The edition · Emergency & Critical Care
Failing the first separation attempt marks a different trajectory, not just a longer one
Three weaning-failure phenotypes from WEAN SAFE, a biomarker that stops working in patients with diabetes, lung ultrasound down the oesophagus, and a third Baxter premix recall in a month.
The edition in brief
A secondary analysis of the WEAN SAFE cohort followed 5,664 ventilated patients. Of the 4,394 who had at least one separation attempt, 3,730 (65.9%) weaned and 664 (15.1%) had not weaned by day 90. ICU mortality was 78% in the failed group against 2% in those who weaned. Three phenotypes separated the failures: a single separation attempt followed by withdrawal of life-sustaining treatment, a single attempt without withdrawal, and more than one attempt. A failed first attempt was strongly associated with the withdrawal decision, and withdrawal with a higher hazard of death and a shorter time to it - an association that cannot separate prognosis from the decision itself. In 466 adults with sepsis and respiratory failure or vasopressor-dependent shock, soluble tumour necrosis factor receptor 1 predicted 90-day mortality in those without diabetes or atherosclerotic disease (hazard ratio 2.25 per standard deviation, 95% CI 1.76-2.88) but not in those with either (1.04, 0.83-1.30; interaction p<0.001). Interleukin-6 and angiopoietin-2 showed no such interaction. Across 23 hospitals, adding transoesophageal lung ultrasound to resuscitative transoesophageal echocardiography in ventilated patients with shock raised operator-reported identification of the cause from 75.3% to 86.5% (odds ratio 1.95, 95% CI 1.02-3.72), at a cost of 2.5 minutes. A Class II recall affects premixed vasopressin bags, the third Baxter premix recall listed on 9 September. The ESPEN intensive care nutrition guideline has been revised into a shorter practical version with flow charts.
Three ways to fail weaning, and the first attempt decides which
When a first separation attempt fails, make the next step explicit - another attempt or a change of goals - rather than letting the trajectory set itself.
A sepsis biomarker that predicts death, unless the patient has diabetes
Treat published sepsis biomarker thresholds as specific to the comorbidity mix that produced them, particularly where diabetes is common.
Lung ultrasound through the oesophagus, added to a probe already in place
If your unit already performs resuscitative transoesophageal echocardiography, adding lung views costs about 2.5 minutes and appears safe.
Premixed vasopressin joins the recalled Baxter bags
Check your premixed vasopressin against the recall, and verify that preparation from vials is a practised skill on nights.
Say the working diagnosis out loud before the team disperses
Before the resuscitation team disperses, state the working diagnosis with its uncertainty and ask what does not fit.
The ESPEN intensive care nutrition guideline, shortened into something usable
Rebuild your unit's feeding protocol around this practical version, and audit how much prescribed feed is actually delivered.
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