Background: The optimum timing to wean is crucial to avoid negative outcomes for mechanically ventilated patients. The rapid shallow breathing index (RSBI), a widely used weaning index, has limitations in predicting weaning outcomes. By replacing the tidal volume of the RSBI with diaphragmatic excursion (DE) and diaphragm thickening fraction (DTF) assessed by ultrasonography, we calculated two weaning indices, the diaphragmatic excursion rapid shallow breathing index (DE-RSBI, respiratory rate [RR]/DE) and the diaphragm thickening fraction rapid shallow breathing index (DTF-RSBI, RR/DTF). The aim of this study was to evaluate the predictive values of DTF-RSBI, DE-RSBI and traditional RSBI in weaning failure. Methods: This prospective observational study included patients undergoing mechanical ventilation (MV) for > 48 h and who were readied for weaning. During a pressure support ventilation (PSV) spontaneous breathing trial (SBT), right hemidiaphragmatic excursion and DTF were measured by bedside ultrasonography as well as RSBI. Weaning failure was defined as: (1) failing the SBT and (2) SBT success but inability to maintain spontaneous breathing for more than 48 h without noninvasive or invasive ventilation. A receiver operator characteristic (ROC) curve was used for analyzing the diagnostic accuracy of RSBI, DE-RSBI, and DTF-RSBI. Results: Of the 110 patients studied, 37 patients (33.6%) failed weaning. The area under the ROC (AUROC) curves for RSBI, DE-RSBI, and DTF-RSBI for predicting failed weaning were 0.639, 0.813, and 0.859, respectively. The AUROC curves for DE-RSBI and DTF-RSBI were significantly higher than for RSBI (P = 0.004 and P < 0.001, respectively). The best cut-off values for predicting failed weaning were RSBI > 51.2 breaths/min/L, DE-RSBI > 1.38 breaths/min/mm, and DTF-RSBI > 78.1 breaths/min/%. Conclusions: In this study, two weaning indices determined by bedside ultrasonography, the DE-RSBI (RR/DE) and DTF-RSBI (RR/DTF), were shown to be more accurate than the traditional RSBI (RR/VT) in predicting weaning outcome during a PSV SBT.

Venous congestion is associated with adverse clinical outcomes in critically ill patients, yet its assessment remains challenging. Recently, the Venous Excess Ultrasound (VExUS) score has shown great potential as a non-invasive tool for assessing venous congestion in cardiac patients. However, the relationship between VExUS and clinical outcomes in patients with sepsis remains understudied. This study aims to evaluate the incidence of venous congestion based on VExUS assessment within the first 5 days of intensive care unit (ICU) admission in critically ill patients with sepsis, and to investigate the association between VExUS and clinical outcomes. We conducted a prospective, observational study in four ICUs, enrolling adult patients with sepsis who stayed in the ICU for at least 24 h. VExUS assessments were performed on days 1 (within 24 h), 3 (48-72 h), and 5 (96-120 h) following ICU admission. Patients were classified according to VExUS score ≥ 2 or < 2. The primary outcome was the prevalence of acute kidney injury (AKI) during ICU stay, while secondary outcomes included 30-day mortality, ICU mortality, and requirement for renal replacement therapy (RRT). Among the 108 patients included, 18% (19 patients) showed VExUS score ≥ 2 on day 1 of ICU admission, and the prevalence progressively decreased to 15% (15 patients) by day 3 and 6% (6 patients) by day 5. The VExUS score ≥ 2 was not associated with AKI (OR 1.82, 95% CI 0.62-5.31, p = 0.274), 30-day mortality (OR 0.82, 95% CI 0.28-2.4, p = 0.711), ICU mortality (OR 1.12, 95% CI 0.41-3.04, p = 0.82), or requirement for RRT (OR 2.29, 95% CI 0.68-7.64, p = 0.179). There was no significant correlation between VExUS and central venous pressure (coefficient: - 0.019, 95% CI -0.01 to 0.05, p = 0.204). In critically ill patients with sepsis, approximately 20% exhibit early (within 24 h of ICU admission) venous congestion, with the prevalence progressively decreasing over the subsequent 5 days. Venous congestion assessed by VExUS was not associated with the occurrence of AKI or with mortality. Chinese Clinical Trial Registry, ChiCTR2200066987. Registered 22 December 2022, https://www.chictr.org.cn/.

Weaning from invasive mechanical ventilation (MV) is a complex and challenging process that involves multiple pathophysiological mechanisms. A combined ultrasound evaluation of the heart, lungs, and diaphragm during the weaning phase can help to identify risk factors and underlying mechanisms for weaning failure. This study aimed to investigate the accuracy of lung ultrasound (LUS), transthoracic echocardiography (TTE), and diaphragm ultrasound for predicting weaning failure in critically ill patients. Patients undergoing invasive MV for > 48 h and who were readied for their first spontaneous breathing trial (SBT) were studied. Patients were scheduled for a 2-h SBT using low-level pressure support ventilation. LUS and TTE were performed prospectively before and 30 min after starting the SBT, and diaphragm ultrasound was only performed 30 min after starting the SBT. Weaning failure was defined as failure of SBT, re-intubation, or non-invasive ventilation within 48 h. Fifty-one patients were included, of whom 15 experienced weaning failure. During the SBT, the global, anterior, and antero-lateral LUS scores were higher in the failed group than in the successful group. Receiver operating characteristic curve analysis showed that the areas under the curves for diaphragm thickening fraction (DTF) and global and antero-lateral LUS scores during the SBT to predict weaning failure were 0.678, 0.719, and 0.721, respectively. There was no correlation between the LUS scores and the average E/e’ ratio during the SBT. Multivariate analysis identified antero-lateral LUS score > 7 and DTF < 31% during the SBT as independent predictors of weaning failure. LUS and diaphragm ultrasound can help to predict weaning failure in patients undergoing an SBT with low-level pressure support. An antero-lateral LUS score > 7 and DTF < 31% during the SBT were associated with weaning failure.

BACKGROUND:The aim of this study was to describe the clinical characteristics and outcomes of patients with coronavirus disease 2019 (COVID-19) and compare these parameters in an elderly group with those in a younger group. MATERIAL AND METHODS:This retrospective, single-center observational study included 69 hospitalized patients with laboratory-confirmed COVID-19 from a tertiary hospital in Wuhan, China, between January 14, 2020, and February 26, 2020. Epidemiological, demographic, clinical, and laboratory data, as well as treatments, complications, and outcomes were extracted from electronic medical records and compared between elderly patients (aged ≥60 years) and younger patients (aged <60 years). Patients were followed until March 19, 2020. RESULTS:Elderly patients had more complications than younger patients, including acute respiratory distress syndrome (ARDS; 9/25, 36% vs. 5/44, 11.4%) and cardiac injury (7/25, 28% vs. 1/44, 2.3%), and they were more likely to be admitted to the intensive care unit (6/25, 24% vs. 2/44, 4.5%). As of March 19, 2020, 60/69 (87%) of the patients had been discharged, 6/69 (8.7%) had died, and 3/69 (4.3%) remained in the hospital. Of those who were discharged or died, the median duration of hospitalization was 13.5 days (interquartile range, 10-18 days). CONCLUSIONS:Elderly patients with confirmed COVID-19 were more likely to develop ARDS and cardiac injury than younger patients and were more likely to be admitted to the intensive care unit. In addition to routine monitoring and respiratory support, cardiac monitoring and supportive care should be a focus in elderly patients with COVID-19.

Introduction: Hepatic portal venous gas (HPVG) is a rare imaging finding. When HPVG is accompanied with pneumatosis intestinalis (PI), the underlying cause is usually mesenteric ischemia with consequent intestinal necrosis. This combination of clinical conditions is associated with a poor prognosis. In this study, we present the cases of 2 elderly patients with HPVG and PI secondary to mesenteric ischemia. Patient concerns: In case 1, a 89-year-old male patient was admitted to intensive care unit with respiratory failure, On the fifth day of admission, he developed a high fever (39.5°C) and abdominal distension. In case 2, a 92-year-old male patient admitted to our intensive care unit and received mechanical ventilation due to acute respiratory failure. During the treatment, the patient developed gastrointestinal bleeding. On physical examination, abdominal bulging and tense abdominal walls were detected. Both patients underwent abdominal contrast-enhanced computed tomography, showed abundant HPVG with PI. Diagnoses: The patients were diagnosed as acute mesenteric ischemia, bowel necrosis, septic shock, multiple organ dysfunction syndrome based on computed tomography scan, abdominal signs, and laboratory tests. Interventions: Fluid resuscitation, high-dose vasopressors, and intravenous antibiotic therapy were given. Outcomes: Despite prompt treatment, the condition of both patients rapidly deteriorated, and the patients died shortly thereafter. Conclusion: Mesenteric ischemia is a clinical emergency. In patients with risk factors and abdominal signs, the clinical suspicion for this condition should be high. Although rare, both HPVG and PI are important radiological clues that usually indicate the presence of mesenteric ischemia with consequent intestinal necrosis.