Weaning and Extubation Criteria in a Patient with Septic Shock and Respiratory Failure

Author: V. Dimov, M.D.
Reviewer: S. Randhawa, M.D.

An 88-year-old CF with C. diff colitis was admitted to ICU for hypotension. Her C. diff. colitis progressed to very severe and she required a total colectomy. After the surgery, she developed a septic shock and had to be intubated. Cardiac enzymes showed a new MI.


CBC in sepsis due to severe C. diff. colitis. CMP, cardiac enzymes. Note the marked elevation in WBC, often seen in severe C. diff. colitis (click to enlarge the images).


ABG and ventilator settings in a patient with septic shock who was successfully extubated (click to enlarge the images).

Note the standard use of A/C (assist control ventilation) as the most common mode of ventilation.

After the weaning parameters were checked, the ventilation mode was switched to Continuous Positive Airway Pressure (CPAP) for 30 min. The patient tolerated CPAP very well and was extubated.

She became acutely SOB after extubation.

What do you think was going on?

With Rapid Shallow Breathing Index (RSBI) of less than 100, the chances for successful extubation are 85%.

There are only a few things that can spoil the picture: pulmonary edema, laryngeal edema with stridor and a lot of secretions.

The patient was suctioned repeatedly and put on BiPAP. Her condition improved within 2 hours and she maintained SpO2 96% on face mask. BiPAP was discontinued.

The sequence was A/C, then CPAP, then BiPAP, and finally, face mask. In less complicated cases, patients can tolerate face mask immediately after the extubation.

Final diagnosis

Respiratory failure in shock. An example of a successful extubation strategy.

What did we learn from this case?

RSBI of less than 100 is the most important predictor of successful extubation.

When can you wean a patient off the ventilator?

- The original problem that caused the intubation has resolved or is stabilized
- CVS is stable and the patient is off pressors
- PaO2 is more than 60 on FiO2 of 40-60
- RR of less than 30
- MV of more than 10 L
- RSBI of less than 100. RSBI is RR/TV which means that the patient must have a low RR and a high TV


RSBI of less than 100 is a predictor of successful extubation (click to enlarge the images).

References

Next for Corzine: Breathing on his own. USA Today. 04/2007.
EMCrit Lecture – Dominating the Vent: Part I, 2010.

Published: 3/12/2005
Updated: 04/17/2010

1 comment:

  1. Definitely the best way to learn. Great case. It's real life and not textbook knowledge.

    ReplyDelete