1. Towards A Care-Bundle For Long-Term Weaning Dr Matthew Jackson Dr Tim Strang & Dr Maria Safar CTCCU, UHSM

2. Content The Past: Literature review The Present: Clinical practice outline The Future: Care-bundle

4. Definition Wean more than 3 weeks Has a tracheostomy

5. Common Factors Cardiac Failure Pleural Effusions Fluid Balance Acid-Base Phosphate Delirium Depression Critical Illness Neuromuscular Abnormalities

6. 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

7. Weaning No method is superior Consistency is important

8. Treatment Continuation & Limitation Appropriate to reinstitute organ support? Patient-family-hospital decision making Rehabilitation Home ventilation Long-term weaning centres

10. Conclusions Long-term wean – a critical care syndrome Local audit & wider implementation Care bundle approach

12. Acid-Base Metabolic-alkalosis is common and associated with morbidity & mortality Acetazolamide improves surrogate markers (pH, PaO 2, PaCO 2 ) Over night ventilation is used Scant evidence that correction improves clinically relevant outcomes Stewarts approach prevents misdiagnosis

13. Phosphate Low phosphate is associated with poor outcomes Multiple potential explanations hypophosphataemia Replacement is safe Weak evidence of benefit

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. Common Factors I Cardiac Failure – Optimise medication – Role for levosimendan Pleural Effusions – Characterise – Drain Fluid Balance – Diuresis – Albumin

21. 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?