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What are the criteria to wean from ventilators?
It is important to wean patients from mechanical ventilation as soon as possible to minimize the risk of ventilator-associated pneumonia.
In general, the following criteria need to be met to ensure successful ventilator weaning and extubation:
- The cause of respiratory failure has been reversed or is improving;
- Patient is breathing spontaneously;
- Patient is awake and alert or is easily arousable and cooperative;
- Sedation has been discontinued;
- Patient has achieved hemodynamic stability;
- Patient has adequate cough and minimal secretions;
- Adequate oxygenation is present, defined as a partial pressure of O 2 in arterial blood (PaO 2 )/FiO 2 ratio >150 to 200; requiring PEEP ≤5 to 8 cm H 2 O; FiO 2 ≤0.4 to 0.5; and pH (e.g., ≥7.25); and
- Rapid shallow breathing index (RSBI) <105. RSBI is calculated as RR/Vt (L). A value of >105 breaths/min/L predicts weaning failure (negative predictive value 95%).
A successful spontaneous breathing trial (SBT) with PSV of ≤5 or T piece for 30 to 120 minutes is currently thought to be the best predictor of successful weaning. SBT must be performed once a day.
General Management of the Neurocritically Ill Patient
| General | Ischemic Stroke | ICH | SAH | TBI | |
|---|---|---|---|---|---|
| Blood pressure goal | BP >100/80 MAP >70 | BP <220/120 with no thrombolytics BP <180/105 after thrombolytics for 24 hours | BP <160/100 | BP <160/100 for unsecured aneurysm BP >160-220/100 for secured aneurysm | SBP >90 |
| Target | Oxygen delivery | Save penumbra | Avoid hematoma expansion | Avoid rebleeding | Avoid ischemia |
| Volume status | Euvolemia | Euvolemia | Euvolemia | Euvolemia | Euvolemia |
| DVT prophylaxis ∗ | On admission unless contraindicated | Within 24 hours if no thrombolytics >24 hours with thrombolytics | Low dose 1-4 days after onset | 24 hours after aneurysm repair | Timing unknown |
| Seizure prophylaxis | Not needed | Not needed unless documented seizure | Not needed unless documented seizure | 3-7 days (avoid phenytoin) | 7 days |
| Fever | Normothermia | Normothermia | Normothermia | Normothermia | Normothermia |
| Glucose | <180 (NICE SUGAR trial) | Not known, recommend normoglycemia | 140-180 mg/dL based on (NICE SUGAR trial) | Not known, 80-200 mg/dL | Avoid hypoglycemia |
ICH , Intracranial hemorrhage; SAH , subarachnoid hemorrhage; TBI , traumatic brain injury; BP , blood pressure; MAP , mean arterial pressure; SBP , systolic blood pressure; DVT , deep vein thrombosis.
∗ Sequential compression device (SCD) on all patients and heparin 5000 U SQ bid if <60 kg or tid if >60 kg or enoxaparin 40 SQ mg daily adjusted for renal function.
