APACHE II score cannot predict successful weaning from prolonged mechanical ventilation.

At least 5% of all intensive care unit patients require prolonged respiratory support. Multiple factors have been suggested as possible predictors of successful respiratory weaning so far. We sought to verify whether the Acute Physiology and Chronic Health Evaluation II (APACHE II) can predict freedom from prolonged mechanical ventilation (PMV) in patients treated in a regional weaning centre. The study group comprised 130 consecutive patients (age; median (interquartile range): 71 (62-77) years), hospitalized between 1 January 2012, and 31 December 2013. APACHE II score was assessed based on the worst values taken during the first 24 hours after admission. Glasgow coma scale was excluded from calculations due to the likely influence of sedative agents. The outcome was defined as freedom from mechanical ventilation, with or without tracheostomy on discharge. Among survivors ( n = 115), 88.2% were successfully liberated from mechanical ventilation and 60.9% from tracheostomy. APACHE II failed to predict freedom from mechanical ventilation (area under the receiver-operating characteristic curve [AUROC] = 0.534; 95% confidence interval [CI]: 0.439-0.628; p = 0.65) and tracheostomy tube removal (AUROC = 0.527; 95% CI: 0.431-0.621; p = 0.63). Weaning outcome was unrelated to the aetiology of respiratory failure on admission ( p = 0.41). APACHE II cannot predict weaning outcome in patients requiring PMV.

APACHE II score predicts mortality in patients requiring prolonged ventilation in a weaning center.

BACKGROUND: In the past decade, the rate and utilization of veno-venous extracorporeal membrane oxygenation (VV-ECMO) has increased dramatically. A single catheter technique has recently come into favour for providing VV-ECMO. Although it has been shown that intensivists can safely place these catheters, the safety of decannulation by intensivists has not been reported in the literature. OBJECTIVE: We describe a technique for safely decannulating the Avalon Elite VV-ECMO catheter at the bedside and assess the safety of this technique, as compared with the standard technique of decannulation in the operating room by a surgeon. METHODS: This was a retrospective cohort design conducted at a tertiary care cardiovascular intensive care unit at an academic medical centre. All patients who underwent VV-ECMO from 2009 to 2014 were included in the study except for those who had been decannulated for withdrawal of care. Complication rates from decannulation were compared between patients who were decannulated by surgeons in the operating room and those decannulated by intensivists in the intensive care unit (ICU). RESULTS: Twenty-eight patients were included in this study, of whom twenty-three patients (82%) were decannulated by intensivists, board certified in Critical Care Medicine through the American Board of Anesthesiology, while five (18%) the patients were decannulated by a surgeon. There was no significant difference in the complications rates between the surgeons (0) and intensivists (1) (P = 1.00). There were no major complications requiring operative intervention associated with decannulation identified in this study. CONCLUSIONS: It is safe for intensivists to decannulate the Avalon Elite VV-ECMO cannula in the ICU using our purse-string suture technique. Performing these decannulations at the bedside compared to operating room may have positive clinical ramifications that include improved patient safety, timely patient care and reduced operating room costs.

Does the APACHE II score predict performance of activities of daily living in patients discharged from a weaning center?

INTRODUCTION: Data regarding the functional status of patients after prolonged mechanical ventilation are scarce, and little is known about its clinical predictors. AIM: To investigate whether the Acute Physiology and Chronic Health Evaluation (APACHE) II score on admission may predict performance in activities of daily living on discharge from a weaning center. MATERIAL AND METHODS: All consecutive patients admitted between January 1, 2012 and December 31, 2013 were enrolled (n = 130). During this period, 15 subjects died, and 115 were successfully discharged (34 women; 81 men). APACHE II was calculated based on the worst values taken during the first 24 hours after admission. On discharge, the Barthel Index (BI) and its extended version, the Early Rehabilitation Barthel Index (ERBI), were assessed. RESULTS: Median BI was 20 points (IQR 5; 40), and ERBI was 20 points (-50; 40). There was no correlation between APACHE II and either BI (R = -0.07; p = 0.47) or ERBI (R = -0.07; p = 0.44). APACHE II predicted the need for assistance with bathing (AUROC = 0.833; p < 0.001), grooming (AUROC = 0.823; p < 0.001), toilet use (AUROC = 0.887; p < 0.001), and urination (AUROC = 0.658; p = 0.04). APACHE II had no impact on any ERBI items associated with ventilator weaning, including the need of further mechanical ventilation (AUROC = 0.534; p = 0.65) or tracheostomy (AUROC = 0.544; p = 0.42). CONCLUSIONS: Although APACHE II cannot predict the overall functional status in patients discharged from a weaning center, it helps identify subjects who will need support with bathing, grooming, and toilet use. The APACHE II score is inadequate to predict performance in activities associated with further respiratory support.

A single-centre seven-year experience with mechanical ventilation weaning.

BACKGROUND: Weaning from mechanical ventilation is a growing and challenging issue in modern intensive care medicine. We aimed to describe a 7-year experience in mechanical ventilation weaning of a single centre in Germany. METHODS: We retrospectively analysed data regarding 403 patients admitted between 2007 and 2013 with difficult or prolonged mechanical ventilation weaning. RESULTS: There were 261 men (64.8%) in the population. The median age was 72 (IQR 63; 77) years. The underlying reasons for ventilator dependence comprised: post-operative respiratory failure (56.3%), exacerbation of chronic obstructive pulmonary disease (14.4%) and pneumonia (7.4%). A tracheostomy was performed about 9 (IQR 7; 14) days after the last attempt of a spontaneous breathing trial, usually with the percutaneous method (89.3%). The median length of stay was 28 (IQR 20; 41) days. Sixty-five (16.1%) patients died. Among the survivors, complete ventilator independence was achieved in 316 (78.4%) subjects while 94 (29.7%) of them required a tracheal tube on discharge. The vast majority of patients were discharged to rehabilitation clinics (56.1%). All of the analysed parameters did not statistically significantly differ between consecutive years in the investigated period. CONCLUSION: Our initial results of mechanical ventilation weaning are encouraging, repeatable in subsequent years of observation and consistent with the literature data. Assessing the predictors of successful mechanical ventilation weaning requires further research.