1
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Kim G, Oh DK, Lee SY, Park MH, Lim CM. Impact of the timing of invasive mechanical ventilation in patients with sepsis: a multicenter cohort study. Crit Care 2024; 28:297. [PMID: 39252133 PMCID: PMC11385489 DOI: 10.1186/s13054-024-05064-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 08/10/2024] [Indexed: 09/11/2024] Open
Abstract
BACKGROUND The potential adverse effects associated with invasive mechanical ventilation (MV) can lead to delayed decisions on starting MV. We aimed to explore the association between the timing of MV and the clinical outcomes in patients with sepsis ventilated in intensive care unit (ICU). METHODS We analyzed data of adult patients with sepsis between September 2019 and December 2021. Data was collected through the Korean Sepsis Alliance from 20 hospitals in Korea. Patients who were admitted to ICU and received MV were included in the study. Patients were divided into 'early MV' and 'delayed MV' groups based on whether they were on MV on the first day of ICU admission or later. Propensity score matching was applied, and patients in the two groups were compared on a 1:1 ratio to overcome bias between the groups. Outcomes including ICU mortality, hospital mortality, length of hospital and ICU stay, and organ failure at ICU discharge were compared. RESULTS Out of 2440 patients on MV during ICU stay, 2119 'early MV' and 321 'delayed MV' cases were analyzed. The propensity score matching identified 295 patients in each group with similar baseline characteristics. ICU mortality was lower in 'early MV' group than 'delayed MV' group (36.3% vs. 46.4%; odds ratio, 0.66; 95% confidence interval, 0.47-0.93; p = 0.015). 'Early MV' group had lower in-hospital mortality, shorter ICU stay, and required tracheostomy less frequently than 'delayed MV' group. Multivariable logistic regression model identified 'early MV' as associated with lower ICU mortality (odds ratio, 0.38; 95% confidence interval, 0.29-0.50; p < 0.001). CONCLUSION In patients with sepsis ventilated in ICU, earlier start (first day of ICU admission) of MV may be associated with lower mortality.
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Affiliation(s)
- Gyungah Kim
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Dong Kyu Oh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Su Yeon Lee
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Mi Hyeon Park
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Chae-Man Lim
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea.
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2
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Lee KG, Roca O, Casey JD, Semler MW, Roman-Sarita G, Yarnell CJ, Goligher EC. When to intubate in acute hypoxaemic respiratory failure? Options and opportunities for evidence-informed decision making in the intensive care unit. THE LANCET. RESPIRATORY MEDICINE 2024; 12:642-654. [PMID: 38801827 DOI: 10.1016/s2213-2600(24)00118-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 03/08/2024] [Accepted: 04/05/2024] [Indexed: 05/29/2024]
Abstract
The optimal timing of intubation in acute hypoxaemic respiratory failure is uncertain and became a point of controversy during the COVID-19 pandemic. Invasive mechanical ventilation is a potentially life-saving intervention but carries substantial risks, including injury to the lungs and diaphragm, pneumonia, intensive care unit-acquired muscle weakness, and haemodynamic impairment. In deciding when to intubate, clinicians must balance premature exposure to the risks of ventilation with the potential harms of unassisted breathing, including disease progression and worsening multiorgan failure. Currently, the optimal timing of intubation is unclear. In this Personal View, we examine a range of parameters that could serve as triggers to initiate invasive mechanical ventilation. The utility of a parameter (eg, the ratio of arterial oxygen tension to fraction of inspired oxygen) to predict the likelihood of a patient undergoing intubation does not necessarily mean that basing the timing of intubation on that parameter will improve therapeutic outcomes. We examine options for clinical investigation to make progress on establishing the optimal timing of intubation.
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Affiliation(s)
- Kevin G Lee
- Department of Physiology, Toronto, ON, Canada; Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Oriol Roca
- Servei de Medicina Intensiva, Parc Taulí Hospital Universitari, Institut de Recerca Parc Taulí-I3PT, Sabadell, Spain; Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain; Ciber Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Jonathan D Casey
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew W Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Christopher J Yarnell
- Interdepartmental Division of Critical Care Medicine University of Toronto, Toronto, ON, Canada; Department of Medicine, Division of Respirology, University Health Network, Toronto, ON, Canada; Institute of Health Policy, Management, and Evaluation at the University of Toronto, Toronto, ON, Canada; Scarborough Health Network, Department of Critical Care Medicine, Toronto, ON, Canada; Scarborough Health Network Research Institute, Toronto, ON, Canada.
| | - Ewan C Goligher
- Department of Physiology, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine University of Toronto, Toronto, ON, Canada; Department of Medicine, Division of Respirology, University Health Network, Toronto, ON, Canada; Toronto General Hospital Research Institute, Toronto, ON, Canada
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3
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Mongardon N, Bauer PR. Intubation in COVID-19: When Severity and Trajectory Collide. Crit Care Med 2024; 52:990-992. [PMID: 38752819 DOI: 10.1097/ccm.0000000000006246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2024]
Affiliation(s)
- Nicolas Mongardon
- Service d'anesthésie-réanimation chirurgicale et médecine péri-opératoire, réanimation chirurgicale, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France
- Université Paris Est Créteil, Faculté de Santé, Créteil, France
- U955-IMRB, Equipe 03 "Stratégies pharmacologiques et thérapeutiques expérimentales des insuffisances cardiaques et coronaires," Inserm, UPEC, Ecole Nationale Vétérinaire d'Alfort, Maisons-Alfort, France
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Philippe R Bauer
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
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4
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Bauer PR, De Jong A. How to Make Tracheal Intubation in the ICU Safer and More Effective? Crit Care Med 2024; 52:859-862. [PMID: 38619347 DOI: 10.1097/ccm.0000000000006214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Affiliation(s)
- Philippe R Bauer
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Audrey De Jong
- Department of Anesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, University of Montpellier, PhyMedExp, INSERM, CNRS, Montpellier, France
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5
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Abdelmalek FM, Angriman F, Moore J, Liu K, Burry L, Seyyed-Kalantari L, Mehta S, Gichoya J, Celi LA, Tomlinson G, Fralick M, Yarnell CJ. Association between Patient Race and Ethnicity and Use of Invasive Ventilation in the United States. Ann Am Thorac Soc 2024; 21:287-295. [PMID: 38029405 DOI: 10.1513/annalsats.202305-485oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 11/28/2023] [Indexed: 12/01/2023] Open
Abstract
Rationale: Outcomes for people with respiratory failure in the United States vary by patient race and ethnicity. Invasive ventilation is an important treatment initiated based on expert opinion. It is unknown whether the use of invasive ventilation varies by patient race and ethnicity. Objectives: To measure 1) the association between patient race and ethnicity and the use of invasive ventilation; and 2) the change in 28-day mortality mediated by any association. Methods: We performed a multicenter cohort study of nonintubated adults receiving oxygen within 24 hours of intensive care admission using the Medical Information Mart for Intensive Care IV (MIMIC-IV, 2008-2019) and Phillips eICU (eICU, 2014-2015) databases from the United States. We modeled the association between patient race and ethnicity (Asian, Black, Hispanic, White) and invasive ventilation rate using a Bayesian multistate model that adjusted for baseline and time-varying covariates, calculated hazard ratios (HRs), and estimated 28-day hospital mortality changes mediated by differential invasive ventilation use. We reported posterior means and 95% credible intervals (CrIs). Results: We studied 38,258 patients, 52% (20,032) from MIMIC-IV and 48% (18,226) from eICU: 2% Asian (892), 11% Black (4,289), 5% Hispanic (1,964), and 81% White (31,113). Invasive ventilation occurred in 9.2% (3,511), and 7.5% (2,869) died. The adjusted rate of invasive ventilation was lower in Asian (HR, 0.82; CrI, 0.70-0.95), Black (HR, 0.78; CrI, 0.71-0.86), and Hispanic (HR, 0.70; CrI, 0.61-0.79) patients compared with White patients. For the average patient, lower rates of invasive ventilation did not mediate differences in 28-day mortality. For a patient on high-flow nasal cannula with inspired oxygen fraction of 1.0, the odds ratios for mortality if invasive ventilation rates were equal to the rate for White patients were 0.97 (CrI, 0.91-1.03) for Asian patients, 0.96 (CrI, 0.91-1.03) for Black patients, and 0.94 (CrI, 0.89-1.01) for Hispanic patients. Conclusions: Asian, Black, and Hispanic patients had lower rates of invasive ventilation than White patients. These decreases did not mediate harm for the average patient, but we could not rule out harm for patients with more severe hypoxemia.
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Affiliation(s)
| | - Federico Angriman
- Institute of Health Policy, Management, and Evaluation
- Interdepartmental Division of Critical Care Medicine
- Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Julie Moore
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
- University Health Network/Sinai Health, Toronto, Ontario, Canada
| | - Kuan Liu
- Institute of Health Policy, Management, and Evaluation
| | - Lisa Burry
- Interdepartmental Division of Critical Care Medicine
- Leslie Dan Faculty of Pharmacy, and
- University Health Network/Sinai Health, Toronto, Ontario, Canada
| | - Laleh Seyyed-Kalantari
- Department of Electrical Engineering and Computer Science, Lassonde School of Engineering, York University, Toronto, Ontario, Canada
| | - Sangeeta Mehta
- Interdepartmental Division of Critical Care Medicine
- University Health Network/Sinai Health, Toronto, Ontario, Canada
| | - Judy Gichoya
- Department of Radiology and Biomedical Informatics, Emory University, Atlanta, Georgia
| | - Leo Anthony Celi
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; and
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - George Tomlinson
- Institute of Health Policy, Management, and Evaluation
- University Health Network/Sinai Health, Toronto, Ontario, Canada
| | - Michael Fralick
- University Health Network/Sinai Health, Toronto, Ontario, Canada
| | - Christopher J Yarnell
- Institute of Health Policy, Management, and Evaluation
- Interdepartmental Division of Critical Care Medicine
- University Health Network/Sinai Health, Toronto, Ontario, Canada
- Department of Critical Care Medicine and
- Scarborough Health Network Research Institute, Scarborough Health Network, Toronto, Ontario, Canada
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6
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Doidge JC, Yarnell CJ. It's time for a trial of the timing of invasive ventilation in COVID-19 and other pneumonias. J Crit Care 2023; 77:154323. [PMID: 37163852 PMCID: PMC10165897 DOI: 10.1016/j.jcrc.2023.154323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 04/25/2023] [Accepted: 04/27/2023] [Indexed: 05/12/2023]
Affiliation(s)
- James C Doidge
- Intensive Care National Audit and Research Centre, London, United Kingdom
| | - Christopher J Yarnell
- Interdepartmental Division of Critical Care Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada; Toronto General Hospital, Toronto, Canada.
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7
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Green A, Rachoin JS, Schorr C, Dellinger P, Casey JD, Park I, Gupta S, Baron RM, Shaefi S, Hunter K, Leaf DE. Timing of invasive mechanical ventilation and death in critically ill adults with COVID-19: A multicenter cohort study. PLoS One 2023; 18:e0285748. [PMID: 37379286 PMCID: PMC10306211 DOI: 10.1371/journal.pone.0285748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 05/02/2023] [Indexed: 06/30/2023] Open
Abstract
PURPOSE To investigate if the timing of initiation of invasive mechanical ventilation (IMV) for critically ill patients with COVID-19 is associated with mortality. MATERIALS AND METHODS The data for this study were derived from a multicenter cohort study of critically ill adults with COVID-19 admitted to ICUs at 68 hospitals across the US from March 1 to July 1, 2020. We examined the association between early (ICU days 1-2) versus late (ICU days 3-7) initiation of IMV and time-to-death. Patients were followed until the first of hospital discharge, death, or 90 days. We adjusted for confounding using a multivariable Cox model. RESULTS Among the 1879 patients included in this analysis (1199 male [63.8%]; median age, 63 [IQR, 53-72] years), 1526 (81.2%) initiated IMV early and 353 (18.8%) initiated IMV late. A total of 644 of the 1526 patients (42.2%) in the early IMV group died, and 180 of the 353 (51.0%) in the late IMV group died (adjusted HR 0.77 [95% CI, 0.65-0.93]). CONCLUSIONS In critically ill adults with respiratory failure from COVID-19, early compared to late initiation of IMV is associated with reduced mortality.
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Affiliation(s)
- Adam Green
- Cooper University Health Care and Cooper Medical School of Rowan University, Camden, NJ, United States of America
| | - Jean-Sebastien Rachoin
- Cooper University Health Care and Cooper Medical School of Rowan University, Camden, NJ, United States of America
| | - Christa Schorr
- Cooper University Health Care and Cooper Medical School of Rowan University, Camden, NJ, United States of America
| | - Phil Dellinger
- Cooper University Health Care and Cooper Medical School of Rowan University, Camden, NJ, United States of America
| | - Jonathan D. Casey
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Isabel Park
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, MA, United States of America
| | - Shruti Gupta
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, MA, United States of America
| | - Rebecca M. Baron
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, MA, United States of America
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States of America
| | - Krystal Hunter
- Cooper University Health Care and Cooper Medical School of Rowan University, Camden, NJ, United States of America
| | - David E. Leaf
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, MA, United States of America
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8
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Han CH, Park M, Kim H, Roh YY, Kim SY, Kim JD, Kim MJ, Lee YJ, Kim KW, Kim YH. Radiologic Assessment of Lung Edema Score as a Predictor of Clinical Outcome in Children with Acute Respiratory Distress Syndrome. Yonsei Med J 2023; 64:384-394. [PMID: 37226565 DOI: 10.3349/ymj.2022.0653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/27/2023] [Accepted: 03/28/2023] [Indexed: 05/26/2023] Open
Abstract
PURPOSE The radiographic assessment of lung edema (RALE) score enables objective quantification of lung edema and is a valuable prognostic marker of adult acute respiratory distress syndrome (ARDS). We aimed to evaluate the validity of RALE score in children with ARDS. MATERIALS AND METHODS The RALE score was measured for its reliability and correlation to other ARDS severity indices. ARDS-specific mortality was defined as death from severe pulmonary dysfunction or the need for extracorporeal membrane oxygenation therapy. The C-index of the RALE score and other ARDS severity indices were compared via survival analyses. RESULTS Among 296 children with ARDS, 88 did not survive, and there were 70 ARDS-specific non-survivors. The RALE score showed good reliability with an intraclass correlation coefficient of 0.809 [95% confidence interval (CI), 0.760-0.848]. In univariable analysis, the RALE score had a hazard ratio (HR) of 1.19 (95% CI, 1.18-3.11), and the significance was maintained in multivariable analysis adjusting with age, ARDS etiology, and comorbidity, with an HR of 1.77 (95% CI, 1.05-2.91). The RALE score was a good predictor of ARDS-specific mortality, with a C-index of 0.607 (95% CI, 0.519-0.695). CONCLUSION The RALE score is a reliable measure for ARDS severity and a useful prognostic marker of mortality in children, especially for ARDS-specific mortality. This score provides information that clinicians can use to decide the proper time of aggressive therapy targeting severe lung injury and to appropriately manage the fluid balance of children with ARDS.
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Affiliation(s)
- Chang Hoon Han
- Department of Pediatrics, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Mireu Park
- Department of Pediatrics, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
- Institute of Allergy, Severance Biomedical Science Institute, Brain Korea 21 PLUS Project for Medical Science, Seoul, Korea
| | - Hamin Kim
- Department of Pediatrics, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
- Institute of Allergy, Severance Biomedical Science Institute, Brain Korea 21 PLUS Project for Medical Science, Seoul, Korea
| | - Yun Young Roh
- Department of Pediatrics, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
- Institute of Allergy, Severance Biomedical Science Institute, Brain Korea 21 PLUS Project for Medical Science, Seoul, Korea
| | - Soo Yeon Kim
- Department of Pediatrics, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
- Institute of Allergy, Severance Biomedical Science Institute, Brain Korea 21 PLUS Project for Medical Science, Seoul, Korea
| | - Jong Deok Kim
- Department of Pediatrics, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
- Institute of Allergy, Severance Biomedical Science Institute, Brain Korea 21 PLUS Project for Medical Science, Seoul, Korea
| | - Min Jung Kim
- Institute of Allergy, Severance Biomedical Science Institute, Brain Korea 21 PLUS Project for Medical Science, Seoul, Korea
- Department of Pediatrics, Yongin Severance Hospital, Yongin, Korea
| | - Yong Ju Lee
- Institute of Allergy, Severance Biomedical Science Institute, Brain Korea 21 PLUS Project for Medical Science, Seoul, Korea
- Department of Pediatrics, Yongin Severance Hospital, Yongin, Korea
| | - Kyung Won Kim
- Department of Pediatrics, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
- Institute of Allergy, Severance Biomedical Science Institute, Brain Korea 21 PLUS Project for Medical Science, Seoul, Korea
| | - Yoon Hee Kim
- Department of Pediatrics, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
- Institute of Allergy, Severance Biomedical Science Institute, Brain Korea 21 PLUS Project for Medical Science, Seoul, Korea.
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9
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Yarnell CJ, Angriman F, Ferreyro BL, Liu K, De Grooth HJ, Burry L, Munshi L, Mehta S, Celi L, Elbers P, Thoral P, Brochard L, Wunsch H, Fowler RA, Sung L, Tomlinson G. Oxygenation thresholds for invasive ventilation in hypoxemic respiratory failure: a target trial emulation in two cohorts. Crit Care 2023; 27:67. [PMID: 36814287 PMCID: PMC9944781 DOI: 10.1186/s13054-023-04307-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 01/06/2023] [Indexed: 02/24/2023] Open
Abstract
BACKGROUND The optimal thresholds for the initiation of invasive ventilation in patients with hypoxemic respiratory failure are unknown. Using the saturation-to-inspired oxygen ratio (SF), we compared lower versus higher hypoxemia severity thresholds for initiating invasive ventilation. METHODS This target trial emulation included patients from the Medical Information Mart for Intensive Care (MIMIC-IV, 2008-2019) and the Amsterdam University Medical Centers (AmsterdamUMCdb, 2003-2016) databases admitted to intensive care and receiving inspired oxygen fraction ≥ 0.4 via non-rebreather mask, noninvasive ventilation, or high-flow nasal cannula. We compared the effect of using invasive ventilation initiation thresholds of SF < 110, < 98, and < 88 on 28-day mortality. MIMIC-IV was used for the primary analysis and AmsterdamUMCdb for the secondary analysis. We obtained posterior means and 95% credible intervals (CrI) with nonparametric Bayesian G-computation. RESULTS We studied 3,357 patients in the primary analysis. For invasive ventilation initiation thresholds SF < 110, SF < 98, and SF < 88, the predicted 28-day probabilities of invasive ventilation were 72%, 47%, and 19%. Predicted 28-day mortality was lowest with threshold SF < 110 (22.2%, CrI 19.2 to 25.0), compared to SF < 98 (absolute risk increase 1.6%, CrI 0.6 to 2.6) or SF < 88 (absolute risk increase 3.5%, CrI 1.4 to 5.4). In the secondary analysis (1,279 patients), the predicted 28-day probability of invasive ventilation was 50% for initiation threshold SF < 110, 28% for SF < 98, and 19% for SF < 88. In contrast with the primary analysis, predicted mortality was highest with threshold SF < 110 (14.6%, CrI 7.7 to 22.3), compared to SF < 98 (absolute risk decrease 0.5%, CrI 0.0 to 0.9) or SF < 88 (absolute risk decrease 1.9%, CrI 0.9 to 2.8). CONCLUSION Initiating invasive ventilation at lower hypoxemia severity will increase the rate of invasive ventilation, but this can either increase or decrease the expected mortality, with the direction of effect likely depending on baseline mortality risk and clinical context.
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Affiliation(s)
- Christopher J. Yarnell
- grid.17063.330000 0001 2157 2938Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada ,grid.231844.80000 0004 0474 0428Department of Medicine, Division of Respirology, University Health Network and Sinai Health System, Toronto, Canada ,grid.17063.330000 0001 2157 2938Institute of Health Policy, Management and Evaluation, University of Toronto, Medical-Surgical ICU, 10th floor, 585 University Avenue, Toronto, ON M5G 1X5 Canada
| | - Federico Angriman
- grid.17063.330000 0001 2157 2938Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada ,grid.17063.330000 0001 2157 2938Institute of Health Policy, Management and Evaluation, University of Toronto, Medical-Surgical ICU, 10th floor, 585 University Avenue, Toronto, ON M5G 1X5 Canada ,grid.413104.30000 0000 9743 1587Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Bruno L. Ferreyro
- grid.17063.330000 0001 2157 2938Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada ,grid.231844.80000 0004 0474 0428Department of Medicine, Division of Respirology, University Health Network and Sinai Health System, Toronto, Canada ,grid.17063.330000 0001 2157 2938Institute of Health Policy, Management and Evaluation, University of Toronto, Medical-Surgical ICU, 10th floor, 585 University Avenue, Toronto, ON M5G 1X5 Canada
| | - Kuan Liu
- grid.17063.330000 0001 2157 2938Institute of Health Policy, Management and Evaluation, University of Toronto, Medical-Surgical ICU, 10th floor, 585 University Avenue, Toronto, ON M5G 1X5 Canada
| | - Harm Jan De Grooth
- grid.12380.380000 0004 1754 9227Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Lisa Burry
- grid.17063.330000 0001 2157 2938Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada ,grid.492573.e0000 0004 6477 6457Department of Pharmacy and Medicine, Sinai Health System, Toronto, Canada ,grid.17063.330000 0001 2157 2938Leslie Dan Faculty of Pharmacy and Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON Canada
| | - Laveena Munshi
- grid.17063.330000 0001 2157 2938Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada ,grid.231844.80000 0004 0474 0428Department of Medicine, Division of Respirology, University Health Network and Sinai Health System, Toronto, Canada
| | - Sangeeta Mehta
- grid.17063.330000 0001 2157 2938Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada ,grid.231844.80000 0004 0474 0428Department of Medicine, Division of Respirology, University Health Network and Sinai Health System, Toronto, Canada
| | - Leo Celi
- grid.116068.80000 0001 2341 2786Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA 02142 USA ,grid.239395.70000 0000 9011 8547Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215 USA ,grid.38142.3c000000041936754XDepartment of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA 02115 USA
| | - Paul Elbers
- grid.12380.380000 0004 1754 9227Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Patrick Thoral
- grid.12380.380000 0004 1754 9227Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Laurent Brochard
- grid.415502.7Keenan Research Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St Michael’s Hospital, Unity Health Toronto, Toronto, Canada ,grid.17063.330000 0001 2157 2938Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Hannah Wunsch
- grid.418647.80000 0000 8849 1617Institute for Clinical Evaluative Sciences, Toronto, Canada ,grid.17063.330000 0001 2157 2938Institute of Health Policy, Management and Evaluation, University of Toronto, Medical-Surgical ICU, 10th floor, 585 University Avenue, Toronto, ON M5G 1X5 Canada ,grid.413104.30000 0000 9743 1587Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Robert A. Fowler
- grid.17063.330000 0001 2157 2938Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada ,grid.17063.330000 0001 2157 2938Department of Medicine, University of Toronto, Toronto, Canada ,grid.418647.80000 0000 8849 1617Institute for Clinical Evaluative Sciences, Toronto, Canada ,grid.17063.330000 0001 2157 2938Institute of Health Policy, Management and Evaluation, University of Toronto, Medical-Surgical ICU, 10th floor, 585 University Avenue, Toronto, ON M5G 1X5 Canada ,grid.413104.30000 0000 9743 1587Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Lillian Sung
- grid.17063.330000 0001 2157 2938Institute of Health Policy, Management and Evaluation, University of Toronto, Medical-Surgical ICU, 10th floor, 585 University Avenue, Toronto, ON M5G 1X5 Canada ,grid.42327.300000 0004 0473 9646Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
| | - George Tomlinson
- grid.231844.80000 0004 0474 0428Department of Medicine, University Health Network and Sinai Health System, Toronto, Canada ,grid.17063.330000 0001 2157 2938Institute of Health Policy, Management and Evaluation, University of Toronto, Medical-Surgical ICU, 10th floor, 585 University Avenue, Toronto, ON M5G 1X5 Canada
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10
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Yarnell CJ, Johnson A, Dam T, Jonkman A, Liu K, Wunsch H, Brochard L, Celi LA, De Grooth HJ, Elbers P, Mehta S, Munshi L, Fowler RA, Sung L, Tomlinson G. Do Thresholds for Invasive Ventilation in Hypoxemic Respiratory Failure Exist? A Cohort Study. Am J Respir Crit Care Med 2023; 207:271-282. [PMID: 36150166 DOI: 10.1164/rccm.202206-1092oc] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Rationale: Invasive ventilation is a significant event for patients with respiratory failure. Physiologic thresholds standardize the use of invasive ventilation in clinical trials, but it is unknown whether thresholds prompt invasive ventilation in clinical practice. Objectives: To measure, in patients with hypoxemic respiratory failure, the probability of invasive ventilation within 3 hours after meeting physiologic thresholds. Methods: We studied patients admitted to intensive care receiving FiO2 of 0.4 or more via nonrebreather mask, noninvasive positive pressure ventilation, or high-flow nasal cannula, using data from the Medical Information Mart for Intensive Care (MIMIC)-IV database (2008-2019) and the Amsterdam University Medical Centers Database (AmsterdamUMCdb) (2003-2016). We evaluated 17 thresholds, including the ratio of arterial to inspired oxygen, the ratio of saturation to inspired oxygen ratio, composite scores, and criteria from randomized trials. We report the probability of invasive ventilation within 3 hours of meeting each threshold and its association with covariates using odds ratios (ORs) and 95% credible intervals (CrIs). Measurements and Main Results: We studied 4,726 patients (3,365 from MIMIC, 1,361 from AmsterdamUMCdb). Invasive ventilation occurred in 28% (1,320). In MIMIC, the highest probability of invasive ventilation within 3 hours of meeting a threshold was 20%, after meeting prespecified neurologic or respiratory criteria while on vasopressors, and 19%, after a ratio of arterial to inspired oxygen of <80 mm Hg. In AmsterdamUMCdb, the highest probability was 34%, after vasopressor initiation, and 25%, after a ratio of saturation to inspired oxygen of <90. The probability after meeting the threshold from randomized trials was 9% (MIMIC) and 13% (AmsterdamUMCdb). In MIMIC, a race/ethnicity of Black (OR, 0.75; 95% CrI, 0.57-0.96) or Asian (OR, 0.6; 95% CrI, 0.35-0.95) compared with White was associated with decreased probability of invasive ventilation after meeting a threshold. Conclusions: The probability of invasive ventilation within 3 hours of meeting physiologic thresholds was low and associated with patient race/ethnicity.
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Affiliation(s)
- Christopher J Yarnell
- Interdepartmental Division of Critical Care Medicine.,Institute of Health Policy, Management and Evaluation, and.,Division of Respirology
| | | | - Tariq Dam
- Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - Annemijn Jonkman
- Department of Intensive Care Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Kuan Liu
- Institute of Health Policy, Management and Evaluation, and
| | - Hannah Wunsch
- Interdepartmental Division of Critical Care Medicine.,Institute of Health Policy, Management and Evaluation, and.,Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine.,Keenan Research Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Leo Anthony Celi
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts.,Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Department of Biostatistics, T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts; and
| | - Harm-Jan De Grooth
- Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - Paul Elbers
- Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - Sangeeta Mehta
- Interdepartmental Division of Critical Care Medicine.,Division of Respirology
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine.,Division of Respirology
| | - Robert A Fowler
- Interdepartmental Division of Critical Care Medicine.,Institute of Health Policy, Management and Evaluation, and.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Haematology/Oncology.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Lillian Sung
- Institute of Health Policy, Management and Evaluation, and.,Division of Haematology/Oncology
| | - George Tomlinson
- Institute of Health Policy, Management and Evaluation, and.,Department of Medicine, University Health Network and Sinai Health System, Toronto, Ontario, Canada
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11
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Fletcher JJ, Aughenbaugh A, Svabek C, Hahn PY, Grifka RG. Ventilator avoidance among critically ill COVID-19 patients with acute respiratory distress syndrome. J Int Med Res 2022; 50:3000605221135446. [PMID: 36324277 PMCID: PMC9634208 DOI: 10.1177/03000605221135446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Objective To determine the incidence and significance of ventilator avoidance in
patients with critical coronavirus disease 2019 (COVID-19). Methods This prospective observational cohort study evaluated hospital mortality and
1-year functional outcome among critically ill patients with severe acute
respiratory syndrome coronavirus 2 (SARS-CoV-2)-associated acute respiratory
distress syndrome (ARDS). The explanatory variable was ventilator avoidance,
modeled as ‘initial refusal’ of intubation (yes/no). Modified Rankin Scale
(mRS) scores were obtained from surviving patients (or their surrogates) via
phone or email questionnaire. Results Among patients for whom intubation was recommended
(n = 102), 40 (39%) initially refused (95% confidence
interval [CI] 30%, 49%). The risk of death was 79.3% (49/62) in those who
did not initially refuse intubation compared with 77.5% (31/40) in those who
initially refused, with an adjusted odds ratio for death of 1.27 (95% CI
0.47, 3.48). The distribution of 1-year mRS scores was not significantly
different between groups. Conclusion Among critically ill patients with COVID-19-associated ARDS, ventilator
avoidance was common, but was not associated with increased in-hospital
mortality or 1-year functional outcome.
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Affiliation(s)
- Jeffrey J Fletcher
- Department of Critical Care
Medicine, University of Michigan Health West, Wyoming, MI, USA,Department of Neurosurgery,
University of Michigan Medical School, Ann Arbor, MI, USA,Jeffrey J Fletcher, University of Michigan
Health West, Critical Care Medicine, 5900 Byron Center Ave, Wyoming, MI 49519,
USA.
| | - Arielle Aughenbaugh
- Michigan State University College
of Osteopathic Medicine, East Lansing, MI, USA
| | - Catherine Svabek
- Department of Research, University
of Michigan Health West, Wyoming, MI, USA
| | - Peter Y Hahn
- Department of Critical Care
Medicine, University of Michigan Health West, Wyoming, MI, USA
| | - Ronald G Grifka
- Department of Research, University
of Michigan Health West, Wyoming, MI, USA
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12
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Association between timing of intubation and clinical outcomes of critically ill patients: A meta-analysis. J Crit Care 2022; 71:154062. [PMID: 35588639 DOI: 10.1016/j.jcrc.2022.154062] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 04/29/2022] [Accepted: 05/03/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE Optimal timing of intubation is controversial. We attempted to investigate the association between timing of intubation and clinical outcomes of critically ill patients. METHODS PubMed was systematically searched for studies reporting on mortality of critically ill patients undergoing early versus late intubation. Studies involving patients with new coronavirus disease (COVID-19) were excluded because a relevant meta-analysis has been published. "Early" intubation was defined according to the authors of the included studies. All-cause mortality was the primary outcome. Pooled risk ratio (RR) and 95% confidence intervals (CI) were calculated using a random effects model. The meta-analysis was registered with PROSPERO (CRD42021284850). RESULTS In total, 27 studies involving 15,441 intubated patients (11,943 early, 3498 late) were included. All-cause mortality was lower in patients undergoing early versus late intubation (7338 deaths; 45.8% versus 53.5%; RR 0.92, 95% CI 0.87-0.97; p = 0.001). This was also the case in the sensitivity analysis of studies defining "early" as intubation within 24 h from admission in the intensive care unit (6279 deaths; 45.8% versus 53.6%; RR 0.93, 95% CI 0.89-0.98; p = 0.005). CONCLUSION Avoiding late intubation may be associated with lower mortality in critically ill patients without COVID-19.
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13
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Xie Z, Liu J, Yang Z, Tang L, Wang S, Du Y, Yang L. Risk Factors for Post-operative Planned Reintubation in Patients After General Anesthesia: A Systematic Review and Meta-Analysis. Front Med (Lausanne) 2022; 9:839070. [PMID: 35355600 PMCID: PMC8959864 DOI: 10.3389/fmed.2022.839070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 02/09/2022] [Indexed: 11/13/2022] Open
Abstract
Background The occurrence of postoperative reintubation (POR) in patients after general anesthesia (GA) is often synonymous with a poor prognosis in patients. This is the first review analyzing scientific literature to identify risk factors of POR after general anesthesia. The purpose of this study was to collect currently published studies to determine the most common and consistent risk factors associated with POR after GA. Methods We have retrieved all relevant research published before April 2021 from PubMed, Embase, Web of Science, and the Cochrane Library electronic databases. These studies were selected according to the inclusion and exclusion criteria. The Z test determined the combined odds ratio (OR) of risk factors. We used OR and its corresponding 95% confidence interval (CI) to identify significant differences in risk factors. The quality of the study was evaluated with the NOS scale, and meta-analysis was carried out with Cochrane Collaboration's Revman 5.0 software. Results A total of 10 studies were included, with a total of 7,789 recipients of POR. We identified 7 risk factors related to POR after GA: ASA ≥ 3 (OR = 3.58), COPD (OR = 2.09), thoracic surgery (OR = 17.09), airway surgery (OR = 9.93), head-and-neck surgery (OR = 3.49), sepsis (OR = 3.50), DVT (OR = 4.94). Conclusion Our meta-analysis showed that ASA ≥ 3, COPD, thoracic surgery, airway surgery, head-and-neck surgery, sepsis and DVT were associated with POR after GA. Systematic Review Registration https://www.crd.york.ac.uk/prospero/display_record.php?, Identifier: CRD42021252466.
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Affiliation(s)
- Zhiqin Xie
- Department of Nursing, First Affiliated Hospital of Nanchang University, Nanchang, China.,School of Nursing, Nanchang University, Nanchang, China
| | - Jiawen Liu
- School of Nursing, Nanchang University, Nanchang, China
| | - Zhen Yang
- Department of Nursing, First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Liping Tang
- Department of Nursing, First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Shuilian Wang
- Department of Nursing, First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yunyu Du
- School of Nursing, Nanchang University, Nanchang, China
| | - Lina Yang
- School of Nursing, Nanchang University, Nanchang, China
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14
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Goel NN, Chen J, Roberts R, Sevransky J, Gong MN, Mathews KS. Effects of Timing of Invasive Mechanical Ventilation in Patients with Shock. An Analysis of the Multicenter Prospective Observational VOLUME–CHASERS Cohort. J Intensive Care Med 2022; 37:1435-1441. [DOI: 10.1177/08850666221081102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives: Describe the variation in practice and identify predictors of invasive mechanical ventilation (IMV) use in shock. Explore the association between the timing of IMV initiation (“Early” vs. “Delayed”) on shock duration. Design: Multicenter, prospective, observational cohort study between September 2017 and February 2018 Setting: 34 hospitals in the United States and Jordan. Patients: Consecutive, adult, critically ill patients with shock, defined as a systolic blood pressure less than or equal to 90mm Hg, mean arterial pressure less than or equal to 65mm Hg, or need for a vasopressor medication. Interventions: None. Measurements and Main Results: “Early” IMV was defined as starting IMV 0–6 hours of shock onset and “Delayed” IMV was defined as starting IMV between 6 and 48 hours of shock onset. The primary outcome was shock–free days, defined as the number of days without shock after the first 48 hours of shock onset. Variation and predictors of IMV use were examined within the whole cohort as well as the subgroup of those intubated within 0–48 hours of shock onset. Mixed effects modeling with hospital site as a random effect showed that there was 7% variation by site in the use and timing of IMV in this shock cohort. In a propensity–matched model for the timing of IMV, “Early” IMV after shock onset was associated with more shock–free days when compared to “Delayed” IMV in those intubated within 0–48 hours of shock onset (Beta coefficient 0.65 days, 95% CI 0.14-1.16 days). Conclusions: Timing of IMV initiation for patients in shock has potentially important implications for patient outcomes and merits further study.
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Affiliation(s)
- Neha N. Goel
- Division of Pulmonary, Critical Care, & Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai
| | - Jen–Ting Chen
- Division of Critical Care Medicine, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Russel Roberts
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA
| | - Jonathan Sevransky
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Emory University Hospital, Atlanta, GA
| | - Michelle N. Gong
- Division of Critical Care Medicine, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Kusum S. Mathews
- Division of Pulmonary, Critical Care, & Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai
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15
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Timing to Intubation COVID-19 Patients: Can We Put It Off until Tomorrow? Healthcare (Basel) 2022; 10:healthcare10020206. [PMID: 35206821 PMCID: PMC8871804 DOI: 10.3390/healthcare10020206] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 01/02/2022] [Accepted: 01/05/2022] [Indexed: 02/04/2023] Open
Abstract
Background: The decision to intubate COVID-19 patients receiving non-invasive respiratory support is challenging, requiring a fine balance between early intubation and risks of invasive mechanical ventilation versus the adverse effects of delaying intubation. This present study analyzes the association between intubation day and mortality in COVID-19 patients. Methods: We performed a unicentric retrospective cohort study considering all COVID-19 patients consecutively admitted between March 2020 and August 2020 requiring invasive mechanical ventilation. The primary outcome was all-cause mortality within 28 days after intubation, and a Cox model was used to evaluate the effect of time from onset of symptoms to intubation in mortality. Results: A total of 592 (20%) patients of 3020 admitted with COVID-19 were intubated during study period, and 310 patients who were intubated deceased 28 days after intubation. Each additional day between the onset of symptoms and intubation was significantly associated with higher in-hospital death (adjusted hazard ratio, 1.018; 95% CI, 1.005–1.03). Conclusion: Among patients infected with SARS-CoV-2 who were intubated and mechanically ventilated, delaying intubation in the course of symptoms may be associated with higher mortality. Trial registration: The study protocol was approved by the local Ethics Committee (opinion number 3.990.817; CAAE: 30417520.0.0000.0068).
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16
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Bauer PR. Intubation to Nowhere in COVID-19: Can Noninvasive Ventilation Help? Mayo Clin Proc 2022; 97:4-6. [PMID: 34996564 PMCID: PMC8585607 DOI: 10.1016/j.mayocp.2021.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 11/03/2021] [Indexed: 01/03/2023]
Affiliation(s)
- Philippe R Bauer
- Division of Pulmonary and Critical Care, Mayo Clinic, Rochester, MN.
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17
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Yang T, Shen Y, Park JG, Schulte PJ, Hanson AC, Herasevich V, Dong Y, Bauer PR. Outcome after intubation for septic shock with respiratory distress and hemodynamic compromise: an observational study. BMC Anesthesiol 2021; 21:253. [PMID: 34696738 PMCID: PMC8543776 DOI: 10.1186/s12871-021-01471-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 10/07/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Acute respiratory failure in septic patients contributes to higher in-hospital mortality. Intubation may improve outcome but there are no specific criteria for intubation. Intubation of septic patients with respiratory distress and hemodynamic compromise may result in clinical deterioration and precipitate cardiovascular failure. The decision to intubate is complex and multifactorial. The purpose of this study was to evaluate the impact of intubation in patients with respiratory distress and predominant hemodynamic instability within 24 h after ICU admission for septic shock. METHODS We conducted a retrospective analysis of a prospective registry of adult patients with septic shock admitted to the medical ICU at Mayo Clinic, between April 30, 2014 and December 31, 2017. Septic shock was defined by persistent lactate > 4 mmol/L, mean arterial pressure < 65 mmHg, or vasopressor use after 30 mL/kg fluid boluses and suspected or confirmed infection. Patients who remained hospitalized in the ICU at 24 h were separated into intubated while in the ICU and non-intubated groups. The primary outcome was hospital mortality. The first analysis used linear regression models and the second analysis used time-dependent propensity score matching to match intubated to non-intubated patients. RESULTS Overall, 358 (33%) ICU patients were eventually intubated after their ICU admission and 738 (67%) were not. Intubated patients were younger, transferred more often from an outside facility, more critically ill, had more lung infection, and achieved blood pressure goals more often, but lactate normalization within 6 h occurred less often. Among those who remained hospitalized in the ICU 24 h after sepsis diagnosis, the crude in-hospital mortality was higher in intubated than non-intubated patients, 89 (26%) vs. 82 (12%), p < 0.001, as was the ICU mortality and ICU and hospital length of stay. After adjustment, intubation showed no effect on hospital mortality but resulted in fewer hospital-free days through day 28. One-to-one propensity resulted in similar conclusion. CONCLUSIONS Intubation within 24 h of sepsis was not associated with hospital mortality but resulted in fewer 28-day hospital-free days. Although intubation remains a high-risk procedure, we did not identify an increased risk in mortality among septic shock patients with predominant hemodynamic compromise.
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Affiliation(s)
- Ting Yang
- Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
- Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, 55905, USA
| | - Yongchun Shen
- Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
- Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, 55905, USA
| | - John G Park
- Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, 55905, USA
| | - Phillip J Schulte
- Health Science Research - Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, 55905, USA
| | - Andrew C Hanson
- Health Science Research - Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, 55905, USA
| | | | - Yue Dong
- Critical Care Medicine, Mayo Clinic, Rochester, MN, 55905, USA
| | - Philippe R Bauer
- Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, 55905, USA.
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18
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Darreau C, Martino F, Saint-Martin M, Jacquier S, Hamel JF, Nay MA, Terzi N, Ledoux G, Roche-Campo F, Camous L, Pene F, Balzer T, Bagate F, Lorber J, Bouju P, Marois C, Robert R, Gaudry S, Commereuc M, Debarre M, Chudeau N, Labroca P, Merouani K, Egreteau PY, Peigne V, Bornstain C, Lebas E, Benezit F, Vally S, Lasocki S, Robert A, Delbove A, Lerolle N. Use, timing and factors associated with tracheal intubation in septic shock: a prospective multicentric observational study. Ann Intensive Care 2020; 10:62. [PMID: 32449053 PMCID: PMC7245631 DOI: 10.1186/s13613-020-00668-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 04/22/2020] [Indexed: 01/20/2023] Open
Abstract
Background No recommendation exists about the timing and setting for tracheal intubation and mechanical ventilation in septic shock. Patients and methods This prospective multicenter observational study was conducted in 30 ICUs in France and Spain. All consecutive patients presenting with septic shock were eligible. The use of tracheal intubation was described across the participating ICUs. A multivariate analysis was performed to identify parameters associated with early intubation (before H8 following vasopressor onset). Results Eight hundred and fifty-nine patients were enrolled. Two hundred and nine patients were intubated early (24%, range 4.5–47%), across the 18 centers with at least 20 patients included. The cumulative intubation rate during the ICU stay was 324/859 (38%, range 14–65%). In the multivariate analysis, seven parameters were significantly associated with early intubation and ranked as follows by decreasing weight: Glasgow score, center effect, use of accessory respiratory muscles, lactate level, vasopressor dose, pH and inability to clear tracheal secretions. Global R-square of the model was only 60% indicating that 40% of the variability of the intubation process was related to other parameters than those entered in this analysis. Conclusion Neurological, respiratory and hemodynamic parameters only partially explained the use of tracheal intubation in septic shock patients. Center effect was important. Finally, a vast part of the variability of intubation remained unexplained by patient characteristics. Trial registration Clinical trials NCT02780466, registered on May 23, 2016. https://clinicaltrials.gov/ct2/show/NCT02780466?term=intubatic&draw=2&rank=1.
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Affiliation(s)
- C Darreau
- Medical and Surgical Intensive Care Unit, Le Mans Hospital, Le Mans, France
| | - F Martino
- Medical and Surgical Intensive Care Unit, Guadeloupe University Hospital, Les Abymes, Guadeloupe, France
| | - M Saint-Martin
- Medical and Surgical Intensive Care Unit, Le Mans Hospital, Le Mans, France
| | - S Jacquier
- Medical Intensive Care Unit, Tours University Hospital, Tours, France
| | - J F Hamel
- Methodology and Statistics Department, Angers University Hospital, Angers, France
| | - M A Nay
- Medical Intensive Care Unit, Orleans Regional Hospital, Orléans, France
| | - N Terzi
- Medical Intensive Care Unit, Grenoble University Hospital, La Tronche, France
| | - G Ledoux
- Medical and Surgical Intensive Care Unit, Lille University Hospital, Lille, France
| | - F Roche-Campo
- Intensive Care Unit, Hospital Verge de la Cinta, Tortosa, Spain
| | - L Camous
- Medical Intensive Care Unit, Bicêtre Hospital, AP-HP, Paris, France
| | - F Pene
- Medical Intensive Care Unit, Cochin Hospital, AP-HP, Paris, France
| | - T Balzer
- Medical Intensive Care Unit, Brest University Hospital, Brest, France
| | - F Bagate
- Medical Intensive Care Unit, Henri Mondor Hospital, AP-HP, Paris, France
| | - J Lorber
- Medical and Surgical Intensive Care Unit, La-Roche-sur-Yon Hospital, La Roche-sur-Yon, France
| | - P Bouju
- Medical and Surgical Intensive Care Unit, Sud Bretagne Hospital, Lorient, France
| | - C Marois
- Medical Intensive Care Unit, Pitié-Salpétrière Hospital, AP-HP, Paris, France
| | - R Robert
- Medical Intensive Care Unit, Poitiers University Hospital, Poitiers, France
| | - S Gaudry
- Medical Intensive Care Unit, Louis Mourier Hospital, AP-HP, Colombes, France
| | - M Commereuc
- Medical Intensive Care Unit, Georges Pompidou European Hospital, AP-HP, Paris, France
| | - M Debarre
- Medical and Surgical Intensive Care Unit, Saint Brieuc Hospital, Saint Brieuc, France
| | - N Chudeau
- Medical and Surgical Intensive Care Unit, Le Mans Hospital, Le Mans, France
| | - P Labroca
- Medical Intensive Care Unit, Nancy University Central Hospital, Nancy, France
| | - K Merouani
- Medical and Surgical Intensive Care Unit, Alençon Hospital, Alençon, France
| | - P Y Egreteau
- Medical and Surgical Intensive Care Unit, Morlaix Hospital, Morlaix, France
| | - V Peigne
- Medical and Surgical Intensive Care Unit, Métropole Savoie Hospital, Chambéry, France
| | - C Bornstain
- Medical Intensive Care Unit, Le Raincy-Montfermeil Hospital, Montfermeil, France
| | - E Lebas
- Medical and Surgical Intensive Care Unit, Bretagne Atlantique Hospital, Vannes, France
| | - F Benezit
- Medical and Surgical Intensive Care Unit, Rennes University Hospital, Rennes, France
| | - S Vally
- Medical and Surgical Intensive Care Unit, Martinique University Hospital, Fort-de-France, Martinique, France
| | - S Lasocki
- Surgical Intensive Care Unit, Angers University Hospital, Angers, France
| | - A Robert
- Medical Intensive Care Unit, Nice University Hospital, Nice, France
| | - A Delbove
- Medical Intensive Care Unit, Nantes University Hospital, Nantes, France
| | - N Lerolle
- Medical Intensive Care Unit, Angers University Hospital, Angers, France.
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19
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Goel NN, Owyang C, Ranginwala S, Loo GT, Richardson LD, Mathews KS. Noninvasive Ventilation for Critically Ill Subjects With Acute Respiratory Failure in the Emergency Department. Respir Care 2020; 65:82-90. [PMID: 31575708 PMCID: PMC7119184 DOI: 10.4187/respcare.07111] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND We aimed to investigate the association between noninvasive ventilation (NIV) initiated in the emergency department and patient outcomes for those requiring invasive mechanical ventilation so that we could understand the effect of extended NIV use (ie, > 4 h) prior to invasive mechanical ventilation on patient outcomes. METHODS We conducted a retrospective single-center cohort study at an academic tertiary care hospital center. All emergency department patients with acute respiratory failure requiring invasive mechanical ventilation and admission to the ICU within 48 h of initial presentation over a 24-month period were included. RESULTS Subject characteristics, ventilator parameters, and clinical course were captured via electronic query, respiratory billing data, and standardized chart abstraction. A total of 431 subjects with acute respiratory failure requiring invasive mechanical ventilation within 48 h of arrival were identified, of whom 115 (26.7%) were exposed to NIV prior to invasive mechanical ventilation, with a median duration of 4 h (interquartile range 1.9-9.3). Based on a multivariable model controlling for covariates, any NIV exposure prior to invasive mechanical ventilation was not associated with an increased odds of persistent organ dysfunction or death. However, in the subset of subjects exposed to NIV, extended NIV use (ie, > 4 h) prior to invasive mechanical ventilation was associated with increased odds of persistent organ dysfunction or death (odds ratio 4.11, 95% CI 1.51-11.19). Extended NIV use was also associated with increased odds of in-hospital mortality (odds ratio 4.02, 95% CI 1.51-10.74). CONCLUSIONS Although any exposure to NIV prior to invasive mechanical ventilation did not appear to affect morbidity and mortality, extended NIV use prior to invasive mechanical ventilation was associated with worse patient outcomes, suggesting a need for additional study to better understand the ramifications of duration of NIV use prior to failure on outcomes. Given this early timeframe for intervention, future studies should be collaborations between the emergency department and ICU.
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Affiliation(s)
- Neha N Goel
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Clark Owyang
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Shamsuddoha Ranginwala
- Department of Respiratory Therapy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - George T Loo
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Lynne D Richardson
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Kusum S Mathews
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
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20
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Bauer PR, Chevret S, Azoulay E. Acute hypoxaemic respiratory failure in immunocompromised patients: abandon bronchoscopy or make it better? Eur Respir J 2019; 54:54/6/1902177. [PMID: 31831677 DOI: 10.1183/13993003.02177-2019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 11/10/2019] [Indexed: 11/05/2022]
Affiliation(s)
- Philippe R Bauer
- Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Elie Azoulay
- Intensive Care Unit, CHU Saint Louis, Paris, France
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21
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Dumas G, Demoule A, Mokart D, Lemiale V, Nseir S, Argaud L, Pène F, Kontar L, Bruneel F, Klouche K, Barbier F, Reignier J, Stoclin A, Louis G, Constantin JM, Wallet F, Kouatchet A, Peigne V, Perez P, Girault C, Jaber S, Cohen Y, Nyunga M, Terzi N, Bouadma L, Lebert C, Lautrette A, Bigé N, Raphalen JH, Papazian L, Benoit D, Darmon M, Chevret S, Azoulay E. Center effect in intubation risk in critically ill immunocompromised patients with acute hypoxemic respiratory failure. Crit Care 2019; 23:306. [PMID: 31492179 PMCID: PMC6731598 DOI: 10.1186/s13054-019-2590-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 08/29/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Acute respiratory failure is the leading reason for intensive care unit (ICU) admission in immunocompromised patients, and the need for invasive mechanical ventilation has become a major clinical endpoint in randomized controlled trials (RCTs). However, data are lacking on whether intubation is an objective criteria that is used unbiasedly across centers. This study explores how this outcome varies across ICUs. METHODS Hierarchical models and permutation procedures for testing multiple random effects were applied on both data from an observational cohort (the TRIAL-OH study: 703 patients, 17 ICUs) and a randomized controlled trial (the HIGH trial: 776 patients, 31 ICUs) to characterize ICU variation in intubation risk across centers. RESULTS The crude intubation rate varied across ICUs from 29 to 80% in the observational cohort and from 0 to 86% in the RCT. This center effect on the mean ICU intubation rate was statistically significant, even after adjustment on individual patient characteristics (observational cohort: p value = 0.013, median OR 1.48 [1.30-1.72]; RCT: p value 0.004, median OR 1.51 [1.36-1.68]). Two ICU-level characteristics were associated with intubation risk (the annual rate of intubation procedure per center and the time from respiratory symptoms to ICU admission) and could partly explain this center effect. In the RCT that controlled for the use of high-flow oxygen therapy, we did not find significant variation in the effect of oxygenation strategy on intubation risk across centers, despite a significant variation in the need for invasive mechanical ventilation. CONCLUSION Intubation rates varied considerably among ICUs, even after adjustment on individual characteristics.
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Affiliation(s)
- Guillaume Dumas
- Medical Intensive Care Unit, Saint-Louis Teaching Hospital, APHP, Paris, France
- ECSTRA team, Biostatistics and Clinical Epidemiology, UMR 1153 (Center of Epidemiology and Biostatistic Sorbonne Paris Cité, CRESS), INSERM, Paris Diderot University, Paris, France
| | - Alexandre Demoule
- Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie, Médecine Intensive et Réanimation (Département R3S), AP-HP, INSERM, UMRS1158 neurophysiologie respiratoire expérimentale et clinique, Sorbonne Université, Paris, France
| | | | - Virginie Lemiale
- Medical Intensive Care Unit, Saint-Louis Teaching Hospital, APHP, Paris, France
| | - Saad Nseir
- Critical Care Center, CHU de Lille, Lille, France
| | - Laurent Argaud
- Medical Intensive Care Unit, Edouard Herriot Teaching Hospital, Lyon, France
| | - Frédéric Pène
- Medical Intensive Care Unit, Cochin Teaching Hospital, Paris, France
| | - Loay Kontar
- Critical Care Center, Centre Hospitalier Universitaire-Amiens, Amiens, France
| | - Fabrice Bruneel
- Intensive Care Unit, Hôpital Andre Mignot-Le Chesnay, Paris, France
| | - Kada Klouche
- Intensive Care Unit, Lapeyronie University Hospital, Montpellier, France
| | - François Barbier
- Medical Intensive Care Unit, La Source Hospital-CHR Orleans, Orléans, France
| | - Jean Reignier
- Réanimation Médicale, Centre Hospitalier Universitaire-Nantes, Nantes, France
| | | | | | - Jean-Michel Constantin
- Department of Anesthesiology and Critical Care, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Paris, France
| | - Florent Wallet
- Medical Intensive Care Unit, Hôpital Lyon-Sud, Lyon, France
| | - Achille Kouatchet
- Medical Intensive Care Unit, Angers Teaching hospital, Angers, France
| | - Vincent Peigne
- Intensive Care Unit, Centre Hospitalier Métropole-Savoie, Chambery, France
| | - Pierre Perez
- Medical Intensive Care Unit, Brabois University Hospital, Nancy, France
| | | | - Samir Jaber
- Critical Care Center, CHRU Montpellier-Saint-Eloi, Montpellier, France
| | - Yves Cohen
- Intensive Care Unit, Hôpital d'Avicenne, APHP, Bobigny, France
| | - Martine Nyunga
- Medical Intensive Care Unit, Victor Provo Hospital, Roubaix, France
| | - Nicolas Terzi
- Medical Intensive Care Unit, CHU de Grenoble Alpes, Grenoble, France
| | - Lila Bouadma
- Medical Intensive Care Unit, CHU Bichat, Paris, France
| | - Christine Lebert
- Intensive Care Unit, Centre Hospitalier Départemental Les Oudairies, La Roche-Sur-Yon, France
| | - Alexandre Lautrette
- Medical Intensive Care Unit, Gabriel-Montpied University Hospital, Clermont-Ferrand, France
| | - Naike Bigé
- Medical Intensive Care Unit, Hôpital Saint-Antoine, Paris, France
| | | | | | | | - Michael Darmon
- Medical Intensive Care Unit, Saint-Louis Teaching Hospital, APHP, Paris, France
- ECSTRA team, Biostatistics and Clinical Epidemiology, UMR 1153 (Center of Epidemiology and Biostatistic Sorbonne Paris Cité, CRESS), INSERM, Paris Diderot University, Paris, France
| | - Sylvie Chevret
- ECSTRA team, Biostatistics and Clinical Epidemiology, UMR 1153 (Center of Epidemiology and Biostatistic Sorbonne Paris Cité, CRESS), INSERM, Paris Diderot University, Paris, France
| | - Elie Azoulay
- Medical Intensive Care Unit, Saint-Louis Teaching Hospital, APHP, Paris, France.
- ECSTRA team, Biostatistics and Clinical Epidemiology, UMR 1153 (Center of Epidemiology and Biostatistic Sorbonne Paris Cité, CRESS), INSERM, Paris Diderot University, Paris, France.
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