BACKGROUND:Obesity is a growing public health issue associated with increased peri-induction risk during general anesthesia, particularly airway-related complications. Substantial variability in national and international guidelines may contribute to heterogeneous clinical practice. This study aimed to describe anesthetic induction practices in patients with obesity in France and to explore the influence of body mass index and obesity-related comorbidities on the decision for or against rapid sequence induction. METHODS:This nationwide declarative survey used an anonymous online questionnaire distributed to French anesthesiologists between May and December 2024. Using standardized theoretical clinical scenarios, induction strategies were classified as rapid sequence induction or conventional induction, as reported by participants. Data were analyzed descriptively, with group comparisons performed using Pearson's chi-square test. RESULTS:Of the 665 responses collected, 652 were analyzed, revealing wide variability in practices. For a body mass index of 43 kg/m2, 57% of participants would not perform rapid sequence induction. Among respondents, 33% regarded a body mass index threshold of ≥40 kg/m2 as appropriate for initiating rapid sequence induction, whereas 24% did not define any specific threshold. Rapid sequence induction was primarily selected for patients with daily gastroesophageal reflux disease, gastroesophageal reflux disease associated with a hiatal hernia, or a history of bariatric surgery. Anesthesiologist experience was associated with differences in the choice of induction sequence (p = 0.003). Considerable heterogeneity remained in the calculation of neuromuscular blocking agent doses: 28% of practitioners used total body weight for non-depolarizing agents. Apneic oxygenation remained underused, with 32% of respondents reporting that they never used it. CONCLUSIONS:This nationwide survey highlights substantial variability in anesthetic induction practices for patients with obesity, reflecting the absence of consensus. These findings underscore the need for further evidence to inform future recommendations and optimize anesthetic management in this high-risk population.

Whether dexmedetomidine improves the control of hyperactive delirium in non-intubated intensive care unit (ICU) patients as compared with placebo remains uncertain. In a multicenter, double-blind, placebo-controlled, two-arm, investigator-initiated, randomized trial conducted in 9 ICUs, we randomly assigned non-intubated critically ill adults with hyperactive delirium to receive continuous intravenous infusion of dexmedetomidine or placebo for at least 36 h. The primary outcome was a joint modelling of multiple outcomes of agitation duration (score of + 1 or higher on the Richmond agitation-sedation scale), delirium duration, or the need for intubation and deep sedation. Key secondary outcomes included the occurrence of complications (such as bradycardia or hypotension), length of stay in ICU, or death. Enrollment occurred from December 2017 to February 2022. Final follow-up was in February 2023. The study was stopped for efficacy at the time of the preplanned interim analysis. Among the 151 patients who were included in the final analysis, the between-group difference in the primary outcome was statistically significant (median difference, -30 points; 95 https://clinicaltrials.gov/search?term=NCT03317067 .

Airway driving pressure has garnered considerable attention for lung-protective ventilation. We evaluated the clinical effectiveness of airway driving pressure as a target to individualize positive-end-expiratory pressure (PEEP) setting in mechanically ventilated patients at risk for postoperative respiratory failure. We conducted a multicenter, pragmatic, assessor-masked, randomized trial among adult patients undergoing emergency abdominal surgery in 22 hospitals in France. Patients were assigned 1:1 to receive individually adjusted highest PEEP targeting a driving pressure < 13 cmH2O after an initial recruitment maneuver (intervention group) or to a fixed PEEP level of 5 cmH2O (control group). The primary outcome was a composite of postoperative respiratory failure (failure to wean from the ventilator or the composite of reintubation or curative non-invasive ventilation) or all-cause mortality at 30 days. Secondary outcomes included components of the composite primary outcome. The primary outcome occurred in 87 out of 338 (25.7

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

Importance:Whether the use of inhaled or intravenous sedation affects outcomes differentially in mechanically ventilated adults with acute respiratory distress syndrome (ARDS) is unknown. Objective:To determine the efficacy and safety of inhaled sevoflurane compared with intravenous propofol for sedation in patients with ARDS. Design, Setting, and Participants:Phase 3 randomized, open-label, assessor-blinded clinical trial conducted from May 2020 to October 2023 with 90-day follow-up. Adults with early moderate to severe ARDS (defined by a ratio of Pao2 to the fraction of inspired oxygen of <150 mm Hg with a positive end-expiratory pressure of ≥8 cm H2O) were enrolled in 37 French intensive care units. Interventions:Patients were randomized to a strategy of inhaled sedation with sevoflurane (intervention group) or to a strategy of intravenous sedation with propofol (control group) for up to 7 days. Main Outcomes and Measures:The primary end point was the number of ventilator-free days at 28 days; the key secondary end point was 90-day survival. Results:Of 687 patients enrolled (mean [SD] age, 65 [12] years; 30% female), 346 were randomized to sevoflurane and 341 to propofol. The median total duration of sedation was 7 days (IQR, 4 to 7) in both groups. The number of ventilator-free days through day 28 was 0.0 days (IQR, 0.0 to 11.9) in the sevoflurane group and 0.0 days (IQR, 0.0 to 18.7) in the propofol group (median difference, -2.1 [95% CI, -3.6 to -0.7]; standardized hazard ratio, 0.76 [95% CI, 0.50 to 0.97]). The 90-day survival rates were 47.1% and 55.7% in the sevoflurane and propofol groups, respectively (hazard ratio, 1.31 [95% CI, 1.05 to 1.62]). Among 4 secondary outcomes, sevoflurane was associated with higher 7-day mortality (19.4% vs 13.5%, respectively; relative risk, 1.44 [95% CI, 1.02 to 2.03]) and fewer intensive care unit-free days through day 28 (median, 0.0 [IQR, 0.0 to 6.0] vs 0.0 [IQR, 0.0 to 15.0]; median difference, -2.5 [95% CI, -3.7 to -1.4]) compared with propofol. Conclusions and Relevance:Among patients with moderate to severe ARDS, inhaled sedation with sevoflurane resulted in fewer ventilator-free days at day 28 and lower 90-day survival than sedation with propofol. Trial Registration:ClinicalTrials.gov Identifier: NCT04235608.

Whether the use of inhaled or intravenous sedation affects outcomes differentially in mechanically ventilated adults with acute respiratory distress syndrome (ARDS) is unknown. To determine the efficacy and safety of inhaled sevoflurane compared with intravenous propofol for sedation in patients with ARDS. Phase 3 randomized, open-label, assessor-blinded clinical trial conducted from May 2020 to October 2023 with 90-day follow-up. Adults with early moderate to severe ARDS (defined by a ratio of Pao2 to the fraction of inspired oxygen of <150 mm Hg with a positive end-expiratory pressure of ≥8 cm H2O) were enrolled in 37 French intensive care units. Patients were randomized to a strategy of inhaled sedation with sevoflurane (intervention group) or to a strategy of intravenous sedation with propofol (control group) for up to 7 days. The primary end point was the number of ventilator-free days at 28 days; the key secondary end point was 90-day survival. Of 687 patients enrolled (mean [SD] age, 65 [12] years; 30% female), 346 were randomized to sevoflurane and 341 to propofol. The median total duration of sedation was 7 days (IQR, 4 to 7) in both groups. The number of ventilator-free days through day 28 was 0.0 days (IQR, 0.0 to 11.9) in the sevoflurane group and 0.0 days (IQR, 0.0 to 18.7) in the propofol group (median difference, −2.1 [95% CI, −3.6 to −0.7]; standardized hazard ratio, 0.76 [95% CI, 0.50 to 0.97]). The 90-day survival rates were 47.1% and 55.7% in the sevoflurane and propofol groups, respectively (hazard ratio, 1.31 [95% CI, 1.05 to 1.62]). Among 4 secondary outcomes, sevoflurane was associated with higher 7-day mortality (19.4% vs 13.5%, respectively; relative risk, 1.44 [95% CI, 1.02 to 2.03]) and fewer intensive care unit–free days through day 28 (median, 0.0 [IQR, 0.0 to 6.0] vs 0.0 [IQR, 0.0 to 15.0]; median difference, –2.5 [95% CI, –3.7 to –1.4]) compared with propofol. Among patients with moderate to severe ARDS, inhaled sedation with sevoflurane resulted in fewer ventilator-free days at day 28 and lower 90-day survival than sedation with propofol. ClinicalTrials.gov Identifier: NCT04235608

BACKGROUND:New-onset atrial fibrillation (NOAF) occurs in 10% of intensive care unit (ICU) stays and worsens clinical outcomes. Despite its significance, no specific guidelines exist for the general ICU population. Our study investigates potential therapeutic approaches to NOAF, focusing on the rhythmic and haemodynamic outcomes associated with dedicated strategies. METHODS:In our prospective multicentre cohort study, we included adult patients admitted to 33 ICUs in France, exhibiting at least one episode of NOAF. Exclusions included permanent and post-cardiac/thoracic surgery AF. Data on demographics, clinical history, haemodynamic monitoring, and treatment choice for NOAF episodes were prospectively recorded. Heart rate, blood pressure, and rhythm status were assessed immediately before, at +5, +30, +60 min, and +24 h after NOAF onset. RESULTS:Between May and December 2019, 453 ICU patients with 735 NOAF episodes were included. Therapeutic approaches included wait-and-see (n = 159 (22%)), IV fluid (n = 338 (46%)), magnesium (n = 299 (41%)), amiodarone (n = 295 (40%)), and beta blockers (n = 73 (10%)); alone or combined in 354 episodes (61%). Electric cardioversion, preferred for poor haemodynamic tolerance, was most effective for sinus rhythm conversion at +1 h (n = 17/30 (57%)). Heart rate and rhythm control were achieved at 87% (n = 588/674) and 80% (n = 259/654) at +24 h, with no significant difference between the strategies. On ICU discharge, 48 (13%) patients remained in AF; independent predictors included age, obesity, prior stroke, and hypercholesterolemia. CONCLUSIONS:Therapeutic approaches for NOAF in ICU patients were heterogeneous, with nearly a quarter managed by a wait-and-see approach. Most strategies achieved rhythm and rate control within 24 h. These findings highlight the frequent transient nature of NOAF episodes and support the need for individualized treatment decisions, particularly in unstable patients and those at risk for persistent AF. Trial registration ClinicalTrials.gov NCT03977883 (https://clinicaltrials.gov/study/NCT03977883?term=NCT03977883&rank=1).

Introduction Intensive care units (ICUs) manage patients with or likely to have one or more life-threatening acute organ failures that might require the use of invasive supportive therapies. The use of physical restraint is frequent, with rates up to 50%, and usually initiated to maintain patient safety especially if the patient is agitated. Physical restraints have been associated with delirium, post-traumatic stress disorder and physical injuries while restricting patients’ individual freedom. Moreover, the incidence of invasive therapeutic devices’ self-removal by patients might not be decreased by physical restraint use. No recommendation is available concerning ICU patients and physical restraint management, despite being a daily practice. The main objective is to evaluate whether a strategy aimed at decreasing physical restraint use in ICU patients with that of a strategy based on routine and subjective caregivers’ decision is safe and efficient.Methods and analysis ARBORea is a multicentre randomised, stepped-wedge trial testing an innovative, dedicated web-based, multiprofessionally developed, experts validated, nursing management strategy in comparison with standard care. The primary outcome is physical restraint use rate (effectiveness) measured at least every 8 hours and incidents’ rate (tolerance) defined as the rate of incidents attributable to non-compliance, corresponding to the deterioration or self-removal of critical devices, a fall or self-aggressive or heteroaggressive behaviours. Planned enrolment is 4000 ICU adult participants at 20 French academic and non-academic centres. Safety and long-term outcomes will be evaluated.Ethics and dissemination Trial results will be reported according to the Consolidated Standards of Reporting Trials 2010 guidelines. Findings will be published in peer-reviewed journals and presented at local, national and international meetings and conferences to publicise and explain the research to clinicians, commissioners and service users. The trial is funded by the French Ministry of Health and has been approved by the French local ethics committee (Comité de Protection des Personnes Sud-Ouest et Outre-Mer 2, Toulouse, France with registration number: 2020-A02904-35).Trial registration number (ClinicalTrials.gov) NCT04957238 on 12 July 2021 before first inclusion in study.

Introduction In the intensive care unit (ICU), brain-injured patients are frequently exposed to mechanical ventilation to protect the brain and preserve physiology. After intracranial pressure control and sedation withdrawal, this population is prone to residual disorder of consciousness and altered neurological control of respiratory drive, cough and airway protection. Consequently, extubation failure is more frequent than in general ICU patients, and there is no clear evidence-based clinical trigger for extubation. Different risk factors for extubation failure were described in observational trials, and clinical scores were constructed to detect patients at higher risk of extubation failure. Nevertheless, none of these scores were prospectively tested as interventional tools to prevent extubation failure. The Brain-Injured Patients Extubation Readiness (BIPER) study is an ongoing multicentre stepped-wedge cluster-randomised controlled trial aiming to test one of these scores as an intervention protocol to decrease extubation failure in neurocritical care patients with residual disorder of consciousness.Methods and analysis Trial design: Stepped-wedge cluster-randomised controlled trial with five groups of three to six clusters (20 ICUs). Groups of clusters are randomised to five possible sequences of nine periods with crossing from a control condition period (usual care for extubation) to an intervention condition period (BIPER-guided extubation protocol), separated by a 3-month transition period.Participants: Participants are clinically stable brain-injured patients (18–75 years old), requiring more than 48 hours of invasive mechanical ventilation with residual disorder of consciousness after sedation withdrawal, and who achieved a spontaneous breathing trial.Interventions: The control condition consists of extubation based on usual care and local practice. The intervention condition consists of extubation triggered by a clinical score evaluating deglutition, gag reflex, cough and visual tracking (Coma Recovery Scale-Revised Visual Scale).Objective: To determine whether adoption of an extubation protocol based on a clinical score can lessen extubation failure compared with usual care in brain-injured patients with residual disorder of consciousness.Outcome: The primary outcome measure is extubation failure, defined within 5 days following extubation. The key secondary outcome measure is time to effective extubation.Randomisation: Clusters are allocated to sequence of treatments using random blocks randomisation. The constitution of groups of clusters was stratified according to planned recruitment of each centre.Blinding: Investigators and outcome assessors are not blinded to condition allocation.Number of participants: 660 patients (220 in the control condition and 440 in the intervention condition).Ethics and dissemination The BIPER trial was approved by an independent ethics committee. The study began on 9 February 2020, and 571 participants are now included. Results will be published in an international peer-reviewed medical journal. Trial registration number NCT04080440.

L’utilisation et la surveillance de la pression transpulmonaire basée sur la manométrie œsophagienne a largement contribué à la personnalisation de la ventilation mécanique adaptée à la physiopathologie respiratoire des patients de soins critiques. Cependant, cette technique reste encore sous-utilisée dans la pratique clinique, même si elle apporte des informations majeures concernant la répartition des contraintes mécaniques entre poumons et paroi thoracique, et reste peu invasive. L’accès aux pressions transpulmonaires fournit des informations majeures pour limiter les atélectasies, améliorer l’aération pulmonaire et limiter les risques de surdistension et barotraumatisme. En ventilation spontanée, la surveillance de la pression œsophagienne fournit des informations importantes sur l’effort inspiratoire et le travail respiratoire du patient. Néanmoins, plusieurs controverses persistent sur les aspects techniques, l’interprétation et la prise de décisions cliniques basées sur les valeurs dérivées de cette technique de surveillance. L’objectif de cette mise au point est de proposer un résumé des bases physiologiques du monitorage de la pression œsophagienne, en discutant les aspects pratiques de son utilisation, l’interprétation des informations fournies, ses avantages et ses limites chez les patients de soins critiques et de bloc opératoire.

INTRODUCTION:Extubation of the trachea in the operating theatre may increase the time spent there. Conversely, tracheal extubation in the post-anaesthesia care unit may prolong the duration of anaesthesia and increase the incidence of complications. Our primary objective was to quantify the additional occupancy time associated with tracheal extubation in the operating theatre compared with the post-anaesthesia care unit. Secondary objectives were to assess the incidence of complications after tracheal extubation, including the need for ventilatory support. METHODS:This was a prospective dual-centre observational cohort study of patients whose tracheas were intubated for surgery in the operating theatre of two university hospitals. The primary endpoint was operating theatre occupancy time between the end of surgical procedure and discharge from the operating theatre. RESULTS:In total, 756 patients were included, and 494 (65.3%) tracheal extubations occurred in the operating theatre. Room occupancy time was increased by 7 min (95%CI 5-8 min, p = 0.001) when tracheal extubation was performed in the operating theatre compared with the post-anaesthesia care unit. After adjustment by matched or weighted propensity score, this time increased to 8 min (95%CI 6-10 min, p = 0.001) and 8 min (95%CI 6-9 min, p = 0.001), respectively. Desaturation after tracheal extubation (20.9% vs. 36.3%, p < 0.001) and arterial hypotension (0.6% vs. 3.1%, p = 0.019) were less frequent when tracheal extubation took place in the operating theatre. DISCUSSION:Tracheal extubation in the operating theatre is associated with an increase in theatre occupancy of < 8 min and a lower incidence of postoperative respiratory and cardiovascular complications.

The use and monitoring of trans-pulmonary pressure based on esophageal manometry has made a major contribution to the personalization of mechanical ventilation according to the respiratory pathophysiology of critical care patients. However, this minimally invasive technique is still underused in clinical practice, even though it provides major information about the distribution of mechanical stresses between the lungs and the chest wall. Access to trans-pulmonary pressures provides major information for limiting atelectasis, improving lung aeration, and limiting the risk of overdistension and barotrauma. In spontaneous ventilation, monitoring esophageal pressure provides important information about inspiratory efforts and work of breathing. Nevertheless, a number of controversies persist concerning the technical aspects, interpretation, and clinical decision-making based on the values derived from this monitoring technique. The aim of this update is to provide a summary of the physiological basis of esophageal pressure monitoring, discussing the practical aspects of its use, the interpretation of the information provided, and its advantages and limitations in critical care and operating theatre patients.

BACKGROUND:The optimal method to prevent treatment failure after tracheal extubation in postoperative critically ill patients with obesity and morbid obesity remains unknown. METHODS:We conducted a secondary analysis of the EXTUBOBESE multicentre RCT comparing prophylactic noninvasive ventilation (NIV) and oxygen therapy (high-flow nasal oxygen [HFNO] and standard oxygen) in 585 postoperative critically ill patients with obesity (BMI ≥30 kg m-2) and morbid obesity (BMI ≥40 kg m-2). The primary outcome was treatment failure within 3 days after extubation, a composite of reintubation within 3 days (also analysed separately as secondary outcome), switch to the other study treatment, or premature study treatment discontinuation. The primary outcome analysis used a χ2 test. A Cox model was used for time without reintubation. RESULTS:Treatment failure occurred in 39/292 patients (13.4%) in the NIV group and in 70/293 patients (23.9%) in the oxygen therapy group (absolute risk difference: -10.5; 95% confidence interval: -16.8 to -4.3). Similar results were found when analysing separately HFNO from standard oxygen in the oxygen therapy group. Reintubation rate was 8.6% (25 patients) in the NIV group and 9.9% (29 patients) in the oxygen therapy group (P=0.58). Interaction test was significant for level of obesity (P=0.045). Time without reintubation according to level of obesity significantly differed between NIV group and oxygen therapy group (P=0.02) in patients with BMI ≥40 kg m-2, but not in patients with 30≤BMI<40 kg m-2 (P=0.70). CONCLUSIONS:Among postoperative critically ill adults with obesity undergoing tracheal extubation, our results suggest that use of noninvasive ventilation is effective to reduce treatment failure in comparison with oxygen therapy alone. These effects were more pronounced in patients with morbid obesity. CLINICAL TRIAL REGISTRATION:NCT04014920.

Purpose Treatment of circulatory failure involves fluid and/or catecholamines infusion. Excessive fluid infusion is associated with worse outcomes, while restrictive fluid strategies show no significant benefits. We aimed to evaluate efficacy of a personalized hemodynamic optimization protocol including three pillars: (i) diagnosing acute circulatory failure, (ii) using a validated hemodynamic monitoring, and (iii) evaluating preload dependency state before any fluid resuscitation. Methods Multicenter, stepped-wedge, cluster-randomized trial involving adult patients with septic shock due to an abdominal or a pulmonary infection. Patients received either usual care (control period), or a personalized hemodynamic optimization strategy (intervention period). Hierarchized primary outcomes included delta SOFA (Sepsis-related Organ Failure Assessment) score from inclusion to day 5, ICU length of stay, hospital length of stay, ventilator-free days, renal failure-free days and catecholamine-free days. Results 517 patients were enrolled: 289 in the control group and 228 in the intervention group. Delta SOFA score was 2.4 in the control group and 1.8 in the intervention group (p = 0.41). ICU length of stay was reduced by 2.5 days (95% CI 0 to 5) in the intervention group. In overall population, other primary outcomes showed no differences. For severe patients (i.e., baseline SOFA ≥ 10), ICU and hospital stay length of stay was also reduced by 3.7 days (95% CI -0.4 to 7.8) and 6.9 days (95% CI -0.7 to 14.4), respectively. Conclusion Although no statistically significant difference was observed in delta SOFA score, a personalized hemodynamic optimization strategy reduced ICU length of stay. Trial Registration ClinicalTrials.gov Identifier NCT03461900

Background We aimed to determine the epidemiology and outcomes of unplanned extubation (UE), both accidental and self-extubation, in ICU. Methods A multicentre prospective cohort study was conducted in 47 French ICUs. The number of mechanical ventilation (MV) days, and planned and unplanned extubation were recorded in each center over a minimum period of three consecutive months to evaluate UE incidence. Patient characteristics, UE environmental factors, and outcomes were compared based on the UE mechanism (accidental or self-extubation). Self-extubation outcomes were compared with planned extubation using a propensity-matched population. Finally, risk factors for extubation failure (re-intubation before day 7) were determined following self-extubation. Results During the 12-month inclusion period, we found a pooled UE incidence of 1.0 per 100 MV days. UE accounted for 9% of all endotracheal removals. Of the 605 UE, 88% were self-extubation and 12% were accidental-extubations. The latter had a worse prognosis than self-extubation (34%vs. 8% ICU-mortality, p < 0.001). Self-extubation did not increase mortality compared with planned extubation (8 vs. 11%, p =  0.075). Regardless of the type of extubation, planned or unplanned, extubation failure was independently associated with a poor outcome. Cancer, higher respiratory rate, lower PaO2/FiO2 at the time of extubation, weaning process not-ongoing, and immediate post-extubation respiratory failure were independent predictors of failed self-extubation. Conclusion Unplanned extubation, mostly represented by self-extubation, is common in ICU and accounts for 9% of all endotracheal extubations. While accidental extubations are a serious and infrequent adverse event, self-extubation does not increase mortality compared to planned extubation.

Background & AimsSerum prealbumin is considered to be a sensitive predictor of clinical outcomes and a quality marker for nutrition support. However, its susceptibility to inflammation restricts its usage in critically ill patients according to current guidelines. We assessed the performance of the initial value of prealbumin and dynamic changes for predicting the ICU mortality and the effectiveness of nutrition support in critically ill patients.MethodsThis monocentric study included patients admitted to the ICU between 2009-2016, having at least one initial prealbumin value available. Prospectively recorded data were extracted from the electronic ICU charts. We used both univariable and multivariable logistic regressions to estimate the performance of prealbumin for the prediction of ICU mortality. Additionally, the association between prealbumin dynamic changes and nutrition support was assessed via a multivariable linear mixed-effects model and multivariable linear regression. Performing subgroup analysis assisted in identifying patients for whom prealbumin dynamic assessment holds specific relevance.ResultsWe included 3136 patients with a total of 4942 prealbumin levels available. Both prealbumin measured at ICU admission (adjusted odds-ratio (aOR) 0.04, confidence interval (CI) 95% 0.01-0.23) and its change over the first week (aOR 0.02, CI95 0.00-0.19) were negatively associated with ICU mortality. Throughout the entire ICU stay, prealbumin dynamic changes were associated with both cumulative energy (estimate: 33.2, standard error (SE) 0.001, p < 0.01) and protein intakes (1.39, SE 0.001, p<0.01). During the first week of stay, prealbumin change was independently associated with mean energy (6.03e-04, SE 2.32e-04, p<0.01) and protein intakes (1.97e-02, SE 5.91e-03, p<0.01). Notably, the association between prealbumin and energy intake was strongest among older or malnourished patients, those suffering from increased inflammation and those with high disease severity. Finally, prealbumin changes were associated with a positive mean nitrogen balance at day 7 only in patients with SOFA<4 (p=0.047).ConclusionPrealbumin measured at ICU admission and its change during the first-week serve as an accurate predictor of ICU mortality. Prealbumin dynamic assessment may be a reliable tool to estimate the effectiveness of nutrition support in the ICU, especially among high-risk patients.