TowardsA Care-Bundle For

Long-Term Weaning

Dr Matthew JacksonDr Tim Strang & Dr Maria

SafarCTCCU, UHSM

Content

• The Past: Literature review• The Present: Clinical practice

outline• The Future: Care-bundle

Definition

• Wean more than 3 weeks• Has a tracheostomy

Common Factors

• Cardiac Failure• Pleural Effusions• Fluid Balance• Acid-Base• Phosphate• Delirium• Depression• Critical Illness Neuromuscular

Abnormalities

Screening for Occult Disease

• Bronchoscopy: airway stenosis occurs in 5%

• CT Thorax: new pathology in 30%• Echo: structural/functional cardiac

defects• Infection: Sepsis vs. Colonisation

Weaning

• No method is superior• Consistency is important

TreatmentContinuation & Limitation

• Appropriate to reinstitute organ support?

• Patient-family-hospital decision making

• Rehabilitation• Home ventilation• Long-term weaning centres

Conclusions

• Long-term wean – a critical care syndrome

• Local audit & wider implementation• Care bundle approach

Acid-Base

• Metabolic-alkalosis is common and associated with morbidity & mortality

• Acetazolamide improves surrogate markers (pH, PaO2, PaCO2)

• Over night ventilation is used• Scant evidence that correction

improves clinically relevant outcomes• Stewarts approach prevents

misdiagnosis

Phosphate

• Low phosphate is associated with poor outcomes

• Multiple potential explanations hypophosphataemia

• Replacement is safe• Weak evidence of benefit

Delirium & Depression

• Delirium is associated with prolonged mechanical ventilation

• National guidelines available

• Depression is associated with poor recovery

• Little evidence to suggest treatment works within the required timescale

CINMA

• Critical Illness Neuromuscular Abnormalities – co-existing pathology in the majority of

heart-sink weaners

• The value of this dual-labelling is unclear, given no specific treatment currently exist

Heart Failure

• Common due to multiple causes• Increased demand of weaning

may induce failure• Traditional treatment should be

optimised• Evidence from a small trial to

support levosimendan in long-term wean

Pleural Effusions

• Effusions are common in the ICU population

• Drainage is safe and may improve oxygenation but not respiratory mechanics

• Correct management may differ between transudates and exudates

• The effect of intervention on clinically relevant outcomes is unknown

Fluid

• Positive fluid-balance, renal dysfunction and hypalbuminaemia are each associated with weaning failure

• Fluid balance is complex – impacting up on pre-load, organ perfusion and “third-space” collections

• Fluid restrictive protocols supported by good evidence in acute disease

• Use of diuretics not reported in heart-sink weaners– Naturesis, conceptually attractive alternative

• The use of albumin has weak support in acute disease

• In long-term pathology maybe different and no evidence of benefit with albumin

Local Data for Long-Stay Patients on CTCCU, UHSM

• Over a 3yr period (Apr 2008 – Apr 2011)– Patients who stayed over 4 weeks on CTCCU

• N = 61 (2% all admissions)• In-Patient mortality 24%• Long-term mortality rate 49%• For Pts who survived to home discharged– Average ICU stay 42 days– Average ward stay 24 days

Common Factors I

• Cardiac Failure– Optimise medication– Role for levosimendan

• Pleural Effusions– Characterise– Drain

• Fluid Balance– Diuresis– Albumin

Common Factors II

• Acid-Base– Stewart’s approach– Acetazolamide– Over-night ventilation

• Phosphate– Replacement

• Delirium– National guidance

• Depression– Too little, too late?

• Critical Illness Neuromuscular Abnormalities – Alternative diagnosis?