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
Sarah Wahlster, Monisha Sharma, Shaurya Taran, James A. Town, Robert D. Stevens, Raphaël Cinotti, Karim Asehoune, Paolo Pelosi, Chiara Robba, ENIO Study Group Collaborators, Paër-Sélim Abback, Anaïs Codorniu, Giuseppe Citerio, V. Sala, Marinella Astuto, Eleonora Tringali, Daniela Alampi, Monica Rocco, Jessica Giuseppina Maugeri, Agrippino Bellissima, Matteo Filippini, Nicoletta Lazzeri, Andrea Cortegiani, Mariachiara Ippolito, Denise Battaglini, Patrick Biston, Mohamed Fathi Al-Gharyani, Russell Chabanne, Léo Astier, Benjamin Soyer, Samuel Gaugain, Alice Zimmerli, Urs Pietsch, Miodrag Filipovic, Giovanna Brandi, Giulio Bicciato, Ainhoa Serrano, Berta Monleon, Peter Van de Vliet, Benjamin Marcel Gerretsen, Iris Xóchitl Ortiz-Macías, Jun Oto, Noriya Enomoto, Tomomichi Matsuda, Nobutaka Masui, Pierre Garçon, Jonathan Zarka, Wytze J. Vermeijden, Alexander D. Cornet, Sergio Reyes Inurrigarro, Rafael Cirino Lara Domínguez, Maria Mercedes Bellini, Maria Milagros Gomez Haedo, Laura Lamot, Jose Orquera, Matthieu Biais, Delphine Georges, Arvind Baronia, Roberto Carlos Miranda-Ackerman, Francisco José Barbosa‐Camacho, John Porter, Miguel Lopez-Morales, Thomas Geeraerts, Baptiste Compagnon, David Pérez-Torres, Estefanía Prol‐Silva, Hana Basheer Yahya, Ala Khaled, Mohamed Ghula, Cracchiolo Neville Andrea, Palma Maria Daniela, Cristian Deana, Luigi Vetrugno, Manuel J. Rivera Chavez, Rocio Mendoza Trujillo, Vincent Legros, Benjamin Brochet, Olivier Huet, Marie Geslain, Mathieu van der Jagt, Job van Steenkiste, Hazem Ahmed, Alexander Edward Coombs, Jessie Welbourne, Ana Alícia Velarde Pineda, Víctor Hugo Nubert Castillo, Mohammed A. Azab, Ahmed Y. Azzam, David Michael Paul van Meenen, Gilberto Adrian Gasca, Alfredo Arellano, Forttino Galicia-Espinosa, José Carlos García-Ramos, Ghanshyam Yadav, Amarendra Kumar Jha, Vincent Robert-Edan, Pierre-André Rodie-Talbere, Gaurav Jain, Sagarika Panda, Sonika Agarwal
Abstract
BACKGROUND: There 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. METHODS: In 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). RESULTS: We 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). CONCLUSIONS: Exposure 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.