Journal Article

A multi-faceted strategy to reduce ventilation-associated mortality in brain-injured patients. The BI-VILI project: a nationwide quality improvement project

Perrigault, Pierre François, Muller, Laurent, Rozec, Bertrand, Pujol, Anne, Hanouz, Jean Luc, Ichai, Carole, Sebille, Véronique, Asehnoune, Karim, Pelosi, Paolo, Geeraerts, Thomas, Jaber, Samir, Seguin, Philippe, Hammad, Emmanuelle, Kerforne, Thomas, Lasocki, Sigismond, Dalichampt, Marie, Mrozek, Ségolène, Elaroussi, Djillali, Roquilly, Antoine, Cinotti, Raphael, Feuillet, Fanny, Martin, Mathieu, Chabanne, Russel, Dahyot-Fizelier, Claire

2017

Overview

Purpose We assessed outcomes in brain-injured patients after implementation of a multi-faceted approach to reduce respiratory complications in intensive care units. Methods Prospective nationwide before–after trial. Consecutive adults with acute brain injury requiring mechanical ventilation for ≥24 h in 20 French intensive care units (ICUs) were included. The management of invasive ventilation in brain-injured patients admitted between 1 July 2013 and 31 October 2013 (4 months) was monitored and analysed. After the baseline period (1 November 2013–31 December 2013), ventilator settings and decision to extubate were selected as targets to hasten weaning from invasive ventilation. During the intervention period, low tidal volume (≤7 ml/kg), moderate positive end-expiratory pressure (PEEP, 6–8 cm H 2 O) and an early extubation protocol were recommended. The primary endpoint was the number of days free of invasive ventilation at day 90. Comparisons were performed between the two periods and between the compliant and non-compliant groups. Results A total of 744 patients from 20 ICUs were included (391 pre-intervention; 353 intervention). No difference in the number of invasive ventilation-free days at day 90 was observed between the two periods [71 (0–80) vs. 67 (0–80) days; P  = 0.746]. Compliance with the complete set of recommendations increased from 8 (2%) to 52 (15%) patients after the intervention ( P  < 0.001). At day 90, the number of invasive ventilation-free days was higher in the 60 (8%) patients whose care complied with recommendations than in the 684 (92%) patients whose care deviated from recommendations [77 (66–82) and 71 (0–80) days, respectively; P  = 0.03]. The mortality rate was 10% in the compliant group and 26% in the non-compliant group ( P  = 0.023). Both multivariate analysis [hazard ratio (HR) 1.78, 95% confidence interval (95% CI) 1.41–2.26; P  < 0.001] and propensity score-adjusted analysis (HR 2.25, 95% CI 1.56–3.26, P  < 0.001) revealed that compliance was an independent factor associated with the reduction in the duration of mechanical ventilation. Conclusions Adherence to recommendations for low tidal volume, moderate PEEP and early extubation seemed to increase the number of ventilator-free days in brain-injured patients, but inconsistent adoption limited their impact. Trail registration number : NCT01885507.

• Publisher: Springer Berlin Heidelberg,Springer Nature B.V,Springer Verlag
• Subject: Adult / Adults / Aged / Airway Extubation - adverse effects / Airway Extubation - mortality / Anesthesiology / Brain / Brain Injuries - diagnostic imaging / Brain Injuries - mortality / Brain Injuries - therapy / Brain injury / Confidence intervals / Controlled Before-After Studies / Critical Care Medicine / Emergency Medicine / Extubation / Female / Glasgow Coma Scale / Head injuries / Human health and pathology / Humans / Injury prevention / Intensive / Intensive care / Intensive Care Units / Life Sciences / Male / Mechanical ventilation / Medicine / Medicine & Public Health / Middle Aged / Mortality / Multivariate analysis / Non-Randomized Controlled Trials as Topic / Pain Medicine / Patients / Pediatrics / Pneumology/Respiratory System / Positive-Pressure Respiration - adverse effects / Positive-Pressure Respiration - methods / Positive-Pressure Respiration - mortality / Prospective Studies / Quality control / Quality Improvement / Seven-Day Profile Publication / Statistics, Nonparametric / Tidal Volume / Tomography, X-Ray Computed / Ventilation / Ventilator Weaning - methods / Ventilator-Induced Lung Injury - mortality / Ventilator-Induced Lung Injury - prevention & control / Ventilators / Weaning