Search

Purpose Variations in clinical characteristics and management and in the mortality of mechanically ventilated patients have not been sufficiently evaluated. We hypothesized that mortality shows a variability associated with country after adjustment for clinical characteristics and management. Methods Analysis of four studies carried out at 6-year intervals over an 18-year period. The studies included 26,024 patients (5183 in 1998, 4968 in 2004, 8108 in 2010, and 7765 in 2016) admitted to 1253 units from 38 countries. The primary outcome was 28-day mortality. We performed analyses using multilevel logistic modeling with mixed-random effects, including country as a random variable. To evaluate the effect of management strategies on mortality, a mediation analysis was performed. Results Adjusted 28-day mortality decreased significantly over time (first study as reference): 2004: odds ratio 0.82 (95% confidence interval [CI] 0.72-0.93); 2010: 0.63 (95% CI 0.53-0.75); 2016: 0.49 (95% CI 0.39-0.61). A protective ventilatory strategy and the use of continuous sedation mediated a moderate fraction of the effect of time on mortality in patients with moderate hypoxemia and without hypoxemia, respectively. Logistic multilevel modeling showed a significant effect of country on mortality: median odds ratio (MOR) in 1998: 2.02 (95% CI 1.57-2.48); in 2004: 1.76 (95% CI 1.47-2.06); in 2010: 1.55 (95% CI 1.37-1.74), and in 2016: 1.39 (95% CI 1.25-1.54). Conclusions These findings suggest that country could contribute, independently of confounder variables, to outcome. The magnitude of the effect of country decreased over time. Clinical trials registered with http://www.clinicaltrials.gov (NCT02731898)., Author(s): Oscar Peñuelas [sup.1], Alfonso Muriel [sup.2], Victor Abraira [sup.2], Fernando Frutos-Vivar [sup.1], Jordi Mancebo [sup.3], Konstantinos Raymondos [sup.4], Bin Du [sup.5], Arnaud W. Thille [sup.6], Fernando Ríos [sup.7], Marco [...]

Purpose To analyze the relationship between hypercapnia developing within the first 48 h after the start of mechanical ventilation and outcome in patients with acute respiratory distress syndrome (ARDS). Patients and methods We performed a secondary analysis of three prospective non-interventional cohort studies focusing on ARDS patients from 927 intensive care units (ICUs) in 40 countries. These patients received mechanical ventilation for more than 12 h during 1-month periods in 1998, 2004, and 2010. We used multivariable logistic regression and a propensity score analysis to examine the association between hypercapnia and ICU mortality. Main outcomes We included 1899 patients with ARDS in this study. The relationship between maximum PaCO.sub.2 in the first 48 h and mortality suggests higher mortality at or above PaCO.sub.2 of [greater than or equal to]50 mmHg. Patients with severe hypercapnia (PaCO.sub.2 [greater than or equal to]50 mmHg) had higher complication rates, more organ failures, and worse outcomes. After adjusting for age, SAPS II score, respiratory rate, positive end-expiratory pressure, PaO.sub.2/FiO.sub.2 ratio, driving pressure, pressure/volume limitation strategy (PLS), corrected minute ventilation, and presence of acidosis, severe hypercapnia was associated with increased risk of ICU mortality [odds ratio (OR) 1.93, 95% confidence interval (CI) 1.32 to 2.81; p = 0.001]. In patients with severe hypercapnia matched for all other variables, ventilation with PLS was associated with higher ICU mortality (OR 1.58, CI 95% 1.04-2.41; p = 0.032). Conclusions Severe hypercapnia appears to be independently associated with higher ICU mortality in patients with ARDS. Trial registration Clinicaltrials.gov identifier, NCT01093482., Author(s): Nicolas Nin [sup.1] [sup.13], Alfonso Muriel [sup.2], Oscar Peñuelas [sup.3] [sup.33], Laurent Brochard [sup.4] [sup.5], José Angel Lorente [sup.3] [sup.33], Niall D. Ferguson [sup.6], Konstantinos Raymondos [sup.7], Fernando Ríos [...]

Purpose There are limited data available about the role of sedation and analgesia during noninvasive positive pressure ventilation (NPPV). The objective of study was to estimate the effect of analgesic or sedative drugs on the failure of NPPV. Methods We studied patients who received at least 2 h of NPPV as first-line therapy in a prospective observational study carried out in 322 intensive care units from 30 countries. A marginal structural model (MSM) was used to analyze the association between the use of analgesic or sedative drugs and NPPV failure (defined as need for invasive mechanical ventilation). Results 842 patients were included in the analysis. Of these, 165 patients (19.6 %) received analgesic or sedative drugs at some time during NPPV; 33 of them received both. In the adjusted analysis, the use of analgesics (odds ratio 1.8, 95 % confidence interval 0.6-5.4) or sedatives (odds ratio 2.8, 95 % CI 0.85-9.4) alone was not associated with NPPV failure, but their combined use was associated with failure (odds ratio 5.7, 95 % CI 1.8-18.4). Conclusions Slightly less than 20 % of patients received analgesic or sedative drugs during NPPV, with no apparent effect on outcome when used alone. However, the simultaneous use of analgesics and sedatives may be associated with failure of NPPV., Author(s): Alfonso Muriel [sup.1], Oscar Peñuelas [sup.2], Fernando Frutos-Vivar [sup.3], Alejandro C. Arroliga [sup.4], Victor Abraira [sup.1], Arnaud W. Thille [sup.5], Laurent Brochard [sup.6], Nicolás Nin [sup.7], Andrew R. Davies [...]