Early rise in central venous pressure during a spontaneous breathing trial: A promising test to identify patients at high risk of weaning failure?


Autoři: Sebastián Dubo aff001;  Emilio Daniel Valenzuela aff003;  Andrés Aquevedo aff004;  Manuel Jibaja aff005;  Dolores Berrutti aff007;  Christian Labra aff003;  Rossana Lagos aff003;  María Fernanda García aff005;  Vanessa Ramírez aff005;  Milton Tobar aff005;  Fabricio Picoita aff005;  Cristian Peláez aff005;  David Carpio aff003;  Leyla Alegría aff003;  Carolina Hidalgo aff009;  Karen Godoy aff010;  Alejandro Bruhn aff003;  Glenn Hernández aff003;  Jan Bakker aff003;  Ricardo Castro aff003
Působiště autorů: Departamento de Kinesiología, Facultad de Medicina, Universidad de Concepción, Concepción, Chile aff001;  Programa de Doctorado en Ciencias Médicas, Universidad de la Frontera, Temuco, Chile aff002;  Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile aff003;  Unidad de Pacientes Críticos, Hospital Dr. Sótero del Río, Santiago, Chile aff004;  Unidad de Cuidados Intensivos, Hospital Eugenio Espejo, Quito, Ecuador aff005;  Escuela de Medicina, Universidad Internacional de Ecuador, Quito, Ecuador aff006;  Centro de Terapia Intensiva, Hospital de Clínicas, Universidad de la Republica de Uruguay, Montevideo, Uruguay aff007;  Programa de Doctorado en Ciencias Médicas, Pontificia Universidad Católica de Chile, Santiago, Chile aff008;  Unidad de Cuidados Intensivos Cardioquirúrgicos, Hospital Guillermo Grant Benavente, Concepción, Chile aff009;  Unidad de Cuidados Intensivos Neuroquirúrgicos, Hospital Guillermo Grant Benavente, Concepción, Chile aff010;  Department of Pulmonary and Critical Care, Columbia University College of Physicians and Surgeons, New York, New York, United States of America aff011;  Department of Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, Netherlands aff012;  Department of Pulmonary and Critical Care, New York University Medical Center, New York, New York, United States of America aff013
Vyšlo v časopise: PLoS ONE 14(12)
Kategorie: Research Article
prolekare.web.journal.doi_sk: 10.1371/journal.pone.0225181

Souhrn

Background

The spontaneous breathing trial (SBT) assesses the risk of weaning failure by evaluating some physiological responses to the massive venous return increase imposed by discontinuing positive pressure ventilation. This trial can be very demanding for some critically ill patients, inducing excessive physical and cardiovascular stress, including muscle fatigue, heart ischemia and eventually cardiac dysfunction. Extubation failure with emergency reintubation is a serious adverse consequence of a failed weaning process. Some data suggest that as many as 50% of patients that fail weaning do so because of cardiac dysfunction. Unfortunately, monitoring cardiovascular function at the time of the SBT is complex. The aim of our study was to explore if central venous pressure (CVP) changes were related to weaning failure after starting an SBT. We hypothesized that an early rise on CVP could signal a cardiac failure when handling a massive increase on venous return following a discontinuation of positive pressure ventilation. This CVP rise could identify a subset of patients at high risk for extubation failure.

Methods

Two-hundred and four mechanically ventilated patients in whom an SBT was decided were subjected to a monitoring protocol that included blinded assessment of CVP at baseline, and at 2 minutes after starting the trial (CVP-test). Weaning failure was defined as reintubation within 48-hours following extubation. Comparisons between two parametric or non-parametric variables were performed with student T test or Mann Whitney U test, respectively. A logistic multivariate regression was performed to determine the predictive value on extubation failure of usual clinical variables and CVP at 2-min after starting the SBT.

Results

One-hundred and sixty-five patients were extubated after the SBT, 11 of whom were reintubated within 48h. Absolute CVP values at 2-minutes, and the change from baseline (dCVP) were significantly higher in patients with extubation failure as compared to those successfully weaned. dCVP was an early predictor for reintubation (OR: 1.70 [1.31,2.19], p<0.001).

Conclusions

An early rise in CVP after starting an SBT was associated with an increased risk of extubation failure. This might represent a warning signal not captured by usual SBT monitoring and could have relevant clinical implications.

Klíčová slova:

Blood pressure – Breathing – Cardiovascular physiology – Catheters – Heart rate – Intensive care units – Respiratory physiology


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