and Medicine, Unity Health Toronto, St. Michael's Hospital, 30 Bond Street, 4-045 Donnelly Wing, Toronto, ON, M5B 1W8, Canada.
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.
- Li Ka Shing Knowledge Institute, Unity Health Toronto, St. Michael's Hospital, Toronto, Canada.
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada.
| | - Behnam Sadeghirad
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
- Departments of Anesthesia and Medicine, McMaster University, Hamilton, Canada
| | - Maryam Ghadimi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Jeena Khan
- Departments of Critical Care Medicine and Medicine, Unity Health Toronto, St. Michael's Hospital, 30 Bond Street, 4-045 Donnelly Wing, Toronto, ON, M5B 1W8, Canada
- Royal College of Surgeons of Ireland, University of Medicine and Health Sciences, Dublin, Ireland
| | - Vorakamol Phoophiboon
- Departments of Critical Care Medicine and Medicine, Unity Health Toronto, St. Michael's Hospital, 30 Bond Street, 4-045 Donnelly Wing, Toronto, ON, M5B 1W8, Canada
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Vatsal Trivedi
- Department of Anesthesiology & Pain Medicine, University of Toronto, Toronto, ON, Canada
- Institute for Better Health, Trillium Health Partners, Mississauga, Canada
| | - Carolina Gomez Builes
- Department of Anesthesiology & Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Benedetta Giammarioli
- Department of Anesthesiology & Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Kimberley Lewis
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
- Departments of Anesthesia and Medicine, McMaster University, Hamilton, Canada
- Department of Critical Care, St. Joseph's Healthcare, Hamilton, Canada
| | - Dipayan Chaudhuri
- Departments of Anesthesia and Medicine, McMaster University, Hamilton, Canada
- Department of Critical Care, St. Joseph's Healthcare, Hamilton, Canada
| | - Kairavi Desai
- Michael DeGroote School of Medicine, McMaster University, Hamilton, Canada
| | - Jan O Friedrich
- Departments of Critical Care Medicine and Medicine, Unity Health Toronto, St. Michael's Hospital, 30 Bond Street, 4-045 Donnelly Wing, Toronto, ON, M5B 1W8, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Li Ka Shing Knowledge Institute, Unity Health Toronto, St. Michael's Hospital, Toronto, Canada
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Abu-Sultaneh S, Iyer NP, Fernández A, Tume LN, Kneyber MCJ, López-Fernández YM, Emeriaud G, Ramnarayan P, Khemani RG. Framework for Research Gaps in Pediatric Ventilator Liberation. Chest 2024:S0012-3692(24)00688-3. [PMID: 38852880 DOI: 10.1016/j.chest.2024.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Revised: 05/03/2024] [Accepted: 05/11/2024] [Indexed: 06/11/2024] Open
Abstract
BACKGROUND The 2023 International Pediatric Ventilator Liberation Clinical Practice Guidelines provided evidence-based recommendations to guide pediatric critical care providers on how to perform daily aspects of ventilator liberation. However, because of the lack of high-quality pediatric studies, most recommendations were conditional based on very low to low certainty of evidence. RESEARCH QUESTION What are the research gaps related to pediatric ventilator liberation that can be studied to strengthen the evidence for future updates of the guidelines? STUDY DESIGN AND METHODS We conducted systematic reviews of the literature in eight predefined Population, Intervention, Comparator, Outcome (PICO) areas related to pediatric ventilator liberation to generate recommendations. Subgroups responsible for each PICO question subsequently identified major research gaps by synthesizing the literature. These gaps were presented at an international symposium at the Pediatric Acute Lung Injury and Sepsis Investigators meeting in spring 2022 for open discussion. Feedback was incorporated, and final evaluation of research gaps are summarized herein. Although randomized controlled trials (RCTs) represent the highest level of evidence, the panel sought to highlight areas where alternative study designs also may be appropriate, given challenges with conducting large multicenter RCTs in children. RESULTS Significant research gaps were identified in six broad areas related to pediatric ventilator liberation. Several of these areas necessitate multicenter RCTs to provide definitive results, whereas other gaps can be addressed with multicenter observational studies or quality improvement initiatives. Furthermore, a need for some physiologic studies in several areas remains, particularly regarding newer diagnostic methods to improve identification of patients at high risk of extubation failure. INTERPRETATION Although pediatric ventilator liberation guidelines have been created, the certainty of evidence remains low and multiple research gaps exist that should be filled through high-quality RCTs, multicenter observational studies, and quality improvement initiatives.
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Affiliation(s)
- Samer Abu-Sultaneh
- Division of Pediatric Critical Care, Department of Pediatrics Riley Hospital for Children at Indiana University Health and Indiana University School of Medicine Indianapolis, IN.
| | - Narayan Prabhu Iyer
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Analía Fernández
- Division of Critical Care Medicine, Hospital General de Agudos "C. Durand," Universidad de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
| | - Lyvonne N Tume
- Edge Hill University Health Research Institute, Ormskirk, England
| | - Martin C J Kneyber
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Yolanda M López-Fernández
- Pediatric Critical Care Division, Department of Pediatrics, Cruces University Hospital, BioBizkaia Health Research Institute, Bizkaia, Spain
| | - Guillaume Emeriaud
- Department of Pediatrics, Sainte-Justine Hospital, Université de Montréal, Montreal, QC, Canada
| | - Padmanabhan Ramnarayan
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, England
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA
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Burns KEA, Khan J, Phoophiboon V, Trivedi V, Gomez-Builes JC, Giammarioli B, Lewis K, Chaudhuri D, Desai K, Friedrich JO. Spontaneous Breathing Trial Techniques for Extubating Adults and Children Who Are Critically Ill: A Systematic Review and Meta-Analysis. JAMA Netw Open 2024; 7:e2356794. [PMID: 38393729 PMCID: PMC10891471 DOI: 10.1001/jamanetworkopen.2023.56794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 12/28/2023] [Indexed: 02/25/2024] Open
Abstract
Importance Considerable controversy exists regarding the best spontaneous breathing trial (SBT) technique to use. Objective To summarize trials comparing alternative SBTs. Data Sources Several databases (MEDLINE [from inception to February 2023], the Cochrane Central Register of Controlled Trials [in February 2023], and Embase [from inception to February 2023] and 5 conference proceedings (from January 1990 to April 2023) were searched in this systematic review and meta-analysis. Study Selection Randomized trials directly comparing SBT techniques in critically ill adults or children and reporting at least 1 clinical outcome were selected. Data Extraction and Synthesis Paired reviewers independently screened citations, abstracted data, and assessed quality for the systematic review and meta-analysis using Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA guidelines). Data were pooled using random-effects models. Main Outcomes and Measures Primary outcomes included SBT success, extubation success, and reintubation. Results The systematic review and meta-analysis identified 40 trials that included 6716 patients. Low-quality evidence (14 trials [n = 4459]) suggested that patients were not more likely to pass a pressure support (PS) compared with a T-piece SBT (risk ratio [RR], 1.04; 95% CI, 0.97-1.11; P = .31; I2 = 73%), unless 1 outlier trial accounting for all heterogeneity was excluded (RR, 1.09; 95% CI, 1.06-1.12; P < .001; I2 = 0% [13 trials; n = 3939]; moderate-quality evidence), but were significantly more likely to be successfully extubated (RR, 1.07; 95% CI, 1.04-1.10; P < .001; I2 = 0%; 16 trials [n = 4462]; moderate-quality evidence). Limited data (5 trials [n = 502]) revealed that patients who underwent automatic tube compensation/continuous positive airway pressure compared with PS SBTs had a significantly higher successful extubation rate (RR, 1.10; 95% CI, 1.00-1.21; P = .04; I2 = 0% [low-quality evidence]). Compared with T-piece SBTs, high-flow oxygen SBTs (3 trials [n = 386]) had significantly higher successful extubation (RR, 1.06; 95% CI, 1.00-1.11; P = .04; I2 = 0%) and lower reintubation (RR, 0.37; 95% CI, 0.21-0.65; P = <.001; I2 = 0% [both low-quality evidence]) rates. Credible subgroup effects were not found. Conclusions and Relevance In this systematic review and meta-analysis, the findings suggest that patients undergoing PS compared with T-piece SBTs were more likely to be extubated successfully and more likely to pass an SBT, after exclusion of an outlier trial. Pressure support SBTs were not associated with increased risk of reintubation. Future trials should compare SBT techniques that maximize differences in inspiratory support.
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Affiliation(s)
- Karen E. A. Burns
- Department of Critical Care, St. Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Division of General Internal Medicine, Department of Medicine, St. Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Jeena Khan
- Department of Critical Care, St. Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin, Ireland
| | - Vorakamol Phoophiboon
- Department of Critical Care, St. Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Vatsal Trivedi
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute for Better Health, Trillium Health Partners, Mississauga, Ontario, Canada
| | | | - Benedetta Giammarioli
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kimberley Lewis
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Department of Critical Care, St. Joseph’s Healthcare, Hamilton, Ontario, Canada
| | - Dipayan Chaudhuri
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Department of Critical Care, St. Joseph’s Healthcare, Hamilton, Ontario, Canada
| | - Kairavi Desai
- Michael G. DeGroote School of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Jan O. Friedrich
- Department of Critical Care, St. Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Division of General Internal Medicine, Department of Medicine, St. Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
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Descriptors of Failed Extubation in Norwood Patients Using Physiologic Data Streaming. Pediatr Cardiol 2023; 44:396-403. [PMID: 36562780 DOI: 10.1007/s00246-022-03084-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 12/18/2022] [Indexed: 12/24/2022]
Abstract
The objective of this study is to evaluate the utility of high-frequency physiologic data during the extubation process and other clinical variables for describing the physiologic profile of extubation failure in neonates with hypoplastic left heart syndrome (HLHS) post-Norwood procedure. This is a single-center, retrospective analysis. Extubation events were collected from January 2016 until July 2021. Extubation failure was defined as the need for re-intubation within 48 h of extubation. The data included streaming heart rate, respiratory rate, blood pressure, arterial oxygen saturation, and cerebral/renal near-infrared spectroscopy (NIRS). The most recent blood laboratory results before extubation were also included. These markers, demographics, clinical characteristics, and ventilatory settings were compared between successful and failed extubations. The analysis included 311 extubations. The extubation failure rate was 10%. According to univariable analyses, failed extubations were preceded by higher respiratory rates (p = 0.029), lower end-tidal CO2 (p = 0.009), lower pH (p = 0.043), lower serum bicarbonate (p = 0.030), and lower partial pressure of O2 (p = 0.022). In the first 10 min after extubation, the failed events were characterized by lower arterial (p = 0.028) and cerebral NIRS (p = 0.018) saturations. Failed events were associated with persistently lower values for cerebral NIRS 2 h post-extubation (p = 0.027). In multivariable analysis, vocal cord anomaly, cerebral NIRS at 10 min post-extubation, renal NIRS at pre-extubation and post-extubation, and end-tidal CO2 at pre-extubation remained as significant co-variables. Oximetric indices before, in the 10 min immediately after, and 2 h after extubation and vocal cords paralysis are associated with failed extubation events in patients with parallel circulation.
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Zheng YC, Huang YM, Chen PY, Chiu HY, Wu HP, Chu CM, Chen WS, Kao YC, Lai CF, Shih NY, Lai CH. Prediction of survival time after terminal extubation: the balance between critical care unit utilization and hospice medicine in the COVID-19 pandemic era. Eur J Med Res 2023; 28:21. [PMID: 36631882 PMCID: PMC9832251 DOI: 10.1186/s40001-022-00972-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 12/26/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND We established 1-h and 1-day survival models after terminal extubation to optimize ventilator use and achieve a balance between critical care for COVID-19 and hospice medicine. METHODS Data were obtained from patients with end-of-life status at terminal extubation from 2015 to 2020. The associations between APACHE II scores and parameters with survival time were analyzed. Parameters with a p-value ≤ 0.2 in univariate analysis were included in multivariate models. Cox proportional hazards regression analysis was used for the multivariate analysis of survival time at 1 h and 1 day. RESULTS Of the 140 enrolled patients, 76 (54.3%) died within 1 h and 35 (25%) survived beyond 24 h. No spontaneous breathing trial (SBT) within the past 24 h, minute ventilation (MV) ≥ 12 L/min, and APACHE II score ≥ 25 were associated with shorter survival in the 1 h regression model. Lower MV, SpO2 ≥ 96% and SBT were related to longer survival in the 1-day model. Hospice medications did not influence survival time. CONCLUSION An APACHE II score of ≥ 25 at 1 h and SpO2 ≥ 96% at 1 day were strong predictors of disposition of patients to intensivists. These factors can help to objectively tailor pathways for post-extubation transition and rapidly allocate intensive care unit resources without sacrificing the quality of palliative care in the era of COVID-19. Trial registration They study was retrospectively registered. IRB No.: 202101929B0.
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Affiliation(s)
- Yun-Cong Zheng
- grid.413801.f0000 0001 0711 0593Departments of Neurosurgery, Chang Gung Memorial Hospital, Keelung and Linkou & Chang Gung University, Taoyuan, Taiwan ,grid.19188.390000 0004 0546 0241Department of Biomedical Engineering, National Taiwan University, Taipei, Taiwan
| | - Yen-Min Huang
- grid.454209.e0000 0004 0639 2551Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital, No. 222, Maijin Rd., Anle Dist., Keelung, 204 Taiwan ,grid.411641.70000 0004 0532 2041Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Pin-Yuan Chen
- grid.413801.f0000 0001 0711 0593Departments of Neurosurgery, Chang Gung Memorial Hospital, Keelung and Linkou & Chang Gung University, Taoyuan, Taiwan
| | - Hsiao-Yean Chiu
- grid.412896.00000 0000 9337 0481School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan ,grid.412896.00000 0000 9337 0481Research Center of Sleep Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan ,grid.412897.10000 0004 0639 0994Department of Nursing, Taipei Medical University Hospital, Taipei, Taiwan
| | - Huang-Pin Wu
- grid.454209.e0000 0004 0639 2551Division of Pulmonary, Critical Care and Sleep Medicine, Chang Gung Memorial Hospital, Keelung, 20401 Taiwan ,grid.145695.a0000 0004 1798 0922College of Medicine, Chang Gung University, Taoyuan, 33302 Taiwan
| | - Chien-Ming Chu
- grid.454209.e0000 0004 0639 2551Division of Pulmonary, Critical Care and Sleep Medicine, Chang Gung Memorial Hospital, Keelung, 20401 Taiwan
| | - Wei-Siang Chen
- grid.145695.a0000 0004 1798 0922Division of Cardiology Section, Internal Medicine, Chang Gung Memorial Hospital, Keelung & Chang Gung University, Taoyuan, Taiwan
| | - Yu-Cheng Kao
- grid.145695.a0000 0004 1798 0922Division of Cardiology Section, Internal Medicine, Chang Gung Memorial Hospital, Keelung & Chang Gung University, Taoyuan, Taiwan
| | - Ching-Fang Lai
- grid.454209.e0000 0004 0639 2551Department of Social Services, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Ning-Yi Shih
- grid.454209.e0000 0004 0639 2551Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital, No. 222, Maijin Rd., Anle Dist., Keelung, 204 Taiwan
| | - Chien-Hong Lai
- grid.454209.e0000 0004 0639 2551Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital, No. 222, Maijin Rd., Anle Dist., Keelung, 204 Taiwan
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Knox KE, Hotz JC, Newth CJL, Khoo MCK, Khemani RG. A 30-Minute Spontaneous Breathing Trial Misses Many Children Who Go On to Fail a 120-Minute Spontaneous Breathing Trial. Chest 2023; 163:115-127. [PMID: 36037984 PMCID: PMC9993340 DOI: 10.1016/j.chest.2022.08.2212] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 08/09/2022] [Accepted: 08/18/2022] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND The optimal length of spontaneous breathing trials (SBTs) in children is unknown. RESEARCH QUESTIONS What are the most common reasons for SBT failure in children, and when do they occur? Can clinical parameters at the 30-min mark of a 120-min SBT predict outcome? STUDY DESIGN AND METHODS We performed a secondary analysis of a clinical trial in pediatric ARDS, in which 2-h SBTs are conducted daily. SBT failure is based on objective criteria, including esophageal manometry for effort of breathing, categorized as passage, early failure (≤ 30 min), or late failure (30-120 min). Spirometry was used to calculate respiratory rate (RR), tidal volume (Vt), and rapid shallow breathing index (RSBI), in addition to pulse oximetry and capnography. Predictive models evaluated parameters at 30 min against SBT outcome, using receiver operating characteristic plots and area under the curve. RESULTS We included 100 children and 305 SBTs, with 42% of SBTs being successful, 32% failing within 30 min, and 25% failing between 30 and 120 min. Of the patients passing SBTs at 30 min, 40% went on to fail by 120 min. High respiratory effort (esophageal manometry) was present in > 80% of failed SBTs. At the 30-min mark, there were no clear thresholds for RR, Vt, RSBI, Fio2, oxygen saturation, or capnography that could reliably predict SBT outcome. Multivariable modeling identified RR (P < .001) and RSBI > 7 (P = .034) at 30 min, pre-SBT inspiratory pressure level (P = .009), and pre-SBT retractions (P = .042) as predictors for SBT failure, but this model performed poorly in an independent validation set with the receiver operating characteristic plot crossing the reference line (area under the curve, 0.67). INTERPRETATION A 30-min SBT may be too short in children recovering from pediatric ARDS because many go on to fail between 30 and 120 min. Reassuring values of Vt, RR, and gas exchange at 30 min do not reliably predict SBT passage at 2 h, likely because they do not capture the effort of breathing. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov; No.: NCT03266016; URL: www. CLINICALTRIALS gov.
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Affiliation(s)
- Kelby E Knox
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA.
| | - Justin C Hotz
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Christopher J L Newth
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA; Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Michael C K Khoo
- Department of Biomedical Engineering, University of Southern California Viterbi School of Engineering, Los Angeles, CA
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA; Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, CA
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Abu-Sultaneh S, Iyer NP, Fernández A, Gaies M, González-Dambrauskas S, Hotz JC, Kneyber MCJ, López-Fernández YM, Rotta AT, Werho DK, Baranwal AK, Blackwood B, Craven HJ, Curley MAQ, Essouri S, Fioretto JR, Hartmann SMM, Jouvet P, Korang SK, Rafferty GF, Ramnarayan P, Rose L, Tume LN, Whipple EC, Wong JJM, Emeriaud G, Mastropietro CW, Napolitano N, Newth CJL, Khemani RG. Executive Summary: International Clinical Practice Guidelines for Pediatric Ventilator Liberation, A Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network Document. Am J Respir Crit Care Med 2023; 207:17-28. [PMID: 36583619 PMCID: PMC9952867 DOI: 10.1164/rccm.202204-0795so] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 08/12/2022] [Indexed: 12/31/2022] Open
Abstract
Rationale: Pediatric-specific ventilator liberation guidelines are lacking despite the many studies exploring elements of extubation readiness testing. The lack of clinical practice guidelines has led to significant and unnecessary variation in methods used to assess pediatric patients' readiness for extubation. Methods: Twenty-six international experts comprised a multiprofessional panel to establish pediatrics-specific ventilator liberation clinical practice guidelines, focusing on acutely hospitalized children receiving invasive mechanical ventilation for more than 24 hours. Eleven key questions were identified and first prioritized using the Modified Convergence of Opinion on Recommendations and Evidence. A systematic review was conducted for questions that did not meet an a priori threshold of ⩾80% agreement, with Grading of Recommendations, Assessment, Development, and Evaluation methodologies applied to develop the guidelines. The panel evaluated the evidence and drafted and voted on the recommendations. Measurements and Main Results: Three questions related to systematic screening using an extubation readiness testing bundle and a spontaneous breathing trial as part of the bundle met Modified Convergence of Opinion on Recommendations criteria of ⩾80% agreement. For the remaining eight questions, five systematic reviews yielded 12 recommendations related to the methods and duration of spontaneous breathing trials, measures of respiratory muscle strength, assessment of risk of postextubation upper airway obstruction and its prevention, use of postextubation noninvasive respiratory support, and sedation. Most recommendations were conditional and based on low to very low certainty of evidence. Conclusions: This clinical practice guideline provides a conceptual framework with evidence-based recommendations for best practices related to pediatric ventilator liberation.
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Affiliation(s)
- Samer Abu-Sultaneh
- Division of Pediatric Critical Care, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
- Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana
| | - Narayan Prabhu Iyer
- Fetal and Neonatal Institute, Division of Neonatology, Department of Pediatrics, Children’s Hospital Los Angeles, Los Angeles, California
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Analía Fernández
- Pediatric Critical Care Unit, Acute Care General Hospital “Carlos G. Durand,” Buenos Aires, Argentina
| | - Michael Gaies
- Division of Pediatric Cardiology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center Heart Institute, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Sebastián González-Dambrauskas
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Facultad de Medicina, Unidad de Cuidados Intensivos de Niños del Centro Hospitalario Pereira Rossell, Universidad de la República, Montevideo, Uruguay
| | - Justin Christian Hotz
- Department of Anesthesiology and Critical Care, Children’s Hospital Los Angeles, Los Angeles, California
| | - Martin C. J. Kneyber
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children’s Hospital, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Yolanda M. López-Fernández
- Department of Pediatrics, Biocruces-Bizkaia Health Research Institute, Cruces University Hospital, Bizkaia, Spain
| | - Alexandre T. Rotta
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Duke University, Durham, North Carolina
| | - David K. Werho
- Division of Pediatric Cardiology, Cardiothoracic Intensive Care, Rady Children’s Hospital, University of California, San Diego, San Diego, California
| | - Arun Kumar Baranwal
- Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen’s University Belfast, Belfast, United Kingdom
| | - Hannah J. Craven
- Ruth Lilly Medical Library, Indiana University School of Medicine, Indianapolis, Indiana
| | - Martha A. Q. Curley
- Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
- Research Institute, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sandrine Essouri
- Department of Pediatrics, Sainte-Justine Hospital, University of Montreal, Montreal, Quebec, Canada
| | - Jose Roberto Fioretto
- Pediatric Critical Care Division, Department of Pediatrics, Botucatu Medical School, Sao Paulo State University, Botucatu, Sao Paulo, Brazil
| | - Silvia M. M. Hartmann
- Division of Critical Care Medicine, Department of Pediatrics, Seattle Children’s Hospital, University of Washington, Seattle, Washington
| | - Philippe Jouvet
- Department of Pediatrics, Sainte-Justine Hospital, University of Montreal, Montreal, Quebec, Canada
| | - Steven Kwasi Korang
- Department of Anesthesiology and Critical Care, Children’s Hospital Los Angeles, Los Angeles, California
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Gerrard F. Rafferty
- Centre for Human and Applied Physiological Sciences, Faculty of Life Sciences & Medicine, and
| | - Padmanabhan Ramnarayan
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Louise Rose
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King’s College London, London United Kingdom
| | - Lyvonne N. Tume
- Edge Hill University Health Research Institute, Ormskirk, England
| | - Elizabeth C. Whipple
- Ruth Lilly Medical Library, Indiana University School of Medicine, Indianapolis, Indiana
| | | | - Guillaume Emeriaud
- Department of Pediatrics, Sainte-Justine Hospital, University of Montreal, Montreal, Quebec, Canada
| | - Christopher W. Mastropietro
- Division of Pediatric Critical Care, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
- Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana
| | | | - Christopher J. L. Newth
- Keck School of Medicine, University of Southern California, Los Angeles, California
- Department of Anesthesiology and Critical Care, Children’s Hospital Los Angeles, Los Angeles, California
| | - Robinder G. Khemani
- Keck School of Medicine, University of Southern California, Los Angeles, California
- Department of Anesthesiology and Critical Care, Children’s Hospital Los Angeles, Los Angeles, California
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8
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Charernjiratragul K, Saelim K, Ruangnapa K, Sirianansopa K, Prasertsan P, Anuntaseree W. Predictive parameters and model for extubation outcome in pediatric patients. Front Pediatr 2023; 11:1151068. [PMID: 37077338 PMCID: PMC10106763 DOI: 10.3389/fped.2023.1151068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 03/10/2023] [Indexed: 04/21/2023] Open
Abstract
Background Prolonged mechanical ventilation is associated with significant morbidity in critically ill pediatric patients. In addition, extubation failure and deteriorating respiratory status after extubation contribute to increased morbidity. Well-prepared weaning procedures and accurate identification of at-risk patients using multimodal ventilator parameters are warranted to improve patient outcomes. This study aimed to identify and assess the diagnostic accuracy of single parameters and to develop a model that can help predict extubation outcomes. Materials and methods This prospective observational study was conducted at a university hospital between January 2021 and April 2022. Patients aged 1 month to 15 years who were intubated for more than 12 h and deemed clinically ready for extubation were enrolled. A weaning process with a spontaneous breathing trial (SBT), with or without minimal setting, was employed. The ventilator and patient parameters during the weaning period at 0, 30, and 120 min and right before extubation were recorded and analyzed. Results A total of 188 eligible patients were extubated during the study. Of them, 45 (23.9%) patients required respiratory support escalation within 48 h. Of 45, 13 (6.9%) were reintubated. The predictors of respiratory support escalation consisted of a nonminimal-setting SBT [odds ratio (OR) 2.2 (1.1, 4.6), P = 0.03], >3 ventilator days [OR 2.4 (1.2, 4.9), P = 0.02], occlusion pressure (P0.1) at 30 min ≥0.9 cmH2O [OR 2.3 (1.1, 4.9), P = 0.03], and exhaled tidal volume per kg at 120 min ≤8 ml/kg [OR 2.2 (1.1, 4.6), P = 0.03]; all of these predictors had an area under the curve (AUC) of 0.72. A predictive scoring system to determine the probability of respiratory support escalation was developed using a nomogram. Conclusion The proposed predictive model, which integrated both patient and ventilator parameters, showed a modest performance level (AUC 0.72); however, it could facilitate the process of patient care.
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9
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Gökgöz G, Karabacak Ü, Kan Öntürk Z. The effects of milking and suction drain management methods in paediatric patients after cardiac surgery. Int J Nurs Pract 2022; 29:e13122. [PMID: 36517932 DOI: 10.1111/ijn.13122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 09/07/2022] [Accepted: 11/21/2022] [Indexed: 12/23/2022]
Abstract
AIM The aim of this study is to determine the effects of milking and suction methods on maintaining drain patency following cardiac surgery in paediatric patients. METHODS This was a randomized controlled trial. The patients were assigned to three groups (suction method, milking method, and control group) between July 2018 and December 2019. RESULTS The most frequent medical diagnoses were tetralogy of Fallot (34.4%, n = 31) and ventricular septal defect (14.4%, n = 13). Heart rate may increase unless a method was chosen to maintain drain patency (F: 4.450, p = 0.003); suction (F: 0.528 p = 0.781) and milking (F: 2.281 p = 0.070) methods did not significantly increase the heart rate. The use of a manipulation method for maintaining drain patency maintained stability of the blood pressure values and did not affect haemodynamic stability, oxygen saturation, and body temperature. There was no statistically significant difference within and among the groups (p > 0.05) in relation to the volume of bleeding between admission until the sixth hour, although there was greater bleeding with the milking method (2.67 ± 15.30 ml) and less bleeding (-5.00 ± 23.30) with the suction method. CONCLUSION The milking and suction methods used to maintain drain patency can be employed and will assist with maintaining the stability of the patient within the first critical 6 h. Further studies need to be conducted in order to clarify that the recommendations can be generalized to all children with congenital heart disease.
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Affiliation(s)
- Göksu Gökgöz
- Istanbul Training and Research Hospital TR. Ministry of Health İstanbul Turkey
| | - Ükke Karabacak
- Faculty of Health Sciences, Department of Nursing, Acıbadem Mehmet Ali Aydınlar Üniversitesi Kerem Aydınlar Kampüsü Acıbadem Mehmet Ali Aydınlar University İstanbul Turkey
| | - Zehra Kan Öntürk
- Faculty of Health Sciences, Department of Nursing, Acıbadem Mehmet Ali Aydınlar Üniversitesi Kerem Aydınlar Kampüsü Acıbadem Mehmet Ali Aydınlar University İstanbul Turkey
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10
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Ramnarayan P, Blackwood B, Khemani RG. What's new in paediatric ventilator liberation? Intensive Care Med 2022; 48:1635-1637. [PMID: 36048243 DOI: 10.1007/s00134-022-06865-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 08/09/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Padmanabhan Ramnarayan
- Anaesthesia, Pain Medicine and Critical Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Room 508, Imperial College Medical School Building, Norfolk Place, London, W2 1PB, UK.
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Northern Ireland, UK
| | - Robinder G Khemani
- Department of Anaesthesiology and Critical Care, Children's Hospital Los Angeles, Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, USA
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11
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The cardioprotective and anti-inflammatory effect of inhaled nitric oxide during Fontan surgery in patients with single ventricle congenital heart defects: a prospective randomized study. J Intensive Care 2022; 10:48. [PMID: 36229863 PMCID: PMC9558421 DOI: 10.1186/s40560-022-00639-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 09/24/2022] [Indexed: 11/10/2022] Open
Abstract
Background Fontan surgery with cardiopulmonary bypass (CPB) causes tremendous systemic stress and inflammatory responses, affecting postoperative organ function, morbidity, and mortality. Although this reaction triggers partially protective anti-inflammatory responses, it is harmful in patients with single ventricle congenital heart defects. Despite decades of research, an effective anti-inflammatory and stress defense strategy is lacking. This study investigated the influence of inhaled nitric oxide (NO) during CPB on early clinical results, including the duration of postoperative respiratory support as a primary outcome and a panel of laboratory analytes. Methods In this study, 115 patients were randomized to the Fontan-NO group (n = 48) and the Fontan group (n = 49). Eighteen patients were excluded from the study. The Fontan-NO group received NO inhaled directly into the oxygenator during CPB. Clinical data were collected, and blood samples were drawn for analysis at repeated intervals. Multiplex assays were used to analyze a proteome profile of molecules involved in stress response, inflammation, metabolic reactions, as well as heart and lung protection. Results Fontan-NO patients had significantly shorter respiratory support time with a median of 9.3 h (7.0; 13,2) vs 13.9 h (3.7; 18.5) by the absolute difference of 4.6 h [95% confidence interval, − 30.9 to 12.3; (p = 0.03)]. In addition, they have a shorter time in intensive care (p = 0.04) and lower pulmonary artery pressure after CPB discontinuation (p = 0.04), 4 h (p = 0.03) and 8 h (p = 0.03) after surgery. Fontan-NO patients also had a lower concentration of lactates (p = 0.04) and glucose after separation from CPB (p = 0.02) and lower catecholamine index (p = 0.042). Plasma factors analysis has shown a significantly higher concentration of interleukin-10, and a lower concentration of interleukin-6, interleukin-8, interleukin-1β, pentraxin, matrix metalloproteinase-8, troponin-I, creatine kinase myocardial band (CK-MB), and insulin in Fontan-NO group. Conclusions NO inhaled into the oxygenator during CPB can improve short-term clinical outcomes. It shortens intubation time and intensive care time. It reduces inflammatory response, improves myocardial and lung protection, and diminishes metabolic stress in patients with a single ventricle undergoing Fontan surgery. Trial registration number: The trial was preregistered, supervised, and supported by The Polish National Science Center (NCN/01/B/NZ5/04246). Supplementary Information The online version contains supplementary material available at 10.1186/s40560-022-00639-y.
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12
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Prediction of extubation failure in the paediatric cardiac ICU using machine learning and high-frequency physiologic data. Cardiol Young 2022; 32:1649-1656. [PMID: 34924086 PMCID: PMC9207151 DOI: 10.1017/s1047951121004959] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Cardiac intensivists frequently assess patient readiness to wean off mechanical ventilation with an extubation readiness trial despite it being no more effective than clinician judgement alone. We evaluated the utility of high-frequency physiologic data and machine learning for improving the prediction of extubation failure in children with cardiovascular disease. METHODS This was a retrospective analysis of clinical registry data and streamed physiologic extubation readiness trial data from one paediatric cardiac ICU (12/2016-3/2018). We analysed patients' final extubation readiness trial. Machine learning methods (classification and regression tree, Boosting, Random Forest) were performed using clinical/demographic data, physiologic data, and both datasets. Extubation failure was defined as reintubation within 48 hrs. Classifier performance was assessed on prediction accuracy and area under the receiver operating characteristic curve. RESULTS Of 178 episodes, 11.2% (N = 20) failed extubation. Using clinical/demographic data, our machine learning methods identified variables such as age, weight, height, and ventilation duration as being important in predicting extubation failure. Best classifier performance with this data was Boosting (prediction accuracy: 0.88; area under the receiver operating characteristic curve: 0.74). Using physiologic data, our machine learning methods found oxygen saturation extremes and descriptors of dynamic compliance, central venous pressure, and heart/respiratory rate to be of importance. The best classifier in this setting was Random Forest (prediction accuracy: 0.89; area under the receiver operating characteristic curve: 0.75). Combining both datasets produced classifiers highlighting the importance of physiologic variables in determining extubation failure, though predictive performance was not improved. CONCLUSION Physiologic variables not routinely scrutinised during extubation readiness trials were identified as potential extubation failure predictors. Larger analyses are necessary to investigate whether these markers can improve clinical decision-making.
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13
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Klompas M, Branson R, Cawcutt K, Crist M, Eichenwald EC, Greene LR, Lee G, Maragakis LL, Powell K, Priebe GP, Speck K, Yokoe DS, Berenholtz SM. Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol 2022; 43:687-713. [PMID: 35589091 PMCID: PMC10903147 DOI: 10.1017/ice.2022.88] [Citation(s) in RCA: 64] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The purpose of this document is to highlight practical recommendations to assist acute care hospitals to prioritize and implement strategies to prevent ventilator-associated pneumonia (VAP), ventilator-associated events (VAE), and non-ventilator hospital-acquired pneumonia (NV-HAP) in adults, children, and neonates. This document updates the Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology (SHEA), and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America, the American Hospital Association, the Association for Professionals in Infection Control and Epidemiology, and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.
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Affiliation(s)
- Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Richard Branson
- Department of Surgery, University of Cincinnati Medicine, Cincinnati, Ohio
| | - Kelly Cawcutt
- Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Matthew Crist
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Eric C Eichenwald
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Linda R Greene
- Highland Hospital, University of Rochester, Rochester, New York
| | - Grace Lee
- Stanford University School of Medicine, Palo Alto, California
| | - Lisa L Maragakis
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Krista Powell
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Gregory P Priebe
- Department of Anesthesiology, Critical Care and Pain Medicine; Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts; and Harvard Medical School, Boston, Massachusetts
| | - Kathleen Speck
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Deborah S Yokoe
- Department of Medicine, University of California San Francisco, San Francisco, California
| | - Sean M Berenholtz
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Health Policy & Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
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14
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Garcia AAA, Vieira AGDS, Kuramoto DAB, Leite IG, Freitas TRD, Reicher ME, Trevisani VFM, Guedes Neto HJ, Flumignan RLG, Amorim JED, Nakano LCU. Ventilatory weaning strategies for predicting extubation success in children following cardiac surgery for congenital heart disease: a protocol for a systematic review and meta-analysis. BMJ Open 2022; 12:e054128. [PMID: 35487746 PMCID: PMC9058692 DOI: 10.1136/bmjopen-2021-054128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Congenital heart disease (CHD) comprises the anatomic malformations that jeopardise the structure and function of the heart. It can be extremely complex and serious, corresponding to 30% of all deaths in the first month of life. The surgical approach for adequate treatment requires postoperative mechanical ventilation. The most critical decision related to the postoperative management of patients submitted to cardiac surgery is the right time for extubation, especially because not only abrupt or inadequate discontinuation of ventilatory support can lead to clinical decline and necessity of reintubation but also extended time of mechanical ventilation, which can lead to complications, such as pneumonia, atelectasis, diaphragm hypertrophy, and increasing morbidity and mortality. METHODS AND ANALYSIS This systematic review plans to include individual parallel, cross-over and cluster randomised controlled trials regarding any breathing trial test to predict extubation success in children submitted to cardiac surgery due to CHD. Studies with paediatric patients submitted to cardiac surgery for congenital cardiopathy repair, attended at a critical care unit, and under mechanical ventilatory support will be included. The main outcomes analysed will be success of extubation, reduction of pulmonary complications and time reduction of mechanical ventilation. ETHICS AND DISSEMINATION We will not treat patients directly; therefore, ethics committee approval was not necessary because it is not a primary study. We expect that this study may improve healthcare and medical assistance, helping healthcare professionals with routine daily decisions regarding the correct time for extubation. PROSPERO REGISTRATION NUMBER CRD42021223999.
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Affiliation(s)
| | | | | | - Ilana Gomes Leite
- Division of Vascular and Endovascular Surgery, Department of Surgery, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Thais Rodrigues de Freitas
- Division of Vascular and Endovascular Surgery, Department of Surgery, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Marcello Erich Reicher
- Division of Vascular and Endovascular Surgery, Department of Surgery, Federal University of Sao Paulo, Sao Paulo, Brazil
| | | | - Henrique Jorge Guedes Neto
- Division of Vascular and Endovascular Surgery, Department of Surgery, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Ronald Luiz Gomes Flumignan
- Division of Vascular and Endovascular Surgery, Department of Surgery, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Jorge Eduardo de Amorim
- Division of Vascular and Endovascular Surgery, Department of Surgery, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Luis Carlos Uta Nakano
- Division of Vascular and Endovascular Surgery, Department of Surgery, Federal University of Sao Paulo, Sao Paulo, Brazil
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15
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Blackwood B, Morris KP, Jordan J, McIlmurray L, Agus A, Boyle R, Clarke M, Easter C, Feltbower RG, Hemming K, Macrae D, McDowell C, Murray M, Parslow R, Peters MJ, Phair G, Tume LN, Walsh TS, McAuley DF. Co-ordinated multidisciplinary intervention to reduce time to successful extubation for children on mechanical ventilation: the SANDWICH cluster stepped-wedge RCT. Health Technol Assess 2022; 26:1-114. [PMID: 35289741 DOI: 10.3310/tcfx3817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Daily assessment of patient readiness for liberation from invasive mechanical ventilation can reduce the duration of ventilation. However, there is uncertainty about the effectiveness of this in a paediatric population. OBJECTIVES To determine the effect of a ventilation liberation intervention in critically ill children who are anticipated to have a prolonged duration of mechanical ventilation (primary objective) and in all children (secondary objective). DESIGN A pragmatic, stepped-wedge, cluster randomised trial with economic and process evaluations. SETTING Paediatric intensive care units in the UK. PARTICIPANTS Invasively mechanically ventilated children (aged < 16 years). INTERVENTIONS The intervention incorporated co-ordinated multidisciplinary care, patient-relevant sedation plans linked to sedation assessment, assessment of ventilation parameters with a higher than usual trigger for undertaking an extubation readiness test and a spontaneous breathing trial on low levels of respiratory support to test extubation readiness. The comparator was usual care. Hospital sites were randomised sequentially to transition from control to intervention and were non-blinded. MAIN OUTCOME MEASURES The primary outcome measure was the duration of invasive mechanical ventilation until the first successful extubation. The secondary outcome measures were successful extubation, unplanned extubation and reintubation, post-extubation use of non-invasive ventilation, tracheostomy, post-extubation stridor, adverse events, length of intensive care and hospital stay, mortality and cost per respiratory complication avoided at 28 days. RESULTS The trial included 10,495 patient admissions from 18 paediatric intensive care units from 5 February 2018 to 14 October 2019. In children with anticipated prolonged ventilation (n = 8843 admissions: control, n = 4155; intervention, n = 4688), the intervention resulted in a significantly shorter time to successful extubation [cluster and time-adjusted median difference -6.1 hours (interquartile range -8.2 to -5.3 hours); adjusted hazard ratio 1.11, 95% confidence interval 1.02 to 1.20; p = 0.02] and a higher incidence of successful extubation (adjusted relative risk 1.01, 95% confidence interval 1.00 to 1.02; p = 0.03) and unplanned extubation (adjusted relative risk 1.62, 95% confidence interval 1.05 to 2.51; p = 0.03), but not reintubation (adjusted relative risk 1.10, 95% confidence interval 0.89 to 1.36; p = 0.38). In the intervention period, the use of post-extubation non-invasive ventilation was significantly higher (adjusted relative risk 1.22, 95% confidence interval 1.01 to 1.49; p = 0.04), with no evidence of a difference in intensive care length of stay or other harms, but hospital length of stay was longer (adjusted hazard ratio 0.89, 95% confidence interval 0.81 to 0.97; p = 0.01). Findings for all children were broadly similar. The control period was associated with lower, but not statistically significantly lower, total costs (cost difference, mean £929.05, 95% confidence interval -£516.54 to £2374.64) and significantly fewer respiratory complications avoided (mean difference -0.10, 95% confidence interval -0.16 to -0.03). LIMITATIONS The unblinded intervention assignment may have resulted in performance or detection bias. It was not possible to determine which components were primarily responsible for the observed effect. Treatment effect in a more homogeneous group remains to be determined. CONCLUSIONS The intervention resulted in a statistically significant small reduction in time to first successful extubation; thus, the clinical importance of the effect size is uncertain. FUTURE WORK Future work should explore intervention sustainability and effects of the intervention in other paediatric populations. TRIAL REGISTRATION This trial is registered as ISRCTN16998143. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 18. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Kevin P Morris
- Paediatric Intensive Care Unit, Birmingham Children's Hospital, Birmingham, UK
| | - Joanne Jordan
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Lisa McIlmurray
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Ashley Agus
- Northern Ireland Clinical Trials Unit, Belfast Health and Social Care Trust, Belfast, UK
| | - Roisin Boyle
- Northern Ireland Clinical Trials Unit, Belfast Health and Social Care Trust, Belfast, UK
| | - Mike Clarke
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Christina Easter
- Institute of Applied Health, University of Birmingham, Birmingham, UK
| | - Richard G Feltbower
- School of Medicine, Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
| | - Karla Hemming
- Institute of Applied Health, University of Birmingham, Birmingham, UK
| | - Duncan Macrae
- Paediatric Intensive Care Unit, Royal Brompton Hospital, London, UK
| | - Clíona McDowell
- Northern Ireland Clinical Trials Unit, Belfast Health and Social Care Trust, Belfast, UK
| | - Margaret Murray
- Northern Ireland Clinical Trials Unit, Belfast Health and Social Care Trust, Belfast, UK
| | - Roger Parslow
- School of Medicine, Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
| | - Mark J Peters
- Paediatric Intensive Care Unit, Great Ormond Street Hospital, London, UK
| | - Glenn Phair
- Northern Ireland Clinical Trials Unit, Belfast Health and Social Care Trust, Belfast, UK
| | - Lyvonne N Tume
- School of Health and Society, University of Salford, Salford, UK
| | - Timothy S Walsh
- Anaesthesia, Critical Care and Pain Medicine, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Daniel F McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
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16
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Marupudi NK, Steurer-Muller M, Franzon D. The Decision to Extubate: The Association Between Clinician Impressions and Objective Extubation Readiness Criteria in a Pediatric Intensive Care Unit. J Pediatr Intensive Care 2022. [DOI: 10.1055/s-0041-1741403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Abstract
Objective Objective tools such as spontaneous breathing trials (SBT) aim to identify patients ready for extubation and shorten the length of mechanical ventilation (MV). Despite passing an SBT, patients sometimes are not extubated based on clinicians' subjective impressions. In this article, we explored the factors that influence the decision to extubate among pediatric intensivists and their association with objective criteria.
Design This is a single-center prospective observational study.
Setting This study was conducted in an academic, multidisciplinary 20-bed pediatric intensive care unit (PICU).
Patients The study group involves mechanically ventilated, orally intubated patients admitted to the PICU from January 1 to June 30, 2019.
Measurements and Main Results Objective clinical data were collected for 650 MV days. Attending surveys about extubation readiness were completed for 419 (64.5%) MV days and 63 extubation events. Extubation occurred on 42% of days after passing an SBT. The primary reasons patients who passed an SBT were not extubated on days were unresolved lung pathology (66.6%) and fluid overload (37.6%). On days without extubation, there was no association between a specific reason for not extubating and SBT result (p > 0.05).
Conclusions In this single-center study, the decision to extubate was not strongly associated with passing an SBT, indicating that clinician impressions, namely unresolved lung pathology and fluid overload, outweighed objective measures for determining extubation readiness. To mitigate morbidities and costs associated with unnecessarily prolonged intubations, a better-defined extubation readiness process is needed to guide the decision to extubate in the pediatric population.
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Affiliation(s)
- Neelima K. Marupudi
- Department of Pediatrics, Division of Pediatric Critical Care, University of Chicago, Chicago, IL, United States
| | - Martina Steurer-Muller
- Department of Pediatrics, Division of Pediatric Critical Care, University of Chicago, Chicago, IL, United States
| | - Deborah Franzon
- Department of Pediatrics, Division of Pediatric Critical Care, University of Chicago, Chicago, IL, United States
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17
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Elisa P, Francesca C, Marco P, Davide V, Laura Z, Fabrizio Z, Andrea P, Marco D, Maria BC. Ventilation Weaning and Extubation Readiness in Children in Pediatric Intensive Care Unit: A Review. Front Pediatr 2022; 10:867739. [PMID: 35433554 PMCID: PMC9010786 DOI: 10.3389/fped.2022.867739] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 03/04/2022] [Indexed: 11/13/2022] Open
Abstract
Ventilation is one of the most common procedures in critically ill children admitted to the pediatric intensive care units (PICUs) and is associated with potential severe side effects. The longer the mechanical ventilation, the higher the risk of infections, mortality, morbidity and length of stay. Protocol-based approaches to ventilation weaning could have potential benefit in assisting the physicians in the weaning process but, in pediatrics, clear significant outcome difference related to their use has yet to be shown. Extubation failure occurs in up to 20% of patients in PICU with evidences demonstrating its occurrence related to a worse patient outcome including higher mortality. Various clinical approaches have been described to decide the best timing for extubation which can usually be achieved by performing a spontaneous breathing trial before the extubation. No clear evidence is available over which technique best predicts extubation failure. Within this review we summarize the current strategies of ventilation weaning and extubation readiness evaluation employed in the pediatric setting in order to provide an updated view on the topic to guide intensive care physicians in daily clinical practice. We performed a thorough literature search of main online scientific databases to identify principal studies evaluating different strategies of ventilation weaning and extubation readiness including pediatric patients receiving mechanical ventilation. Various strategies are available in the literature both for ventilation weaning and extubation readiness assessment with unclear clear data supporting the superiority of any approach over the others.
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Affiliation(s)
- Poletto Elisa
- Department of Woman's and Child's Health, University Hospital of Padua, Padua, Italy
| | - Cavagnero Francesca
- Department of Woman's and Child's Health, University Hospital of Padua, Padua, Italy
| | - Pettenazzo Marco
- Department of Woman's and Child's Health, University Hospital of Padua, Padua, Italy
| | - Visentin Davide
- Department of Woman's and Child's Health, University Hospital of Padua, Padua, Italy
| | - Zanatta Laura
- Department of Woman's and Child's Health, University Hospital of Padua, Padua, Italy
| | - Zoppelletto Fabrizio
- Department of Woman's and Child's Health, University Hospital of Padua, Padua, Italy
| | - Pettenazzo Andrea
- Pediatric Intensive Care Unit, Department of Woman's and Child's Health, University Hospital of Padua, Padua, Italy
| | - Daverio Marco
- Pediatric Intensive Care Unit, Department of Woman's and Child's Health, University Hospital of Padua, Padua, Italy
| | - Bonardi Claudia Maria
- Pediatric Intensive Care Unit, Department of Woman's and Child's Health, University Hospital of Padua, Padua, Italy
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Engel J, von Borell F, Baumgartner I, Kumpf M, Hofbeck M, Michel J, Neunhoeffer F. Modified ABCDEF-Bundles for Critically Ill Pediatric Patients - What Could They Look Like? Front Pediatr 2022; 10:886334. [PMID: 35586826 PMCID: PMC9108250 DOI: 10.3389/fped.2022.886334] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 04/11/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND SIGNIFICANCE Advances in pediatric intensive care have led to markedly improved survival rates in critically ill children. Approximately 70% of those children survive with varying forms of complex chronic diseases or impairment/disabilities. Length of stay, length of mechanical ventilation and number of interventions per patient are increasing with rising complexity of underlying diseases, leading to increasing pain, agitation, withdrawal symptoms, delirium, immobility, and sleep disruption. The ICU-Liberation Collaborative of the Society of Critical Care Medicine has developed a number of preventative measures for prevention, early detection, or treatment of physical and psychiatric/psychological sequelae of oftentimes traumatic intensive care medicine. These so called ABCDEF-Bundles consist of elements for (A) assessment, prevention and management of pain, (B) spontaneous awakening and breathing trials (SAT/SBT), (C) choice of analgesia and sedation, (D) assessment, prevention and management of delirium, (E) early mobility and exercise and (F) family engagement and empowerment. For adult patients in critical care medicine, research shows significant effects of bundle-implementation on survival, mechanical ventilation, coma, delirium and post-ICU discharge disposition. Research regarding PICS in children and possible preventative or therapeutic intervention is insufficient as yet. This narrative review provides available information for modification and further research on the ABCDEF-Bundles for use in critically ill children. MATERIAL AND METHODS A narrative review of existing literature was used. RESULTS One obvious distinction to adult patients is the wide range of different developmental stages of children and the even closer relationship between patient and family. Evidence for pediatric ABCDEF-Bundles is insufficient and input can only be collected from literature regarding different subsections and topics. CONCLUSION In addition to efforts to improve analgesia, sedation and weaning protocols with the aim of prevention, early detection and effective treatment of withdrawal symptoms or delirium, efforts are focused on adjusting ABCDEF bundle for the entire pediatric age group and on strengthening families' decision-making power, understanding parents as a resource for their child and involving them early in the care of their children.
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Affiliation(s)
- Juliane Engel
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | - Florian von Borell
- Department of Pediatric Cardiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - Isabella Baumgartner
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | - Matthias Kumpf
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | - Michael Hofbeck
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | - Jörg Michel
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | - Felix Neunhoeffer
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
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Baalaaji ARM. Weaning from Mechanical Ventilation in Children: Are We Getting It Right? Indian J Crit Care Med 2021; 25:974-975. [PMID: 34963712 PMCID: PMC8664013 DOI: 10.5005/jp-journals-10071-23974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
How to cite this article: Baalaaji ARM. Weaning from Mechanical Ventilation in Children: Are We Getting It Right? Indian J Crit Care Med 2021;25(9):974-975.
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Affiliation(s)
- AR Mullai Baalaaji
- Department of Pediatric Critical Care, Kovai Medical Centerand Hospital, Coimbatore, Tamil Nadu, India
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Blackwood B, Tume LN, Morris KP, Clarke M, McDowell C, Hemming K, Peters MJ, McIlmurray L, Jordan J, Agus A, Murray M, Parslow R, Walsh TS, Macrae D, Easter C, Feltbower RG, McAuley DF. Effect of a Sedation and Ventilator Liberation Protocol vs Usual Care on Duration of Invasive Mechanical Ventilation in Pediatric Intensive Care Units: A Randomized Clinical Trial. JAMA 2021; 326:401-410. [PMID: 34342620 PMCID: PMC8335576 DOI: 10.1001/jama.2021.10296] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE There is limited evidence on the optimal strategy for liberating infants and children from invasive mechanical ventilation in the pediatric intensive care unit. OBJECTIVE To determine if a sedation and ventilator liberation protocol intervention reduces the duration of invasive mechanical ventilation in infants and children anticipated to require prolonged mechanical ventilation. DESIGN, SETTING, AND PARTICIPANTS A pragmatic multicenter, stepped-wedge, cluster randomized clinical trial was conducted that included 17 hospital sites (18 pediatric intensive care units) in the UK sequentially randomized from usual care to the protocol intervention. From February 2018 to October 2019, 8843 critically ill infants and children anticipated to require prolonged mechanical ventilation were recruited. The last date of follow-up was November 11, 2019. INTERVENTIONS Pediatric intensive care units provided usual care (n = 4155 infants and children) or a sedation and ventilator liberation protocol intervention (n = 4688 infants and children) that consisted of assessment of sedation level, daily screening for readiness to undertake a spontaneous breathing trial, a spontaneous breathing trial to test ventilator liberation potential, and daily rounds to review sedation and readiness screening and set patient-relevant targets. MAIN OUTCOMES AND MEASURES The primary outcome was the duration of invasive mechanical ventilation from initiation of ventilation until the first successful extubation. The primary estimate of the treatment effect was a hazard ratio (with a 95% CI) adjusted for calendar time and cluster (hospital site) for infants and children anticipated to require prolonged mechanical ventilation. RESULTS There were a total of 8843 infants and children (median age, 8 months [interquartile range, 1 to 46 months]; 42% were female) who completed the trial. There was a significantly shorter median time to successful extubation for the protocol intervention compared with usual care (64.8 hours vs 66.2 hours, respectively; adjusted median difference, -6.1 hours [interquartile range, -8.2 to -5.3 hours]; adjusted hazard ratio, 1.11 [95% CI, 1.02 to 1.20], P = .02). The serious adverse event of hypoxia occurred in 9 (0.2%) infants and children for the protocol intervention vs 11 (0.3%) for usual care; nonvascular device dislodgement occurred in 2 (0.04%) vs 7 (0.1%), respectively. CONCLUSIONS AND RELEVANCE Among infants and children anticipated to require prolonged mechanical ventilation, a sedation and ventilator liberation protocol intervention compared with usual care resulted in a statistically significant reduction in time to first successful extubation. However, the clinical importance of the effect size is uncertain. TRIAL REGISTRATION isrctn.org Identifier: ISRCTN16998143.
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Affiliation(s)
- Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen’s University Belfast, Belfast, Ireland
| | - Lyvonne N. Tume
- School of Health and Society, University of Salford, Manchester, England
- Alder Hey Children’s NHS Trust, Liverpool, England
| | - Kevin P. Morris
- Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, England
- Institute of Applied Health Research, University of Birmingham, Birmingham, England
| | - Mike Clarke
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, Ireland
| | - Clíona McDowell
- Northern Ireland Clinical Trials Unit, Royal Hospitals, Belfast, Ireland
| | | | - Mark J. Peters
- Great Ormond Street Hospital, London, England
- University College London, Great Ormond Street Institute of Child Health, NIHR Biomedical Research Centre, London, England
| | - Lisa McIlmurray
- Wellcome-Wolfson Institute for Experimental Medicine, Queen’s University Belfast, Belfast, Ireland
| | - Joanne Jordan
- Wellcome-Wolfson Institute for Experimental Medicine, Queen’s University Belfast, Belfast, Ireland
| | - Ashley Agus
- Northern Ireland Clinical Trials Unit, Royal Hospitals, Belfast, Ireland
| | - Margaret Murray
- Northern Ireland Clinical Trials Unit, Royal Hospitals, Belfast, Ireland
| | - Roger Parslow
- Leeds Institute for Data Analytics, School of Medicine, University of Leeds, Leeds, England
| | - Timothy S. Walsh
- Usher Institute of Population Health Sciences, University of Edinburgh, Edinburgh, Scotland
| | | | | | - Richard G. Feltbower
- Leeds Institute for Data Analytics, School of Medicine, University of Leeds, Leeds, England
| | - Daniel F. McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen’s University Belfast, Belfast, Ireland
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Baumann P, Cannizzaro V. Lung function assessment in critically ill children: craving for standardisation. CURRENT OPINION IN PHYSIOLOGY 2021. [DOI: 10.1016/j.cophys.2021.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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22
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Assessing Pain, Both Spontaneous Awakening and Breathing Trials, Choice of Sedation, Delirium Monitoring/Management, Early Exercise/Mobility, and Family Engagement/Empowerment Bundle Practices for Critically Ill Children: An International Survey of 161 PICUs in 18 Countries. Crit Care Med 2021; 50:114-125. [PMID: 34259659 DOI: 10.1097/ccm.0000000000005168] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate current international practice in PICUs regarding components of the "Assessing Pain, Both Spontaneous Awakening and Breathing Trials, Choice of Sedation, Delirium Monitoring/Management, Early Exercise/Mobility, and Family Engagement/Empowerment" ("ABCDEF") bundle. DESIGN Online surveys conducted between 2017 and 2019. SETTING One-hundred sixty-one PICUs across the United States (n = 82), Canada (n = 14), Brazil (n = 27), and Europe (n = 38) participating in the Prevalence of Acute Rehabilitation for Kids in the PICU study. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of the 161 participating PICUs, 83% were in academic teaching hospitals and 42% were in free-standing children's hospitals. Median size was 16 beds (interquartile range, 10-24 beds). Only 15 PICUs (9%) had incorporated all six ABCDEF bundle components into routine practice. Standardized pain assessment (A) was the most common (91%), followed by family engagement (F, 88%) and routine sedation assessment (C) with validated scales (84%). Protocols for testing extubation readiness or conducting spontaneous breathing trials (B) were reported in 57%, with 34% reporting a ventilator weaning protocol. Routine delirium monitoring with a validated screening tool (D) was reported by 44% of PICUs, and 26% had a guideline, protocol, or policy for early exercise/mobility (E). Practices for spontaneous breathing trials were variable in 29% of Canadian PICUs versus greater than 50% in the other regions. Delirium monitoring was lowest in Brazilian PICUs (18%) versus greater than 40% in other regions, and family engagement was reported in 55% of European PICUs versus greater than 90% in other regions. CONCLUSIONS ABCDEF bundle components have been adopted with substantial variability across regions. Additional research must rigorously evaluate the efficacy of specific elements with a focus on B, D, E, and full ABCDEF bundle implementation. Implementation science is needed to facilitate an understanding of the barriers to ABCDEF implementation and sustainability with a focus on specific cultural and regional differences.
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Liberation From Mechanical Ventilation After Cardiac Surgery in Infants and Children: Need for Better Definitions and Approach. Pediatr Crit Care Med 2019; 20:990-992. [PMID: 31580275 DOI: 10.1097/pcc.0000000000002032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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