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Use, Timing and Factors Associated with Tracheal Intubation in Septic Shock: a Prospective Multicentric Observational Study C

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Use, Timing and Factors Associated with Tracheal Intubation in Septic Shock: a Prospective Multicentric Observational Study C Darreau et al. Ann. Intensive Care (2020) 10:62 https://doi.org/10.1186/s13613-020-00668-6 RESEARCH Open Access Use, timing and factors associated with tracheal intubation in septic shock: a prospective multicentric observational study C. Darreau1, F. Martino2, M. Saint‑Martin1, S. Jacquier3, J. F. Hamel4, M. A. Nay5, N. Terzi6, G. Ledoux7, F. Roche‑Campo8, L. Camous9, F. Pene10, T. Balzer11, F. Bagate12, J. Lorber13, P. Bouju14, C. Marois15, R. Robert16, S. Gaudry17, M. Commereuc18, M. Debarre19, N. Chudeau1, P. Labroca20, K. Merouani21, P. Y. Egreteau22, V. Peigne23, C. Bornstain24, E. Lebas25, F. Benezit26, S. Vally27, S. Lasocki28, A. Robert29, A. Delbove30 and N. Lerol le31* Abstract Background: No recommendation exists about the timing and setting for tracheal intubation and mechanical venti‑ lation in septic shock. Patients and methods: This prospective multicenter observational study was conducted in 30 ICUs in France and Spain. All consecutive patients presenting with septic shock were eligible. The use of tracheal intubation was described across the participating ICUs. A multivariate analysis was performed to identify parameters associated with early intubation (before H8 following vasopressor onset). Results: Eight hundred and ffty‑nine patients were enrolled. Two hundred and nine patients were intubated early (24%, range 4.5–47%), across the 18 centers with at least 20 patients included. The cumulative intubation rate during the ICU stay was 324/859 (38%, range 14–65%). In the multivariate analysis, seven parameters were signifcantly asso‑ ciated with early intubation and ranked as follows by decreasing weight: Glasgow score, center efect, use of acces‑ sory respiratory muscles, lactate level, vasopressor dose, pH and inability to clear tracheal secretions. Global R‑square of the model was only 60% indicating that 40% of the variability of the intubation process was related to other param‑ eters than those entered in this analysis. Conclusion: Neurological, respiratory and hemodynamic parameters only partially explained the use of tracheal intubation in septic shock patients. Center efect was important. Finally, a vast part of the variability of intubation remained unexplained by patient characteristics. Trial registration Clinical trials NCT02780466, registered on May 23, 2016. https ://clini caltr ials.gov/ct2/show/NCT02 78046 6?term intub atic&draw 2&rank 1. = = = Keywords: Septic shock, Tracheal intubation, Mechanical ventilation Background patient [1]. However, these guidelines do not indicate the Several international guidelines such as the Surviving place for tracheal intubation and initiation of mechanical Sepsis Campaign help physicians to manage septic shock ventilation. Several arguments have been put forward in favor of *Correspondence: nicolas.lerolle@univ‑angers.fr early ventilatory support in septic shock patients, as part 31 Medical Intensive Care Unit, Angers University Hospital, Angers, France of the bundle that should be introduced in the frst hours Full list of author information is available at the end of the article © The Author(s) 2020. This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creat iveco mmons .org/licen ses/by/4.0/. Darreau et al. Ann. Intensive Care (2020) 10:62 Page 2 of 10 of care together with antibiotic, fuid, and vasopressor intubation were defned a priori, based on accepted use. Reducing work of breathing and oxygen consump- recommendations for invasive ventilation initiation in tion to maintain adequate tissue oxygenation, preventing neurologic or respiratory failure. Frequency of early intu- diaphragmatic dysfunction and self-inficted lung injury bation and patient characteristics were described among are expected benefts of invasive ventilation [2, 3]. Several those with such criteria [12–16]. Second, a multivariate studies have shown that diaphragmatic dysfunction may analysis entering a wide array of parameters was per- occur as early as in the frst 4 h of septic shock [4, 5]. On formed to assess the link between these parameters and the other hand, arguments to challenge a systematic use early intubation among all patients. An evaluation of the of ventilatory support in septic shock include immediate goodness-of-ft of the model was performed to determine complications of tracheal intubation (including hemody- the amount of early intubation variability explained by namic impairment) as well as potential side efects related the diferent covariates. to ventilation (ventilator-induced diaphragm dysfunc- Te inclusion period ran from May 2016 to October tion, muscle atrophy, ventilation-induced lung injuries, 2017. ICUs were involved gradually and had 12-months and ventilator-associated pneumonia) [6–8]. In recent to include patients. Te protocol allowed for a maximum multicenter trials on septic shock patients, the percent- of 60 patients enrolled per center. Physicians participat- age of patients who received invasive ventilation ranged ing in the study were aware of its main objective, but widely from 40 to 80% [9, 10]. In a declarative interna- were instructed to perform patient’s care as they usually tional survey, 86% of clinicians declared that the decision did, and no specifc hypothesis was put forward regard- to initiate invasive ventilation was based on “common ing optimal management of these patients. Patients, or sense” or “human physiological data” [11]. Agreement a proxy if the patient was deemed unable to consent, between responders regarding hemodynamic parameters received oral and written information about the study, to initiate mechanical ventilation was low, contrary to and oral consent was obtained before inclusion. When neurologic and respiratory criteria. In acute neurologic a proxy gave the initial consent, the patient’s consent and respiratory failures, indications for intubation and was further obtained whenever possible. Tis study was mechanical ventilation are generally well-accepted across approved by the Angers University Hospital Ethics com- studies, based on reliable quantitative parameters (res- mittee (n° 2015/96). piratory rate, use of accessory respiratory muscles, PaO 2/ Patients FiO2 ratio, and Glasgow coma score) [12–16]. How phy- sicians apply these criteria in septic shock patients and Patients aged 18 years and above were eligible if admit- whether other parameters, in particular hemodynamic, ted in a participating ICU for septic shock, defned by a are involved is unknown. documented or clinical suspicion of infection and hypo- To assess use, timing and factors associated with tra- tension requiring vasopressor infusion despite adequate cheal intubation in septic shock patients, we conducted a fuid loading. Patients could be included if a vasopressor multicenter observational prospective study in 30 inten- was introduced in the 24 h preceding ICU admission, sive care units (ICUs) in France and Spain. Our hypoth- i.e., in another hospital or the emergency room. Patients esis was that in the absence of specifc recommendations were not eligible if vasopressor infusion was started after in the sepsis care bundle, use and timing of tracheal intu- tracheal intubation and mechanical ventilation (non- bation might vary greatly between patients. invasive ventilation through facial mask did not pre- vent inclusion). Incapacitated adults, pregnant women, Methods patients with a decision of withdrawal or withholding of Te INTUBATIC study was a prospective, multicenter care before ICU admission, patients without social health observational study conducted in 30 ICUs (29 in France insurance and patients who refused to participate in the and one in Spain) in both academic and non-academic study were not included. hospitals. Te primary endpoint was to assess rate of intubation, early and late, and factors associated with Measurements intubation practice in septic shock patients. Te sec- Age, sex, and main comorbidities were noted. SAPS II ondary endpoint was to assess mortality according to and SOFA score were calculated 24 h after ICU admis- intubation. sion [18, 19]. Infection site, causal pathogen(s), and noso- We considered a time window of 8 h following vaso- comial or community-acquired subset of infection were pressor onset to defne early intubation, from the results registered. Hemodynamic, respiratory, and neurological of our previous study [17]. Two approaches were used to parameters were recorded between the time of vasopres- assess the parameters associated with early intubation. sor onset (H0) and H8: oxygen administration device and First, criteria for standard indications for early tracheal PaO2/FiO2 ratio (see Additional fle 1: Table S1 for FiO 2 Darreau et al. Ann. Intensive Care (2020) 10:62 Page 3 of 10 determination), respiratory rate, accessory inspiratory literature review and advice
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