Mechanical power density, spontaneous breathing indexes, and prolonged weaning failure: a prospective cohort study.

A prospective observational study comparing mechanical power density (MP normalized to dynamic compliance) with traditional spontaneous breathing indexes (e.g., predicted body weight normalized tidal volume [VT/PBW], rapid shallow breathing index [RSBI], or the integrative weaning index [IWI]) for predicting prolonged weaning failure in 140 tracheotomized patients. We assessed the diagnostic accuracy of these indexes at the start and end of the weaning procedure using ROC curve analysis, expressed as the area under the receiver operating characteristic curve (AUROC). Weaning failure occurred in 41 out of 140 patients (29%), demonstrating significantly higher MP density (6156 cmH2O2/min [4402-7910] vs. 3004 cmH2O2/min [2153-3917], P < 0.01), lower spontaneous VT/PBW (5.8 mL*kg-1 [4.8-6.8] vs. 6.6 mL*kg-1 [5.7-7.9], P < 0.01) higher RSBI (68 min-1*L-1 [44-91] vs. 55 min-1*L-1 [41-76], P < 0.01) and lower IWI (41 L2/cmH2O*%*min*10-3 [25-72] vs. 71 L2/cmH2O*%*min*10-3 [50-106], P < 0.01) and at the end of weaning. MP density was more accurate at predicting weaning failures (AUROC 0.91 [95%CI 0.84-0.95]) than VT/PBW (0.67 [0.58-0.74]), RSBI (0.62 [0.53-0.70]), or IWI (0.73 [0.65-0.80]), and may help clinicians in identifying patients at high risk for long-term ventilator dependency.

Prompt closure versus gradual weaning of external ventricular drain for hydrocephalus following aneurysmal subarachnoid haemorrhage: a statistical analysis plan for the DRAIN randomised clinical trial.

BACKGROUND: Insertion of an external ventricular drain (EVD) is a first-line treatment of acute hydrocephalus caused by aneurysmal subarachnoid haemorrhage (aSAH). Once the patient is clinically stable, the EVD is either removed or replaced by a permanent internal shunt. The optimal strategy for cessation of the EVD is unknown. Prompt closure carries a risk of acute hydrocephalus or redundant shunt implantations, whereas gradual weaning may increase the risk of EVD-related infections. METHODS: DRAIN (Danish RAndomised Trial of External Ventricular Drainage Cessation IN Aneurysmal Subarachnoid Haemorrhage) is an international multicentre randomised clinical trial comparing prompt closure versus gradual weaning of the EVD after aSAH. The primary outcome is a composite of VP-shunt implantation, all-cause mortality, or EVD-related infection. Secondary outcomes are serious adverse events excluding mortality and health-related quality of life (EQ-5D-5L). Exploratory outcomes are modified Rankin Scale, Fatigue Severity Scale, Glasgow Outcome Scale Extended, and length of stay in the neurointensive care unit and hospital. Outcome assessment will be performed 6 months after ictus. Based on the sample size calculation (event proportion 80% in the gradual weaning group, relative risk reduction 20%, alpha 5%, power 80%), 122 participants are required in each intervention group. Outcome assessment for the primary outcome, statistical analyses, and conclusion drawing will be blinded. Two independent statistical analyses and reports will be tracked using a version control system, and both will be published. Based on the final statistical report, the blinded steering group will formulate two abstracts. CONCLUSION: We present a pre-defined statistical analysis plan for the randomised DRAIN trial, which limits bias, p-hacking, and data-driven interpretations. This statistical analysis plan is accompanied by tables with simulated data, which increases transparency and reproducibility. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03948256. Registered on May 13, 2019.

A Randomized Controlled Clinical Trial Investigating the Weaning Process From Mechanical Ventilation in Elderly Patients With Dementia.

BACKGROUND: Limited data is available regarding the weaning techniques employed for mechanical ventilation (MV) in elderly patients with dementia in China. OBJECTIVE: The primary objective of this study is to investigate diverse weaning methods in relation to the prognostic outcomes of elderly patients with dementia undergoing MV in the intensive care unit (ICU). Specifically, we seek to compare the prognosis, likelihood of successful withdrawal from MV, and the length of stay (LOS) in the ICU. METHODS: The study was conducted as a randomized controlled trial, encompassing a group of 169 elderly patients aged ≥ 65 years with dementia who underwent MV. Three distinct weaning methods were used for MV cessation, namely, the tapering parameter, spontaneous breathing trial (SBT), and SmartCare (Dräger, Germany). RESULTS: In the tapering parameter group, the LOS in the ICU was notably prolonged compared to both the SBT and SmartCare groups. However, no statistically significant differences were observed among the groups with respect to demographic characteristics, such as age and sex, as well as factors including the rationale for ICU admission, cause of MV, MV mode, oxygenation index, hemoglobin levels, albumin levels, ejection fraction, sedation and analgesia practices, tracheotomy, duration of MV, successful extubation, successful weaning, incidences of ventilator-associated pneumonia, and overall prognosis. CONCLUSIONS: Both the SBT and SmartCare withdrawal methods demonstrated a reduction in the duration of MV and LOS in the ICU when compared to the tapering parameter method. TRIAL REGISTRATION: Chinese Clinical Trial Registry: ChiCTR1900028449.

Effect of altrenogest treatment before weaning on reproductive performance and production efficiency in primiparous and multiparous sows.

BACKGROUND: Most sows will experience negative energy balance during lactation resulting in impaired follicular development. This study aimed to treat 28-day lactating sows with altrenogest (ALT) to suppress follicle enlargement during lactation, and to assess the estrus and reproductive performance post-weaning. METHODS: In this study, we conducted two trials. In trial 1, we monitored the follicular development of lactating sows including 10 primiparous sows and 10 multiparous sows during the whole lactation to confirm the ALT administration time. In trial 2, a total of 42 primiparous and 111 multiparous sows were allocated to three treatments: Ctrl (control group, n = 51): no treatment; TAI (timed artificial insemination group, n = 51): sows were injected with equine chorionic gonadotropin (eCG) after weaning 24 h and gonadotropin-releasing hormone (GnRH) when they expressed estrus; and AT-TAI (ALT treatment-timed artificial insemination group, n = 51): base on the process of TAI group, the sows were fed with 20 mg ALT per day before weaning 10 days. All sows were artificially inseminated twice at 12 h and 36 h after estrus. The follicle size changes and serum hormone levels were explored in this process. RESULTS: Although the follicle size of multiparous sows was larger than primiparous sows during the whole lactation (P < 0.05), similar change trends of follicle size were observed in primiparous and multiparous sows. Meanwhile, the FSH, LH and E2 levels of multiparous sows were higher than primiparous sows. The ALT treatment significantly inhibits the increase in follicle size (P < 0.05) and reduces the serum levels of FSH, LH and E2 (P > 0.05). Additionally, ALT treatment increases estrus concentration and the preovulatory follicle size (P < 0.05), meanwhile, it delays the weaning-to-estrus interval (WEI, P < 0.001). However, the estrus rate, pregnancy rate, total pigs born and born alive did not differ between treatments (P > 0.05). CONCLUSIONS: There were significant differences in the size of follicles in the lactation between primiparous and multiparous sows. ALT treatment during the last ten days of lactation concentrated estrus expression leading to higher work efficiency of breeder in batch production, however, with no improvement in reproductive performance.

Peripheral perfusion index as a predictor of reintubation in critically ill surgical patients.

PURPOSE: We aimed to evaluate the ability of the peripheral perfusion index (PPI) to predict reintubation of critically ill surgical patients. METHODS: This prospective observational study included mechanically ventilated adults who were extubated after a successful spontaneous breathing trial (SBT). The patients were followed up for the next 48 h for the need for reintubation. The heart rate, systolic blood pressure, respiratory rate, peripheral arterial oxygen saturation (SpO2), and PPI were measured before-, at the end of SBT, 1 and 2 h postextubation. The primary outcome was the ability of PPI 1 h postextubation to predict reintubation using area under the receiver operating characteristic curve (AUC) analysis. Univariate and multivariate analyses were performed to identify predictors for reintubation. RESULTS: Data from 62 patients were analysed. Reintubation occurred in 12/62 (19%) of the patients. Reintubated patients had higher heart rate and respiratory rate; and lower SpO2 and PPI than successfully weaned patients. The AUC (95%confidence interval) for the ability of PPI at 1 h postextubation to predict reintubation was 0.82 (0.71-0.91) with a negative predictive value of 97%, at a cutoff value of ≤ 2.5. Low PPI and high respiratory rate were the independent predictors for reintubation. CONCLUSION: PPI early after extubation is a useful tool for prediction of reintubation. Low PPI is an independent risk factor for reintubation. A PPI > 2.5, one hour after extubation can confirm successful extubation.

Factors Influencing Successful Weaning From Venoarterial Extracorporeal Membrane Oxygenation: A Systematic Review.

With advancements in extracorporeal life support (ECLS) technologies, venoarterial extracorporeal membrane oxygenation (VA-ECMO) has emerged as a crucial cardiopulmonary support mechanism. This review explores the significance of VA-ECMO system configuration, cannulation strategies, and timing of initiation. Through an analysis of medication management strategies, complication management, and comprehensive preweaning assessments, it aims to establish a multidimensional evaluation framework to assist clinicians in making informed decisions regarding weaning from VA-ECMO, thereby ensuring the safe and effective transition of patients.

Treatment time limit for successful weaning from veno-arterial extracorporeal membrane oxygenation in cardiogenic shock.

AIMS: Knowing the upper time limit for successful weaning from temporary mechanical circulatory support in cardiogenic shock will help with decision-making regarding advanced heart failure (HF) therapy or considering withdrawal of care. The aim of this study was to investigate the association between the support duration and successful weaning from veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in patients with cardiogenic shock. METHODS AND RESULTS: A retrospective single-centre cohort study was conducted between January 2013 and June 2023. It included 100 consecutive patients with cardiogenic shock who were treated with VA-ECMO. Patients with out-of-hospital cardiac arrest were excluded. The primary outcome was successful weaning from VA-ECMO (i.e., VA-ECMO decannulation and survival to discharge). The association between the length of support duration and the weaning success rate was analysed. Patients were divided into three groups according to ECMO support duration: Group A (≤7 days), Group B (8-14 days), and Group C (≥15 days). Multivariable logistic regression analysis was used to evaluate the impact of the length of support duration on successful weaning of VA-ECMO. The median age was 67 years, and 73% of study participants were male. The underlying aetiologies of cardiogenic shock were as follows: acute myocardial infarction, 50; fulminant myocarditis, 19; cardiomyopathy, 15; valvular heart disease, 8; and other, 8. Seventy-five patients (75%) were attempted to wean VA-ECMO, and 67 moved on to decannulation. In total, 43 (43%) patients were successfully weaned from VA-ECMO. The median length of ECMO support duration was 8 [3-15] days. Compared with those who underwent successful ECMO decannulation, those who did not had a significantly longer support duration of VA-ECMO (5 [3-9] days vs. 12 [3-22] days, P = 0.004). The weaning success rate was significantly higher in patients with short support duration; 58% (29/50), 40% (10/25), 16% (4/25) in Groups A, B, and C, respectively (P = 0.002). Overall, none of the patients supported for over 24 days (0/11) were successfully weaned from VA-ECMO. On multivariable logistic regression analysis, the length of support duration was independently associated with successful weaning after adjusting for age, sex, underlying aetiology, and left ventricular ejection fraction (odds ratio, 0.813 [per 3 days]; 95% confidence interval, 0.679-0.914; P = 0.025). CONCLUSIONS: Long support duration of VA-ECMO was significantly associated with a low rate of successful weaning in patients with cardiogenic shock. Patients who require VA-ECMO for over 1 week should start considering advanced HF therapy or withdrawal of care.

Dietary complex probiotic supplementation changed the composition of intestinal short-chain fatty acids and improved the average daily gain of weaned piglets.

Probiotics are a group of active microorganisms that form colonies within the body and alter the composition of the flora in a specific area to provide benefits to the host. In this study, a total of 96 Duroc × Landrace × Yorkshire weaned piglets with an initial body weight (BW) of 8.56 ± 0.53 kg were employed in a randomized complete block design for a 28-day experiment. Pigs were randomly divided into two treatment groups: the control group (CON) and the complex probiotic group (CON + 0.2% probiotics), respectively. The study found that through the 28-day experiment, the average daily gain (ADG) of the complex probiotic group was significantly higher than that of the CON (p < 0.05). However, compared with the CON, the feed conversion efficiency significantly decreased on days 0-14 (p < 0.05). The addition of dietary complex probiotic significantly increased the villus height (VH) of duodenum and ileum, acetate, propionate, butyrate, and total short-chain fatty acids (SCFAs) in feces, and decreased fecal methyl mercaptans, acetic acid, and CO2 (p < 0.05). It concluded that feeding weaned piglets 0.2% complex probiotic increased the VH of duodenum and ileum, as well as changed the content of SCFAs in feces. This ultimately led to an increase in ADG.

Analysis of risk factors for weaning failure from mechanical ventilation in critically ill older patients with coronavirus disease 2019.

Objective: This study aimed to investigate the factors influencing weaning failure from invasive mechanical ventilation (IMV) in critically ill older patients with coronavirus disease 2019 (COVID-19). Methods: We enrolled critically ill older patients with COVID-19 who were admitted to the medical intensive care unit (ICU) and received IMV between December 2022 and June 2023. Results: We included 68 critically ill older patients with COVID-19 (52 male [76.5 %] and 16 female individuals [23.5 %]). The patients' median age (interquartile range) was 75.5 (70.3-82.8) years. The median length of ICU stay was 11.5 (7.0-17.8) days; 34 cases (50.0 %) were successfully weaned from IMV. The successfully weaned group had a higher proportion of underlying chronic obstructive pulmonary disease [6 (17.6 %) vs. 0, P = 0.033] and fewer cases of diabetes [7 (20.6 %) vs. 16 (47.1 %), P = 0.021] compared with the weaning failure group. Serum lactate levels [1.5 (1.2-2.3) vs. 2.6 (1.9-3.1) mmol/L, P < 0.001], blood urea nitrogen [8.2 (6.3-14.4) vs. 11.4 (8.0-21.3) mmol/L, P = 0.033], Acute Physiology and Chronic Health Evaluation (APACHE) II score [19.0 (12.0-23.3) vs. 22.5 (16.0-29.3), P = 0.014], and hospitalization days before endotracheal intubation [1.0 (0.0-5.0) vs. 3.0 (0.0-11.0), P = 0.023] were significantly decreased in the successfully weaned group, whereas PaO2/FiO2 [148.3 (94.6-200.3) vs. 101.1 (67.0-165.1), P = 0.038] and blood lymphocyte levels [0.6 (0.4-1.0) vs. 0.5 (0.2-0.6) 109/L, P = 0.048] were significantly increased, compared with the weaning failure group. Multivariate logistic regression analysis showed that diabetes (OR= 3.413, 95 %CI 1.029-11.326), P = 0.045), APACHE II Score (OR = 1.089, 95 % CI 1.008-1.175), P = 0.030), and hospitalization days before endotracheal intubation (OR = 1.137, 95 % CI 1.023-1.264), P = 0.017) were independent risk factors for weaning failure. Conclusion: In critically ill older patients with COVID-19 with diabetes, higher APACHE II Score, and longer hospitalization days before endotracheal intubation, weaning from IMV was more challenging. The study could help develop strategies for improving COVID-19 treatment.

Tracheostomy-related data from an intensive care unit for two consecutive years before the COVID-19 pandemic.

BACKGROUND: Tracheostomy is commonly used in intensive care unit (ICU) patients who are expected to be on long-term mechanical ventilation or suffer from emergency upper airway obstruction. However, some studies have conflicting findings regarding the optimal technique and its timing and benefits. AIM: To provide evidence of practice, characteristics, and outcome concerning tracheostomy in an ICU of a tertiary care hospital. METHODS: This was a retrospective cohort study including adult critical care patients in a single ICU for two consecutive years. Patients' demographic characteristics, severity of illness (APACHE II score), level of consciousness [Glasgow Coma Scale (GCS)], comorbidities, timing and type of tracheostomy procedure performed and outcome were recorded. We defined late as tracheostomy placement after 8 days or no tracheotomy. RESULTS: Data of 660 patients were analyzed (median age of 60 years), median APACHE II score of 19 and median GCS score of 12 at admission. Tracheostomy was performed in 115 patients, of whom 63 had early and 52 late procedures. Early tracheostomy was mainly executed in case of altered level of consciousness and severe critical illness polyneuromyopathy, however there were no significant statistical results (47.6% vs 36.5%, P = 0.23) and (23.8% vs 19.2%, P = 0.55) respectively. Regarding the method selected, early surgical tracheostomy (ST) was conducted in patients with maxillofacial injuries (50.0% vs 0.0%, P = 0.033), whereas late surgical tracheostomy was selected for patients with goiter (44.4% vs 0.0% P = 0.033). Patients with early tracheostomy spent significantly fewer days on mechanical ventilation (15.3 ± 8.5 vs 22.8 ± 9.6, P < 0.001) and in ICU in general (18.8 ± 9.1 vs 25.4 ± 11.5, P < 0.001). Percutaneous dilatation tracheostomy (PDT) vs ST was preferable in older critical care patients in the case of Central Nervous System underlying cause of admission (62.5% vs 26.3%, P = 0.004). ST was the method of choice in compromised airway (31.6%, vs 7.3% P = 0.008). A large proportion of patients (88/115) with tracheostomy managed to wean from mechanical ventilation and were transferred out of the ICU (100% vs 17.4%, P < 0.001). CONCLUSION: PDT was performed more frequently in our cohort. This technique did not affect mechanical ventilation days, ventilator-associated pneumonia (VAP), ICU length of stay, or survival. No complications were observed in the percutaneous or surgical tracheostomy groups. Patients undergoing early tracheostomy benefited in terms of mechanical ventilation days and ICU length of stay but not of discharge status, presence of VAP, or survival.

Influence of proportion of Brahman genetics on productivity of Brahman-Angus cows at weaning.

This study evaluated the association between the proportion of Brahman genetics and productivity of Brahman-Angus cows at weaning using a 31-yr dataset containing 6,312 cows and 5,405 pregnancies. Cows were contemporaneously reared and enrolled in yearly breeding seasons under subtropical conditions of North-Central Florida. They were evenly distributed in six-breed groups (G) according to the proportion of Brahman genetics: G0% to 19%, G21% to 34%, G38% (Brangus), G41% to 59%, G63% to 78%, and G81% to 100%. The proportion of cows calving (84.9%) did not differ across the six-breed groups. However, cows in the G81% to 100% weaned fewer calves (90.8%) than cows in the G0% to 19% and G21% to 34% (95.7%, each). The weaning rate of cows in the G38% (94.3%), G41% to 59% (94.2%), and G63% to 78% (93.0%) was intermediate between these three breed groups. The preweaning calf mortality was greater for cows in the G81% to 100% (9.2%) than cows in the G0% to 19% and G21% to 34% (4.3%, each), but intermediate for cows in the G38% (5.7%), G41% to 59% (5.8%), and G63% to 78% (7.0%). Cows in the G81% to 100% also weaned lighter calves (220.6 kg) than cows in the G0% to 19% (245.2 kg), G21% to 34% (250.2 kg), G38% (247.9 kg), G41% to 59% (252.5 kg), and G63% to 78% (245.2 kg). Cows in the G0% to 19% weaned lighter calves than cows with 21% to 78% of Brahman genetics. The 205-d adjusted weaning weight evidenced the less productive results of cows in G0% to 19% and G81% to 100% compared with other genetic groups, as they calved at the fastest and slowest rate, respectively. Thus, the 205-d adjusted weaning weight eliminated this bias. Additionally, younger cows weaned lighter calves; and male calves were heavier at weaning than female calves. Both parity order of cow and calf sex altered the magnitude of the described association between breed group of cows and calf weaning weights. Overall, after adjusting for weaning rate and age of calves at weaning, the number of kilograms produced per cow submitted to reproduction was less for cows in the G0% to 19% (191.1 kg) and G81% to 100 (181.8 kg) compared with cows in the G21% to 34 (197.0 kg), G38 (195.9 kg), G41% to 59 (199.7), and G63% to 78 (196.2). Cows in the G81% to 100% were the least productive. Thus, a proportion of Brahman genetics between 21% and 78% ensured superior productivity of Brahman-Angus cows subjected to subtropical conditions.

Evaluation of the combined predictive value of multiple indicators based on diaphragmatic ultrasound using logistic regression and ROC curve in weaning from mechanical ventilation in pediatric patients.

Background: Conventional single indicators have low sensitivity and specificity for predicting weaning from mechanical ventilation in pediatric patients, necessitating the establishment of a combined prediction model for predicting weaning outcomes. Objectives: To explore the combined predictive value of PaO2/FiO2 Ratio (P/F ratio), diaphragm excursion-rapid shallow breathing index (DE-RSBI), diaphragm thickening fraction-rapid shallow breathing index (DTF-RSBI), and Pediatric Critical Illness Score (PCIS) in weaning from mechanical ventilation in pediatric patients. Methods: Sixty critically ill pneumonia pediatric patients requiring mechanical ventilation treatment from July 2022 to June 2023 at the Second Affiliated Hospital of Jiaxing University were selected. They all underwent a spontaneous breathing trial (SBT) and were divided into the weaning success group (42 cases) and weaning failure group (18 cases) based on the weaning outcome. Parameters including total duration of illness, mechanical ventilation duration, heart rate (HR), P/F ratio, diaphragm excursion (DE), DE-RSBI, diaphragm thickening fraction (DTF), DTF-RSBI, and PCIS were included in univariate and multivariate logistic regression analyses to determine independent factors affecting pediatric weaning success. Receiver operating characteristic (ROC) curves were plotted to evaluate the predictive value of P/F ratio, DE-RSBI, DTF-RSBI, PCIS alone or in combination for weaning success. Results: Comparing P/F ratio, DE, DE-RSBI, DTF, DTF-RSBI and PCIS, there were statistically significant differences (P < 0.05). Through collinearity analysis and binary logistic regression analysis,P/F ratio [OR = 0.777, 95% CI (0.641,0.941)], DE-RSBI [OR = 1.694, 95% CI (1.172, 2.447)], DTF-RSBI [OR = 1.057, 95% CI (1.002, 1.114)], and PCIS [OR = 0.661, 95% CI (0.445, 0.982)] were identified as independent factors affecting successful weaning(P < 0.05).The regression equation was: LogitP = 73.299-0.253 P/F ratio + 0.525DE-RSBI + 0.055DTF-RSBI-0.43PCIS.The sensitivity of the combined indicator Logit(P) in predicting successful weaning from mechanical ventilation in pediatric patients was 88.9%, with a specificity of 95.2% (optimal cutoff value of 0.511), and the area under the ROC curve (AUC) was 0.960 [95% CI (0.915, 1.000)]. The AUC of the combined prediction model for predicting pediatric weaning was greater than that of P/F ratio, DE-RSBI, DTF-RSBI and PCIS alone (Z values = 9.129, 2.061, 2.075, 8.326, P < 0.05). Conclusions: In mechanically ventilated pediatric patients, the combined prediction model has better predictive value for weaning success compared to using P/F ratio, DE-RSBI, DTF-RSBI, or PCIS alone.

Feeding protocol for the Amazonian ornamental cichlid Apistogramma cacatuoides and a histological approach to the nutritional condition of larvae.

The aim of this study was to develop a feeding protocol for the larviculture of Apistogramma cacatuoides, using the histological approach to larval nutrition conditions. For this, three experiments were carried out. Experiment 1 was carried out in a randomized design to determine the optimal amount of Artemia nauplii (AN) per larva, and three treatments were evaluated: P1-feeding with 25 A. nauplii per larva (AN/L) during the first 5 days, followed by 50 AN/L from the 6th to the 10th day and 100 AN/L from the 11th to the 20th day; P2 and P3-37 and 50 AN/L during the first 5 days, 75 and 100 AN/L from the 6th to the 10th day and 150 and 200 AN/L from the 11th to the 20th day. Experiment 2 was carried out in a randomized design to determine the daily frequency of feeding and evaluated four feeding frequencies: F1-feeding only once a day (09:00); (F2)-feeding twice a day (09:00 and 17:00); F3-feeding three times a day (09:00, 11:30 and 17:00); and F4-feeding four times a day (09:00, 11: 30, 14:00 and 17:00). Experiment 3 lasted 40 days and was conducted in a randomized design to evaluate three periods for the beginning of the feeding transition: WE10:AN for 10 days, followed by 3 days of co-feeding and commercial feed until the end of the experimental period; WE15:AN for 15 days, followed by 3 days of co-feeding and commercial feed; WE20:AN for 20 days, followed by 3 days of co-feeding and commercial feed. The results of this study showed that, for the best development of the larvae, they should receive the feeding protocol 50-100-200 AN/L (P3) until the 20th day of exogenous feeding. From the 21st day, the transition to inert food should begin with 3 days of co-feeding, and feeding during larviculture should be carried out at a frequency of twice a day; this protocol provided a good nutritional status for the larvae, as shown by the histological approach.

Central venous pressure waveform analysis during sleep/rest: a novel approach to enhance intensive care unit post-extubation monitoring of extubation failure.

This pilot study aimed to investigate the relation between cardio-respiratory parameters derived from Central Venous Pressure (CVP) waveform and Extubation Failure (EF) in mechanically ventilated ICU patients during post-extubation period. This study also proposes a new methodology for analysing these parameters during rest/sleep periods to try to improve the identification of EF. We conducted a prospective observational study, computing CVP-derived parameters including breathing effort, spectral analyses, and entropy in twenty critically ill patients post-extubation. The Dynamic Warping Index (DWi) was calculated from the respiratory component extracted from the CVP signal to identify rest/sleep states. The obtained parameters from EF patients and patients without EF were compared both during arbitrary periods and during reduced DWi (rest/sleep). We have analysed data from twenty patients of which nine experienced EF. Our findings may suggest significantly increased respiratory effort in EF patients compared to those successfully extubated. Our study also suggests the occurrence of significant change in the frequency dispersion of the cardiac signal component. We also identified a possible improvement in the differentiation between the two groups of patients when assessed during rest/sleep states. Although with caveats regarding the sample size, the results of this pilot study may suggest that CVP-derived cardio-respiratory parameters are valuable for monitoring respiratory failure during post-extubation, which could aid in managing non-invasive interventions and possibly reduce the incidence of EF. Our findings also indicate the possible importance of considering sleep/rest state when assessing cardio-respiratory parameters, which could enhance respiratory failure detection/monitoring.

Association between spontaneous breathing trial methods and reintubation in adult critically ill patients: A systematic review and network meta-analysis of randomized controlled trials.

BACKGROUND: Reintubation is associated with higher risk of mortality. There is no clear evidence on the best spontaneous breathing trial (SBT) method to reduce the risk of reintubation. RESEARCH QUESTION: Are different methods of conducting SBT in critically ill patients associated with different risk of reintubation compared to T-tube? STUDY DESIGN AND METHODS: We conducted a systematic review and Bayesian network meta-analysis of randomized controlled trials (RCTs) investigating the effects of different SBT methods on reintubation. We surveyed PubMed, MEDLINE, CINAHL and CENTRAL databases from inception to 26th January 2024. The Surface Under the Cumulative Ranking curve (SUCRA) was used to determine the likelihood that an intervention was ranked as the best. Pairwise comparisons were also investigated by frequentist meta-analysis. Certainty of the evidence was assessed according to the GRADE approach. RESULTS: A total of 22 RCTs were included, for a total of 6196 patients. The network included nine nodes, with 13 direct pairwise comparisons. About 71% of the patients were allocated to T-tube and PSV-ZEEP, with 2135 and 2101 patients, respectively. The only intervention with a significantly lower risk of reintubation compared to T-tube was high flow oxygen (HFO) (RR 0.23, CrI 0.09 to 0.51, moderate quality evidence). HFO was associated with the highest probability of being the best intervention for reducing the risk of reintubation (81.86%, SUCRA 96.42), followed by continuous positive airway pressure (11.8%, SUCRA 76.75). INTERPRETATION: HFO SBT was associated with a lower risk of reintubation in comparison to other SBT methods. The results of our analysis should be considered with caution due to the low number of studies that investigated HFO SBT, and potential clinical heterogeneity related to co-interventions. Further trials should be performed to confirm the results on larger cohorts of patients and assess specific subgroups.

Initial timing of alfalfa hay supplementation manipulates blood parameters, rumen gene expression, and epithelial microbiota in pre-weaning lambs.

The present study aimed to investigate the impact of initiating alfalfa supplementation at either 14 or 42 days of age on growth performance, blood parameters, rumen tissue gene expression, and epithelial microbiota in pre-weaning lambs. A total of 42 seven-day-old male Hu lambs (3.88 ± 0.92 kg) were selected for this study. After 7 d of adjustment period, six lambs were slaughtered at 14 d of age to establish a baseline control. The remaining 36 lambs were randomly allocated to two treatment groups, every three lambs were considered a unit, including fed milk replacer, starter pellets, and either alfalfa hay fed at 14 (EAF) or 42 d of age (LAF). Body weight and feed intake were recorded for lamb until 70 d of age. Blood samples, rumen tissue samples, and epithelial microbiota samples were collected from the lambs at 42, 56, and 70 d of age. The results indicated that average daily gain, starter intake, and total dry matter intake were greater in the EAF group compared to the LAF group from 14 to 42 d of age (P < 0.01), but no significant differences from 43 to 70 d of age or during the entire trial. Treatment and age interactively affected the alfalfa intake (P = 0.02) from 43 to 70 d of age. The concentration of serum immunoglobulin A (IgA) (P < 0.01) and the expression of the rumen gene insulin-like growth factor 1 (P < 0.01) were greater in the EAF group compared to the LAF group at 42 d of age. Furthermore, the concentrations of alkaline phosphatase (P = 0.03), albumin (P < 0.01), total protein (P = 0.03), urea (P = 0.04), lipopolysaccharide (P < 0.01), ß-hydroxybutyric acid (P = 0.02), interleukin-1ß (IL-1ß) (P < 0.01), IL-4 (P < 0.01), and tumor necrosis factor α (P < 0.01) were affected by age. The abundance of Prevotella was lower (P < 0.05), whereas Megasphaera (P < 0.05) was greater in the EAF group compared to the LAF group at 42 d of age. The early addition of alfalfa promotes rumen epithelial microbiota colonization. In conclusion, this study demonstrated that alfalfa provision at 14 d of age promotes growth performance in lambs, but this effect disappeared at 43 to 70 d of age. Moreover, provision of alfalfa at 14 d of age enhances the immune response, promotes rumen tissue cell proliferation, and affects dynamical changes of rumen epithelial microbiota. Meanwhile, our findings showed that the rumen undergoes significant physiological challenges during the transition from a liquid diet to a solid diet.

Impact of tracheostomy tube modalities on ventilatory mechanics: a bench study.

PURPOSE: Tracheostomized patients often present with muscle weakness, altered consciousness, or swallowing difficulties. Hence, the literature is scarce regarding the challenging management of tracheostomy weaning. There is a need to strengthen the understanding of respiratory mechanisms with the different tracheostomy tube modalities that compose this weaning pathway. We aimed to evaluate the impact of these modalities on the work of breathing (WOB), total positive end-expiratory pressure (PEEPtot), and tidal volume (VT). METHODS: With a three-dimensional (3D) printed head mimicking human upper airways, we added a tracheal extension, and pierced to allow insertion of a size 7.0 tracheostomy cannula. The whole was connected to an artificial lung. Three lung mechanics were simulated (normal, obstructive and restrictive). We compared five different tracheostomy tube modalities to a control scenario in which the tube was capped and the cuff was deflated. RESULTS: A marginal difference was observed on the WOB within conditions with a slight increase + 0.004 [95% CI (0.003-0.004); p < 0.001] when the cuff was inflated in the normal and restrictive models and a slight decrease in the obstructive model. The highest PEEPtot that was reached was + 1 cmH2O [95% CI (1-1.1); p < 0.001] with high-flow therapy (HFT) with the cuff inflated in the obstructive model. We observed a statistically significant reduction in VT [up to - 57 mL 95% CI (- 60 to - 54); p < 0.001] when the cuff was inflated, in both the normal and obstructive models. CONCLUSIONS: Our results support the use of conditions that involve cuff deflation. Intermediate modalities with the cuff deflated produced similar results than cannula capping.

Clinically Relevant Topics and New Tendencies in Childhood Nutrition during the First 2 Years of Life: A Survey among Primary Care Spanish Paediatricians.

A multicenter cross-sectional study was conducted among 245 experienced Spanish paediatricians, who completed an online survey based on clinically relevant topics in nutrition during the first two years of life and their recommendations to parents in daily clinical practice. Most participants advise about the choking risk associated with baby-led weaning (BLW) and more than 60% consider that infants can receive an insufficient variety and quantity of nutrients with this practice. The general opinion is that there is a lack of evidence for delaying the introduction of gluten and other allergenic foods in the complementary feeding of healthy infants. Most participants agree/strongly agree that two servings of dairy products are the adequate daily amount in a diversified diet and 93.4% disagree/strongly disagree with the use of vegetal beverages under 1 year of life. There is a general agreement to avoid added salt and sugar before 12 months of life, the consideration that organic foods do not have a better nutritional profile than non-organic ones, and the limitations of vegetarian diets especially for adequate provision of micronutrients. Overall, there is an adequate knowledge of the new trends by paediatricians and younger ones seemed more in favor of them and interested in receiving more information on most topics.

Effect of lung volume preservation during spontaneous breathing trial on successful extubation in patients receiving mechanical ventilation: protocol for a multicenter clinical trial.

BACKGROUND: In standard weaning from mechanical ventilation, a successful spontaneous breathing test (SBT) consisting of 30 min 8 cmH2O pressure-support ventilation (PSV8) without positive end-expiratory pressure (PEEP) is followed by extubation with continuous suctioning; however, these practices might promote derecruitment. Evidence supports the feasibility and safety of extubation without suctioning. Ultrasound can assess lung aeration and respiratory muscles. We hypothesize that weaning aiming to preserve lung volume can yield higher rates of successful extubation. METHODS: This multicenter superiority trial will randomly assign eligible patients to receive either standard weaning [SBT: 30-min PSV8 without PEEP followed by extubation with continuous suctioning] or lung-volume-preservation weaning [SBT: 30-min PSV8 + 5 cmH2O PEEP followed by extubation with positive pressure without suctioning]. We will compare the rates of successful extubation and reintubation, ICU and hospital stays, and ultrasound measurements of the volume of aerated lung (modified lung ultrasound score), diaphragm and intercostal muscle thickness, and thickening fraction before and after successful or failed SBT. Patients will be followed for 90 days after randomization. DISCUSSION: We aim to recruit a large sample of representative patients (N = 1600). Our study cannot elucidate the specific effects of PEEP during SBT and of positive pressure during extubation; the results will show the joint effects derived from the synergy of these two factors. Although universal ultrasound monitoring of lungs, diaphragm, and intercostal muscles throughout weaning is unfeasible, if derecruitment is a major cause of weaning failure, ultrasound may help clinicians decide about extubation in high-risk and borderline patients. TRIAL REGISTRATION: The Research Ethics Committee (CEIm) of the Fundació Unió Catalana d'Hospitals approved the study (CEI 22/67 and 23/26). Registered at ClinicalTrials.gov in August 2023. Identifier: NCT05526053.

Operator independent continuous ultrasound monitoring of diaphragm excursion predicts successful weaning from mechanical ventilation: a prospective observational study.

BACKGROUND: In mechanically ventilated patients, diaphragm ultrasound can identify diaphragm weakness and predict weaning failure. We evaluated whether a novel operator-independent ultrasound-based medical device allowing continuous monitoring of the diaphragm (CUSdi) could reliably (1) measure diaphragm excursion (EXdi) and peak contraction velocity (PCVdi), (2) predict weaning outcome, and (3) approximate transdiaphragmatic pressure (Pdi). METHODS: In 49 mechanically ventilated patients, CUSdi was recorded during a 30-min spontaneous breathing trial (SBT), and EXdi and PCVdi were measured. In subgroups of patients, standard ultrasound measurement of EXdi and PCVdi was performed (n = 36), and Pdi derived parameters (peak and pressure time product, n = 30) were measured simultaneously. RESULTS: The agreement bias between standard ultrasound and CUSdi for EXdi was 0.1 cm (95% confidence interval -0.7-0.9 cm). The regression of Passing-Bablok indicated a lack of systematic difference between EXdi measured with standard ultrasound and CUSdi, which were positively correlated (Rho = 0.84, p < 0.001). Weaning failure was observed in 54% of patients. One, two and three minutes after the onset of the SBT, EXdi was higher in the weaning success group than in the failure group. Two minutes after the onset of the SBT, an EXdi < 1.1 cm predicted weaning failure with a sensitivity of 0.83, a specificity of 0.68, a positive predictive value of 0.76, and a negative predictive value of 0.24. There was a weak correlation between EXdi and both peak Pdi (r = 0.22, 95% confidence interval 0.15 - 0.28) and pressure time product (r = 0.13, 95% confidence interval 0.06 - 0.20). Similar results were observed with PCVdi. CONCLUSIONS: Operator-independent continuous diaphragm monitoring quantifies EXdi reliably and can predict weaning failure with an identified cut-off value of 1.1 cm. Trial registration clinicaltrial.gov, NCT04008875 (submitted 12 April 2019, posted 5 July 2019) and NCT03896048 (submitted 27 March 2019, posted 29 March 2019).