Weaning Failure in Critically Ill Patients Is Related to the Persistence of Sepsis Inflammation

Lung ultrasound score versus HACOR score as a predictor for weaning outcome in patients at high risk for extubation failure

BACKGROUND

Pulmonary complications from mechanical ventilation are a significant concern in intensive care. Reducing the duration of respiratory support is vital to minimize these risks. Extubation, the final step in the weaning process, is critical. Most weaning indices rely on complex ventilatory parameters. This study aimed to evaluate the utility of the heart rate, acidosis, Glasgow Coma Scale, oxygenation, respiratory rate (HACOR) score, and Lung Ultrasound Score (LUS) as predictors of weaning outcomes in the intensive care unit.

METHODS

This prospective observational study was conducted in the Department of Critical Care Medicine at Sri Ramachandra Institute of Higher Education and Research, involving 100 patients aged 18 years and above. Both the HACOR score and LUS were assessed at the 30th minute during a 60-minute spontaneous breathing trial (SBT).

RESULTS

Of the 100 patients, 65 (65%) were successfully weaned, while 35 (35%) experienced weaning failure. The median HACOR score was 3 (interquartile range: 0-3) in the successful group and 6 (IQR: 5-8) in the failed group. The median LUS was 10 (IQR: 8-10) in the successful group and 16 (IQR: 13-16) in the failed group. A HACOR score ≥5 predicted weaning failure with a sensitivity of 87.7%, specificity of 77.1%, and area under the curve of 0.824. The LUS had an area under curve of 0.831, sensitivity of 86.2%, specificity of 80% at a threshold of ≥13 for failure.

CONCLUSION

A HACOR score of ≥5 and a Lung Ultrasound Score of ≥13 are excellent predictors of weaning failure and can be incorporated into ICU weaning strategies.

Predicting Successful Weaning through Sonographic Measurement of the Rapid Shallow Breathing Index

Background: Diaphragmatic dysfunction correlates with weaning failure, highlighting the need to independently assess the diaphragm's effects on weaning. We modified the rapid shallow breathing index (RSBI), a predictor of successful weaning, by incorporating temporal variables into existing ultrasound-derived diaphragm index to create a simpler index closer to tidal volume. Methods: We conducted a prospective observational study of patients who underwent a spontaneous breathing trial in the medical intensive care unit (ICU) at Severance Hospital between October 2022 and June 2023. Diaphragmatic displacement (DD) and diaphragm inspiratory time (Ti) were measured using lung ultrasonography. The modified RSBI was defined as follows: respiratory rate (RR) divided by DD was defined as D-RSBI, and RR divided by the sum of the products of DD and Ti on both sides was defined as DTi-RSBI. Results: Among the sonographic indices, DTi-RSBI had the highest area under the receiver operating characteristic (ROC) curve of 0.774 in ROC analysis, and a correlation was found between increased DTi-RSBI and unsuccessful extubation in a multivariable logistic regression analysis (adjusted odds ratio 0.02, 95% confidence interval 0.00-0.97). Conclusions: The DTi-RSBI is beneficial in predicting successful weaning in medical ICU patients.

The Predictive Value of Heparin-Binding Protein and D-Dimer in Patients with Sepsis

Objective

To explore the serial measurement of heparin-binding protein and D-dimer in the prediction of 28-day mortality and efficacy evaluation of critically-ill patients with sepsis.

Methods

We recruited a total of 51 patients with sepsis in the ICU of our hospital. They were divided into a survival group or a death group according to their prognosis 28 days after treatment. The HBP and D-dimer levels in these patients were determined on the 1st (24h), 3rd, and 5th days. Besides, the sequential organ failure assessment (SOFA) score of these patients was recorded at admission. The patients in both groups were subjected to comparison regarding HBP and D-dimer levels and SOFA scores within 24h of admission. Additionally, a correlation between the levels of HBP and D-dimer and the SOFA score was statistically measured, while the predictive effectiveness of these factors for the prognosis of patients with sepsis was also determined. Moreover, the dynamic changes in HBP and D-dimer during the treatment of both groups were analyzed.

Results

The HBP and D-dimer levels and the SOFA scores in the survival group were considerably lower than those in the death group, and the differences were statistically significant (P<0.05). Additionally, the levels of HBP and D-dimer in sepsis patients were positively correlated with the SOFA score (P<0.05). The area under the curve (AUC) of HBP, D-dimer, and their combination in predicting the prognosis of patients with sepsis was 0.824, 0.771, and 0.830, respectively. Besides, the sensitivity and specificity of their combination in predicting the prognosis of patients with sepsis were 68.42% and 92.31%, respectively. The HBP and D-dimer levels presented a downward trend in the survival group during treatment, while they exhibited an upward trend in the death group.

Conclusion

HBP and D-dimer realize high predictive effectiveness for the prognosis of patients with sepsis, while the combined use of these two factors achieves superior effectiveness. Thus, they can be applied to the prediction of 28-day mortality and efficacy evaluation of sepsis patients.

Biomarkers of Sepsis

Sepsis is a highly complex disease caused by a deregulated host's response to infection [...].

A cytokine/PTX3 prognostic index as a predictor of mortality in sepsis

Background

Early prognostic stratification of patients with sepsis is a difficult clinical challenge. Aim of this study was to evaluate novel molecules in association with clinical parameters as predictors of 90-days mortality in patients admitted with sepsis at Humanitas Research Hospital.

Methods

Plasma samples were collected from 178 patients, diagnosed based on Sepsis-3 criteria, at admission to the Emergency Department and after 5 days of hospitalization. Levels of pentraxin 3 (PTX3), soluble IL-1 type 2 receptor (sIL-1R2), and of a panel of pro- and anti-inflammatory cytokines were measured by ELISA. Cox proportional-hazard models were used to evaluate predictors of 90-days mortality.

Results

Circulating levels of PTX3, sIL-1R2, IL-1β, IL-6, IL-8, IL-10, IL-18, IL-1ra, TNF-α increased significantly in sepsis patients on admission, with the highest levels measured in shock patients, and correlated with SOFA score (PTX3: r=0.44, p&lt;0.0001; sIL-1R2: r=0.35, p&lt;0.0001), as well as with 90-days mortality. After 5 days of hospitalization, PTX3 and cytokines, but not sIL-1R2 levels, decreased significantly, in parallel with a general improvement of clinical parameters. The combination of age, blood urea nitrogen, PTX3, IL-6 and IL-18, defined a prognostic index predicting 90-days mortality in Sepsis-3 patients and showing better apparent discrimination capacity than the SOFA score (AUC=0.863, 95% CI: 0.780−0.945 vs. AUC=0.727, 95% CI: 0.613-0.840; p=0.021 respectively).

Conclusion

These data suggest that a prognostic index based on selected cytokines, PTX3 and clinical parameters, and hence easily adoptable in clinical practice, performs in predicting 90-days mortality better than SOFA. An independent validation is required.