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

Critical Care

卷:27

Research

Robert D. Stevens¹  Raphaël Cinotti²  Karim Asehoune²  Monisha Sharma³  Shaurya Taran⁴  Paolo Pelosi⁵  Chiara Robba⁶  James A. Town⁷  Sarah Wahlster⁸ 

[1] Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA;

[2] Department of Anesthesiology and Critical Care, CHU Nantes, Nantes Université, Nantes, France;

[3] Department of Global Health, University of Washington, Seattle, USA;

[4] Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA;Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada;

[5] Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy;Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy;

[6] Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy;Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy;San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, 10 Largo Rosanna Benzi, 16100, Genoa, Italy;

[7] Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, USA;

[8] Neurocritical Care, Department of Neurology, Harborview Medical Center, University of Washington, Box 359702, 325 9th Avenue, 98104-2499, Seattle, WA, USA;Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, USA;Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, USA;

关键词: Acute brain injury;    Mechanical power;    Acute respiratory distress syndrome;    Mechanical ventilation;    Traumatic brain injury;    Subarachnoid hemorrhage;    Acute ischemic stroke;    Intracranial hemorrhage;   

DOI  :  10.1186/s13054-023-04410-z

 received in 2023-02-08, accepted in 2023-03-20,  发布年份 2023

来源: Springer

【 摘 要 】

BackgroundThere 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.MethodsIn this preplanned, secondary analysis of a prospective, multi-center, observational cohort study (ENIO, NCT03400904), we included adult patients with ABI (Glasgow Coma Scale ≤ 12 before intubation) who required mechanical ventilation (MV) ≥ 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).ResultsWe 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).ConclusionsExposure 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.

【 授权许可】

CC BY   
© The Author(s) 2023

【 图 表 】

Fig. 2

Scheme 1.