Effectiveness of "Physician Prompt Clinical Decision Criteria" in Weaning Outcome Prediction for Neurocritical Patients

Endotracheal intubation and invasive mechanical ventilation are fundamental components for the resuscitation of neurocritically ill patients to achieve various goals which include ensuring the protection of the airway, participating in tissue oxygen delivery and indirectly modulating cerebral vascular reactivity. The neurocritical patients demand special attention to their systemic involvement regarding weaning. Physician prompt clinical decision criteria (PPC) can play a better role in weaning of such patients. The aim of this study was to evaluate the effectiveness of 'Physician prompt clinical decision criteria' for successful weaning in neurocritical patients. This prospective observational study was conducted in the ICU, Department of Anaesthesia, Analgesia, Palliative & Intensive Care Medicine, Dhaka Medical College Hospital (DMCH), Dhaka, Bangladesh from March 2018 to April 2020. In total 100 neurocritical patients who fulfilled the inclusion criteria were taken as samples by informed written consent. The outcome was observed as successful weaning or as failed weaning. Finally, the existence of Standard extubation criteria (SEC) was compared with Physician prompt clinical decision criteria (PPC). Weaning was succeeded in 80.0% of patients and failed in 20.0% according to the Standard extubation criteria (SEC) while weaning was succeeded in 85.7% of patients and failed in 14.28% according to the Physician prompt clinical decision criteria (PPC). There were some differences in results but no significant differences were observed statistically between the groups in predicting the weaning outcome. Physician prompt clinical decision criteria were found to be 75.0% sensitive and specificity was 50.0%. Positive predictive value for Physician prompt clinical decision criteria was 85.70% with a Positive likelihood ratio for these criteria was 1.5 times. So, according to the study findings, accuracy of Physician prompt clinical decision criteria was 70.0%. According to the findings of this current study we can conclude that Physician prompt clinical decision criteria are an effective weaning readiness predictor in neurocritical patients.

Extubation in neurocritical care patients: the ENIO international prospective study

PURPOSE

Neurocritical care patients receive prolonged invasive mechanical ventilation (IMV), but there is poor specific information in this high-risk population about the liberation strategies of invasive mechanical ventilation.

METHODS

ENIO (NCT03400904) is an international, prospective observational study, in 73 intensive care units (ICUs) in 18 countries from 2018 to 2020. Neurocritical care patients with a Glasgow Coma Score (GCS) ≤ 12, receiving IMV ≥ 24 h, undergoing extubation attempt or tracheostomy were included. The primary endpoint was extubation failure by day 5. An extubation success prediction score was created, with 2/3 of patients randomly allocated to the training cohort and 1/3 to the validation cohort. Secondary endpoints were the duration of IMV and in-ICU mortality.

RESULTS

1512 patients were included. Among the 1193 (78.9%) patients who underwent an extubation attempt, 231 (19.4%) failures were recorded. The score for successful extubation prediction retained 20 variables as independent predictors. The area under the curve (AUC) in the training cohort was 0.79 95% confidence interval (CI₉₅) [0.71-0.87] and 0.71 CI₉₅ [0.61-0.81] in the validation cohort. Patients with extubation failure displayed a longer IMV duration (14 [7-21] vs 6 [3-11] days) and a higher in-ICU mortality rate (8.7% vs 2.4%). Three hundred and nineteen (21.1%) patients underwent tracheostomy without extubation attempt. Patients with direct tracheostomy displayed a longer duration of IMV and higher in-ICU mortality than patients with an extubation attempt (success and failure).

CONCLUSIONS

In neurocritical care patients, extubation failure is high and is associated with unfavourable outcomes. A score could predict extubation success in multiple settings. However, it will be mandatory to validate our findings in another prospective independent cohort.

Geoeconomic variations in epidemiology, ventilation management, and outcomes in invasively ventilated intensive care unit patients without acute respiratory distress syndrome: a pooled analysis of four observational studies

Background

Geoeconomic variations in epidemiology, the practice of ventilation, and outcome in invasively ventilated intensive care unit (ICU) patients without acute respiratory distress syndrome (ARDS) remain unexplored. In this analysis we aim to address these gaps using individual patient data of four large observational studies.

Methods

In this pooled analysis we harmonised individual patient data from the ERICC, LUNG SAFE, PRoVENT, and PRoVENT-iMiC prospective observational studies, which were conducted from June, 2011, to December, 2018, in 534 ICUs in 54 countries. We used the 2016 World Bank classification to define two geoeconomic regions: middle-income countries (MICs) and high-income countries (HICs). ARDS was defined according to the Berlin criteria. Descriptive statistics were used to compare patients in MICs versus HICs. The primary outcome was the use of low tidal volume ventilation (LTVV) for the first 3 days of mechanical ventilation. Secondary outcomes were key ventilation parameters (tidal volume size, positive end-expiratory pressure, fraction of inspired oxygen, peak pressure, plateau pressure, driving pressure, and respiratory rate), patient characteristics, the risk for and actual development of acute respiratory distress syndrome after the first day of ventilation, duration of ventilation, ICU length of stay, and ICU mortality.

Findings

Of the 7608 patients included in the original studies, this analysis included 3852 patients without ARDS, of whom 2345 were from MICs and 1507 were from HICs. Patients in MICs were younger, shorter and with a slightly lower body-mass index, more often had diabetes and active cancer, but less often chronic obstructive pulmonary disease and heart failure than patients from HICs. Sequential organ failure assessment scores were similar in MICs and HICs. Use of LTVV in MICs and HICs was comparable (42·4% vs 44·2%; absolute difference –1·69 [–9·58 to 6·11] p=0·67; data available in 3174 [82%] of 3852 patients). The median applied positive end expiratory pressure was lower in MICs than in HICs (5 [IQR 5–8] vs 6 [5–8] cm H₂O; p=0·0011). ICU mortality was higher in MICs than in HICs (30·5% vs 19·9%; p=0·0004; adjusted effect 16·41% [95% CI 9·52–23·52]; p<0·0001) and was inversely associated with gross domestic product (adjusted odds ratio for a US$10 000 increase per capita 0·80 [95% CI 0·75–0·86]; p<0·0001).

Interpretation

Despite similar disease severity and ventilation management, ICU mortality in patients without ARDS is higher in MICs than in HICs, with a strong association with country-level economic status.

Funding

No funding.

Multidisciplinary Team Effort Results in Better Outcomes in Critically Ill Obstetric Patients Admitted in ICU

Management of critically ill obstetric patients is a great challenge for the ICU team. The safety of both mother and fetus are of real concerns. Teamwork is essential for better outcome in obstetric patients in the ICU. A 26 years old female was admitted in Dhaka Medical College Hospital, Dhaka, Bangladesh on 18 August 2019 with 7 months pregnancy with brain tumor (later diagnosed as Gliosarcoma) and was managed surgically by left temporal craniotomy with excision of the tumor. The patient was shifted to the ICU due to repeated convulsions and need mechanical ventilator support. Later on, she was suffering from sepsis with pseudomonas in blood culture, grade IV pressure ulcer and electrolyte imbalance and needed tracheostomy for airway management. On 34th weeks of her pregnancy she developed antepartum hemorrhage with respiratory distress. Emergency LUCS was done and she delivered a LBW baby who was managed in NICU. Mother was managed in the ICU and later on both mother and child were discharge with good conditions. Multidisciplinary team work is vital for better management of critically ill obstetric patients.

Epidemiological Characteristics, Ventilator Management, and Clinical Outcome in Patients Receiving Invasive Ventilation in Intensive Care Units from 10 Asian Middle-Income Countries (PRoVENT-iMiC): An International, Multicenter, Prospective Study

Epidemiology, ventilator management, and outcome in patients receiving invasive ventilation in intensive care units (ICUs) in middle-income countries are largely unknown. PRactice of VENTilation in Middle-income Countries is an international multicenter 4-week observational study of invasively ventilated adult patients in 54 ICUs from 10 Asian countries conducted in 2017/18. Study outcomes included major ventilator settings (including tidal volume [V _T] and positive end-expiratory pressure [PEEP]); the proportion of patients at risk for acute respiratory distress syndrome (ARDS), according to the lung injury prediction score (LIPS), or with ARDS; the incidence of pulmonary complications; and ICU mortality. In 1,315 patients included, median V _T was similar in patients with LIPS < 4 and patients with LIPS ≥ 4, but lower in patients with ARDS (7.90 [6.8-8.9], 8.0 [6.8-9.2], and 7.0 [5.8-8.4] mL/kg Predicted body weight; P = 0.0001). Median PEEP was similar in patients with LIPS < 4 and LIPS ≥ 4, but higher in patients with ARDS (five [5-7], five [5-8], and 10 [5-12] cmH₂O; P < 0.0001). The proportions of patients with LIPS ≥ 4 or with ARDS were 68% (95% CI: 66-71) and 7% (95% CI: 6-8), respectively. Pulmonary complications increased stepwise from patients with LIPS < 4 to patients with LIPS ≥ 4 and patients with ARDS (19%, 21%, and 38% respectively; P = 0.0002), with a similar trend in ICU mortality (17%, 34%, and 45% respectively; P < 0.0001). The capacity of the LIPS to predict development of ARDS was poor (ROC AUC of 0.62, 95% CI: 0.54-0.70). In Asian middle-income countries, where two-thirds of ventilated patients are at risk for ARDS according to the LIPS and pulmonary complications are frequent, setting of V _T is globally in line with current recommendations.

Extubation strategies in neuro-intensive care unit patients and associations with outcomes: the ENIO multicentre international observational study

Background

Prolonged invasive ventilation is common in patients with severe brain injury. Information on optimal management of extubation and on the use of tracheostomy in these patients is scarce. International guidelines regarding the ventilator liberation and tracheostomy are currently lacking.

Methods

The aim of ‘Extubation strategies in Neuro-Intensive care unit patients and associations with Outcomes’ (ENIO) study is to describe current management of weaning from invasive ventilation, focusing on decisions on timing of tracheal extubation and tracheostomy in intensive care unit (ICU) patients with brain injury. We conducted a prospective, international, multi-centre observational study enrolling patients with various types of brain injury, including trauma, stroke, and subarachnoid haemorrhage, with an initial Glasgow Coma Score equal or less than 12, and a duration of invasive ventilation longer than 24 hours from ICU admission. ENIO is expected to include at least 1,500 patients worldwide. The primary endpoint of the ENIO study is extubation success in the 48 hours following endotracheal tube removal. The primary objective is to validate a score predictive of extubation success. To accomplish this, the study population will be randomly divided to a development cohort (2/3 of the included patients) and a validation cohort (the remaining 1/3). Secondary objectives are: to determine the incidence of extubation success rate according to various time-frames (within 96 hours, >96 hours after extubation); to validate (existing) prediction scores for successful extubation according to various time-frames and definitions (i.e., tracheostomy as extubation failure); and to describe the current practices of extubation and tracheostomy, and their associations.

Discussion

ENIO will be the largest prospective observational study of ventilator liberation and tracheostomy practices in patients with severe brain injury undergoing invasive mechanical ventilation, providing a validated predictive score of successful extubation.

Trial registration

The ENIO study is registered in the Clinical Trials database: NCT 03400904.