towards a care-bundle for long-term weaning dr matthew jackson dr tim strang & dr maria safar...
TRANSCRIPT
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TowardsA Care-Bundle For
Long-Term Weaning
Dr Matthew JacksonDr Tim Strang & Dr Maria
SafarCTCCU, UHSM
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Content
• The Past: Literature review• The Present: Clinical practice
outline• The Future: Care-bundle
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Definition
• Wean more than 3 weeks• Has a tracheostomy
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Common Factors
• Cardiac Failure• Pleural Effusions• Fluid Balance• Acid-Base• Phosphate• Delirium• Depression• Critical Illness Neuromuscular
Abnormalities
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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
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Weaning
• No method is superior• Consistency is important
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TreatmentContinuation & Limitation
• Appropriate to reinstitute organ support?
• Patient-family-hospital decision making
• Rehabilitation• Home ventilation• Long-term weaning centres
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Conclusions
• Long-term wean – a critical care syndrome
• Local audit & wider implementation• Care bundle approach
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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
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Phosphate
• Low phosphate is associated with poor outcomes
• Multiple potential explanations hypophosphataemia
• Replacement is safe• Weak evidence of benefit
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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
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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
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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
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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
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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
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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
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Common Factors I
• Cardiac Failure– Optimise medication– Role for levosimendan
• Pleural Effusions– Characterise– Drain
• Fluid Balance– Diuresis– Albumin
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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?