학술논문
Utilization of mechanical power and associations with clinical outcomes in brain injured patients: a secondary analysis of the extubation strategies in neuro-intensive care unit patients and associations with outcome (ENIO) trial
Document Type
Report
Author
Wahlster, Sarah; Sharma, Monisha; Taran, Shaurya; Town, James A.; Stevens, Robert D.; Cinotti, Raphaël; Asehoune, Karim; Pelosi, Paolo; Robba, Chiara; Abback, Paër-sélim; Codorniu, Anaïs; Citerio, Giuseppe; Sala, Vittoria Ludovica; Astuto, Marinella; Tringali, Eleonora; Alampi, Daniela; Rocco, Monica; Maugeri, Jessica Giuseppina; Bellissima, Agrippino; Filippini, Matteo; Lazzeri, Nicoletta; Cortegiani, Andrea; Ippolito, Mariachiara; Battaglini, Denise; Biston, Patrick; Al-Gharyani, Mohamed Fathi; Chabanne, Russell; Astier, Léo; Soyer, Benjamin; Gaugain, Samuel; Zimmerli, Alice; Pietsch, Urs; Filipovic, Miodrag; Brandi, Giovanna; Bicciato, Giulio; Serrano, Ainhoa; Monleon, Berta; van Vliet, Peter; Gerretsen, Benjamin Marcel; Ortiz-Macias, Iris Xochitl; Oto, Jun; Enomoto, Noriya; Matsuda, Tomomichi; Masui, Nobutaka; Garçon, Pierre; Zarka, Jonathan; Vermeijden, Wytze J.; Cornet, Alexander Daniel; Inurrigarro, Sergio Reyes; Domínguez, Rafael Cirino Lara; Bellini, Maria Mercedes; Gomez Haedo, Maria Milagros; Lamot, Laura; Orquera, Jose; Biais, Matthieu; Georges, Delphine; Baronia, Arvind; Miranda-Ackerman, Roberto Carlos; Barbosa-Camacho, Francisco José; Porter, John; Lopez-Morales, Miguel; Geeraerts, Thomas; Compagnon, Baptiste; Pérez-Torres, David; Prol-Silva, Estefanía; Yahya, Hana Basheer; Khaled, Ala; Ghula, Mohamed; Andrea, Cracchiolo Neville; Daniela, Palma Maria; Deana, Cristian; Vetrugno, Luigi; Chavez, Manuel J. Rivera; Trujillo, Rocio Mendoza; Legros, Vincent; Brochet, Benjamin; Huet, Olivier; Geslain, Marie; van der Jagt, Mathieu; van Steenkiste, Job; Ahmed, Hazem; Coombs, Alexander Edward; Welbourne, Jessie; Velarde Pineda, Ana Alicia; Nubert Castillo, Víctor Hugo; Azab, Mohammed A.; Azzam, Ahmed Y.; van Meenen, David Michael Paul; Gasca, Gilberto Adrian; Arellano, Alfredo; Galicia-Espinosa, Forttino; García-Ramos, José Carlos; Yadav, Ghanshyam; Jha, Amarendra Kumar; Robert-Edan, Vincent; Rodie-Talbere, Pierre-Andre; Jain, Gaurav; Panda, Sagarika; Agarwal, Sonika; Deewan, Yashbir; Reza, Syed Tariq; Hossain, Md.Mozaffer; Papadas, Christos; Chantziara, Vasiliki; Sklavou, Chrysanthi; Hourmant, Yannick; Grillot, Nicolas; Pirracchio, Romain; Akkari, Abdelraouf; Abdelaty, Mohamed; Hashim, Ahmed; Launey, Yoann; Masseret, Elodie; Lasocki, Sigismond; Gergaud, Soizic; Mouclier, Nicolas; Saxena, Sulekha; Agrawal, Avinash; Mishra, Shakti Bedanta; Samal, Samir; Mijangos, Julio Cesar; Haënggi, Mattias; Gurjar, Mohan; Schultz, Marcus J.; Kaye, Callum; Godoy, Daniela Agustin; Alvarez, Pablo; Ioakeimidou, Aikaterini; Ueno, Yoshitoyo; Badenes, Rafael; Suei Elbuzidi, Abdurrahmaan Ali; Piagnerelli, Michaël; Elhadi, Muhammed; Digitale, Jean Catherine; Fong, Nicholas; Cerda, Ricardo Campos; de la Torre Peredo, Norma
Source
Critical Care. April 20, 2023, Vol. 27 Issue 1
Subject
Language
English
ISSN
1364-8535
Abstract
Author(s): Sarah Wahlster[sup.1,2,3] , Monisha Sharma[sup.4] , Shaurya Taran[sup.5,6] , James A. Town[sup.7] , Robert D. Stevens[sup.8] , Raphaël Cinotti[sup.9] , Karim Asehoune[sup.9] , Paolo Pelosi[sup.10,11] , Chiara Robba[sup.10,11,20] , [...]
Background There is insufficient evidence to guide ventilatory targets in acute brain injury (ABI). Recent studies have shown associations between mechanical power (MP) and mortality in critical care populations. We aimed to describe MP in ventilated patients with ABI, and evaluate associations between MP and clinical outcomes. Methods In this preplanned, secondary analysis of a prospective, multi-center, observational cohort study (ENIO, NCT03400904), we included adult patients with ABI (Glasgow Coma Scale [less than or equai to] 12 before intubation) who required mechanical ventilation (MV) [greater than or equal to] 24 h. Using multivariable log binomial regressions, we separately assessed associations between MP on hospital day (HD)1, HD3, HD7 and clinical outcomes: hospital mortality, need for reintubation, tracheostomy placement, and development of acute respiratory distress syndrome (ARDS). Results We included 1217 patients (mean age 51.2 years [SD 18.1], 66% male, mean body mass index [BMI] 26.3 [SD 5.18]) hospitalized at 62 intensive care units in 18 countries. Hospital mortality was 11% (n = 139), 44% (n = 536) were extubated by HD7 of which 20% (107/536) required reintubation, 28% (n = 340) underwent tracheostomy placement, and 9% (n = 114) developed ARDS. The median MP on HD1, HD3, and HD7 was 11.9 J/min [IQR 9.2-15.1], 13 J/min [IQR 10-17], and 14 J/min [IQR 11-20], respectively. MP was overall higher in patients with ARDS, especially those with higher ARDS severity. After controlling for same-day pressure of arterial oxygen/fraction of inspired oxygen (P/F ratio), BMI, and neurological severity, MP at HD1, HD3, and HD7 was independently associated with hospital mortality, reintubation and tracheostomy placement. The adjusted relative risk (aRR) was greater at higher MP, and strongest for: mortality on HD1 (compared to the HD1 median MP 11.9 J/min, aRR at 17 J/min was 1.22, 95% CI 1.14-1.30) and HD3 (1.38, 95% CI 1.23-1.53), reintubation on HD1 (1.64; 95% CI 1.57-1.72), and tracheostomy on HD7 (1.53; 95%CI 1.18-1.99). MP was associated with the development of moderate-severe ARDS on HD1 (2.07; 95% CI 1.56-2.78) and HD3 (1.76; 95% CI 1.41-2.22). Conclusions Exposure to high MP during the first week of MV is associated with poor clinical outcomes in ABI, independent of P/F ratio and neurological severity. Potential benefits of optimizing ventilator settings to limit MP warrant further investigation. Keywords: Acute brain injury, Mechanical power, Acute respiratory distress syndrome, Mechanical ventilation, Traumatic brain injury, Subarachnoid hemorrhage, Acute ischemic stroke, Intracranial hemorrhage
Background There is insufficient evidence to guide ventilatory targets in acute brain injury (ABI). Recent studies have shown associations between mechanical power (MP) and mortality in critical care populations. We aimed to describe MP in ventilated patients with ABI, and evaluate associations between MP and clinical outcomes. Methods In this preplanned, secondary analysis of a prospective, multi-center, observational cohort study (ENIO, NCT03400904), we included adult patients with ABI (Glasgow Coma Scale [less than or equai to] 12 before intubation) who required mechanical ventilation (MV) [greater than or equal to] 24 h. Using multivariable log binomial regressions, we separately assessed associations between MP on hospital day (HD)1, HD3, HD7 and clinical outcomes: hospital mortality, need for reintubation, tracheostomy placement, and development of acute respiratory distress syndrome (ARDS). Results We included 1217 patients (mean age 51.2 years [SD 18.1], 66% male, mean body mass index [BMI] 26.3 [SD 5.18]) hospitalized at 62 intensive care units in 18 countries. Hospital mortality was 11% (n = 139), 44% (n = 536) were extubated by HD7 of which 20% (107/536) required reintubation, 28% (n = 340) underwent tracheostomy placement, and 9% (n = 114) developed ARDS. The median MP on HD1, HD3, and HD7 was 11.9 J/min [IQR 9.2-15.1], 13 J/min [IQR 10-17], and 14 J/min [IQR 11-20], respectively. MP was overall higher in patients with ARDS, especially those with higher ARDS severity. After controlling for same-day pressure of arterial oxygen/fraction of inspired oxygen (P/F ratio), BMI, and neurological severity, MP at HD1, HD3, and HD7 was independently associated with hospital mortality, reintubation and tracheostomy placement. The adjusted relative risk (aRR) was greater at higher MP, and strongest for: mortality on HD1 (compared to the HD1 median MP 11.9 J/min, aRR at 17 J/min was 1.22, 95% CI 1.14-1.30) and HD3 (1.38, 95% CI 1.23-1.53), reintubation on HD1 (1.64; 95% CI 1.57-1.72), and tracheostomy on HD7 (1.53; 95%CI 1.18-1.99). MP was associated with the development of moderate-severe ARDS on HD1 (2.07; 95% CI 1.56-2.78) and HD3 (1.76; 95% CI 1.41-2.22). Conclusions Exposure to high MP during the first week of MV is associated with poor clinical outcomes in ABI, independent of P/F ratio and neurological severity. Potential benefits of optimizing ventilator settings to limit MP warrant further investigation. Keywords: Acute brain injury, Mechanical power, Acute respiratory distress syndrome, Mechanical ventilation, Traumatic brain injury, Subarachnoid hemorrhage, Acute ischemic stroke, Intracranial hemorrhage