Edoardo Picetti1, Paolo Pelosi2,3, Fabio Silvio Taccone4, Giuseppe Citerio5, Jordi Mancebo6, Chiara Robba2. 1. Department of Anesthesia and Intensive Care, Parma University Hospital, Via Gramsci 14, 43100, Parma, Italy. edoardopicetti@hotmail.com. 2. Department of Anesthesia and Intensive Care, IRCCS for Oncology and Neurosciences, Genoa, Italy. 3. Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy. 4. Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium. 5. School of Medicine and Surgery, University of Milan - Bicocca, Monza, Italy. 6. Department of Intensive Care, Sant Pau Hospital, Barcelona, Spain.
Abstract
BACKGROUND: Severe traumatic brain injury (TBI) patients often develop acute respiratory failure. Optimal ventilator strategies in this setting are not well established. We performed an international survey to investigate the practice in the ventilatory management of TBI patients with and without respiratory failure. METHODS: An electronic questionnaire, including 38 items and 3 different clinical scenarios [arterial partial pressure of oxygen (PaO2)/inspired fraction of oxygen (FiO2) > 300 (scenario 1), 150-300 (scenario 2), < 150 (scenario 3)], was available on the European Society of Intensive Care Medicine (ESICM) website between November 2018 and March 2019. The survey was endorsed by ESICM. RESULTS: There were 687 respondents [472 (69%) from Europe], mainly intensivists [328 (48%)] and anesthesiologists [206 (30%)]. A standard protocol for mechanical ventilation in TBI patients was utilized by 277 (40%) respondents and a specific weaning protocol by 198 (30%). The most common tidal volume (TV) applied was 6-8 ml/kg of predicted body weight (PBW) in scenarios 1-2 (72% PaO2/FIO2 > 300 and 61% PaO2/FiO2 150-300) and 4-6 ml/kg/PBW in scenario 3 (53% PaO2/FiO2 < 150). The most common level of highest positive end-expiratory pressure (PEEP) used was 15 cmH2O in patients with a PaO2/FiO2 ≤ 300 without intracranial hypertension (41% if PaO2/FiO2 150-300 and 50% if PaO2/FiO2 < 150) and 10 cmH2O in patients with intracranial hypertension (32% if PaO2/FiO2 150-300 and 33% if PaO2/FiO2 < 150). Regardless of the presence of intracranial hypertension, the most common carbon dioxide target remained 36-40 mmHg whereas the most common PaO2 target was 81-100 mmHg in all the 3 scenarios. The most frequent rescue strategies utilized in case of refractory respiratory failure despite conventional ventilator settings were neuromuscular blocking agents [406 (88%)], recruitment manoeuvres [319 (69%)] and prone position [292 (63%)]. CONCLUSIONS: Ventilatory management, targets and practice of adult severe TBI patients with and without respiratory failure are widely different among centres. These findings may be helpful to define future investigations in this topic.
BACKGROUND: Severe traumatic brain injury (TBI) patients often develop acute respiratory failure. Optimal ventilator strategies in this setting are not well established. We performed an international survey to investigate the practice in the ventilatory management of TBIpatients with and without respiratory failure. METHODS: An electronic questionnaire, including 38 items and 3 different clinical scenarios [arterial partial pressure of oxygen (PaO2)/inspired fraction of oxygen (FiO2) > 300 (scenario 1), 150-300 (scenario 2), < 150 (scenario 3)], was available on the European Society of Intensive Care Medicine (ESICM) website between November 2018 and March 2019. The survey was endorsed by ESICM. RESULTS: There were 687 respondents [472 (69%) from Europe], mainly intensivists [328 (48%)] and anesthesiologists [206 (30%)]. A standard protocol for mechanical ventilation in TBIpatients was utilized by 277 (40%) respondents and a specific weaning protocol by 198 (30%). The most common tidal volume (TV) applied was 6-8 ml/kg of predicted body weight (PBW) in scenarios 1-2 (72% PaO2/FIO2 > 300 and 61% PaO2/FiO2 150-300) and 4-6 ml/kg/PBW in scenario 3 (53% PaO2/FiO2 < 150). The most common level of highest positive end-expiratory pressure (PEEP) used was 15 cmH2O in patients with a PaO2/FiO2 ≤ 300 without intracranial hypertension (41% if PaO2/FiO2 150-300 and 50% if PaO2/FiO2 < 150) and 10 cmH2O in patients with intracranial hypertension (32% if PaO2/FiO2 150-300 and 33% if PaO2/FiO2 < 150). Regardless of the presence of intracranial hypertension, the most common carbon dioxide target remained 36-40 mmHg whereas the most common PaO2 target was 81-100 mmHg in all the 3 scenarios. The most frequent rescue strategies utilized in case of refractory respiratory failure despite conventional ventilator settings were neuromuscular blocking agents [406 (88%)], recruitment manoeuvres [319 (69%)] and prone position [292 (63%)]. CONCLUSIONS: Ventilatory management, targets and practice of adult severe TBIpatients with and without respiratory failure are widely different among centres. These findings may be helpful to define future investigations in this topic.
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