Karim Asehnoune1,2, Ségolène Mrozek3, Pierre François Perrigault4, Philippe Seguin5, Claire Dahyot-Fizelier6, Sigismond Lasocki7, Anne Pujol8, Mathieu Martin9, Russel Chabanne10, Laurent Muller11, Jean Luc Hanouz12, Emmanuelle Hammad13, Bertrand Rozec14, Thomas Kerforne15, Carole Ichai16, Raphael Cinotti17, Thomas Geeraerts3, Djillali Elaroussi8, Paolo Pelosi18, Samir Jaber19, Marie Dalichampt20, Fanny Feuillet21, Véronique Sebille20,21, Antoine Roquilly17. 1. Intensive Care Unit, Anesthesia and Critical Care Department, Hôtel Dieu-HME-University Hospital of Nantes , Centre Hospitalier Universitaire (CHU) de Nantes, Nantes, France. karim.asehnoune@chu-nantes.fr. 2. Service d'Anesthésie Réanimation, CHU de Nantes, 1 Place Alexis Ricordeau, 44093, Nantes Cedex 1, France. karim.asehnoune@chu-nantes.fr. 3. Department of Anesthesiology and Critical Care Department, University Hospital of Toulouse, Toulouse, France. 4. Intensive Care Unit, Anesthesia and Critical Care Department, Gui Chauliac University Hospital of Montpellier, Montpellier, France. 5. Intensive Care Unit, Anesthesia and Critical Care Department, Pontchaillou-University Hospital of Rennes, Rennes, France. 6. Neuro-Intensive Care Unit, Anesthesia and Critical Care Department, University Hospital of Poitiers, Poitiers, France. 7. Intensive Care Unit, Anesthesia and Critical Care Department, University Hospital of Angers, Angers, France. 8. Intensive Care Unit, Anesthesia and Critical Care Department, University Hospital of Tours, Tours, France. 9. Intensive Care Unit, Anesthesia and Critical Care Department, University Hospital of Créteil-CHU Henri Mondor, Assistance publique-Hôpitaux de Paris (AP-HP), Créteil, France. 10. Department of Anesthesiology and Intensive Care, University Hospital of Clermont Ferrand, Clermont Ferrand, France. 11. Department of Anesthesiology and Intensive Care, University Hospital of Nimes, Nimes, France. 12. Department of Anesthesiology and Intensive Care, University Hospital of Caen, Caen, France. 13. Department of Anesthesiology and Intensive Care, University Hospital of Marseille, Marseille, France. 14. Intensive Care Unit, Anesthesia and Critical Care Department, Laennec-University Hospital of Nantes, Nantes, France. 15. Surgical Intensive Care Unit, Anesthesia and Critical Care Department, University Hospital of Poitiers, Poitiers, France. 16. Intensive Care Unit , Pasteur 2-University Hospital of Nice, Nice, France. 17. Intensive Care Unit, Anesthesia and Critical Care Department, Hôtel Dieu-HME-University Hospital of Nantes , Centre Hospitalier Universitaire (CHU) de Nantes, Nantes, France. 18. Department of Surgical Sciences and Integrated Diagnostics, IRCCS AOU San Martino-IST National Cancer Research Institute, University of Genoa, Genoa, Italy. 19. Intensive Care Unit, Anesthesia and Critical Care Department, Saint Eloi University Hospital of Montpellier, Montpellier, France. 20. Plateforme de Biométrie, Département Promotion de la Recherche Clinique, University Hospital of Nantes, Nantes, France. 21. EA 4275, MethodS for Patients-centered Outcomes and HEalth REsearch (SPHERE), UFR des Sciences Pharmaceutiques, Nantes University, Nantes, France.
Abstract
PURPOSE: We assessed outcomes in brain-injured patients after implementation of a multi-faceted approach to reduce respiratory complications in intensive care units. METHODS: Prospective nationwide before-after trial. Consecutive adults with acute brain injury requiring mechanical ventilation for ≥24 h in 20 French intensive care units (ICUs) were included. The management of invasive ventilation in brain-injured patients admitted between 1 July 2013 and 31 October 2013 (4 months) was monitored and analysed. After the baseline period (1 November 2013-31 December 2013), ventilator settings and decision to extubate were selected as targets to hasten weaning from invasive ventilation. During the intervention period, low tidal volume (≤7 ml/kg), moderate positive end-expiratory pressure (PEEP, 6-8 cm H2O) and an early extubation protocol were recommended. The primary endpoint was the number of days free of invasive ventilation at day 90. Comparisons were performed between the two periods and between the compliant and non-compliant groups. RESULTS: A total of 744 patients from 20 ICUs were included (391 pre-intervention; 353 intervention). No difference in the number of invasive ventilation-free days at day 90 was observed between the two periods [71 (0-80) vs. 67 (0-80) days; P = 0.746]. Compliance with the complete set of recommendations increased from 8 (2%) to 52 (15%) patients after the intervention (P < 0.001). At day 90, the number of invasive ventilation-free days was higher in the 60 (8%) patients whose care complied with recommendations than in the 684 (92%) patients whose care deviated from recommendations [77 (66-82) and 71 (0-80) days, respectively; P = 0.03]. The mortality rate was 10% in the compliant group and 26% in the non-compliant group (P = 0.023). Both multivariate analysis [hazard ratio (HR) 1.78, 95% confidence interval (95% CI) 1.41-2.26; P < 0.001] and propensity score-adjusted analysis (HR 2.25, 95% CI 1.56-3.26, P < 0.001) revealed that compliance was an independent factor associated with the reduction in the duration of mechanical ventilation. CONCLUSIONS: Adherence to recommendations for low tidal volume, moderate PEEP and early extubation seemed to increase the number of ventilator-free days in brain-injured patients, but inconsistent adoption limited their impact. Trail registration number: NCT01885507.
PURPOSE: We assessed outcomes in brain-injured patients after implementation of a multi-faceted approach to reduce respiratory complications in intensive care units. METHODS: Prospective nationwide before-after trial. Consecutive adults with acute brain injury requiring mechanical ventilation for ≥24 h in 20 French intensive care units (ICUs) were included. The management of invasive ventilation in brain-injured patients admitted between 1 July 2013 and 31 October 2013 (4 months) was monitored and analysed. After the baseline period (1 November 2013-31 December 2013), ventilator settings and decision to extubate were selected as targets to hasten weaning from invasive ventilation. During the intervention period, low tidal volume (≤7 ml/kg), moderate positive end-expiratory pressure (PEEP, 6-8 cm H2O) and an early extubation protocol were recommended. The primary endpoint was the number of days free of invasive ventilation at day 90. Comparisons were performed between the two periods and between the compliant and non-compliant groups. RESULTS: A total of 744 patients from 20 ICUs were included (391 pre-intervention; 353 intervention). No difference in the number of invasive ventilation-free days at day 90 was observed between the two periods [71 (0-80) vs. 67 (0-80) days; P = 0.746]. Compliance with the complete set of recommendations increased from 8 (2%) to 52 (15%) patients after the intervention (P < 0.001). At day 90, the number of invasive ventilation-free days was higher in the 60 (8%) patients whose care complied with recommendations than in the 684 (92%) patients whose care deviated from recommendations [77 (66-82) and 71 (0-80) days, respectively; P = 0.03]. The mortality rate was 10% in the compliant group and 26% in the non-compliant group (P = 0.023). Both multivariate analysis [hazard ratio (HR) 1.78, 95% confidence interval (95% CI) 1.41-2.26; P < 0.001] and propensity score-adjusted analysis (HR 2.25, 95% CI 1.56-3.26, P < 0.001) revealed that compliance was an independent factor associated with the reduction in the duration of mechanical ventilation. CONCLUSIONS: Adherence to recommendations for low tidal volume, moderate PEEP and early extubation seemed to increase the number of ventilator-free days in brain-injured patients, but inconsistent adoption limited their impact. Trail registration number: NCT01885507.
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