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

OBJECTIVES: The practice of limiting life-sustaining therapy (LST) at end-of-life is widespread globally. The goal of this study was to evaluate whether patient's age influences end-of-life limitations overall and of various LST in ICUs worldwide. DESIGN: Multinational, multicenter, prospective observational study. SETTING: One hundred ninety-nine ICUs in 36 countries worldwide. PATIENTS: Consecutive adult patients admitted to ICUs who died and/or had LST limitations (withholding, withdrawing, or active shortening of the dying process) were included during a 6-month period between September 2015 and September 2016. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients were grouped: younger than 65 years, 65-79 years old, and 80 years old or older. A total of 12,200 patients were included. In multivariate logistic regression analysis, odds ratio (OR) for any LST limitation in the 80 years old or older group was higher than in younger than the 65 years old group (OR 1.47 [95% CI, 1.22-1.76], p < 0.001). When stratified by region, this association was significant in Central and Southern Europe (OR 1.56 [95% CI, 1.11-2.20], p = 0.037 and OR 2.23 [95% CI, 1.58-3.17], p < 0.001, respectively), but not in the other regions. The proportion of withholding therapy of each LST was highest in the group of individuals 80 years or older, whereas the proportion of withdrawing therapy was highest in the group younger than 65 years. The 80-year-old or older group also had a shorter time from ICU admission to first limitation. The predominant reason for any LST limitation in all age groups was unresponsiveness to maximal therapy, followed by neurologic and chronic diseases. Patient age was rarely the primary reason for limitations for all groups. CONCLUSIONS: End-of-life limitations were higher in patients 80 years or older compared to those 65 years old or younger, with regional variations. The main reasons for limitations were comparable across age groups, with age not being the primary reason.

Introduction Mortality has traditionally served as a primary endpoint in clinical trials. However, advancements in treatments and standard care have resulted in notable reductions in mortality rates. Consequently, detecting differences in mortality between interventions has become more challenging and often requires larger sample sizes. As a result, alternative endpoints have been proposed, such as Ventilator-Free Days (VFDs), although these are characterised by inconsistent definitions. Further development of other patient-reported outcome measures (PROMs), including assessments of quality of life and survival without sequelae, is warranted, as these may be more meaningful to patients. The survey aimed to characterise how intensivists perceive and use outcome measures in critical respiratory care research. Methods An anonymous electronic survey was distributed through two French intensive care society websites, enabling members to share their views; no individual email invitations were sent. Results A total of 267 participants completed the survey. Variability in VFDs definitions raised concerns about their use in clinical trials. Several respondents struggled to interpret recent outcomes, such as the win ratio and its effect sizes. It was ultimately agreed that additional PROMs—such as communication ability and the absence of sequelae at discharge—should be incorporated. Finally, three respondent clusters were identified, all of which recognised the importance of PROMs. Conclusion While French critical care physicians tend to have a clearer understanding of VFD’s definition, various alternative outcomes were also recognised. There was a consensus among respondents on the importance of further developing PROMs in clinical research.

Medical paternalism, where physicians decide based on perceived patient interests, contrasts with the value of patient autonomy, which emphasizes patients’ rights to make informed choices about their medical care. This study explores how trainees from cultures emphasizing these contrasting values interpret limitations on life-sustaining treatments, focusing on potential differences in decision-making. A survey was designed with two clinical vignettes and trainees rated their agreement or disagreement with 21 different treatment choices on a 5-point Likert scale. Surveys were distributed via Fellowship Program Directors in the U.S. and the ANJMIR in France. Statistical analysis used the Mann–Whitney U test to compare responses across countries and code status groups. A total of 217 trainees responded. Both American and French critical care trainees made different decisions based on patient code status alone, with the Americans being very polarized in their decisions and the French less so. Significant variations across interventions reflected cultural influences on medical decision-making. This study reveals significant cultural differences in decision-making between French and American critical care trainees. Americans align more closely with patient preferences, while French trainees show greater variability, highlighting the impact of cultural norms on medical practices and patient care.

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

Acute kidney injury (AKI) is common in hospitalized patients, and its incidence is rising sharply in intensive care units. It is associated with significant morbidity and mortality due to a profound change in its epidemiological profile - multifactorial in origin, often septic, and associated with other organ failures. The mortality rate reaches 30–50% in the most severe forms, particularly when AKI requires renal replacement therapy (RRT). Temporary RRT, when indicated, must be part of an overall therapeutic approach that also includes support for other vital functions, particularly cardio-circulatory, respiratory and nutritional. The current diversification of these methods means that they must be well mastered and the potential of each of them in terms of cost, efficacy, limitations and risks must be fully understood before a therapeutic decision can be taken. This narrative review was written by an expert panel and presented to the members of the jury of the French consensus conference to help in the development of guidelines for the use of RRT in critically ill adult and pediatric patients, excluding cases related to acute intoxication.

We propose the concept of “renal congestion syndrome” as a pathophysiological construct describing a potential contributor to acute kidney injury (AKI) in the intensive care unit (ICU). This concept should be considered as hypothesis-generating rather than a validated clinical entity with established diagnostic or therapeutic implications. Growing experimental and clinical evidence supports a plausible contributory role in kidney dysfunction. However, interventional evidence is currently lacking, and the clinical utility of targeting congestion remains to be established.When renal venous pressure rises, hydrostatic pressure in Bowman’s space and the interstitium increases. This reduces net ultrafiltration pressure and glomerular filtration rate, even if arterial pressure is preserved. Edema within the non-distensible capsule compresses tubules and peritubular capillaries, aggravating hypoxia and tubular injury. Lymphatic drainage may initially buffer this process, but fails with sustained congestion. In the ICU, congestion is common and multifactorial: fluid overload, right heart dysfunction, high intrathoracic pressures from ventilation, or intra-abdominal hypertension. Experimental data suggest that congestion may precipitate early loss of renal autoregulation, leaving kidneys vulnerable even at apparently normal mean arterial pressures. Moreover, it often coexists with hypotension, reducing mean perfusion pressure (MPP), further lowering renal perfusion pressure, and increasing the risk of AKI.Diagnosis relies on an integrated assessment combining clinical context with haemodynamic monitoring and, when available, imaging-based evaluation of venous congestion. Central venous pressure remains the standard reference for assessing central venous hypertension; however, its specificity for renal congestion is limited. Doppler ultrasound with Venous Excess Ultrasound (VExUS) score may improve detection and risk stratification, though interpretation can be confounded by mechanical ventilation or intra-abdominal hypertension.Management is conceptually aimed at relieving congestion while preserving renal perfusion. Based on physiological rationale and limited observational data, this may involve preventing fluid accumulation and implementing individualized decongestive strategies (e.g., fluid stewardship, diuretics when appropriate, or ultrafiltration when indicated). Haemodynamic-guided deresuscitation, integrating congestion markers with real-time MPP assessment, appears promising but remains supported only by feasibility data.Renal congestion-related mechanisms are likely frequent, under-recognized, and potentially reversible contributors to AKI in the critically ill patient. Systematic assessment of congestion-related mechanisms warrants further investigation. Whether their integration into haemodynamic evaluation improves clinical outcomes remains to be determined.

Legionella is the second cause of community-acquired pneumonia in Intensive Care Unit (ICU) patients. The aim of this study was to describe the epidemiology and outcome in patients with Legionella pneumonia (LP) in French ICUs. A multi-center, retrospective, observational study in 12 French ICUs was performed between January 2014 and December 2019. LP was diagnosed in 162 patients during the study period. Invasive mechanical ventilation was required in 95 patients (58

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

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

RATIONALE:The COVID-19 pandemic required unprecedented measures including visitation restrictions. OBJECTIVES:To assess their impact on psychological symptoms (anxiety-depression, posttraumatic stress disorder (PTSD)) among ICU family members. METHODS:In this prospective multicentre quasi-experimental study, family members of patients with invasive mechanical ventilation with or without COVID-19, were enrolled during one of three periods (March 15 - June 5) subject to visitation restriction policies mandated by French health authorities: forbidden (2020, n= 304), restricted (2021, n= 294) and unrestricted (2022, n= 213). Primary outcome was prevalence of anxiety-depression symptoms in family members 90 days after ICU discharge. MEASUREMENTS AND MAIN RESULTS:Among 811 members, prevalence of anxiety-depression symptoms did not significantly differ across the three periods (57.2%, 56.8% and 61.5%, P= 0.52; unrestricted vs restricted visitations: Relative Risk (RR), 1.08 (95%CI, 0.94‒1.25), P= 0.28; unrestricted vs forbidden visitations: RR, 1.08 (0.93‒1.24), P= 0.33). Similar findings were observed for PTSD risk (36.5%, 40.8% and 34.3%, P= 0.29). Anxiety-depression symptoms were associated with female relatives of patients (adjusted RR, 1.78 (1.28‒2.46), P= 0.001), dissatisfaction with ICU team's communication (aRR, 1.83 (1.22‒2.74), P= 0.004), and spouses of patients (aRR, 2.15 (1.42‒3.26), P< 0.001). For PTSD, these risk factors were also significant, in addition to COVID-19 disease (aRR, 1.52 (1.10‒2.10), P= 0.01) and patient death in ICU (aRR, 2.59 (1.91‒3.51], P< 0.001). CONCLUSIONS:This study does not support the hypothesis that visitation restriction policies during the COVID-19 pandemic exacerbated high prevalence of long-term psychological symptoms among ICU family members. This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License 4.0 (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Background: ICU nurses are most frequently at the patient's bedside, providing care for both patients and family members. They perform an essential role and are involved in decision-making. Despite this, research suggests that nurses have a limited role in the end-of-life decision-making process and are occasionally not involved. Objective: Explore global ICU nurse involvement in end of life decisions based on the physician's perceptions and sub-analyses from the ETHICUS-2 study. Design: This is a secondary analysis of a prospective multinational, observational study of the ETHICUS-2 study. Setting: End of life decision-making processes in ICU patients were studied during a 6-month period between Sept 1, 2015, and Sept 30, 2016, in 199 ICUs in 36 countries. Intervention: None. Methods: The ETHICUS II study instrument contained 20 questions. This sub-analysis addressed the four questions related to nurse involvement in end-of-life decision-making: Who initiated the end-of-life discussion? Was withholding or withdrawing treatment discussed with nurses? Was a nurse involved in making the end-of-life decision? Was there agreement between physicians and nurses? These 4 questions are the basis for our analysis. Global regions were compared. Results: Physicians completed 91.8 % of the data entry. A statistically significant difference was found between regions (p < 0.001) with Northern Europe and Australia/New Zealand having the most discussion with nurses and Latin America, Africa, Asia and North America the least. The percentages of end-of-life decisions in which nurses were involved ranged between 3 and 44 %. These differences were statistically significant. Agreement between physicians and nurses related to decisions resulted in a wide range of responses (27-86 %) (p < 0.001). There was a wide range of those who replied "not applicable" to the question of agreement between physicians and nurses on EOL decisions (0-41 %). Conclusion: There is large variability in nurse involvement in end-of-life decision-making in the ICU. The most concerning findings were that in some regions, according to physicians, nurses were not involved in EOL decisions and did not initiate the decision-making process. There is a need to develop the collaboration between nurses and physicians. Nurses have valuable contributions for best possible patient-centered decisions and should be respected as important parts of the interdisciplinary team. Tweetable abstract: Wide global differences were found in nurse end of life decision involvement, with low involvement in North and South America and Africa and higher involvement in Europe and Australia/New Zealand. (c) 2024 Elsevier Ltd. All rights reserved.

Cytomegalovirus (CMV) infection in patients with cellular immune deficiencies is associated with significant morbidity and mortality. However, data on CMV end-organ disease (CMV-EOD) in critically ill, immunocompromised patients are scarce. Our objective here was to describe the clinical characteristics and outcomes of CMV-EOD in this population. We conducted a multicenter, international, retrospective, observational study in adults who had CMV-EOD and were admitted to any of 18 intensive care units (ICUs) in France, Israel, and Spain in January 2010–December 2021. Patients with AIDS were excluded. We collected the clinical characteristics and outcomes of each patient. Survivors and non-survivors were compared, and multivariate analysis was performed to identify risk factors for hospital mortality. We studied 185 patients, including 80 (43.2

Better cost-awareness is a prerogative in achieving the best benefit/risk/cost ratio in the care. We aimed to assess the cost-awareness of intensivists in their daily clinical practice and to identify factors associated with accurate estimate of cost (50–150

Rationale: Psychological resilience (the ability to thrive in adversity) may protect against mental-health symptoms in healthcare professionals during coronavirus disease (COVID-19) waves. Objectives: To identify determinants of resilience in ICU staff members. Methods: In this cross-sectional survey in 21 French ICUs, staff members completed the 10-item Connor-Davidson Resilience Scale, Hospital Anxiety and Depression Scale, and Impact of Event Scale-Revised (for post-traumatic stress disorder [PTSD]). Factors independently associated with resilience were identified. Measurements and Main Results: The response rate was 73.1% (950 of 1,300). The median 10-item Connor-Davidson Resilience Scale score was 29 (interquartile range, 25-32). Symptoms of anxiety, depression, and PTSD were present in 61%, 39%, and 36% of staff members, respectively. Distress associated with the COVID-19 infodemic was correlated with symptoms of depression and PTSD. More resilient respondents less often had symptoms of anxiety, depression, and PTSD. Greater resilience was independently associated with male sex, having provided intensive care during the early waves, having managed more than 50 patients with COVID-19, and, compared with earlier waves, working longer hours, having greater motivation, and more often involving families in end-of-life decisions. Independent risk factors for lower resilience were having managed more than 10 patients who died of COVID-19, having felt frightened or isolated, and greater distress from the COVID-19 infodemic. Conclusions: This study identifies modifiable determinants of resilience among ICU staff members. Longitudinal studies are needed to determine whether prior resilience decreases the risk of mental ill health during subsequent challenges. Hospital and ICU managers, for whom preserving mental well-being among staff members is a key duty, should pay careful attention to resilience.

Guidelines for diabetic ketoacidosis (DKA) management are limited, resulting in varied practices. This study assessed Intensive Care Unit (ICU) admission criteria, fluid resuscitation, insulin therapy, and metabolic management in adult patients with DKA. An international survey of ICU clinicians consisted of 39 items that focused on management of DKA and was endorsed by the European Society of the Intensive Care Medicine. An experienced ICU was defined as a unit admitting > 20 patients with DKA per year. A total of 522 respondents from 57 different countries participated: 295(57

IntroductionFirst-line oxygenation strategy in patients with acute hypoxaemic respiratory failure consists in standard oxygen or high-flow nasal oxygen therapy. Clinical practice guidelines suggest the use of high-flow nasal oxygen rather than standard oxygen. However, findings remain contradictory with a low level of certainty. We hypothesise that compared with standard oxygen, high-flow nasal oxygen may reduce mortality in patients with acute hypoxaemic respiratory failure.Method and analysisThe Standard Oxygen versus High-flow nasal Oxygen-trial is an investigator-initiated, multicentre, open-label, randomised controlled trial comparing high-flow nasal oxygen versus standard oxygen in patients admitted to an intensive care unit (ICU) for acute respiratory failure with moderate-to-severe hypoxaemia. 1110 patients will be randomly assigned to one of the two groups with a ratio of 1:1. The primary outcome is the number of patients who died 28 days after randomisation. Secondary outcomes include comfort, dyspnoea and oxygenation 1 hour after treatment initiation, the number of patients intubated at day 28, mortality in ICU, in hospital and until day 90, and complications during ICU stay.Ethics and disseminationThe study has been approved by the central Ethics Committee ‘Sud Méditerranée III’ (2020-07-05) and patients will be included after informed consent. The results will be submitted for publication in peer-reviewed journals.Trial registration numberNCT04468126.

Background and aims: To investigate the contribution of FGF23 in explaining the cases of hypophosphatemia observed in clinical practice, we aimed to determine for the first time the prevalence of FGF23 elevation in patients with hypophosphatemia and to describe the different mechanisms of FGF23-related hypophosphatemic disorders. Materials and methods: We performed a prospective, observational, multicenter, cohort study of 260 patients with hypophosphatemia. Blood measurements (PTH, 1,25-dihydroxyvitamin D, bone alkaline phosphatase, 25hydroxyvitamin D, and FGF23) were performed on a Liaison XL (R) (DiaSorin) analyzer. Results: Primary elevation of FGF23 (>95.4 pg/mL) was reported in 10.4% (95CI: 7.0-14.7) of patients (n = 27) with hypophosphatemia, suggesting that at least 1 in 10 cases of hypophosphatemia was erroneously attributed to an etiology other than FGF23 elevation. Patients with elevated blood FGF23 were grouped according to the etiology of the FGF23 elevation. Thus, 10 patients had a renal pathology, chronic kidney disease or post-renal transplantation condition. The remaining patients (n = 17) had the following etiologies: malignancies (n = 9), benign pancreatic tumor (n = 1), post-cardiac surgery (n = 4), cirrhosis (n = 2), and chronic obstructive pulmonary disease (n = 1). Conclusion: In order to improve patient management, it seems essential to better integrate plasma FGF23 measurement into the routine evaluation of hypophosphatemia.