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.
Vincent JL, Sakr Y, Sprung CL, Ranieri VM, Reinhart K, Gerlach H, et al. Sepsis in European intensive care units: Results of the SOAP study. Crit Care Med 2006;34:344–53.
Boyd JH, Forbes J, Nakada T, Walley KR, Russell JA. Fluid resuscitation in septic shock: A positive fluid balance and elevated central venous pressure are associated with increased mortality. Crit Care Med 2011;39:259-65.
Murphy CV, Schramm GE, Doherty JA, Reichley RM, Gajic O, Afessa B, et al. The importance of fluid management in acute lung injury secondary to septic shock. Chest 2009;136:102-9.
Cordemans C, De laet I, Van Regenmortel N, Schoonheydt K, Dits H, Martin G, et al. Aiming for a negative fluid balance in patients with acute lung injury and increased intra-abdominal pressure: A pilot study looking at the effects of PAL-treatment. Ann Intensive Care 2012;2:S15.
Martin GS, Moss M, Wheeler AP, Mealer M, Morris JA, Bernard GR. A randomized, controlled trial of furosemide with or without albumin in hypoproteinemic patients with acute lung injury. Crit Care Med 2005;33:1681-7.
D'Orio V, Mendes P, Carlier P, Fatemi M, Marcelle R. Lung fluid dynamics and supply dependency of oxygen uptake during experimental endotoxic shock and volume resuscitation. Crit Care Med 1991;19:955-62.
Wiedemann HP, Wheeler AP, Bernard GR, Thompson BT, Hayden D, deBoisblanc B, et al. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med 2006;354:2564-75.
Upadya A, Tilluckdharry L, Muralidharan V, Amoateng-Adjepong Y, Manthous CA. Fluid balance and weaning outcomes. Intensive Care Med 2005;31:1643-7.
Frutos-Vivar F, Ferguson ND, Esteban A, Epstein SK, Arabi Y, Apezteguía C, et al. Risk factors for extubation failure in patients following a successful spontaneous breathing trial. Chest 2006;130:1664-71.
Boles J-M, Bion J, Connors A, Herridge M, Marsh B, Melot C, et al. Weaning from mechanical ventilation. Eur Respir J 2007;29:1033-56.
McConville JF, Kress JP. Weaning patients from the ventilator. N Engl J Med 2012;367:2233-9.
Nava S, Gregoretti C, Fanfulla F, Squadrone E, Grassi M, Carlucci A, et al. Noninvasive ventilation to prevent respiratory failure after extubation in high-risk patients. Crit Care Med 2005; 33:2465-70.
Ferrer M, Valencia M, Nicolas JM, Bernadich O, Badia JR, Torres A. Early Noninvasive Ventilation Averts Extubation Failure in Patients at Risk - A Randomized Trial. Am J Respir Crit Care Med 2006; 173:164–70.
Thille AW, Harrois A, Schortgen FD, Brun-Buisson C, Brochard L. Outcomes of extubation failure in medical intensive care unit patients. Crit Care Med 2011; 39:2612-8.
Hsiung Lee ES, Jiann Lim DT, Taculod JM, Sahagun JT, Otero JP, Teo K, et al. Factors associated with reintubation in an intensive care unit: A prospective observational study. Indian J Cri Care Med 2017; 21:131-7.
Epstein SK, Ciubotaru RL, Wong JB. Effect of failed extubation on the outcome of mechanical ventilation. Chest 1997; 112:186–92.
Epstein SK, Ciubotaru RL. Independent effects of etiology of failure and time to reintubation on outcome for patients failing extubation. Am J Respir Crit Care Med 1998;158:489-93.
Gomersall CD. Critical care in the developing world - a challenge for us all. Crit Care 2010;14:131.
Blackwood B, Burns KE, Cardwell CR, O'Halloran P. Protocolized versus non-protocolized weaning for reducing the duration of mechanical ventilation in critically ill adult patients. Cochrane Database Syst Rev. 2014 Nov 6; (11) CD006904. doi: 10.1002/14651858.CD006904.pub3