The document discusses the processes of weaning and extubation in pediatric intensive care, outlining techniques for determination of weaning readiness, sedation withdrawal management, and predictive indices for successful weaning. It emphasizes the importance of monitoring during spontaneous breathing trials, recognizing extubation feasibility, and managing sedation withdrawal symptoms, which may arise from opioid and benzodiazepine usage. Various strategies for managing withdrawal, including tapering of medications, are also detailed, along with the assessment tools to evaluate the patient's response.

1. WEANING AND EXTUBATION AND
MANAGEMENT OF SEDATION
WITHDRAWAL
Dr C Abhiram Kumar
Fellow in PICU
Aster CMI Hospital

2.  Introduction
 Weaning
 Techniques of weaning
 Predictive indices for weaning
 Weaning failure
 Extubation
 Extubation failure
 Role of tracheostomy
 Sedation withdrawal
 Management of sedation withdrawal

3.  The thought of weaning should begin from the day
of intubation.
 Too early or too late extubation have their own
adverse consequences
 60% of accidental extubations donot require
reintubation

4.  Weaning- transition from ventilatory support to
spontaneous breathing during which time patient
assumes the responsibility for effective gas
exchange while positive pressure support is
reduced
 Extubation- The process of removal of the
endotracheal tube

6. WHEN TO CONSIDER WEANING???
 Whether the disease is resolving or stable?
 Is there adequate gas exchange?
 Are the hemodynamics stable?
 Is the patient having good respiratory drive?

7. TECHNIQUES OF WEANING
 Old methods-
 Full support
 Partial support-SIMV/PS
 CPAP
 T-piece trial
 New method
 Establish readiness of weaning
 SBT
 Weaning parameters

8.  Spontaneous Breathing Trial(SBT)-
 Subjective determination of whether the underlying
disease process necessitating mechanical ventilation
has improved to allow adequate gas exchange with
spontaneous breathing
 SBT using T-piece trials/ PSV/ CPAP
 Initial screening and then 30-120min if tolerating
 End SBT if patient shows signs of failure

9. Monitoring parameters on SBT
 Overall comfort status
 Mental status
 Respiratory rate and pattern
 Hemodynamic stability
 Satisfactory gas exchange
 Effective cough

10. Criteria for failure of SBT
 Anxiety, diaphoresis
 Agitated or drowsy
 RR> 95th centile for age
 Increased use of accesory muscles
 Inability to maintain effective ventilation(<5ml/kg)
 Increase in HR >20% from baseline
 Hypertension or hypotension
 pH<7.3/ pCO2 >50mm Hg or more than 10 from
baseline

11. Management of SBT failure
 Ventilatory muscle rest
 Assesment of factors responsible for failure
 Correction of factors
 New attempt after 24hrs

12. PREDICTIVE INDICES OF WEANING
 Over 60 predictors of weaning success
 RSBI and CROP index more commonly used.
 RSBI- RR/VT(in L).
<8bpm/ml/kg
63% sensitivity
 CROP Index-dynamic compliance, RR,
oxygenation, maximum inspiratory effort
Cdyn* Pimax* PaO2/PAO2/ F
>0.18ml/kg/bpm

13. Factors contributing to weaning failure
 A- Acid Base status
 B- Breathing/respiratory factors
 C- cardiac factors
 D- Drugs and neurologic status
 E- Electrolyte imbalance
 Nutrition
 Psychological status

14. EXTUBATION FEASIBILITY
 Controlled underlying disease
 No high dose of vasoactive drug
 Approved SBT
 FiO2<0.4 with SPO2>92%/ PF ratio >150MM HG
 PEEP <5-8cm H2O
 RSBI<8 cpm/ml/kg
 Intact airway reflexes
 Adequate conscience level
 No/minimal UAO(Cuff leak test)

15. Cuff Leak Test
 Predicts upper airway patency
 Deflate the cuff
 Hear for the leak of air
 If no leak- chances of extubation failure high

16. Technique of Extubation
 Withhold feeds for atleast 6 hrs prior to extubation
 Position in semifowler position
 Give 100% oxygen
 Physiotherapy and ET suctioning
 Oropharyngeal suctioning before cuff deflation
 Withdraw tube during positive pressure inflation
with AMBU bag
 Administer humidified oxygen with head end
elevated

17. Post Extubation Complications
1. Stridor-
Usually self limiting
Rarely require steroid and/or nebulised adrenaline
Can be minimised by administration of corticosteroids
6-12 hrs prior to extubation
2. Upper Lobe Atelectasis-
Due to microaspirations
Managed by postural physiotherapy/ 02/ CPAP

18. EXTUBATION FAILURE
 Reintubation within 24-48 hrs of extubation
 Early- reintubation within 6hrs
 Intermediate- reintubation within 6-24 hrs
 Late- reintubation from 24-48 hrs of extubation

19. SEDATION WITHDRAWAL
 Tolerance- development of a need to increase the
dose of a drug to achieve the same effect of the
drug which was previously achieved at a lower
dose
 Physical Dependance- also called as
neuroadaptation.
Repeated administration of a drug which
necessitates it’s continuous administration to prevent
the appearance of withdrawal or abstinence
syndrome that is characteristic to that drug

20.  Drugs that commonly cause abstinence syndrome
in PICU- Opioids, Benzodiazepines, alpha agonist
 Withdrawal syndromes usually develop after 3-5
days of continuous infusion and after 10days of
intermittent therapy
 Dependance also depends upon the duration of
receptor activation

21. WITHDRAWAL ASSESSMENT TOOLS
 WAT-1- Consists of four components
 1.review of patient records for past 12 hours
 2.observation of the patient for 2 minutes
 3.patient assessment during a progressive
stimulated exam to assess the level of
consciousness at beginning of each 12 hour shift
 4.assessment of poststimulation recovery

24.  Benzodiazepine withdrawal-occurs on abrupt
cessation of bezodiazepines.
 Symptoms include anxiety, tremors, palpitation,
diaphoresis, headache and nausea
 Signs include tachycardia, hypertension,
diaphoresis, tachypnea

25.  Weanig strategies-
 If used for 3-5days-
 Initiate withdrawal assessment tool every 4-6th hlry
and continue for 1-2 days after cessation of the
drug
 Reduce benzodiazepine administration by 20% of
pretapered dose everyday
 Idf withdrawal symptoms occur, stop weaning for 24
hrs
 If withdrawal symptoms persist then increase the
dose to previous dose and consider adding
clonidine

26.  If used for 10days-
 Follow above guidelines
 Slower tapering of drug by 10% of pretapered dose
every day
 If withdrawal symptoms develop stop weaning for
24 hrs
 If withdrawal symptoms persist then increase the
dose to previous dose and consider adding
clonidine

27. Conversion strategies for benzodiazepines
 Iv midazolam to oral lorazepam-
 1.Calculate the last 24 hr midazolam infusion dose
 2.Dose in mg/8 gives the dose of lorazepam per
day in mg
 3.Give lorazepam in 4-6 divided doses
 4.After 2nd dose of lorazepam taper midazolam
infusion by 50%
 5.After 3rd taper further by 50%
 6.After 4th dose of lorazepam stop midazolam
infusion

28. Opioid withdrawal
 CNS- anxiety, irritability, trmors
 Gastrointestinal-nausea, vomiting, increased NG
aspirates, diarrhea
 Autonomic dysfunction-tachycardia, tachypnea,
hypertension, diaphoresis

29. /
 Weaning strategies-
 Conversion of IV morphine to oral-
 _mg/24 hr of IV multiplied by 3= _mg/24 hr of oral
morphine given 4-6th hrly
 Conversion of IV fentanyl to IV morphine-
 _ mcg/ 24 hrs iv fentanyl/1000 * 25= _mg/24 hr iv
morphine in 4-6 divided doses
 To convert iv fentanyl to oral morphine first convert
to iv morphine and then to oral morphine

30.  Once oral morphine is added then start tapering by
20%(3-5 days) or 10%(>10days) every day until 0.2
mg/ dose is achieved.
 Increase the interval rather than decreasing the
dose ie 4hrly-6hrly-8hrly-12hrly.
 Stop after 48hrs of 0.2mg 8th hrly for infants and
children and 0.2 mg 12th hrly for neonates

31. THANQ