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Purpose The aim of this study was to determine whether selective decontamination of the digestive tract (SDD) reduces in-hospital mortality in mechanically ventilated critically ill adults admitted to the intensive care unit (ICU) with acute brain injuries or conditions. Methods We carried out a post hoc analysis from a crossover, cluster randomized clinical trial. ICUs were randomly assigned to adopt or not to adopt a SDD strategy for two alternating 12-month periods, separated by a 3-month inter-period gap. Patients in the SDD group (n = 2791; 968 admitted to the ICU with an acute brain injury) received a 6-hourly application of an oral paste and administration of a gastric suspension containing colistin, tobramycin, and nystatin for the duration of mechanical ventilation, plus a 4-day course of an intravenous antibiotic with a suitable antimicrobial spectrum. Patients in the control group (n = 3191; 1093 admitted to the ICU with an acute brain injury) received standard care. The primary outcome was in-hospital mortality within 90 days. There were four secondary clinical outcomes: death in ICU, ventilator-, ICU- and hospital-free days to day 90. Results Of 2061 patients with acute brain injuries (mean age, 55.8 years; 36.4% women), all completed the trial. In patients with acute brain injuries, there were 313/968 (32.3%) and 415/1093 (38%) in-hospital deaths in the SDD and standard care groups (unadjusted odds ratio [OR], 0.76, 95% confidence interval [CI] 0.63-0.92; p = 0.004). The use of SDD was associated with statistically significant improvements in the four clinical secondary outcomes compared to standard care. There was no significant heterogeneity of treatment effect between patients with and without acute brain injuries (interaction p = 0.22). Conclusions In this post hoc analysis of a randomized clinical trial in critically ill patients with acute brain injuries receiving mechanical ventilation, the use of SDD significantly reduced in-hospital mortality in patients compared to standard care without SDD. These findings require confirmation., Author(s): Paul J. Young [sup.1] [sup.2], Anthony Devaux [sup.3] [sup.4], Qiang Li [sup.3] [sup.4], Laurent Billot [sup.3] [sup.4], Joshua S. Davis [sup.5] [sup.6] [sup.7], Anthony Delaney [sup.3] [sup.8], Simon R. [...]

Purpose The prevalence of burnout in intensive care unit (ICU) professionals is difficult to establish due to the variety of survey instruments used, the heterogeneity of the targeted population, the design of the studies, and the differences among countries regarding ICU organization. Methods We performed a systematic review and meta-analysis examining the prevalence of high-level burnout in physicians and nurses working in adult ICUs, including only studies that use the Maslach Burnout Inventory (MBI) as a tool to evaluate burnout and involving at least 3 different ICUs. Results Twenty-five studies with a combined population of 20,723 healthcare workers from adult ICUs satisfied the inclusion criteria. Combining 18 studies including 8187 ICU physicians, 3660 of them reported a high level of burnout (prevalence 0.41, range 0.15-0.71, 95% CI [0.33; 0.5], I.sup.2 97.6%, 95% CI [96.9%; 98.1%]). The heterogeneity can be at least in part explained by the definition of burnout used and the response rate as confirmed by the multivariable metaregression done. In contrast, there was no significant difference regarding other factors such as the study period (before or during the coronavirus disease 2019 (COVID-19) pandemic), the income of the countries, or the Healthcare Access and Quality (HAQ) index. Combining 20 studies including 12,536 ICU nurses, 6232 of nurses were reporting burnout (prevalence 0.44, range 0.14-0.74, [95% CI 0.34; 0.55], I.sup.2 98.6% 95% CI [98.4%; 98.9%]). The prevalence of high-level burnout in ICU nurses for studies performed during the COVID-19 pandemic was higher than that reported for studies performed before the COVID-19 pandemic (0.61 [95% CI, 0.46; 0.75] and 0.37 [95% CI, 0.26; 0.49] respectively, p = 0.003). As for physicians, the heterogeneity is at least in part explained by the definition used for burnout using the MBI but not by the number of participants. When compared, the prevalence of high-level burnout was not different between ICU physicians and ICU nurses. However, the proportion of ICU nurses with a high level of emotional exhaustion was higher than for ICU physicians (0.42 [95% CI, 0.37; 0.48] and 0.28 [0.2; 0.39], respectively, p = 0.022). Conclusion According to this meta-analysis, the prevalence of high-level burnout is higher than 40% in all ICU professionals. However, there is a great heterogeneity in the results. To evaluate and to compare preventive and therapeutic strategies, there is the need to use a consensual definition of burnout when using the MBI instrument., Author(s): Laurent Papazian [sup.1] [sup.2] [sup.3], Sami Hraiech [sup.2] [sup.4], Anderson Loundou [sup.5], Margaret S. Herridge [sup.6], Laurent Boyer [sup.5] Author Affiliations: (1) Centre Hospitalier de Bastia, , 20600, Bastia, [...]

Purpose Whether undocumented migrants admitted to intensive care units (ICUs) have specific features is unknown. We aimed to determine the features and outcomes of undocumented migrants admitted to French ICUs. Methods We retrospectively included all undocumented adult migrants admitted in 2011-2018 and compared them to the general ICU population. We also compared these two groups matched on age, sex, severity, comorbidities, reason for ICU admission and public/private hospital. Results We identified 14,554 ICU stays, with an increase from 2 to 4â° of all ICU admissions over time. Shock (16.7%), post-operative care (13.8%), and trauma (10.5%) were the main reasons for ICU admission. Compared to general ICU patients, migrants were younger and had greater disease severity. After adjustment on age and sex, the following were more common in migrants: shock (OR 1.2 [1.14-1.25]; P < 0.0001), infections (1.48 [1.38-1.54]; P < 0.001), acute respiratory failure (1.09 [1.03-1.15]; P = 0.006), acute kidney injury (1.12 [1.05-1.19]; P < 0.001), obstetric events (1.53 [1.66-1.81]; P < 0.0001), and neurological deficits (1.19 [1.12-1.27]; P < 0.0001). In the matched study, migrants more often required vasopressors, mechanical ventilation, and renal replacement therapy; had longer ICU stays (median 4 [2-8] vs. 4 [2-7] days; P < 0.0001) and hospital stays (10 [5-20] vs. 8 [4-15]; P < 0.0001) and had higher hospital costs (14.2 ± 23.6 vs. 13.4 ± 11.5 K[euro]; P < 0.0001). Hospital mortality was similar (6.7% vs. 6.6%; P = 0.69). Conclusion Admissions of undocumented migrants to French ICUs doubled from 2011 to 2018. The patients were younger and, although sicker, achieved similar outcomes to those in general ICU patients., Author(s): Sami Hraiech [sup.1] [sup.2] [sup.3], Vanessa Pauly [sup.2] [sup.3], Véronica Orleans [sup.2] [sup.3], Pascal Auquier [sup.2] [sup.3], Laurent Boyer [sup.2] [sup.3], Laurent Papazian [sup.1] [sup.2] [sup.3], Elie Azoulay [sup.4] [...]

Treatment of respiratory failure has improved dramatically since the polio epidemic in the 1950s with the use of invasive techniques for respiratory support: mechanical ventilation and extracorporeal respiratory support. However, respiratory support is only a supportive therapy, designed to 'buy time' while the disease causing respiratory failure abates. It ensures viable gas exchange and prevents cardiorespiratory collapse in the context of excessive loads. Because the use of invasive modalities of respiratory support is also associated with substantial harm, it remains the responsibility of the clinician to minimize such hazards. Direct iatrogenic consequences of mechanical ventilation include the risk to the lung (ventilator-induced lung injury) and the diaphragm (ventilator-induced diaphragm dysfunction and other forms of myotrauma). Adverse consequences on hemodynamics can also be significant. Indirect consequences (e.g., immobilization, sleep disruption) can have devastating long-term effects. Increasing awareness and understanding of these mechanisms of injury has led to a change in the philosophy of care with a shift from aiming to normalize gases toward minimizing harm. Lung (and more recently also diaphragm) protective ventilation strategies include the use of extracorporeal respiratory support when the risk of ventilation becomes excessive. This review provides an overview of the historical background of respiratory support, pathophysiology of respiratory failure and rationale for respiratory support, iatrogenic consequences from mechanical ventilation, specifics of the implementation of mechanical ventilation, and role of extracorporeal respiratory support. It highlights the need for appropriate monitoring to estimate risks and to individualize ventilation and sedation to provide safe respiratory support to each patient., Author(s): Irene Telias [sup.1] [sup.2] [sup.3], Laurent J. Brochard [sup.1] [sup.2], Simone Gattarello [sup.4], Hannah Wunsch [sup.5] [sup.6] [sup.7], Detajin Junhasavasdikul [sup.8], Karen J. Bosma [sup.9], Luigi Camporota [sup.10], Daniel [...]

Author(s): Nuttapol Rittayamai [sup.1], Domenico L. Grieco [sup.2] [sup.3], Laurent Brochard [sup.4] [sup.5] Author Affiliations: (1) grid.10223.32, 0000 0004 1937 0490, Division of Respiratory Diseases and Tuberculosis, Department of Medicine, [...]

In patients with the acute respiratory distress syndrome (ARDS), lung imaging is a fundamental tool in the study of the morphological and mechanistic features of the lungs. Chest computed tomography studies led to major advances in the understanding of ARDS physiology. They allowed the in vivo study of the syndrome's lung features in relation with its impact on respiratory physiology and physiology, but also explored the lungs' response to mechanical ventilation, be it alveolar recruitment or ventilator-induced lung injuries. Coupled with positron emission tomography, morphological findings were put in relation with ventilation, perfusion or acute lung inflammation. Lung imaging has always been central in the care of patients with ARDS, with modern point-of-care tools such as electrical impedance tomography or lung ultrasounds guiding clinical reasoning beyond macro-respiratory mechanics. Finally, artificial intelligence and machine learning now assist imaging post-processing software, which allows real-time analysis of quantitative parameters that describe the syndrome's complexity. This narrative review aims to draw a didactic and comprehensive picture of how modern imaging techniques improved our understanding of the syndrome, and have the potential to help the clinician guide ventilatory treatment and refine patient prognostication., Author(s): Laurent Bitker [sup.1] [sup.2] [sup.3], Daniel Talmor [sup.4] [sup.5], Jean-Christophe Richard [sup.1] [sup.2] [sup.3] Author Affiliations: (1) grid.413306.3, 0000 0004 4685 6736, Service de Médecine Intensive - Réanimation, Hôpital [...]

Author(s): Laurent Papazian [sup.1] [sup.2] [sup.3] , Laveena Munshi [sup.4] , Claude Guérin [sup.5] [sup.6] [sup.7] Author Affiliations: (1) Centre Hospitalier de Bastia, Service de Réanimation, , 604 Chemin de [...]

Purpose: We aim to evaluate the association between central venous catheter (CVC) insertion site and microbiological CVC complications in a nationwide cohort. Methods: This study was conducted using the healthcare-associated infection surveillance cohort "REA-REZO" involving 193 intensive care units (ICUs). All CVC inserted and removed during the same ICU stay between January 1st 2018 and December 31st 2022 were eligible but only those whose tips were sent for microbiological analysis were included. Primary objective was to describe CVC insertion sites and subsequent catheter-related bloodstream infection (CRBSI). Results: Out of 126,997 CVCs, 71,314 were not sent for tip culture, and only 55,663 CVCs were included, (30,548 in internal jugular [IJ], 14,423 in femoral and 10,692 in subclavian [SC] sites). The incidence of CRBSI was 0.7 [0.6–0.8] in the IJ site, 0.7 [0.6–0.9] in the femoral site, and 0.6 [0.4–0.7] CRBSI per 1000 CVC days in the SC site (p = 0.248). The multivariable Poisson regression model showed no differences of CRBSI incidence rates between the three insertion sites. Microorganisms observed in CRBSI were coagulase-negative Staphylococci (27.9%), Enterobacterales (27.5%), non-fermenting Gram-negative Bacilli (10.4%), Candida sp. (16.9%), and Staphylococcus aureus (16.9%). Conclusion: Low CRBSI incidence rates were reported. CRBSI incidences rates were similar in the three insertion sites. Uncertainty remains due to potential selection bias since many CVCs had to be excluded. [ABSTRACT FROM AUTHOR]

Author(s): Roberta Teixeira Tallarico [sup.1], Benjamin Deniau [sup.2] [sup.3] [sup.4], Nicholas Fong [sup.1] [sup.5], Jade Ghosn [sup.6] [sup.7], Matthieu Legrand [sup.1] [sup.4], Laurent Abel Amal Abrous, Claire Andrejak, François Angoulvant, [...]

Purpose We compared a restrictive fluid management strategy to usual care among critically ill patients with acute kidney injury (AKI) who had received initial fluid resuscitation. Methods This multicenter feasibility trial randomized 100 AKI patients 1:1 in seven ICUs in Europe and Australia. Restrictive fluid management included targeting negative or neutral daily fluid balance by minimizing fluid input and/or enhancing urine output with diuretics administered at the discretion of the clinician. Fluid boluses were administered as clinically indicated. The primary endpoint was cumulative fluid balance 72 h from randomization. Results Mean (SD) cumulative fluid balance at 72 h from randomization was - 1080 mL (2003 mL) in the restrictive fluid management arm and 61 mL (3131 mL) in the usual care arm, mean difference (95% CI) - 1148 mL (- 2200 to - 96) mL, P = 0.033. Median [IQR] duration of AKI was 2 [1-3] and 3 [2-7] days, respectively (median difference - 1.0 [- 3.0 to 0.0], P = 0.071). Altogether, 6 out of 46 (13%) patients in the restrictive fluid management arm and 15 out of 50 (30%) in the usual care arm received renal replacement therapy (RR 0.42; 95% CI 0.16-0.91), P = 0.043. Cumulative fluid balance at 24 h and 7 days was lower in the restrictive fluid management arm. The dose of diuretics was not different between the groups. Adverse events occurred more frequently in the usual care arm. Conclusions In critically ill patients with AKI, a restrictive fluid management regimen resulted in lower cumulative fluid balance and less adverse events compared to usual care. Larger trials of this intervention are justified., Author(s): Suvi T. Vaara [sup.1] [sup.2] [sup.3], Marlies Ostermann [sup.4], Laurent Bitker [sup.2] [sup.5], Antoine Schneider [sup.6], Elettra Poli [sup.6], Eric Hoste [sup.7], Jan Fierens [sup.7], Michael Joannidis [sup.8], Alexander [...]

Acute respiratory distress syndrome (ARDS) is defined by the association of bilateral infiltrates and hypoxaemia following an initial insult. Although a new definition has been recently proposed (Berlin definition), there are various forms of ARDS with potential differences regarding their management (ventilator settings, prone positioning use, corticosteroids). ARDS can be caused by various aetiologies, and the adequate treatment of the responsible cause is crucial to improve the outcome. It is of paramount importance to characterize the mechanisms causing lung injury to optimize both the aetiological treatment and the symptomatic treatment. If there is no obvious cause of ARDS or if a direct lung injury is suspected, bronchoalveolar lavage (BAL) should be strongly considered to identify microorganisms responsible for pneumonia. Blood samples can also help to identify microorganisms and to evaluate biomarkers of infection. If there is no infectious cause of ARDS or no other apparent aetiology is found, second-line examinations should include markers of immunologic diseases. In selected cases, open lung biopsy remains useful to identify the cause of ARDS when all other examinations remain inconclusive. CT scan is fundamental when there is a suspicion of intra-abdominal sepsis and in some cases of pneumonia. Ultrasonography is important not only in evaluating biventricular function but also in identifying pleural effusions and pneumothorax. The definition of ARDS remains clinical and the main objective of the diagnostic workup should be to be focused on identification of its aetiology, especially a treatable infection.

Exacerbations are part of the natural history of chronic obstructive pulmonary disease and asthma. Severe exacerbations can cause acute respiratory failure, which may ultimately require mechanical ventilation. This review summarizes practical ventilator strategies for the management of patients with obstructive airway disease. Such strategies include non-invasive mechanical ventilation to prevent intubation, invasive mechanical ventilation, from the time of intubation to weaning, and strategies intended to prevent post-extubation acute respiratory failure. The role of tracheostomy, the long-term prognosis, and potential future adjunctive strategies are also discussed. Finally, the physiological background that underlies these strategies is detailed., Author(s): Alexandre Demoule [sup.1] [sup.2], Laurent Brochard [sup.3] [sup.4], Martin Dres [sup.1] [sup.2], Leo Heunks [sup.5], Amal Jubran [sup.6], Franco Laghi [sup.6], Armand Mekontso-Dessap [sup.7] [sup.8], Stefano Nava [sup.9], Lamia [...]

Purpose Recruitment of lung volume is often cited as the reason for using positive end-expiratory pressure (PEEP) in acute respiratory distress syndrome (ARDS) patients. We performed a systematic review on PEEP-induced recruited lung volume measured from inspiratory volume-pressure (VP) curves in ARDS patients to assess the prevalence of patients with PEEP-induced recruited lung volume and the mortality in recruiters and non-recruiters. Methods We conducted a systematic search of PubMed to identify studies including ARDS patients in which the intervention of an increase in PEEP was accompanied by measurement of the recruited volume (V.sub.rec increase versus no increase) using the VP curve in order to assess the relation between V.sub.rec and mortality at ICU discharge. We first analysed the pooled data from the papers identified and then analysed individual patient level data received from the authors via personal contact. The risk of bias of the included papers was assessed using the quality in prognosis studies tool and the certainty of the evidence regarding the relationship of mortality to V.sub.rec by the GRADE approach. Recruiters were defined as patients with a V.sub.rec > 150 ml. A random effects model was used for the pooled data. Multivariable logistic regression analysis was used for individual patient data. Results We identified 16 papers with a total of 308 patients for the pooled data meta-analysis and 14 papers with a total of 384 patients for the individual data analysis. The quality of the articles was moderate. In the pooled data, the prevalence of recruiters was 74% and the mortality was not significantly different between recruiters and non-recruiters (relative risk 1.20 [95% confidence intervals 0.88-1.63]). The certainty of the evidence regarding this association was very low and publication bias evident. In the individual data, the prevalence of recruiters was 70%. In the multivariable logistic regression, V.sub.rec was not associated with mortality but Simplified Acute Physiology Score II and driving pressure at PEEP of 5 cmH.sub.2O were. Conclusion After a PEEP increment, most patients are recruiters. V.sub.rec was not associated with ICU mortality. The presence of similar findings in the individual patient level analysis and the driving pressure at PEEP of 5 cmH.sub.2O was associated with mortality as previously reported validate our findings. Publication bias and the lack of prospective studies suggest more research is required., Author(s): Emanuele Turbil [sup.1], Nicolas Terzi [sup.2] [sup.3], Martin Cour [sup.4] [sup.5], Laurent Argaud [sup.4] [sup.5], Sharon Einav [sup.6], Claude Guérin [sup.4] [sup.5] [sup.7] Author Affiliations: (1) grid.11450.31, 0000 0001 [...]

Author(s): Göran Hedenstierna [sup.1], Lu Chen [sup.2] [sup.3], Laurent Brochard [sup.2] [sup.3] Author Affiliations: (1) grid.8993.b, 0000 0004 1936 9457, Hedenstierna Laboratory, Department of Medical Sciences, University Hospital, Uppsala University, [...]

Proportional modes of ventilation assist the patient by adapting to his/her effort, which contrasts with all other modes. The two proportional modes are referred to as neurally adjusted ventilatory assist (NAVA) and proportional assist ventilation with load-adjustable gain factors (PAV+): they deliver inspiratory assist in proportion to the patient's effort, and hence directly respond to changes in ventilatory needs. Due to their working principles, NAVA and PAV+ have the ability to provide self-adjusted lung and diaphragm-protective ventilation. As these proportional modes differ from 'classical' modes such as pressure support ventilation (PSV), setting the inspiratory assist level is often puzzling for clinicians at the bedside as it is not based on usual parameters such as tidal volumes and PaCO.sub.2 targets. This paper provides an in-depth overview of the working principles of NAVA and PAV+ and the physiological differences with PSV. Understanding these differences is fundamental for applying any assisted mode at the bedside. We review different methods for setting inspiratory assist during NAVA and PAV+, and (future) indices for monitoring of patient effort. Last, differences with automated modes are mentioned., Author(s): Annemijn H. Jonkman [sup.1] [sup.2] [sup.3] , Michela Rauseo [sup.1] [sup.2] , Guillaume Carteaux [sup.4] [sup.5] [sup.6] , Irene Telias [sup.1] [sup.2] , Michael C. Sklar [sup.1] [sup.2] , [...]

Purpose The relationship between lung ultrasound (LUS) and chest computed tomography (CT) scans in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia is not clearly defined. The primary objective of our study was to assess the performance of LUS in determining severity of SARS-CoV-2 pneumonia compared with chest CT scan. Secondary objectives were to test the association between LUS score and location of the patient, use of mechanical ventilation, and the pulse oximetry (SpO.sub.2)/fractional inspired oxygen (FiO.sub.2) ratio. Methods A multicentre observational study was performed between 15 March and 20 April 2020. Patients in the Emergency Department (ED) or Intensive Care Unit (ICU) with acute dyspnoea who were PCR positive for SARS-CoV-2, and who had LUS and chest CT performed within a 24-h period, were included. Results One hundred patients were included. LUS score was significantly associated with pneumonia severity assessed by chest CT and clinical features. The AUC of the ROC curve of the relationship of LUS versus chest CT for the assessment of severe SARS-CoV-2 pneumonia was 0.78 (CI 95% 0.68-0.87; p < 0.0001). A high LUS score was associated with the use of mechanical ventilation, and with a SpO.sub.2/FiO.sub.2 ratio below 357. Conclusion In known SARS-CoV-2 pneumonia patients, the LUS score was predictive of pneumonia severity as assessed by a chest CT scan and clinical features. Within the limitations inherent to our study design, LUS can be used to assess SARS-CoV-2 pneumonia severity., Author(s): Laurent Zieleskiewicz [sup.1] [sup.2], Thibaut Markarian [sup.3], Alexandre Lopez [sup.1], Chloé Taguet [sup.3], Neyla Mohammedi [sup.1], Mohamed Boucekine [sup.4], Karine Baumstarck [sup.4], Guillaume Besch [sup.5], Gautier Mathon [sup.6], Gary [...]

Ventilator-associated pneumonia (VAP) is one of the most frequent ICU-acquired infections. Reported incidences vary widely from 5 to 40% depending on the setting and diagnostic criteria. VAP is associated with prolonged duration of mechanical ventilation and ICU stay. The estimated attributable mortality of VAP is around 10%, with higher mortality rates in surgical ICU patients and in patients with mid-range severity scores at admission. Microbiological confirmation of infection is strongly encouraged. Which sampling method to use is still a matter of controversy. Emerging microbiological tools will likely modify our routine approach to diagnosing and treating VAP in the next future. Prevention of VAP is based on minimizing the exposure to mechanical ventilation and encouraging early liberation. Bundles that combine multiple prevention strategies may improve outcomes, but large randomized trials are needed to confirm this. Treatment should be limited to 7 days in the vast majority of the cases. Patients should be reassessed daily to confirm ongoing suspicion of disease, antibiotics should be narrowed as soon as antibiotic susceptibility results are available, and clinicians should consider stopping antibiotics if cultures are negative., Author(s): Laurent Papazian [sup.1] [sup.2], Michael Klompas [sup.3] [sup.4], Charles-Edouard Luyt [sup.5] [sup.6] Author Affiliations: (1) grid.414244.3, 0000 0004 1773 6284, Médecine Intensive Réanimation, Hôpital Nord, Hôpitaux de Marseille, , [...]