Cumulative fluid balance and outcome of extubation: A prospective observational study from a general intensive care unit

Abstract

Introduction:This study was aimed to examine the impact of cumulative fluid balance on extubation failure following planned extubation.Methods:Consecutive adult patients (≥16 years) admitted in a general intensive care unit (ICU), between January 1, 2016, and December 31, 2017, mechanically ventilated for at least 24 h and extubated following successful spontaneous breathing trial, were prospectively evaluated.Results:The cumulative fluid balance at extubation was significantly higher in the extubation failure group (median 4336.5 ml vs. 2752 ml, P = 0.036). The area under the receiver operating characteristic curve for cumulative balance to predict extubation failure was 0.6 (95% confidence interval [CI]: 0.504–0.697) with optimal cutoff value of 3490 ml (sensitivity and specificity of 60% and 59.5%, respectively). Other risk factors for extubation failure identified by univariate analysis were the duration of mechanical ventilation at extubation, chronic kidney or neurological disease, heart rate, and respiratory rate. In multiple regression model, the cumulative fluid balance >3490 ml retained its predictive potential for extubation failure (odds ratio = 2.191, 95% CI = 1.015–4.730).Conclusions:Our result validates the association between higher cumulative fluid balance and extubation failure in an Indian ICU. A future randomized control trial may examine any role of therapeutic diuresis/ultrafiltration in preventing failed extubation in patients who fulfill the readiness to wean criteria with cumulative net fluid balance ≥3490 ml.

Outcome of Prophylactic Noninvasive Ventilation Following Planned Extubation in High-risk Patients: A Two-year Prospective Observational Study from a General Intensive Care Unit

“…Higher cumulative fluid balance at extubation was identified as an independent risk factor for extubation failure in patients after planned extubation in two earlier studies—one by our group 1 and the other by Upadya and colleagues. 8 In this study, we observed a trend toward higher cumulative fluid balance at extubation and in subsequent 3 days postextubation in failure group but the differences were not statistically significant in any point.…”

“…However, mean cumulative fluid balance in the failure group was much lower in the current study compared to our previous study (4336.5 vs 2810 mL). 1 …”

“…Post-extubation respiratory failure was defined as per literature and broadly followed international guideline: cardiac arrest, respiratory arrest, psychomotor agitation requiring sedation other than low-dose dexmedetomidine, deteriorating consciousness, heart rate <50/minute with loss of alertness, and hemodynamic instability requiring vasopressor support and deteriorating gas exchange values. 1 , 21 The final decision regarding the discontinuation of NIV and the need for reintubation was left to the discretion of the attending consultant intensivist.…”

“…However, failure of extubation and a need for reintubation is clearly associated with high risk of mortality and other adverse consequences including higher risk of pneumonia and longer ICU or hospital length of stay. 1 – 4 Previous studies have identified subset of patients at a higher risk of extubation failure including older age, 2 , 5 higher disease severity, 2 , 5 longer duration of invasive ventilation, 1 , 4 patients with underlying chronic obstructive airway disease with hypercapnia (PaCO 2 >45 mm Hg) at extubation, 6 congestive heart failure, 2 poor neurological status, 1 , 7 underlying chronic kidney disease, 1 poor cough, 6 , 7 higher cumulative fluid balance at extubation, 1 , 8 and previous failed spontaneous breathing trial (SBT). 9 …”

“…In an earlier study by our group, looking for risk factors of postextubation respiratory failure, prophylactic NIV was used as high as 46.2% of patients after planned extubation. 1 …”