1
|
Schönhofer B, Geiseler J, Dellweg D, Fuchs H, Moerer O, Weber-Carstens S, Westhoff M, Windisch W. Prolonged Weaning: S2k Guideline Published by the German Respiratory Society. Respiration 2020; 99:1-102. [PMID: 33302267 DOI: 10.1159/000510085] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 07/09/2020] [Indexed: 01/28/2023] Open
Abstract
Mechanical ventilation (MV) is an essential part of modern intensive care medicine. MV is performed in patients with severe respiratory failure caused by respiratory muscle insufficiency and/or lung parenchymal disease; that is, when other treatments such as medication, oxygen administration, secretion management, continuous positive airway pressure (CPAP), or nasal high-flow therapy have failed. MV is required for maintaining gas exchange and allows more time to curatively treat the underlying cause of respiratory failure. In the majority of ventilated patients, liberation or "weaning" from MV is routine, without the occurrence of any major problems. However, approximately 20% of patients require ongoing MV, despite amelioration of the conditions that precipitated the need for it in the first place. Approximately 40-50% of the time spent on MV is required to liberate the patient from the ventilator, a process called "weaning". In addition to acute respiratory failure, numerous factors can influence the duration and success rate of the weaning process; these include age, comorbidities, and conditions and complications acquired during the ICU stay. According to international consensus, "prolonged weaning" is defined as the weaning process in patients who have failed at least 3 weaning attempts, or require more than 7 days of weaning after the first spontaneous breathing trial (SBT). Given that prolonged weaning is a complex process, an interdisciplinary approach is essential for it to be successful. In specialised weaning centres, approximately 50% of patients with initial weaning failure can be liberated from MV after prolonged weaning. However, the heterogeneity of patients undergoing prolonged weaning precludes the direct comparison of individual centres. Patients with persistent weaning failure either die during the weaning process, or are discharged back to their home or to a long-term care facility with ongoing MV. Urged by the growing importance of prolonged weaning, this Sk2 Guideline was first published in 2014 as an initiative of the German Respiratory Society (DGP), in conjunction with other scientific societies involved in prolonged weaning. The emergence of new research, clinical study findings and registry data, as well as the accumulation of experience in daily practice, have made the revision of this guideline necessary. The following topics are dealt with in the present guideline: Definitions, epidemiology, weaning categories, underlying pathophysiology, prevention of prolonged weaning, treatment strategies in prolonged weaning, the weaning unit, discharge from hospital on MV, and recommendations for end-of-life decisions. Special emphasis was placed on the following themes: (1) A new classification of patient sub-groups in prolonged weaning. (2) Important aspects of pulmonary rehabilitation and neurorehabilitation in prolonged weaning. (3) Infrastructure and process organisation in the care of patients in prolonged weaning based on a continuous treatment concept. (4) Changes in therapeutic goals and communication with relatives. Aspects of paediatric weaning are addressed separately within individual chapters. The main aim of the revised guideline was to summarize both current evidence and expert-based knowledge on the topic of "prolonged weaning", and to use this information as a foundation for formulating recommendations related to "prolonged weaning", not only in acute medicine but also in the field of chronic intensive care medicine. The following professionals served as important addressees for this guideline: intensivists, pulmonary medicine specialists, anaesthesiologists, internists, cardiologists, surgeons, neurologists, paediatricians, geriatricians, palliative care clinicians, rehabilitation physicians, intensive/chronic care nurses, physiotherapists, respiratory therapists, speech therapists, medical service of health insurance, and associated ventilator manufacturers.
Collapse
Affiliation(s)
- Bernd Schönhofer
- Klinikum Agnes Karll Krankenhaus, Klinikum Region Hannover, Laatzen, Germany,
| | - Jens Geiseler
- Klinikum Vest, Medizinische Klinik IV: Pneumologie, Beatmungs- und Schlafmedizin, Marl, Germany
| | - Dominic Dellweg
- Fachkrankenhaus Kloster Grafschaft GmbH, Abteilung Pneumologie II, Schmallenberg, Germany
| | - Hans Fuchs
- Universitätsklinikum Freiburg, Zentrum für Kinder- und Jugendmedizin, Neonatologie und Pädiatrische Intensivmedizin, Freiburg, Germany
| | - Onnen Moerer
- Universitätsmedizin Göttingen, Klinik für Anästhesiologie, Göttingen, Germany
| | - Steffen Weber-Carstens
- Charité, Universitätsmedizin Berlin, Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Campus Virchow-Klinikum und Campus Mitte, Berlin, Germany
| | - Michael Westhoff
- Lungenklinik Hemer, Hemer, Germany
- Universität Witten/Herdecke, Herdecke, Germany
| | - Wolfram Windisch
- Lungenklinik, Kliniken der Stadt Köln gGmbH, Universität Witten/Herdecke, Herdecke, Germany
| |
Collapse
|
2
|
Biagini S, Dale CS, Real JM, Moreira ES, Carvalho CRR, Schettino GPP, Wendel S, Azevedo LCP. Short-term effects of stored homologous red blood cell transfusion on cardiorespiratory function and inflammation: an experimental study in a hypovolemia model. ACTA ACUST UNITED AC 2017; 51:e6258. [PMID: 29185590 PMCID: PMC5685056 DOI: 10.1590/1414-431x20176258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Accepted: 08/11/2017] [Indexed: 01/08/2023]
Abstract
The pathophysiological mechanisms associated with the effects of red blood cell (RBC) transfusion on cardiopulmonary function and inflammation are unclear. We developed an experimental model of homologous 14-days stored RBC transfusion in hypovolemic swine to evaluate the short-term effects of transfusion on cardiopulmonary system and inflammation. Sixteen healthy male anesthetized swine (68±3.3 kg) were submitted to controlled hemorrhage (25% of blood volume). Two units of non-filtered RBC from each animal were stored under blood bank conditions for 14 days. After 30 min of hypovolemia, the control group (n=8) received an infusion of lactated Ringer's solution (three times the removed volume). The transfusion group (n=8) received two units of homologous 14-days stored RBC and lactated Ringer's solution in a volume that was three times the difference between blood removed and blood transfusion infused. Both groups were followed up for 6 h after resuscitation with collection of hemodynamic and respiratory data. Cytokines and RNA expression were measured in plasma and lung tissue. Stored RBC transfusion significantly increased mixed oxygen venous saturation and arterial oxygen content. Transfusion was not associated with alterations on pulmonary function. Pulmonary concentrations of cytokines were not different between groups. Gene expression for lung cytokines demonstrated a 2-fold increase in mRNA level for inducible nitric oxide synthase and a 0.5-fold decrease in mRNA content for IL-21 in the transfused group. Thus, stored homologous RBC transfusion in a hypovolemia model improved cardiovascular parameters but did not induce significant effects on microcirculation, pulmonary inflammation and respiratory function up to 6 h after transfusion.
Collapse
Affiliation(s)
- S Biagini
- Instituto de Ensino e Pesquisa, Hospital Sírio-Libanês, São Paulo, SP, Brasil
| | - C S Dale
- Laboratorio de Neuromodulação e Dor Experimental, Departamento de Anatomia, Universidade de São Paulo, São Paulo, SP, Brasil
| | - J M Real
- Associação TUCCA para Crianças e Adolescentes com Câncer, Departamento de Oncologia Pediátrica, Hospital Santa Marcelina, São Paulo, Brasil.,Centro de Investigação Translacional em Oncologia, Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, São Paulo, SP, Brasil.,Hospital do Servidor Público Estadual de São Paulo (IAMSPE), São Paulo, SP, Brasil
| | - E S Moreira
- Instituto de Ensino e Pesquisa, Hospital Sírio-Libanês, São Paulo, SP, Brasil.,Evidências - Kantar Health, São Paulo, SP, Brasil
| | - C R R Carvalho
- Departamento de Cardiopneumologia, Instituto do Coração, Universidade de São Paulo, São Paulo, SP, Brasil
| | - G P P Schettino
- Departamento de Cardiopneumologia, Instituto do Coração, Universidade de São Paulo, São Paulo, SP, Brasil.,Hospital Municipal da Vila Santa Catarina, Sociedade Beneficente Israelita Albert Einstein, São Paulo, SP, Brasil
| | - S Wendel
- Instituto de Ensino e Pesquisa, Hospital Sírio-Libanês, São Paulo, SP, Brasil.,Banco de Sangue, Hospital Sirio-Libanes, São Paulo, SP, Brasil
| | - L C P Azevedo
- Instituto de Ensino e Pesquisa, Hospital Sírio-Libanês, São Paulo, SP, Brasil.,Disciplina de Emergências Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil
| |
Collapse
|
3
|
Critically ill children: to transfuse or not to transfuse packed red blood cells, that is the question. Pediatr Crit Care Med 2012; 13:204-9. [PMID: 21499178 DOI: 10.1097/pcc.0b013e318219291c] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES This article summarizes the current data on packed red blood cell transfusion in the pediatric intensive care unit setting to help providers make evidence-based decisions regarding packed red blood cell transfusions. DATA SOURCES Review of the literature, including PubMed, citations from relevant articles, and some articles that have been particularly relevant in adult critical care practice regarding packed red blood cell transfusion. CONCLUSIONS The use of packed red blood cell transfusions is common in the pediatric intensive care unit setting. However, until recently there have been little data to guide providers in this practice. Studies in adult intensive care units have shown less favorable outcomes in patients who received packed red blood cell transfusions. This has led to renewed questioning of the practice of packed red blood cell transfusion in critically ill pediatric patients. New data indicate that using a hemoglobin transfusion threshold of >7 g/dL does not yield improved outcomes. Furthermore, smaller studies have suggested that pediatric intensive care unit patients may be at an increased risk for morbidity and mortality when undergoing transfusion.
Collapse
|
4
|
Weiskopf RB, Feiner J, Toy P, Twiford J, Shimabukuro D, Lieberman J, Looney MR, Lowell CA, Gropper MA. Fresh and stored red blood cell transfusion equivalently induce subclinical pulmonary gas exchange deficit in normal humans. Anesth Analg 2012; 114:511-9. [PMID: 22262647 DOI: 10.1213/ane.0b013e318241fcd5] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Transfusion can cause severe acute lung injury, although most transfusions do not seem to induce complications. We tested the hypothesis that transfusion can cause mild pulmonary dysfunction that has not been noticed clinically and is not sufficiently severe to fit the definition of transfusion-related acute lung injury. METHODS We studied 35 healthy, normal volunteers who donated 1 U of blood 4 weeks and another 3 weeks before 2 study days separated by 1 week. On study days, 2 U of blood were withdrawn while maintaining isovolemia, followed by transfusion with either the volunteer's autologous fresh red blood cells (RBCs) removed 2 hours earlier or their autologous stored RBCs (random order). The following week, each volunteer was studied again, transfused with the RBCs of the other storage duration. The primary outcome variable was the change in alveolar to arterial difference in oxygen partial pressure (AaDo(2)) from before to 60 minutes after transfusion with fresh or older RBCs. RESULTS Fresh RBCs and RBCs stored for 24.5 days equally (P = 0.85) caused an increase of AaDo(2) (fresh: 2.8 mm Hg [95% confidence interval: 0.8-4.8; P = 0.007]; stored: 3.0 mm Hg [1.4-4.7; P = 0.0006]). Concentrations of all measured cytokines, except for interleukin-10 (P = 0.15), were less in stored leukoreduced (LR) than stored non-LR packed RBCs; however, vascular endothelial growth factor was the only measured in vivo cytokine that increased more after transfusion with LR than non-LR stored packed RBCs. Vascular endothelial growth factor was the only cytokine tested with in vivo concentrations that correlated with AaDo(2). CONCLUSION RBC transfusion causes subtle pulmonary dysfunction, as evidenced by impaired gas exchange for oxygen, supporting our hypothesis that lung impairment after transfusion includes a wide spectrum of physiologic derangements and may not require an existing state of altered physiology. These data do not support the hypothesis that transfusion of RBCs stored for >21 days is more injurious than that of fresh RBCs.
Collapse
Affiliation(s)
- Richard B Weiskopf
- Department of Anesthesia & Perioperative Care, University of California, San Francisco, Box 0648, San Francisco, CA 94143-0648, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
5
|
Affiliation(s)
- Jang Hoon Lee
- Department of Cardiovascular & Thoracic Surgery, College of Medicine, Yeungnam University, Daegu, Korea
| |
Collapse
|
6
|
Qazi MA, Rizzatti F, Piknova B, Sibmooh N, Stroncek DF, Schechter AN. Effect of storage levels of nitric oxide derivatives in blood components. F1000Res 2012; 1:35. [PMID: 24358838 PMCID: PMC3814924 DOI: 10.12688/f1000research.1-35.v1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/15/2012] [Indexed: 12/17/2022] Open
Abstract
Background: Potential deleterious effects of red blood cell (RBC) transfusions, especially from blood kept at length, have been ascribed to biochemical changes during storage, including those of nitric oxide (NO) metabolism. Study methods and design: In this study, NO metabolites, nitrite and nitrate, were quantified in RBCs and whole blood with time of storage. Whole blood (WB), leukoreduced (LR), and non-leukoreduced (NLR) components were obtained from healthy volunteer donors and stored in polyvinyl chloride bags for 42 days. Nitrite and nitrate were measured using reductive gas-phase chemiluminescence. Results: Nitrite concentrations initially decreased rapidly from about 150nmol/L, but stabilized at about 44nmol/L in room air for up to 42 days. Nitrate concentrations remained stable during storage at about 35µmol/L. Cells from bags maintained in an argon chamber showed decreased nitrite levels compared to those maintained in room air. Inhibition of enzymes implicated in the NO cycle did not alter nitrite levels. Conclusion: As erythrocytes may contribute to the control of blood flow and oxygen delivery through reduction of nitrite to NO under hypoxic conditions, the present findings provide insight into possible effects of blood transfusion. These measurements may explain some adverse effects of RBC transfusion and suggest ways of optimizing the preservation of stored blood.
Collapse
Affiliation(s)
- Melissa A Qazi
- Molecular Medicine Branch, National Institutes of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - Fabiola Rizzatti
- Molecular Medicine Branch, National Institutes of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD 20892, USA ; Federal University of São Carlos, São Paulo, Brazil
| | - Barbora Piknova
- Molecular Medicine Branch, National Institutes of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - Nathawut Sibmooh
- Molecular Medicine Branch, National Institutes of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD 20892, USA ; Department of Pharmacology, Faculty of Science, Mahidol University, Rama 6 Rd., Payathai Rajathewee, Bangkok 10400, Thailand, Thailand
| | - David F Stroncek
- Department of Transfusion Medicine, National Institutes of Health, Bethesda, MD 220892, USA
| | - Alan N Schechter
- Molecular Medicine Branch, National Institutes of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| |
Collapse
|
7
|
Tuinman PR, Vlaar AP, Cornet AD, Hofstra JJ, Levi M, Meijers JCM, Beishuizen A, Schultz MJ, Groeneveld ABJ, Juffermans NP. Blood transfusion during cardiac surgery is associated with inflammation and coagulation in the lung: a case control study. Crit Care 2011; 15:R59. [PMID: 21314930 PMCID: PMC3221992 DOI: 10.1186/cc10032] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2010] [Revised: 01/18/2011] [Accepted: 02/11/2011] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Blood transfusion is associated with increased morbidity and mortality in cardiac surgery patients, but cause-and-effect relations remain unknown. We hypothesized that blood transfusion is associated with changes in pulmonary and systemic inflammation and coagulation occurring in patients who do not meet the clinical diagnosis of transfusion-related acute lung injury (TRALI). METHODS We performed a case control study in a mixed medical-surgical intensive care unit of a university hospital in the Netherlands. Cardiac surgery patients (n = 45) were grouped as follows: those who received no transfusion, those who received a restrictive transfusion (one two units of blood) or those who received multiple transfusions (at least five units of blood). Nondirected bronchoalveolar lavage fluid (BALF) and blood were obtained within 3 hours postoperatively. Normal distributed data were analyzed using analysis of variance and Dunnett's post hoc test. Nonparametric data were analyzed using the Kruskal-Wallis and Mann-Whitney U tests. RESULTS Restrictive transfusion increased BALF levels of interleukin (IL)-1β and D-dimer compared to nontransfused controls (P < 0.05 for all), and IL-1β levels were further enhanced by multiple transfusions (P < 0.01). BALF levels of IL-8, tumor necrosis factor α (TNFα) and thrombin-antithrombin complex (TATc) were increased after multiple transfusions (P < 0.01, P < 0.001 and P < 0.01, respectively) compared to nontransfused controls, but not after restrictive transfusions. Restrictive transfusions were associated with increased pulmonary levels of plasminogen activator inhibitor 1 compared to nontransfused controls with a further increase after multiple transfusions (P < 0.001). Concomitantly, levels of plasminogen activator activity (PAA%) were lower (P < 0.001), indicating impaired fibrinolysis. In the systemic compartment, transfusion was associated with a significant increase in levels of TNFα, TATc and PAA% (P < 0.05). CONCLUSIONS Transfusion during cardiac surgery is associated with activation of inflammation and coagulation in the pulmonary compartment of patients who do not meet TRALI criteria, an effect that was partly dose-dependent, suggesting transfusion as a mediator of acute lung injury. These pulmonary changes were accompanied by systemic derangement of coagulation.
Collapse
Affiliation(s)
- Pieter R Tuinman
- Department of Intensive Care Medicine and Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Academic Medical Center, Meibergdreef 9, Amsterdam, NL-1105 AZ, The Netherlands
| | - Alexander P Vlaar
- Department of Intensive Care Medicine and Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Academic Medical Center, Meibergdreef 9, Amsterdam, NL-1105 AZ, The Netherlands
| | - Alexander D Cornet
- Department of Intensive Care Medicine, VU University Medical Center, De Boelelaan 1117, Amsterdam, NL-1081 HZ, The Netherlands
| | - Jorrit J Hofstra
- Department of Intensive Care Medicine and Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Academic Medical Center, Meibergdreef 9, Amsterdam, NL-1105 AZ, The Netherlands
| | - Marcel Levi
- Department of Internal Medicine, Academic Medical Center, Meibergdreef 9, Amsterdam, NL-1105 AZ, The Netherlands
| | - Joost CM Meijers
- Department of Experimental Vascular Medicine, Academic Medical Center, Meibergdreef 9, Amsterdam, NL-1105 AZ, The Netherlands
| | - Albertus Beishuizen
- Department of Intensive Care Medicine, VU University Medical Center, De Boelelaan 1117, Amsterdam, NL-1081 HZ, The Netherlands
| | - Marcus J Schultz
- Department of Intensive Care Medicine and Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Academic Medical Center, Meibergdreef 9, Amsterdam, NL-1105 AZ, The Netherlands
| | - AB Johan Groeneveld
- Department of Intensive Care Medicine, VU University Medical Center, De Boelelaan 1117, Amsterdam, NL-1081 HZ, The Netherlands
| | - Nicole P Juffermans
- Department of Intensive Care Medicine and Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Academic Medical Center, Meibergdreef 9, Amsterdam, NL-1105 AZ, The Netherlands
| |
Collapse
|