The beneficial effects of prophylactic noninvasive ventilation (NIV) after extubation in patients without hypercapnia are uncertain. Our objective was to assess the effects of prophylactic NIV on reintubation among patients without hypercapnia at the time of extubation. Post hoc analysis of two multicenter clinical trials including high-risk patients (i.e., patients older than 65 years or with underlying cardiac/respiratory disease). Our analysis focused on the 829 patients without hypercapnia (PaCO2 ≤ 45 mmHg), the day of extubation who received NIV alternating high-flow nasal cannula (HFNC) oxygen or HFNC alone after extubation. The primary outcome was the proportion of patients who required reintubation within seven days following extubation. We used G-computation to robustly estimate the marginal causal effect of treatment on the risk of reintubation. After extubation, 540 patients (65

BACKGROUND:Brain death after hanging-induced cardiac arrest is a fatal complication about which few data are available. We aimed at identifying the early predictors of progression to brain death in patients with hanging-induced cardiac arrest. METHODS:Retrospective study including adults with return of spontaneous circulation from hanging-induced cardiac arrest admitted to 34 ICUs in France and Belgium between 2000 and 2024. Logistic multivariate regression was performed to identify factors associated with progression to brain death. RESULTS:Of the 554 patients with hanging-induced cardiac arrest, brain imaging was performed on admission in 443 (80.0%) patients. Overall, 169/554 (30.5%) and 142/443 (32.1%) patients progressed to brain death within a median time of 3 days, and up to 12 days, after the hanging-induced cardiac arrest. In 443 patients with brain imaging, five factors were independently associated with a higher risk of progression to brain death: female (OR, 1.76; 95% CI, 1.06-2.90; p = 0.03), asystole as first recorded rhythm (OR, 2.03; 95% CI, 1.27-3.29; p = 0.004), low-flow time > 30 min (OR, 1.84; 95% CI, 1.07-3.17; p = 0.03), total Logistic Organ Dysfunction System Score at day 1 (OR, 1.93/per point; 95% CI, 1.14-3.29; p = 0.02), and cerebral oedema and/or ischemic complication on brain CT scan at ICU admission (OR, 1.62; 95% CI, 1.01-2.61, p = 0.04). Conversely, age > 50 years (OR, 0.59; 95%CI, 0.35-0.98, p = 0.04) and status myoclonus ≤ day 2 (OR, 0.24; 95%CI, 0.09-0.54, p = 0.001) were associated with a lower risk of progression to brain death after hanging-induced cardiac arrest. CONCLUSION:Our findings emphasise the very high rate of brain death after hanging-induced cardiac arrest. In our population, factors associated with brain death after hanging induced cardiac arrest predominantly reflect initial injury severity.

Background:In patients with septic shock as well as in the critically ill, the impact of hypothermia and core temperature changes during the first 24 h on mortality remains uncertain. In this post-hoc analysis of the SEPSISPAM trial, we investigated the association between hypothermia at inclusion, hypothermia trajectories and 90-day mortality in patients with septic shock. Methods:This post-hoc analysis of the SEPSISPAM trial included patients with septic shock enrolled within 6 h of vasopressors initiation. Core temperature was assessed every 2 h during the first 24 h. Hypothermia was defined by a temperature <36 °C. Mortality was assessed at day 90. Results:We included 691 patients from the SEPSISPAM trial, of whom 103 (14.9%) presented with hypothermia at inclusion. After adjustment for confounding factors, as compared with patients without hypothermia at inclusion, patients with hypothermia at inclusion had a higher mortality (HR 1.92, 95% CI [1.38-2.67], p < 0.001). Three groups of patients were identified according to the evolution of their core temperature: "without hypothermia" (86.6%), i.e., patients without any hypothermia during the first 24 h; "transient hypothermia" (10%), i.e., patients with hypothermia at inclusion and becoming normothermic during the first 24 h, and "persistent hypothermia" (3.4%), i.e., patients with sustained hypothermia both at inclusion and during the first 24 h. Compared with patients without hypothermia, the "persistent hypothermia" group had the highest mortality rate at day 90 (78.3%, HR 2.83 [1.62-4.95], p < 0.0001). Mortality at day 90 increased according to temperature trajectories, being highest in patients with persistent hypothermia (78%), followed by those with transient hypothermia (49%), and lowest in patients without hypothermia (40%). Conclusion:In patients with septic shock, hypothermia at inclusion and persistence of hypothermia during the first 24 h were associated with higher mortality at day 90. Mortality increased according to the course of hypothermia during the first 24 h, being highest in patients with persistent hypothermia, followed by those with transient hypothermia, and lowest in patients who never developed hypothermia.

Patients in the intensive care unit (ICU) with unhealthy alcohol use often experience agitation during mechanical ventilation, which can contribute to post-traumatic stress disorder (PTSD). The BACLOREA trial investigated whether high-dose baclofen could reduce agitation in these patients, but its long-term effects on PTSD symptoms remained unclear. This study aimed to assess whether baclofen administered during ICU stay to reduce the incidence of agitation could reduce the 5-year PTSD symptoms in adult patients with unhealthy alcohol use and improve long-term quality of life and psychological status. This observational follow-up study was conducted between September 2021 and February 2024 and included patients alive five years after participation in the BACLOREA trial, a randomized, placebo-controlled trial evaluating high-dose baclofen for the prevention of agitation-related events during mechanical ventilation in critically ill patients with unhealthy alcohol use. The primary outcome was the prevalence of PTSD symptoms measured using the Impact of Event Scale-Revised (IES-R), with a score ≥ 33 indicating PTSD symptoms. Secondary outcomes included the prevalence of PTSD symptoms using the PTSD Checklist Scale (PCL-S), the quality of life assessed through the SF-36, EQ-5D, and HADS scales. Among the 152 patients who survived five years after ICU admission, 94 (61.8

High-flow oxygen therapy (HFOT) has become the most common oxygen-supplementation modality in patients with acute respiratory failure, based chiefly on data from tightly selected patients included in randomized trials. Our objective was to obtain real-life data on HFOT failure. This prospective observational multicenter French study done in 13 intensive care units in 2019–2020 was designed to determine the proportion of patients with failed HFOT, defined as intubation, noninvasive ventilation, standard oxygen therapy with an estimated FiO2>50%. We included 257 patients before prematurely ending the study due to the COVID-19 pandemic. HFOT failed in 79 patients (32%), including 42 (17%) who required intubation. Mean HFOT duration was 2.4 ± 2.2 days. By multivariate analysis, a low ROX index (ratio of pulse-oximeter saturation (SpO2) over FiO2, over the respiratory rate (RR) was associated with HFOT failure (adjusted hazard ratio [aHR], 0.83; 95%CI, 0.77–0.90, P < 0.0001), as were elevated mean arterial pressure (aHR, 1.03; 95%CI, 1.02–1.05), vasopressor therapy (aHR, 3.35; 95%CI, 1.44–7.79), and worse Glasgow Coma Scale score (aHR, 0.69; 95%CI, 0.57–0.80, P < 0.001). The identification of factors independently associated with HFOT failure should help to determine which patients are most likely to benefit from HFOT, thereby preventing delayed intubation. Additional studies are needed to further assess these risk factors and to determine the optimal HFOT weaning modalities.Trial registration: The study was registered on the ClinicalTrials.gov registry on February 11, 2019 (NCT04141956).

BACKGROUND:Data are needed on the effect of oxygen delivered through a high-flow nasal cannula, as compared with standard oxygen therapy, on intubation and mortality in patients with acute hypoxemic respiratory failure. METHODS:In this multicenter, open-label trial, we randomly assigned patients who had acute hypoxemic respiratory failure to receive high-flow-oxygen or standard-oxygen therapy. All the patients had a ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen of 200 or less, a respiratory rate of more than 25 breaths per minute, and pulmonary infiltrate on chest imaging. The primary outcome was death by day 28. RESULTS:A total of 1116 patients underwent randomization. Of these patients, 1110 (556 in the high-flow-oxygen group and 554 in the standard-oxygen group) were included in the analysis. Mortality at day 28 was 14.6% (in 81 of 556 patients) in the high-flow-oxygen group and 14.6% (in 81 of 554 patients) in the standard-oxygen group (difference, -0.05 percentage points; 95% confidence interval [CI], -4.21 to 4.10; P = 0.98). The incidence of intubation by day 28 was 42.4% (in 236 of 556 patients) in the high-flow-oxygen group and 48.4% (in 268 of 554 patients) in the standard-oxygen group (difference, -5.93 percentage points; 95% CI, -11.78 to -0.08). Serious adverse events (cardiac arrest or pneumothorax) occurred during spontaneous breathing in 13 patients (2.3%) in the high-flow-oxygen group and in 6 patients (1.1%) in the standard-oxygen group. CONCLUSIONS:Among patients with acute hypoxemic respiratory failure, the use of oxygen delivered through a high-flow nasal cannula did not significantly reduce mortality at day 28. (Funded by the French Ministry of Health and Fisher and Paykel Healthcare; SOHO ClinicalTrials.gov number, NCT04468126.).

Clinical practice guidelines recommend prophylactic noninvasive ventilation (NIV) after extubation in high-risk patients. The effects of high-flow nasal cannula (HFNC) oxygen during breaks from NIV after extubation have been poorly explored. Our objective was to assess whether HFNC rather than standard oxygen during breaks from NIV may prevent extubation failure. Observational study based on two multicenter clinical trials including patients at high-risk of extubation failure (> 65 years or with underlying cardiac or respiratory disease). We included the 1077 patients who received prophylactic NIV after extubation, alternating with HFNC (NIV/HFNC) or standard oxygen (NIV/O2). The primary outcome was the proportion of patients who failed extubation (reintubation or death within the seven days following extubation). We used G-computation to estimate the causal effect of HFNC on the risk of extubation failure, while accounting for confounding factors. After extubation, 655 patients (61

BACKGROUND:Assessing sources of job stress in intensive care units is a critical issue for preventing many occupational health and care-related issues, such as burnout, voluntary turnover and decrease in quality and safety of care. Accordingly, this French nation-wide multicentre study aims to provide supplementary evidence regarding the validity of a recent tool: the Perceived Stressors in Intensive Care Units (PS-ICU) scale. More precisely, this study has three main objectives: to 1) confirm the metrological properties of the PS-ICU scale on a large sample of professionals; 2) test its measurement invariance between nurses, physicians and residents (initial population targeted by the scale); 3) examine whether the scale would also be suited for use with nursing auxiliaries. In addition, depending on the results (which may suggest the removal of several items), this study offers the possibility to shorten the scale to facilitate its use. METHOD AND RESULTS:2241 ICU professionals (1135 nurses, 308 physicians, 179 residents, and 619 nursing auxiliaries; overall participation rate of 58.10%) from 42 ICUs in France, voluntarily completed an online questionnaire collecting socio-demographic data and perceived job stressors (PS-ICU). Exploratory structural equation modelling (ESEM), unidimensional reliability (McDonald's Omega) and item response theory (IRT) analyses overall confirmed the metrological properties of the scale, while several items were removed and the sixth factor ("lack of support and resources from the organisation") measured by the scale was revised. Results regarding measurement invariance show that the PS-ICU scale can be used to compare occupational groups, including nursing auxiliaries. Finally, all analyses resulted in a reduction of the scale to a 26-item version. CONCLUSIONS:The PS-ICU scale, which measures generic and ICU-specific job stress factors, is a valid and reliable scale that can be used to collect data from nurses, physicians and residents, as well as from nursing auxiliaries. With 26 items, it can be used by researchers and managers in ICUs to assess the extent and type of stress factors perceived by healthcare professionals.

STUDY OBJECTIVE:We aimed to evaluate mortality and prognostic factors of patients admitted to ICU for obstructive pyelonephritis. METHOD:We conducted a retrospective multicenter study. All patients admitted to an intensive care unit (ICU, N = 8) for obstructive pyelonephritis were included. The primary outcome was in-hospital mortality. RESULTS:A total of 483 patients were included over a 10-year period. Disease was severe at admission with frequent organ support therapy including norepinephrine infusion (70 %) and invasive mechanical ventilation (23 %). The most frequent causes of obstruction were kidney stones, cancer, and ureteral stent obstruction. Escherichia coli was the most prevalent pathogen identified in urine (63 %), and two-thirds of patients had positive blood cultures. Infection with Extended-spectrum beta-lactamase-producing bacteria was observed in 53 (11 %) patients. Urinary drainage was performed either before ICU admission (43 %), < 6 h (28 %), or > 6 h (29 %), mainly using double-J stenting (71 %). In multivariate analysis, factors associated with in-hospital mortality were the need for vasopressors (OR: 3.27 [95 % CI 1.33-8.06], p = 0.01), mechanical ventilation (OR: 2.49 [95 % CI 1.35-4.59, p = 0.004]), lactate levels (per 1 mmol/l increase) (OR: 1.18 [95 % CI 1.06-1.31, p = 0.004]), tumor-related obstruction (OR: 4.78 [95 % CI 2.24-10.17], p < 0.001), and stent obstruction (OR: 3.38 [95 % CI 1.44-7.93, p = 0.005]). Delayed urinary drainage (>12 h) was associated with mortality only in patients receiving vasopressors. CONCLUSION:Obstructive pyelonephritis is a severe condition leading to organ failure and significant in-hospital mortality. Urinary drainage should be performed as soon as possible, especially in patients with septic shock.

Alcohol related hepatitis is responsible for high morbidity and mortality, but little is known about the management of patients with hepatitis specifically in intensive care units (ICU). Retrospective study including patients with alcohol related hepatitis hospitalized in 9 French ICUs (2006–2017). Alcohol related hepatitis was defined histologically or by an association of clinical and biological criteria according to current guidelines. 187 patients (median age: 53 [43–60]; male: 69

Importance:The effect of sodium bicarbonate infusion on outcome in patients with severe metabolic acidemia and moderate to severe acute kidney injury is unknown. Objective:To determine whether sodium bicarbonate infusion is associated with day 90 all-cause mortality in patients with severe metabolic acidemia and moderate to severe acute kidney injury. Design, Setting, and Participants:Randomized, open-label, clinical trial conducted with 640 patients in 43 French intensive care units from October 6, 2019, to December 19, 2023, with 90-day follow-up. The last date of follow-up was June 17, 2024. Adults with severe metabolic acidemia (defined as pH ≤7.20) and moderate to severe acute kidney injury were enrolled. Intervention:Patients were randomized 1:1 to receive either intravenous sodium bicarbonate infusion or no sodium bicarbonate to target an arterial pH of 7.30 or higher. Main Outcomes and Measures:The primary outcome was day 90 all-cause mortality. Secondary outcomes included day 28 and day 180 all-cause mortality; use of organ support therapy, vasopressors, or invasive mechanical ventilation; intensive care unit and hospital length of stay; intensive care unit-acquired infections; fluid balance; day-7 Sequential [Sepsis-related] Organ Failure Assessment score (6 organ systems' function is evaluated and scored from 0 [no dysfunction] to 4 [failure]; total score ranges from 0 [normal] to 24 [maximum failure]); and major adverse kidney events on day 90. Results:Among 640 randomly assigned patients, 627 were analyzed (313 in the control group and 314 in the bicarbonate group). The median age was 67 years (IQR, 59-74 years); 194 of 314 patients (62%) in the bicarbonate group and 185 of 313 controls (59%) were male. In the primary analysis, day 90 all-cause mortality was 195 of 314 patients (62.1%) in the bicarbonate group and 193 of 313 (61.7%) in the control group (absolute difference, 0.4; 95% CI, -7.2 to 8.0; P = .91). There was no evidence of a group effect on day 28 or day 180 all-cause mortality. Among 18 secondary outcomes, kidney replacement therapy was used in 109 of 314 (35%) bicarbonate group patients and 157 of 313 (50%) controls (absolute difference, -15.5; 95% CI, -23.1 to -7.8). No evidence of a group effect was found on other secondary outcomes, including adverse events. Conclusions and Relevance:For patients with severe metabolic acidemia and moderate to severe acute kidney injury, intravenous sodium bicarbonate did not affect mortality. Trial Registration:ClinicalTrials.gov Identifier: NCT04010630.

Aim Hypoxic Ischemic Brain Injury is a major cause of death after cardiac arrest. Identifying optimal mean arterial pressure (MAP) targets to restore brain oxygen delivery remains challenging. This study assessed the feasibility of using transcranial Doppler to guide individualised MAP management in post-cardiac arrest patients. Methods In this single-centre prospective feasibility study, post-cardiac arrest patients were enrolled after intensive care unit admission. After induction of targeted temperature management (TTM) and control of systemic secondary brain insults determinants, cerebral hypoperfusion was screened using transcranial Doppler. A MAP challenge was performed in patients with abnormal transcranial Doppler findings to assess cerebral vascular responsiveness to increased MAP. Jugular bulb oximetry was concurrently used to evaluate cerebral oxygenation. Results A total of 172 patients were screened, and 20 (11.6%) were assessable using transcranial Doppler. After optimisation of cerebral blood flow determinants, 3 patients (15%) showed signs of cerebral hypoperfusion based on transcranial Doppler measurements. A MAP challenge was performed in two of these patients, without normalisation of transcranial Doppler values and with an estimated increase in intracranial pressure. No significant association was found between transcranial Doppler findings and either cerebral oxygenation parameters or neurological outcome. Baseline SjvO2 levels were paradoxically higher in non-survivors. Conclusions Implementing an individualised MAP management strategy guided by transcranial Doppler was challenging, with few patients eligible for evaluation. Still, transcranial Doppler identified a small group with persistent cerebral hypoperfusion despite optimised cerebral blood flow parameters. The study underscored technical and physiological limitations of this approach, which should inform the design and relevance of a larger trial to assess its clinical value.Trial registration: https://www.clinicaltrials.gov NCT04000334.

Introduction Patients in intensive care units (ICUs) frequently require mechanical ventilation, with approximately half needing invasive ventilation through an orotracheal tube. For these patients, gastric tube (GT) insertion is routinely performed to administer nutrition and medications or to drain gastric contents. The insertion route (oral or nasal) may affect the incidence of ventilator-associated pneumonia (VAP), a significant ICU care complication. This study aims to compare the impact of oral versus nasal GT insertion on the incidence of VAP in intubated ICU patients.Methods and analysis The SONG trial (NCT 05915663) is a multicentre, open-label, two-period, two-intervention, cluster randomised crossover superiority trial. 16 French ICUs will participate. ICUs will be randomised to periods of nasogastric or orogastric tube placement. The trial includes a practice standardisation period, followed by two 12-month inclusion periods separated by a monitoring and washout period. The primary endpoint is the incidence rate of VAP at day 28, confirmed by three independent physicians. Secondary endpoints include the ease of GT insertion, measured by the number of attempts.Ethics and dissemination This study received approval from a central ethical review board on 12 April 2024 (CPP Sud-est VI, registration number 23.00943.000175). Patients are included after informed consent or, when not possible, from next of kin. If none are available, the investigator will proceed with emergency inclusion, following French law. When consent is initially obtained from the next of kin or through emergency inclusion, the investigator will seek consent from the patient as soon as possible. Data will be anonymised and patient confidentiality maintained. Results will be published in peer-reviewed journals and presented at scientific meetings.Trial registration number NCT05915663.

The effect of sodium bicarbonate infusion on outcome in patients with severe metabolic acidemia and moderate to severe acute kidney injury is unknown. To determine whether sodium bicarbonate infusion is associated with day 90 all-cause mortality in patients with severe metabolic acidemia and moderate to severe acute kidney injury. Randomized, open-label, clinical trial conducted with 640 patients in 43 French intensive care units from October 6, 2019, to December 19, 2023, with 90-day follow-up. The last date of follow-up was June 17, 2024. Adults with severe metabolic acidemia (defined as pH ≤7.20) and moderate to severe acute kidney injury were enrolled. Patients were randomized 1:1 to receive either intravenous sodium bicarbonate infusion or no sodium bicarbonate to target an arterial pH of 7.30 or higher. The primary outcome was day 90 all-cause mortality. Secondary outcomes included day 28 and day 180 all-cause mortality; use of organ support therapy, vasopressors, or invasive mechanical ventilation; intensive care unit and hospital length of stay; intensive care unit–acquired infections; fluid balance; day-7 Sequential [Sepsis-related] Organ Failure Assessment score (6 organ systems’ function is evaluated and scored from 0 [no dysfunction] to 4 [failure]; total score ranges from 0 [normal] to 24 [maximum failure]); and major adverse kidney events on day 90. Among 640 randomly assigned patients, 627 were analyzed (313 in the control group and 314 in the bicarbonate group). The median age was 67 years (IQR, 59-74 years); 194 of 314 patients (62%) in the bicarbonate group and 185 of 313 controls (59%) were male. In the primary analysis, day 90 all-cause mortality was 195 of 314 patients (62.1%) in the bicarbonate group and 193 of 313 (61.7%) in the control group (absolute difference, 0.4; 95% CI, −7.2 to 8.0; P = .91). There was no evidence of a group effect on day 28 or day 180 all-cause mortality. Among 18 secondary outcomes, kidney replacement therapy was used in 109 of 314 (35%) bicarbonate group patients and 157 of 313 (50%) controls (absolute difference, −15.5; 95% CI, −23.1 to −7.8). No evidence of a group effect was found on other secondary outcomes, including adverse events. For patients with severe metabolic acidemia and moderate to severe acute kidney injury, intravenous sodium bicarbonate did not affect mortality. ClinicalTrials.gov Identifier: NCT04010630

Introduction Out-of-hospital cardiac arrest is a public health concern with a high mortality rate. Hypoxic ischaemic brain injury is the primary cause of death in patients admitted to the intensive care unit (ICU) after return of spontaneous circulation (ROSC). Several systemic factors, such as hypotension, can exacerbate brain injuries. International guidelines recommend targeting a mean arterial pressure (MAP) of at least 65 mm Hg. Several observational studies suggest that a higher MAP may be associated with better outcomes, but no randomised trials have shown an effect of higher MAP. The ongoing METAPHORE (mean arterial pressure after out-of-hospital cardiac arrest) trial aims to compare a standard MAP threshold (MAP ≥65 mm Hg) with a high MAP threshold (MAP ≥90 mm Hg) to evaluate whether implementing a higher MAP threshold can improve neurological outcomes in patients admitted to ICU after cardiac arrest.Methods and analysis METAPHORE is a randomised, controlled, multicentre, open-label trial with a blinded primary outcome assessor, comparing two parallel groups of patients 18 years of age or older, receiving invasive mechanical ventilation for coma defined by a Glasgow Coma Score ≤8/15 after out-of-hospital cardiac arrest and sustained ROSC. Eligible patients are randomly assigned in a 1:1 ratio to either a MAP target threshold of 65 mm Hg or higher throughout the ICU stay (control group) or a MAP target threshold of 90 mm Hg or higher during the first 24 hours after randomisation, followed by 65 mm Hg or higher for the remainder of the ICU stay (intervention group). Both groups receive the same general care concerning post-cardiac arrest syndrome management according to international guidelines. The primary endpoint is the proportion of patients with a favourable neurological outcome as defined by a modified Rankin scale (mRS) of 0 to 3 measured on day 180 after inclusion by a psychologist blinded to the allocation of the intervention. Secondary outcomes are the proportion of patients alive at ICU and hospital discharge, at day 28 and day 180; proportion of patients alive at ICU discharge with a mRS of 0 to 3; the EuroQOL-5D-5L at day 180; the Clinical Frailty Scale at day 180; the number of ICU-free days, ventilator-free days, catecholamine-free days and renal replacement therapy-free days at day 28; the proportion of patients with acute kidney injury stage 3 and need for renal replacement therapy within ICU stay and proportion of patients with persistent need for renal replacement therapy at ICU discharge; and safety outcomes (cardiovascular, neurological, cutaneous, digestive and haemorrhagic complications within 7 days after inclusion). Subgroup analyses are planned according to initial cardiac arrest rhythm (shockable or non-shockable), chronic hypertension and Cardiac Arrest Hospital Prognosis score. Outcomes will be analysed on an intention-to-treat basis. Recruitment started in October 2024 in 27 French ICUs, and a sample of 1380 patients is expected by October 2027.Ethics and dissemination The study received approval from the national ethics review board on 8 February 2024 (Comité de Protection des Personnes Sud-Est V – 2023-A00257-38). Patients are included after informed consent has been obtained either from a proxy or through an emergency procedure. Results will be submitted for publication in peer-reviewed journals.Trial registration number ClinicalTrials.gov: NCT05486884.

BACKGROUND: To our knowledge, no large observational study has compared the incidence and risk factors for extubation failure within 48 h and during ICU stay in the same cohort of unselected critically ill patients with and without obesity. RESEARCH QUESTION: What are the incidence and risk factors of extubation failure in patients with and without obesity? STUDY DESIGN AND METHODS: In the prospective multicenter observational Practices and Risk Factors for Weaning and Extubation Airway Failure in Adult Intensive Care Unit: A Multicenter Trial (FREEREA) study in 26 ICUs, the primary objective was to compare the incidence of extubation failure within 48 h in patients with and without obesity. Secondary objectives were to describe and to identify the independent specific risk factors for extubation failure using first a logistic regression model and second a decision tree analysis. RESULTS: Of 1,370 extubation procedures analyzed, 288 (21%) were performed in patients with obesity and 1,082 (79%) in patients without obesity. The incidence of extubation failure within 48 h among patients with or without obesity was 23 of 288 (8.0%) vs 118 of 1,082 (11%), respectively (unadjusted OR, 0.71; 95% CI, 0.45-1.13; P = .15); alongside patients with obesity receiving significantly more noninvasive ventilation [87 of 288 (30%) vs 233 of 1,082 (22%); P = .002] and physiotherapy [165 of 288 (57%) vs 527 of 1,082 (49%); P = .02] than patients without obesity. Risk factors for extubation failure also differed according to obesity status: female sex (adjusted OR, 4.88; 95% CI, 1.61-13.9; P = .002) and agitation before extubation (adjusted OR, 6.39; 95% CI, 1.91-19.8; P = .001) in patients with obesity, and absence of strong cough before extubation (adjusted OR, 2.38; 95% CI, 1.53-3.84; P = .0002) and duration of invasive mechanical ventilation before extubation (adjusted OR, 1.03/d; 95% CI, 1.01-1.06; P = .01) in patients without obesity. The decision tree analysis found similar risk factors. INTERPRETATION: Our findings indicate that anticipation and application of preventive measures for patients with obesity before and after extubation led to similar rates of extubation failure among patients with and without obesity.

Importance:Posttraumatic growth (PTG) refers to positive psychological changes following adversity, including deeper relationships and a greater appreciation for life. Objective:To assess PTG among intensive care unit (ICU) health care professionals 4 years after the COVID-19 pandemic and explore its association with resilience, anxiety, and depression. Design, Setting, and Participants:This cross-sectional study invited ICU health care professionals (nursing staff, medical staff [residents, interns, clinical fellows, and senior intensivists], and other professionals providing patient care) in ICUs in general or university-affiliated hospitals in France and Belgium to complete online questionnaires between March 15 and May 15, 2024. Exposures:PTG, resilience, anxiety, and depression. Main Outcomes and Measures:The primary outcome was PTG, and secondary outcomes were anxiety, depression, and resilience. Participants completed validated self-reported questionnaires, including the Posttraumatic Growth Inventory (PTGI), Hospital Anxiety and Depression Scale (HADS), and 10-item Connor-Davidson Resilience Scale (CD-RISC 10). Visual analog scales (VASs) assessed professional experiences and psychological impact. Multivariate linear regression identified factors associated with PTG. Results:Among 1371 health care professionals in 23 ICUs, 850 (62%) responded (median age, 39 years [IQR, 32-46 years]; 574 [68%] women). The median PTGI score was 50 (IQR, 33-64), with nursing staff reporting higher PTG than medical staff (51 [IQR, 34-65] vs 47 [IQR, 28-61]; P = .02), mainly in personal strength, spiritual change, and appreciation of life. Anxiety and depression symptoms were present in 492 respondents (58%) and 219 respondents (26%), respectively. Lower PTG was associated with psychological fatigue (regression coefficient, 1.43; 95% CI, 0.91-1.96; P < .001), ICU conflicts (regression coefficient, 0.62; 95% CI, 0.05-1.19; P = .03), and perceived deterioration in family-centered care (regression coefficient, -7.47; 95% CI, -1.10 to -13.80; P = .02). Higher PTG was correlated with higher resilience (Spearman correlation coefficient, 0.24; 95% CI, 0.17-0.30; P < .001) and was associated with a change in personal life since the pandemic (regression coefficient, 1.80 [95% CI, 1.13-2.47] per VAS point; P < .001). Conclusions and Relevance:In this cross-sectional study performed 4 years after the start of the COVID-19 pandemic, ICU health care professionals, particularly nursing staff, exhibited significant PTG. Resilience, rather than psychological distress, emerged as a key driver of PTG, and deterioration in family-centered care was a major contributing factor, underscoring the need for targeted well-being and resilience-building strategies to enhance health care professionals' mental health and professional fulfillment while also improving patient and family care.

Purpose of review The objective of this review is to examine the available evidence concerning feeding interruptions before extubation and other medical procedures in ICUs. We will analyze the physiological mechanisms involved, the potential risks associated with feeding interruptions, as well as the results of recent clinical studies. Additionally, we will explore current practices and recommendations from major professional societies, as well as recent innovations aimed at minimizing feeding interruptions. Recent findings Fasting before extubation is a common yet heterogeneous practice, varying across ICUs. Although dysphagia is a frequent complication after extubation, its prevalence decreases over time. However, physiologically, fasting before extubation appears ineffective in reducing gastric content or preventing aspiration. The Ambroisie study demonstrated that continuing enteral nutrition up to extubation is not inferior to a 6 h fasting strategy in terms of extubation failure at 7 days. The management of perioperative nutrition in intubated patients is debated. A retrospective study found no significant difference in postoperative respiratory events between patients fasting for at least 6 h and those fasting less or not at all but further prospective randomized studies are needed for definitive conclusions. For abdominal and digestive surgeries, fasting remains necessary to simplify procedures and reduce contamination risks. For invasive ICU procedures, such as catheter placement, the continuation of enteral nutrition appears reasonable. However, for percutaneous tracheotomy, limited evidence suggests no clear benefit from fasting, though the risk of large-volume aspiration during the procedure raises concerns. The approach to nutrition in this context requires further investigation. Summary Fasting before extubation in ICUs is a common practice inherited from anesthesia, aiming to reduce the risk of aspiration. The Ambroisie study demonstrates that continuing enteral nutrition until extubation is not inferior to a 6 h fasting strategy regarding extubation failure at 7 days.

BACKGROUND:The COVID-19 pandemic has highlighted the importance of intensive care units (ICUs) and their organization in healthcare systems. However, ICU capacity and availability are ongoing concerns beyond the pandemic, particularly due to an aging population and increasing complexity of care. This study aimed to assess the current and future shortage of ICU physicians in France, ten years after a previous evaluation. A national e-survey was conducted among French ICUs in January 2022 to collect data on ICU characteristics, medical staffing, individual physician characteristics, and education and training capacities.RESULTS:Among 290 ICUs contacted, 242 responded (response rate: 83%), representing 4943 ICU beds. The survey revealed an overall of 300 full time equivalent (FTE) ICU physician vacancies in the country. Nearly two-thirds of the participating ICUs reported at least one physician vacancy and 35% relied on traveling physicians to cover shifts. The ICUs most affected by physician vacancies were the ICUs of non-university affiliated public hospitals. The retirements expected in the next five years represented around 10% of the workforce. The median number of physicians per ICU was 7.0, corresponding to a ratio of 0.36 physician (FTE) per ICU bed. In addition, 27% of ICUs were at risk of critical dysfunction or closure due to vacancies and impending retirements.CONCLUSION:The findings highlight the urgent need to address the shortage of ICU physicians in France. Compared to a similar study conducted in 2012, the inadequacy between ICU physician supply and demand has increased, resulting in a higher number of vacancies. Our study suggests that, among others, increasing the number of ICM residents trained each year could be a crucial step in addressing this issue. Failure to take appropriate measures may lead to further closures of ICUs and increased risks to patients in this healthcare system.

Introduction Fever treatment is commonly applied in patients with sepsis but its impact on survival remains undetermined. Patients with respiratory and haemodynamic failure are at the highest risk for not tolerating the metabolic cost of fever. However, fever can help to control infection. Treating fever with paracetamol has been shown to be less effective than cooling. In the SEPSISCOOL pilot study, active fever control by external cooling improved organ failure recovery and early survival. The main objective of this confirmatory trial is to assess whether fever control at normothermia can improve the evolution of organ failure and mortality at day 60 of febrile patients with septic shock. This study will compare two strategies within the first 48 hours of septic shock: treatment of fever with cooling or no treatment of fever.Methods and analysis SEPSISCOOL II is a pragmatic, investigator-initiated, adaptive, multicentre, open-label, randomised controlled, superiority trial in patients admitted to the intensive care unit with febrile septic shock. After stratification based on the acute respiratory distress syndrome status, patients will be randomised between two arms: (1) cooling and (2) no cooling. The primary endpoint is mortality at day 60 after randomisation. The secondary endpoints include the evolution of organ failure, early mortality and tolerance. The target sample size is 820 patients.Ethics and dissemination The study is funded by the French health ministry and was approved by the ethics committee CPP Nord Ouest II (Amiens, France). The results will be submitted for publication in peer-reviewed journals.Trial registration number NCT04494074.