The 2007 International Consensus Conference Definition in ventilated pediatric patients

Background The Task Force classification (TFC) identifies weaning from mechanical ventilation (MV) in adults as: simple (SW), difficult (DW) and prolonged (PW). The usefulness of this classification is unknown in pediatric patients. Methods Prospective, descriptive, multicenter study in 29 pediatric intensive care units from Argentina during a three-month period including all admitted patients who required MV and met weaning criteria. The evolution of these patients was analyzed according to TFC. Results 474 patients were included, 454 (95.8 %) of whom were successfully extubated. Eighty percent (n=370) were extubated after the first attempt and classified as SW, 84 (18,2%) were DW and only 7 (1,5%) faced a PW. Successful extubation on the first trial was 77.9% (n=356) and for subsequent trials, 56.7%, 64.5% and 66.7%. The duration of MV (in days) by group was [median (interquartile range)]: 5.4 (2.8-9.7) (SW), 10.6 (7.7-18.8) (DW) and 27.4 (15.1-28.4) (PW). Fourteen patients underwent tracheostomy without any weaning attempt, 3 patients were on MV at the end of the study and 3 patients died without any attempt. The only variable associated with PW and DW (as a single group, with SW as reference) in multivariable analysis was ventilator-associated pneumonia (OR 2.58, 95%CI 1.01-6.11). Conclusions We observed a low prevalence of PW. Patients with PW and DW showed no significant differences from patients with SW, albeit a higher incidence of VAP.

Abstract 1122‐000094: EVD Weaning Criteria Decreases VPS/ETV Placement and Hospital Stay in Subarachnoid Hemorrhage Patients

Introduction : The Neurocritical Care Society encourages an external ventricular drain (EVD) wean “as quickly as is clinically feasible” but guidelines on achieving it are limited (1). This study aims to improve quality of care by sharing a protocol to initiate EVD weaning. These criteria were developed over 7 years and showed a reduction in ventriculoperitoneal shunt/endoscopic third ventriculostomy (VPS/ETV) placement and length of stay (LOS) at our institute compared to national averages. Methods : 151 subarachnoid hemorrhage (SAH) patients from January 2016 to January 2019 were analyzed. 60 aneurysmal SAH (aSAH) and 18 non‐aneurysmal nontraumatic SAH (naSAH) patients required EVD placement. A gradual EVD weaning protocol was initiated if patients met the following criteria: the reason for EVD placement has resolved or is resolving, quantity of CSF output must be <250mL over 24 hours, quality of CSF must be nonbloody, ICP must be within normal limits, and the patient must be neurologically stable. It was acceptable to wean when the patient had mild cerebral vasospasm, but not moderate to severe cerebral vasospasm. EVD weaning was performed by increasing drain height by 5 millimeters of mercury every 24 hours if criteria were met. Charts were reviewed for LOS and rate of VPS/ETV. Gender, age, race, wean failure incidence, infection rates, and SIADH/CSW rates were obtained. Results : Average LOS for aSAH patients with EVD at our institute was 20.35 days. Incidence of VPS/ETV was 11%. Chi‐square analysis was performed, and aSAH patients were found to have higher rates of VPS/ETV placement (p<0.001) and EVD wean failures (p<0.001) than naSAH patients. Conclusions : Our criteria to initiate EVD weaning provided a reduction in VPS/ETV placement among aSAH patients compared to national averages and provides a standardized approach to EVD management. aSAH patients at our institute had a lower incidence of VPS/ETV placement of 11% compared to 21% nationally (2). aSAH patients at our institute also had a lower LOS at 20.35 days compared to 21.5 days nationally (3).

Use of Either Non-invasive Ventilation Immediately Post-extubation or Controlled Mechanical Ventilation for One Hour after Fulfilling Weaning Criteria Decreases Re-intubation of Patients with Post-traumatic ARDS

Introduction: Re-intubation and re-ventilation after complete weaning of patients with prolonged ventilation are considered a major problem in ICU. The re-intubation in such patients associated with higher mortalities prolongs the duration of ICU stay. The mortality rate in those patients may exceed 40% in some studies. Aims: The study aimed to compare and evaluate the effect of use of two new maneuvers with control after fulfilling criteria of weaning from prolonged ventilation, either immediate use of NIV post-extubation and every 12 hours for 24 hours or MV for one hour on both re-intubation and ICU discharge of traumatic ARDS patients who ventilated for one week or more. Materials and Methods: It is a prospective double-blind study done on total 300 patients, admitted with respiratory failure ARDS due to severe lung contusion. All of them were selected to be ventilated for > one week. All of them fulfilled the criteria of weaning at the end of the studied period. Patients were randomly allocated in three groups; each group contained 100 patients. Group A was considered the control group. They extubated and followed our routine protocol; patients of group B used our first new maneuver and reconnected to mechanical ventilation before extubation for one hour, while patients of group C used our second new maneuver; patients of this group extubated and immediately connected to NIV with BIPAP mode for 1 hour every 12 hours for 24 hours. Results: There was a significant reduction in the number of patients who experienced deterioration in conscious level throughout the study in patients of both groups B and C compared to group A. Also, a significant reduction was seen in the number of patients who experienced deterioration in clinical parameters of respiration, of both groups B and C compared to group A with regard to high respiratory rate, desaturation and development of hyperdynamic circulation (tachycardia and hypertension). Also, a significant reduction was seen in the number of patients who had multiple quadrant parenchymatous infiltration throughout the study in patients of both groups B and C compared to group A. significant reduction in the number of patients marked limitation to FEV1, FVC and MVV in patients of both groups B and C compared to group A. Conclusion: Use of either immediate NIV every 12 hours for 24 hours or MV for one hour after fulfillment of weaning criteria reduced reintubation, re-ventilation and post-extubation respiratory failure and decreased the ICU stay in prolonged ventilated patients due to ARDS from severe lung trauma with no significant difference between them.

Preoperative Evaluation, Anesthesia and Outcome of a Super Morbidly Obese Patient.

Background; Nowadays anesthesia and outcome of morbidly obese patients became not only challenges but and an obligation in abdominal surgery. Sometimes morbidly obese patients postponed from all the kinds of surgery till it is life-threatening. The ward of anesthetists is obligate for a very careful preoperative evaluation, anesthesia, and outcome of morbidity obese patients. These include the preoperative evaluation of obesity, particularly on cardiac, respiratory, and metabolic systems; airway management; perioperative management (i.e., hemodynamic, respiratory, and hyperglycemic) and postoperative care. Case description: A 62 years old female with BMI=63.7 kg/m² with severe hypertension treatment came to a surgery ward for the plastic abdomen. After a careful preoperative preparation for the respiratory system and prophylaxis for thrombosis home, we started preoperative care 72 hours before surgery done in our hospital. We used general anesthesia for operation, the surgery lasts 190 minutes, and the patient was extubated according to weaning criteria only 16 hours after surgery. The patient stayed 2 days in intensive care and left a safe hospital on her ten days of recovery. Discussion: Super obese surgical patients represent numerous challenges to the anesthetist. Conclusion: A better understanding of the pathophysiology and complications that accompany obesity may improve their care and outcome.

Medical Learning Tool for Ventilator Weaning Protocols.

Mechanical ventilation is one of the most used medical procedures in intensive care units across the world. In clinical practice, it represents a high level of complexity, especially in both stages, the extubation and weaning protocols. In order to enhance medical and nursing student's training skills regarding those topics, an interactive application was developed to teach basic information for ventilator weaning. The application has two fully graphic modules, which provide theoretical information and a set of clinical cases of patients under spontaneous breathing tests. It also includes information about medical records and interactive panels for weaning criteria and patient clinical condition during the weaning trials. A usability testing was performed with 12 subjects to validate the application usability, where the level of satisfaction with them showed that the app provides a straightforward tool to interact with the critical concepts of ventilator weaning.

162 Raising your kids the right way: A survey of rearing practices in Canadian dairy goat farms

Kid rearing is the foundation of goat milk production, yet little is known about how to raise replacement does efficiently to make healthy and productive dairy animals. This study aimed to identify the common rearing practices of Canadian commercial dairy goat farms (≥40 goats/farm), from birth to weaning, and to determine best management practices to improve herd performances. A survey was sent to dairy goat producers across Canada by post or email, and 104 respondents were selected for analysis. The 70-questions survey collected information regarding kidding management, care of the newborn, feeding in the preweaning period, housing, weaning and herd performances. Respondents were from Ontario (69%), Quebec (22%) and the Western provinces (9%). Farm sizes ranged from 42 to 2,500 (median: 190) goats, and most producers (64%) were relatively new to goat milk production (≤10 yrs). A large amount of variation in rearing practices was seen across farms. Ad libitum milk was offered on 55% of farms, and there was no consistency as to when concentrates, forages and water were first offered to kids. Weaning criteria was predominantly a mix of age and weight of the kid (36%), followed by age only (27%) and weight only (22%). Weaning age varied between 4.5 and 20 (median: 8) wks and weaning weight varied between 9 and 35 (median: 15) kg. Weaning methods ranged from abrupt (37%) to different progressive strategies (20% skipping milk feedings, 19% reducing milk quantity, and 10% diluting milk with water). This research provides the dairy goat industry with information concerning current common kid rearing practices used on Canadian goat farms, and the lack of consensus indicates that further research is necessary to determine and refine the best kid rearing practices for Canadian farms.

Tracheostomy, Extubation, Reintubation: Airway Management Decisions in Intubated Stroke Patients

Background: Both delayed and premature extubation increase complication rate, the need for tracheostomy (TT), the duration of intensive care unit stay, and mortality. In this study, we therefore investigated factors associated with primary TT and predictors for extubation failure (EF) in a sample of severely affected ventilated stroke patients. Methods: One hundred eighty five intubated stroke patients were prospectively analyzed in this observational study. Patients not meeting predefined clinical and respiratory extubation criteria received a TT. All other patients were extubated and followed up for the need of reintubation. Characteristics of patients with and without extubation attempt were examined. Additionally, within the group of extubated patients, subgroups of successfully vs. unsuccessfully extubated patients were compared. Clinical factors associated with reintubation, including a previously established semi-quantitative airway score, were determined and predictors of EF were assessed. Results: Ninety-eight of 185 patients (53%) were primarily extubated; EF rate was 37% (36 patients). Eighty-seven (47%) were tracheostomized without a prior extubation attempt. Primarily tracheostomized patients had more severe strokes, which were more often hemorrhagic, presented with a lower level of consciousness, needed neurosurgical intervention more often, had a higher rate of obesity, and were more frequently intubated because of suspicion of compromised protective reflexes. EF was independently predicted by prior neurosurgical treatment and low airway management scores. No differences were found for the ability to follow simple commands and classical weaning criteria. Conclusion: Airway management decisions in intubated stroke patients represent a clinical challenge. Classical weaning criteria and parameters reflecting the patient's state of consciousness are not reliably predictive of extubation success. Criteria more closely related to airway safety and secretion handling may provide the most relevant information and should therefore be assessed by specific clinical scoring systems.