Armand Mekontso Dessap1, Sandrine Katsahian2, Ferran Roche-Campo3, Hugo Varet2, Achille Kouatchet4, Vinko Tomicic5, Gaetan Beduneau6, Romain Sonneville7, Samir Jaber8, Michael Darmon9, Diego Castanares-Zapatero10, Laurent Brochard11, Christian Brun-Buisson12. 1. Service de Réanimation Médicale, AP-HP, CHU Henri Mondor, Créteil, F-94010, France; Faculté de Médecine, Université Paris Est Créteil, Créteil, F-94010, France; INSERM, Unité U955, Créteil, F-94010, France. Electronic address: armand.dessap@hmn.aphp.fr. 2. Unité de Recherche Clinique, AP-HP, CHU Henri Mondor, Créteil, F-94010, France. 3. Service de Réanimation Médicale, AP-HP, CHU Henri Mondor, Créteil, F-94010, France; Servei de Medicina Intensiva, Hospital de Sant Pau, Barcelona, Spain. 4. Service de Réanimation Médicale, CHU d'Angers, Angers, France. 5. Departamento de Paciente Crítico, Clinica Alemana, Santiago de Chile, Chile. 6. Service de Réanimation Médicale and UPRES-EA 3830, CHU de Rouen, Rouen, France. 7. Service de Réanimation Médicale et des Maladies Infectieuses, AP-HP, CHU Bichat-Claude Bernard, Univ Paris Diderot, Sorbonne Paris Cité, Paris, France. 8. Réanimation DAR B, CHU Saint Eloi, INSERM U1046, Montpellier, France. 9. Service de Réanimation Médicale, AP-HP, CHU Saint Louis, Paris, France. 10. Service de Soins Intensifs, Hôpital Universitaire Saint-Luc, Bruxelles, Belgium. 11. Critical Care Department, St. Michael's Hospital, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada. 12. Service de Réanimation Médicale, AP-HP, CHU Henri Mondor, Créteil, F-94010, France; Faculté de Médecine, Université Paris Est Créteil, Créteil, F-94010, France; INSERM, Unité U955, Créteil, F-94010, France.
Abstract
BACKGROUND: Pulmonary edema may alter alveolar bacterial clearance and infectivity. Manipulation of fluid balance aimed at reducing fluid overload may, therefore, influence ventilator-associated pneumonia (VAP) occurrence in intubated patients. The objective of the present study was to assess the impact of a depletive fluid-management strategy on ventilator-associated complication (VAC) and VAP occurrence during weaning from mechanical ventilation. METHODS: We used data from the B-type Natriuretic Peptide for the Fluid Management of Weaning (BMW) randomized controlled trial performed in nine ICUs across Europe and America. We compared the cumulative incidence of VAC and VAP between the biomarker-driven, depletive fluid-management group and the usual-care group during the 14 days following randomization, using specific competing-risk methods (the Fine and Gray model). RESULTS: Among the 304 patients analyzed, 41 experienced VAP, including 27 (17.8%) in the usual-care group vs 14 (9.2%) in the interventional group (P = .03). From the Fine and Gray model, the probabilities of VAC and VAP occurrence were both significantly reduced with the interventional strategy while adjusting for weaning outcome as a competing event (subhazard ratios [25th-75th percentiles], 0.44 [0.22-0.87], P = .02 and 0.50 [0.25-0.96], P = .03, respectively). CONCLUSIONS: Using proper competing risk analyses, we found that a depletive fluid-management strategy, when initiating the weaning process, has the potential for lowering VAP risk in patients who are mechanically ventilated. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT00473148; URL: www.clinicaltrials.gov.
RCT Entities:
BACKGROUND:Pulmonary edema may alter alveolar bacterial clearance and infectivity. Manipulation of fluid balance aimed at reducing fluid overload may, therefore, influence ventilator-associated pneumonia (VAP) occurrence in intubated patients. The objective of the present study was to assess the impact of a depletive fluid-management strategy on ventilator-associated complication (VAC) and VAP occurrence during weaning from mechanical ventilation. METHODS: We used data from the B-type Natriuretic Peptide for the Fluid Management of Weaning (BMW) randomized controlled trial performed in nine ICUs across Europe and America. We compared the cumulative incidence of VAC and VAP between the biomarker-driven, depletive fluid-management group and the usual-care group during the 14 days following randomization, using specific competing-risk methods (the Fine and Gray model). RESULTS: Among the 304 patients analyzed, 41 experienced VAP, including 27 (17.8%) in the usual-care group vs 14 (9.2%) in the interventional group (P = .03). From the Fine and Gray model, the probabilities of VAC and VAP occurrence were both significantly reduced with the interventional strategy while adjusting for weaning outcome as a competing event (subhazard ratios [25th-75th percentiles], 0.44 [0.22-0.87], P = .02 and 0.50 [0.25-0.96], P = .03, respectively). CONCLUSIONS: Using proper competing risk analyses, we found that a depletive fluid-management strategy, when initiating the weaning process, has the potential for lowering VAP risk in patients who are mechanically ventilated. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT00473148; URL: www.clinicaltrials.gov.
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