Background:Parity has been reached among French residents in the intensive care medicine (ICM) specialty; however, concerns about underrepresentation of women in leadership position and gender discriminations remain. We hypothesised that perception of gender inequity differs between female and male ICM residents and increases along the ICM training. Methods:This nationwide observational closed-survey investigated how ICM residents experienced their medical curriculum, how they perceived the ICM specialty, and the potential reasons for women to be underrepresented in leadership position. Results:Among 113 residents who responded to the survey, 63 (55.6%) were females, and 85 (75.2%) were beginners. Twenty-nine (25.7%) answered to be always or often self-confident, and this number was lower in female than in male residents (14.3% versus 40.8%, p = 0.003). Women had less often than men the feeling to keep up with the situation along their medical training (39.7% versus 70.8%, p = 0.004). Societal injunctions to prioritise family over professional responsibilities were more often considered as barriers to leadership position by women than by men (75.8% versus 51.1%, p = 0.015). Fully trained residents agreed more frequently than beginners with the 2 following reasons associated with gender gap in ICM leadership position: men being more ambitious (31.1% versus 9.4%, p = 0.024) and professional environment discriminating against women (64% versus 46.2%, p = 0.017). Experience of non-physical sexual harassment was very common in female residents, with 74.6% of them reporting to have been directly subjected to jokes of a sexual nature (versus 28.6% of men, p = 0.001) and 49.2% of them to have been victims of allegations with humiliating connotation (versus 22.4% of men, p = 0.007). Conclusions:Female ICM residents reported more often the feeling of not coping with their medical training, the lack of self-confidence, and non-physical sexual harassment than men. Reported awareness of a less supportive institutional environment to women academic career and of difference in assertiveness between men and women increased along advancement in ICM training suggesting room for interventions.

OBJECTIVES:To assess the effects of adjunctive inhaled antibiotics in treating ventilator-associated pneumonia (VAP). DATA SOURCES:We searched PubMed, Web of Science, Embase, Cochrane Library, and ClinicalTrials.gov through May 31, 2025. STUDY SELECTION:We included randomized controlled trials (RCTs) and nonrandomized studies comparing adjunctive inhaled antibiotics with placebo/blank or IV antibiotics for VAP treatment. DATA EXTRACTION:Two groups independently screened studies, extracted data, and assessed risk of bias. Analyses used random effects models. Subgroup analyses, meta-regression, trial sequential analysis, and the Grading of Recommendations Assessment, Development, and Evaluation were performed. DATA SYNTHESIS:We included 32 RCTs in the primary analysis and 41 non-RCTs in sensitivity analysis. Compared with placebo/blank, inhaled antibiotics significantly improved clinical cure (16 RCTs; n = 1425; risk ratio [RR], 1.24; 95% CI, 1.07-1.43) and reduced all-cause mortality (21 RCTs; n = 1855; RR, 0.84; 95% CI, 0.71-0.98), with consistent findings in sensitivity analyses including non-RCTs. These benefits were significant in VAP-only patients (clinical cure: 11 RCTs; n = 775; RR, 1.29; 95% CI, 1.10-1.52 and all-cause mortality: 15 RCTs; n = 1152; RR, 0.77; 95% CI, 0.65-0.90), but not in studies including mixed pneumonia populations. Meta-regression confirmed VAP-only population as a significant effect modifier. Inhaled antibiotics also improved microbiological eradication (20 RCTs; n = 1805; RR, 1.42; 95% CI, 1.27-1.58) and reduced emergence of new drug resistance (four RCTs; n = 182; RR, 0.20; 95% CI, 0.06-0.64). No differences were found in ICU length of stay, ventilator duration, or other adverse events. Compared with IV antibiotics, inhaled antibiotics shortened ventilator duration (three RCTs; n = 322; mean difference, -2.11 d; 95% CI, -3.73 to -0.49 d), and reduced nephrotoxicity (three RCTs; n = 292; RR, 0.42; 95% CI, 0.26-0.68). CONCLUSIONS:Compared with placebo/blank, adjunctive inhaled antibiotics improve clinical cure and microbiological eradication, and may reduce mortality, particularly in VAP-only patients. Exploratory analyses based on limited data suggest potential advantages over IV therapy, including shorter ventilator duration and lower nephrotoxicity, warranting further high-quality trials.

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

Over the past five decades, prone positioning has evolved from single case reports to an evidence-based intervention. Initially used as a rescue therapy, it is now recognized as an integral component of lung-protective mechanical ventilation strategies, applied early in intubated patients with acute respiratory distress syndrome (ARDS) with a PaO2/FIO2 ratio < 150 mmHg. The COVID-19 pandemic further expanded its use to non-intubated patients, the so-called awake prone position (APP), with promising results. APP requires confirmation in non-COVID patients and in a more routine ICU practice. Improved oxygenation is a consistent and well-recognized effect of prone positioning in both intubated and non-intubated patients with ARDS. Beyond its effects on gas exchange, prone positioning mitigates ventilator-induced lung injury by reducing lung stress and strain and may also confer favorable hemodynamic effects. This article reviews the physiologic rationale for prone positioning, evidence from randomized controlled trials, current guideline recommendations, practical aspects of implementation, and ongoing questions in both intubated and non-intubated patients.

Amikacin nebulization may be used in mechanically ventilated patients for pneumonia prevention and treatment. Available drug delivery and pharmacokinetic knowledge mainly rely on in vitro data and studies of a limited number of patients. To evaluate pulmonary and systemic pharmacokinetics of nebulized amikacin in mechanically ventilated patients and assess the influence of ventilation and nebulization conditions on drug concentrations in the tracheal aspirate and plasma, this ancillary study of a published randomized trial performed population pharmacokinetic modelling on 498 tracheal aspirates and 602 plasma concentrations following 20 mg/kg amikacin vibrating mesh nebulization among 261 patients. Tracheal aspirate amikacin concentrations were very high but variable between patients (median peak concentration 7269 µg/g, interquartile range 4935–9846 µg/g). The tracheal aspirate concentration declined with a median terminal half-life of 7.6 h (interquartile range 5.3–44.2 h), and no accumulation was observed over three doses. Systemic absorption was marginal (median peak plasma concentration 1.9 mg/L, interquartile range 1.3-3.0 mg/L). Despite differences in ventilation mode, circuit type, humidification, inspiratory flow rate, respiratory rate, and tidal volume, no significant impact on tracheal aspirate and plasma amikacin concentrations was observed. Nebulized amikacin achieved high pulmonary concentrations with minimal systemic exposure. Tracheal aspirate and plasma drug concentration were not significantly influenced by ventilation or nebulization conditions. These findings suggest that strict optimization of nebulization parameters may not be necessary when aiming for tracheobronchial antibiotic inhaled delivery such as to prevent ventilator associated pneumonia.

Intensive care unit (ICU) patients endure significant stress due to their critical condition, communication difficulties, and the hostile environment. Despite efforts to humanize ICUs, there is a lack of real-time assessment tools for patient well-being and sense of safety. The aim of this project was to develop a scale assessing the feeling of well-being and safety in real time among intubated patients. A systematic review was performed to identify study outcomes evaluating well-being and sense of security. Results were used to organize focus groups and explore patients’ experiences during their ICU stay. The scale was then developed via Delphi methodology by a patient-professional group. The scale was validated through patient interviews for face validity and implementation in a multicentric French cohort. Lastly, the scale was translated in English. The systematic review included 137 articles. Focus groups (23 former patients and 5 relatives) highlighted communication challenges and the need for human support. Scale construction resulted in an initial 6-item pragmatic bedside tool. Face validation showed that the constructed scale was acceptable and led to refining the scale by changing item evaluation formats to a 4-stage Likert scale. Cohort validation, comprising 305 scale administrations (84 patients), indicated overall satisfaction and adequate completion rates. Psychometric analysis led to the removal of two items. A simplified 4-item scale (Comfort, Safety, Information, Trust) demonstrated improved reliability and coherence. The final scale provides a practical measure of patient well-being in ICUs and is usable in real time at the bedside. A simple, quick, and effective scale to assess, in real-time at the bedside, the well-being and sense of safety of intubated patients and all patients hospitalized in intensive care units, was co-constructed with former patients, relatives, and healthcare professionals.

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.).

Purpose:Ventilator-associated pneumonia (VAP) remains one of the most serious hospital-acquired infections in the intensive care unit (ICU), with high morbidity and mortality. Early identification of patients at risk for developing VAP could enable timely diagnostics and intervention. However, current clinical tools are limited in their ability to detect early physiologic signals preceding VAP onset. We aimed to build supervised machine learning models to predict short term onset of VAP. Methods:We analyzed electronic health record data from a prospective observational cohort of ICU patients, where VAP was adjudicated using a standardized published protocol by a panel of critical care physicians. Clinical features (including vital signs, ventilator settings, laboratory values, and support devices) were extracted for each patient-ICU-day. We explored unsupervised clustering to characterize feature dynamics associated with VAP onset. We built multiple machine learning models across different prediction windows (3, 5, 7 days before VAP). We examined model performance in two external cohorts, MIMIC-IV and secondary analysis of the AMIKINHAL trial. Results were evaluated with discrimination metrics such as AUROC. Results:The internal cohort included 507 patients with BAL-confirmed diagnoses: 261 developed VAP and 246 did not have VAP. Visualization using clustering identified distinct physiologic states enriched for VAP-labeled days. The best-performing model achieved an AUROC of 0.866 in predicting VAP up to seven days before clinical diagnosis. Temporal model probability trajectories showed rising model confidence in the days leading up to VAP. On external validation in MIMIC-IV, the best model achieved an AUROC of 0.817 for forecasting VAP within five days. There was low feature overlap with the AMIKINHAL trial data, leading to poor model performance. Feature analysis revealed that platelet count, positive end-expiratory pressure (PEEP), ventilator duration, and inflammatory markers were key drivers of model predictions. Conclusions:Machine learning models trained on routinely collected ICU data with careful labeling can anticipate VAP onset up to a week in advance with strong predictive performance. Model performance generalized to data from an entirely different hospital system despite differences in practice and labeling patterns, but did not perform well when there was poor feature overlap. Future work should focus on real-time prospective evaluation.

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

Importance Ethical, administrative, regulatory, and logistical (EARL) procedures can hamper clinical trial delivery. Quantification of these hurdles is rare, prohibiting identification of areas for improvement. Objective To identify and quantify EARL hurdles in trial delivery before and during the COVID-19 pandemic. Design, Setting, and Participants This cohort study used data from the ongoing Randomized Embedded Multifactorial Adaptive Platform Trial for Community-Acquired Pneumonia to enable comparison of EARL procedures for multiple protocols across 19 European countries in the pre-COVID-19 pandemic (February 19, 2016 to March 10, 2020) and COVID-19 pandemic (March 11, 2020, to May 4, 2023) periods. Data were analyzed from November 2024 to March 2025 with contracts and protocol submissions as the units of analysis. Main Outcome and Measures Time to (1) site contract completion, (2) regulatory and ethical approval (TTA), and (3) first patient in (FPI). The UK was compared with non-UK countries because of its distinct research infrastructure. Results There were 257 fully signed first contracts with study sites for analysis. In the UK, contract completion times decreased by 97% (95% CI, 95% to 98%), from a median (IQR) of 196 (154 to 250) days in the pre-COVID-19 pandemic period to 5 (1 to 11) days during the COVID-19 pandemic. In non-UK countries, median (IQR) contract completion times were 224 (119 to 412) days and 183 (62 to 291) days before and during the COVID-19 pandemic, respectively (relative difference, -18%; 95% CI, -43% to 52%). In total, 44 interventions in 16 domains were submitted, yielding 232 protocol approvals for analysis. During the COVID-19 pandemic, median (IQR) TTA was 8 (5 to 31) days in the UK and 115 (47 to 103) days in non-UK countries (median difference, 107 days; 95% CI, 76 to 123 days), with large variation across non-UK countries. Time between approval and FPI during the COVID-19 pandemic was, on average, 3 months faster in the UK compared with non-UK countries (median difference, 90 days; 95% CI, 42 to 141 days). Conclusions and Relevance This study found that EARL procedures were lengthy and variable between countries, reflecting different interpretations of trial regulations, with faster processes in the UK. These findings underscore the need to streamline processes across European countries to improve trial efficiency, in particular during future public health emergencies such as pandemics.

OBJECTIVES:To assess the reliability of conventional automated oscillometric upper arm cuff (cuff ARM ): 1) when finger cuff monitoring (cuff FINGER ) of arterial pressure (AP) is suspected to be unreliable due to poor fingertip perfusion and/or hand edema or 2) fails to provide a reading. DESIGN:Prospective observational study based on cohorts evaluating the CNAP (Dräger Medical) and ClearSight (Edwards Lifesciences) systems. SETTING:Three ICUs. PATIENTS:Adults with an arterial catheter and stable AP. INTERVENTIONS:Three sets of triplicate AP measurements-simultaneous readings from the cuff FINGER , cuff ARM and, as a reference, arterial catheter-were collected for each patient. MEASUREMENTS AND MAIN RESULTS:We analyzed 352 patients: 214 with the CNAP and 138 with the ClearSight cuff FINGER . In the 102 patients (29%) with poor fingertip perfusion-defined as a capillary refill time greater than 4 seconds-and/or hand edema, cuff ARM mean AP measurements ( n = 304) never failed, met the International Organization for Standardization (ISO) 81060-2:2018 standard (bias ± sd : 2.2 ± 7.2 mm Hg), posed no or low risk of harm in 99.7% of cases, and demonstrated good ability to detect hypotension and hypertension (area under the receiver operating characteristic curve, 0.91 [95% CI, 0.87-0.94] and 0.92 [95% CI, 0.75-1], respectively). In these 102 patients, cuff FINGER failed to display a reading in 17 patients (17%), and if not, did not meet the ISO 81060-2:2018 standard. In 38 of 352 patients (11%) in whom the cuff FINGER failed to display an AP measurement, cuff ARM met the ISO 81060-2:2018 standard for mean AP (bias ± sd : 1.7 ± 7.1 mm Hg). In the absence of failure and risk factors for erroneous measurements, ClearSight met the ISO 81060-2:2018 standard for mean AP, unlike the CNAP system. CONCLUSIONS:In a multimodal, noninvasive strategy for AP monitoring, ClearSight cuff FINGER may be suitable as a first-line tool due to its continuous nature. When unreliable or unavailable, cuff ARM provides reliable measurements, effectively detects hypotension and hypertension, and poses no significant risk to the patient.

There are recognized diagnostic criteria for a first ventilator-associated pneumonia (VAP) episode, but not for recurrences. Many randomized clinical trials (RCTs) have used the recurrence of VAP as a criterion for efficacy evaluation. Still, the different definitions used in RCTs make it difficult to compare studies. We aimed to develop a consensual definition of VAP recurrences and of the various types of VAP recurrences. Thirty-six European experts constituting a multidisciplinary group of physicians (critical care, infectious diseases, microbiology) with special interest in the management of VAP were polled using the Delphi methodology. After the completion of four iterations of the DELPHI method, 94

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

Background:Social precariousness hinders access to the cascade of care in people with HIV (PHIV). Its impact on the clinical presentation and outcome of critical illnesses in this patient population is unknown. Methods:We included all PHIV admitted over the 2015 to 2020 period in 12 university-affiliated intensive care units in France. Precarious patients encompassed undocumented migrants, homeless, and individuals facing other forms of socioeconomic deprivation. Precarious and nonprecarious PHIV were compared for baseline characteristics and reasons for admission. The effect of precariousness on in-hospital mortality (primary endpoint) and 1-year mortality (secondary endpoint) was measured through logistic regression. Results:Among the 939 included PHIV, 136 (14.5%) were classified as precarious (migrants, 5.7%; others, 8.7%). Compared to nonprecarious patients, (1) migrants were younger, had fewer comorbidities, and were more often admitted with previously unknown HIV and/or for AIDS-defining opportunistic infections; and (2) precarious patients other than migrants presented with lower rates of viral suppression (despite similar access to combination antiretroviral therapies) and were more often admitted for bacterial sepsis. Overall in-hospital and 1-year mortality rates were 17.8% and 24.2%, respectively. Precariousness was not independently associated with in-hospital mortality (adjusted odds ratio, 1.04; 95% confidence interval, .98-1.10) or 1-year mortality (adjusted odds ratio, .89; 95% confidence interval, .54-1.48), including when analyzing migrants separately. Conclusions:Precarious PHIV requiring intensive care unit admission have particular clinical features that likely reflect chronic inequities in access to HIV care. However, precariousness is probably not linked with a higher hazard of death during the index hospital stay or at 1 year.

Background Mortality of immunocompromised patients is particularly high in intensive care units (ICUs) and mainly depends on severity at admission. Moreover, mortality is also high during the months following ICU discharge. The reasons for these poor outcomes after ICU discharge have not been adequately studied. Research question We hypothesized that the factors associated with poor outcomes after ICU discharge of immunocompromised patients would be different from those associated with in-ICU mortality. Study design and methods This is a post-hoc analysis of a multicenter clinical trial comparing two noninvasive oxygenation strategies in immunocompromised patients admitted to ICU for acute hypoxemic respiratory failure. Multivariable analyses were performed to determine early factors (i.e within 6 h of admission) associated with in-ICU mortality, as well as factors associated with poor functional outcomes (i.e death or survival with poor performance status) at 6 months, only in ICU survivors. Results Among the 299 patients analyzed, the mortality rate was 31% (94 patients) in the ICU and 49% at 6 months (146 patients). Solid cancer (adjusted odds ratio 2.92 [95% confidence interval, 1.22–7.28]), severity SOFA score at admission (aOR 1.29 [1.14–1.48]), the extent of pulmonary infiltrates on chest X-ray (aOR 1.57 [1.17–2.15]) and increased discomfort one hour after initiation of noninvasive respiratory support (aOR 2.08 [1.12–3.85]) were independently associated with in-ICU mortality. Out of the 202 ICU survivors whose performance status was reported, solid cancer (aOR 3.03 [1.33–9.09]) and poor performance status before ICU admission (aOR 2.43 [1.03–5.88]) were both associated with poor outcome at 6 months, independently from the decision to forgo life-sustaining therapies (aOR 5.88 [2.17–20.00]). Interpretation Whereas in-ICU mortality of immunocompromised patients with acute respiratory failure was mainly driven by severity, poor outcomes at 6 months were mainly driven by performance status before ICU admission. Solid cancer was independently associated with both poor short as well as longer-term outcomes.Trial registration Clinical trial registration: NCT04227639

BACKGROUND:In patients with shock, whether noninvasive blood-pressure monitoring is an effective alternative to the recommended use of an arterial catheter is uncertain. METHODS:In this multicenter, open-label, noninferiority trial, we randomly assigned patients who had shock and had been admitted to an intensive care unit within the past 24 hours to receive early insertion (<4 hours after randomization) of an arterial catheter (invasive strategy) or to be monitored with an automated brachial cuff (noninvasive strategy). Insertion of an arterial catheter was allowed later in patients assigned to the noninvasive-strategy group who met prespecified safety criteria. The primary outcome was death from any cause at day 28 (noninferiority margin, 5 percentage points). Adverse events of special interest related to the blood-pressure-monitoring device that was used were recorded, as was patient-reported pain or discomfort related to the ongoing presence of the device. RESULTS:A total of 1010 patients underwent randomization; 504 patients assigned to the noninvasive-strategy group and 502 assigned to the invasive-strategy group were included in the analyses. A total of 74 patients (14.7%) in the noninvasive-strategy group and 493 (98.2%) in the invasive-strategy group underwent insertion of an arterial catheter. Death within 28 days occurred in 173 patients (34.3%) in the noninvasive-strategy group and 185 (36.9%) in the invasive-strategy group (adjusted risk difference, -3.2 percentage points; 95% confidence interval, -8.9 to 2.5; P = 0.006 for noninferiority). Results of per-protocol analyses were similar in the two groups. A total of 66 patients (13.1%) in the noninvasive-strategy group and 45 (9.0%) in the invasive-strategy group had at least 1 day of pain or discomfort related to the ongoing presence of the blood-pressure-monitoring device. Hematoma or hemorrhage related to the arterial catheter occurred in 5 patients (1.0%) in the noninvasive-strategy group and 41 patients (8.2%) in the invasive-strategy group. CONCLUSIONS:Among patients with shock, results for death from any cause at day 28 indicated that management without early arterial catheter insertion was noninferior to early catheter insertion. (Funded by the French Ministry of Health; ClinicalTrials.gov number, NCT03680963.).