Weaning from mechanical ventilation in intensive care units across 50 countries (WEAN SAFE): a multicentre, prospective, observational cohort study

BACKGROUND

Current management practices and outcomes in weaning from invasive mechanical ventilation are poorly understood. We aimed to describe the epidemiology, management, timings, risk for failure, and outcomes of weaning in patients requiring at least 2 days of invasive mechanical ventilation.

METHODS

WEAN SAFE was an international, multicentre, prospective, observational cohort study done in 481 intensive care units in 50 countries. Eligible participants were older than 16 years, admitted to a participating intensive care unit, and receiving mechanical ventilation for 2 calendar days or longer. We defined weaning initiation as the first attempt to separate a patient from the ventilator, successful weaning as no reintubation or death within 7 days of extubation, and weaning eligibility criteria based on positive end-expiratory pressure, fractional concentration of oxygen in inspired air, and vasopressors. The primary outcome was the proportion of patients successfully weaned at 90 days. Key secondary outcomes included weaning duration, timing of weaning events, factors associated with weaning delay and weaning failure, and hospital outcomes. This study is registered with ClinicalTrials.gov, NCT03255109.

FINDINGS

Between Oct 4, 2017, and June 25, 2018, 10 232 patients were screened for eligibility, of whom 5869 were enrolled. 4523 (77·1%) patients underwent at least one separation attempt and 3817 (65·0%) patients were successfully weaned from ventilation at day 90. 237 (4·0%) patients were transferred before any separation attempt, 153 (2·6%) were transferred after at least one separation attempt and not successfully weaned, and 1662 (28·3%) died while invasively ventilated. The median time from fulfilling weaning eligibility criteria to first separation attempt was 1 day (IQR 0-4), and 1013 (22·4%) patients had a delay in initiating first separation of 5 or more days. Of the 4523 (77·1%) patients with separation attempts, 2927 (64·7%) had a short wean (≤1 day), 457 (10·1%) had intermediate weaning (2-6 days), 433 (9·6%) required prolonged weaning (≥7 days), and 706 (15·6%) had weaning failure. Higher sedation scores were independently associated with delayed initiation of weaning. Delayed initiation of weaning and higher sedation scores were independently associated with weaning failure. 1742 (31·8%) of 5479 patients died in the intensive care unit and 2095 (38·3%) of 5465 patients died in hospital.

INTERPRETATION

In critically ill patients receiving at least 2 days of invasive mechanical ventilation, only 65% were weaned at 90 days. A better understanding of factors that delay the weaning process, such as delays in weaning initiation or excessive sedation levels, might improve weaning success rates.

FUNDING

European Society of Intensive Care Medicine, European Respiratory Society.

A Multicentric, Randomized, Controlled Phase III Study of Centhaquine (Lyfaquin®) as a Resuscitative Agent in Hypovolemic Shock Patients

Introduction

Centhaquine (Lyfaquin^®) showed significant safety and efficacy in preclinical and clinical phase I and II studies.

Methods

A prospective, multicentric, randomized phase III study was conducted in patients with hypovolemic shock, systolic blood pressure (SBP) ≤ 90 mmHg, and blood lactate levels ≥ 2 mmol/L. Patients were randomized in a 2:1 ratio to the centhaquine group (n = 71) or the control (saline) group (n = 34). Every patient received standard of care (SOC) and was followed for 28 days. The study drug (normal saline or centhaquine 0.01 mg/kg) was administered in 100 mL of normal saline infusion over 1 h. The primary objectives were to determine changes (mean through 48 h) in SBP, diastolic blood pressure (DBP), blood lactate levels, and base deficit. The secondary objectives included the amount of fluids, blood products, and vasopressors administered in the first 48 h, duration of hospital stay, time in intensive care units, time on ventilator support, change in acute respiratory distress syndrome (ARDS), multiple organ dysfunction syndrome (MODS), and the proportion of patients with 28-day all-cause mortality.

Results

The demographics of patients and baseline vitals in both groups were comparable. The cause of hypovolemic shock was trauma in 29.4 and 47.1% of control group and centhaquine group patients, respectively, and gastroenteritis in 44.1 and 29.4%, respectively. Shock index (SI) and quick sequential organ failure assessment at baseline were similar in the two groups. An equal amount of fluids and blood products were administered in both groups during the first 48 h of resuscitation. A lesser amount of vasopressors was needed in the first 48 h of resuscitation in the centhaquine group. An increase in SBP from baseline was consistently higher up to 48 h (12.9% increase in area under the curve from 0 to 48 h [AUC_0–48]) in the centhaquine group than in the control group. A significant increase in pulse pressure (48.1% increase in AUC_0–48) in the centhaquine group compared with the control group suggests improved stroke volume due to centhaquine. The SI was significantly lower in the centhaquine group from 1 h (p = 0.032) to 4 h (p = 0.049) of resuscitation. Resuscitation with centhaquine resulted in a significantly greater number of patients with improved blood lactate (control 46.9%; centhaquine 69.3%; p = 0.03) and the base deficit (control 43.7%; centhaquine 69.8%; p = 0.01) than in the control group. ARDS and MODS improved with centhaquine, and an 8.8% absolute reduction in 28-day all-cause mortality was observed in the centhaquine group.

Conclusion

Centhaquine is an efficacious resuscitative agent for treating hypovolemic shock. The efficacy of centhaquine in distributive shock is being explored.

Trial Registration

Clinical Trials Registry, India; ctri.icmr.org.in, CTRI/2019/01/017196; clinicaltrials.gov, NCT04045327.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40265-021-01547-5.

A multicentric, randomized, controlled phase III study of centhaquine (Lyfaquin ® ) as a resuscitative agent in hypovolemic shock patients

INTRODUCTION

Centhaquine (Lyfaquin ^® ) showed significant safety and efficacy in preclinical and clinical phase I and II studies.

METHODS

A prospective, multicentric, randomized phase III study was conducted in patients with hypovolemic shock having systolic blood pressure (SBP) of ≤90 mm Hg and blood lactate levels of ≥2 mmol/L. Patients were randomized in a 2:1 ratio, 71 patients to the centhaquine group and 34 patients to the control (saline) group. Every patient received standard of care (SOC) and was followed for 28 days. The study drug (normal saline or centhaquine (0.01 mg/kg)) was administered in 100 mL of normal saline infusion over 1 hour. The primary objectives were to determine changes (mean through 48 hours) in SBP, diastolic blood pressure (DBP), blood lactate levels, and base deficit. The secondary objectives included the amount of fluids, blood products, vasopressors administered in the first 48 hours, duration of hospital stay, time in ICU, time on the ventilator support, change in patient's Acute Respiratory Distress Syndrome (ARDS), Multiple Organ Dysfunction Syndrome (MODS) scores, and the proportion of patients with 28-day all-cause mortality.

RESULTS

The demographics of patients and baseline vitals in both groups were comparable. Trauma was the cause of hypovolemic shock in 29.41% of control and 47.06% of centhaquine, gastroenteritis in 44.12% of control, and 29.41% of centhaquine patients. An equal amount of fluids and blood products were administered in both groups during the first 48 hours of resuscitation. A lesser amount of vasopressors was needed in the first 48 hours of resuscitation in the centhaquine group. An increase in SBP from the baseline was consistently higher in the centhaquine group than in the control. A significant increase in pulse pressure in the centhaquine group than the control group suggests improved stroke volume due to centhaquine. The shock index was significantly lower in the centhaquine group than control from 1 hour (p=0.0320) till 4 hours (p=0.0494) of resuscitation. Resuscitation with centhaquine had a significantly greater number of patients with improved blood lactate and the base deficit than the control group. ARDS and MODS improved with centhaquine, and an 8.8% absolute reduction in 28-day all-cause mortality was observed in the centhaquine group.

CONCLUSION

Centhaquine is a highly efficacious resuscitative agent for treating hypovolemic shock. The efficacy of centhaquine in distributive shock due to sepsis and COVID-19 is being explored.

TRIAL REGISTRATION

Clinical Trials Registry, India; ctri.icmr.org.in, CTRI/2019/01/017196; clinicaltrials.gov, NCT04045327 .

KEY SUMMARY POINTS

A multicentric, randomized, controlled trial was conducted to evaluate the efficacy of centhaquine in hypovolemic shock patients.One hundred and five patients were randomized 2:1 to receive centhaquine or saline. Centhaquine was administered at a dose of 0.01 mg/kg in 100 mL saline and infused over 1 hour. The control group received 100 mL of saline over a 1-hour infusion.Centhaquine improved blood pressure, shock index, reduced blood lactate levels, and improved base deficit. Acute Respiratory Distress Syndrome (ARDS) and Multiple Organ Dysfunction Syndrome (MODS) score improved with centhaquine.An 8.8% absolute reduction in 28-day all-cause mortality was observed in the centhaquine group. There were no drug-related adverse events in the study.