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Mellado-Artigas R, Borrat X, Ferreyro BL, Yarnell C, Hao S, Wanis KN, Barbeta E, Torres A, Ferrando C, Brochard L. Effect of immediate initiation of invasive ventilation on mortality in acute hypoxemic respiratory failure: a target trial emulation. Crit Care 2024; 28:157. [PMID: 38730306 PMCID: PMC11088053 DOI: 10.1186/s13054-024-04926-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Accepted: 04/21/2024] [Indexed: 05/12/2024] Open
Abstract
PURPOSE Invasive ventilation is a fundamental treatment in intensive care but its precise timing is difficult to determine. This study aims at assessing the effect of initiating invasive ventilation versus waiting, in patients with hypoxemic respiratory failure without immediate reason for intubation on one-year mortality. METHODS Emulation of a target trial to estimate the benefit of immediately initiating invasive ventilation in hypoxemic respiratory failure, versus waiting, among patients within the first 48-h of hypoxemia. The eligible population included non-intubated patients with SpO2/FiO2 ≤ 200 and SpO2 ≤ 97%. The target trial was emulated using a single-center database (MIMIC-IV) which contains granular information about clinical status. The hourly probability to receive mechanical ventilation was continuously estimated. The hazard ratios for the primary outcome, one-year mortality, and the secondary outcome, 30-day mortality, were estimated using weighted Cox models with stabilized inverse probability weights used to adjust for measured confounding. RESULTS 2996 Patients fulfilled the inclusion criteria of whom 792 were intubated within 48 h. Among the non-invasive support devices, the use of oxygen through facemask was the most common (75%). Compared to patients with the same probability of intubation but who were not intubated, intubation decreased the hazard of dying for the first year after ICU admission HR 0.81 (95% CI 0.68-0.96, p = 0.018). Intubation was associated with a 30-day mortality HR of 0.80 (95% CI 0.64-0.99, p = 0.046). CONCLUSION The initiation of mechanical ventilation in patients with acute hypoxemic respiratory failure reduced the hazard of dying in this emulation of a target trial.
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Affiliation(s)
- Ricard Mellado-Artigas
- Surgical Intensive Care Unit, Hospital Clínic de Barcelona, Barcelona, Spain.
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain.
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.
| | - Xavier Borrat
- Surgical Intensive Care Unit, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Bruno L Ferreyro
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Division of Respirology, Department of Medicine, University Health Network and Sinai Health System, Toronto, Canada
| | - Christopher Yarnell
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Division of Respirology, Department of Medicine, University Health Network and Sinai Health System, Toronto, Canada
- Department of Critical Care Medicine, Scarborough Health Network, Toronto, ON, Canada
| | - Sicheng Hao
- MIT IMES: Massachussetts Institute of Technology Institute for Medical Engineering and Science, Cambridge, USA
| | - Kerollos N Wanis
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Enric Barbeta
- Surgical Intensive Care Unit, Hospital Clínic de Barcelona, Barcelona, Spain
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Antoni Torres
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
- Respiratory Intensive Care Unit, Pneumology, Respiratory Institute, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Carlos Ferrando
- Surgical Intensive Care Unit, Hospital Clínic de Barcelona, Barcelona, Spain
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Laurent Brochard
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
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Schupp T, Weidner K, Rusnak J, Jawhar S, Forner J, Dulatahu F, Brück LM, Hoffmann U, Bertsch T, Weiß C, Akin I, Behnes M. Diagnostic and prognostic value of the AST/ALT ratio in patients with sepsis and septic shock. Scand J Gastroenterol 2023; 58:392-402. [PMID: 36259154 DOI: 10.1080/00365521.2022.2131331] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The study investigates the diagnostic and prognostic value of the aspartate aminotransferase (AST) to alanine aminotransferase (ALT) ratio in patients with sepsis and septic shock. Limited data regarding the prognostic value of the AST/ALT ratio in patients suffering from sepsis or septic shock is available. METHODS Consecutive patients with sepsis and septic shock from 2019 to 2021 were included monocentrically. Blood samples were retrieved from day of disease onset (day 1), day 2, 3, 5 and 7. First, the diagnostic value of the AST/ALT ratio was tested for septic shock compared to sepsis. Second, the prognostic value of the AST/ALT ratio was tested for 30-d all-cause mortality. Statistical analyses included univariable t-test, Spearman's correlation, C-statistics, Kaplan-Meier analyses, as well as multivariable mixed analysis of variance (ANOVA), Cox proportional regression analyses and propensity score matching. RESULTS A total of 289 patients were included, of which 55% had sepsis and 45% septic shock. The overall rate of all-cause mortality at 30 d was 53%. With an area under the curve (AUC) of 0.651 on day 1 and 0.794 on day 7, the AST/ALT ratio revealed moderate but better diagnostic discrimination of septic shock compared to bilirubin. Furthermore, the AST/ALT ratio was able to discriminate 30-d all-cause mortality (AUC = 0.624; 95% CI 0.559 - 0.689; p = 0.001). Patients with an AST/ALT ratio above the median (>1.8) had higher rates of 30-d all-cause mortality compared to lower values (mortality rate 63 vs. 43%; log-rank p = 0.001), even after multivariable adjustment (HR = 1.703; 95% CI 1.182 - 2.453; p = 0.004) and propensity score matching. CONCLUSIONS The AST/ALT was a reliable diagnostic tool for the diagnosis of septic shock as well as a reliable tool to predict 30-d all-cause mortality in patients suffering from sepsis and septic shock.
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Affiliation(s)
- Tobias Schupp
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, Medical Faculty Mannheim, University Medical Centre Mannheim, Heidelberg University, Heidelberg, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Kathrin Weidner
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, Medical Faculty Mannheim, University Medical Centre Mannheim, Heidelberg University, Heidelberg, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Jonas Rusnak
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, Medical Faculty Mannheim, University Medical Centre Mannheim, Heidelberg University, Heidelberg, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Schanas Jawhar
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, Medical Faculty Mannheim, University Medical Centre Mannheim, Heidelberg University, Heidelberg, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Jan Forner
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, Medical Faculty Mannheim, University Medical Centre Mannheim, Heidelberg University, Heidelberg, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Floriana Dulatahu
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, Medical Faculty Mannheim, University Medical Centre Mannheim, Heidelberg University, Heidelberg, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Lea Marie Brück
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, Medical Faculty Mannheim, University Medical Centre Mannheim, Heidelberg University, Heidelberg, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Ursula Hoffmann
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, Medical Faculty Mannheim, University Medical Centre Mannheim, Heidelberg University, Heidelberg, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Thomas Bertsch
- Institute of Clinical Chemistry, Laboratory Medicine and Transfusion Medicine, Nuremberg General Hospital, Paracelsus Medical University, Nuremberg, Germany
| | - Christel Weiß
- Department of Statistical Analysis, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Ibrahim Akin
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, Medical Faculty Mannheim, University Medical Centre Mannheim, Heidelberg University, Heidelberg, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Michael Behnes
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, Medical Faculty Mannheim, University Medical Centre Mannheim, Heidelberg University, Heidelberg, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
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Qu J, Shen Y, Zhang H. Early intubation and patient-centered outcomes in septic shock. Crit Care 2022; 26:299. [PMID: 36192759 PMCID: PMC9528133 DOI: 10.1186/s13054-022-04152-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 08/19/2022] [Indexed: 11/10/2022] Open
Affiliation(s)
- Jianmin Qu
- Department of Intensive Care, Tongxiang First People’s Hospital, Jiaochang Road 1918, 314500, Tongxiang, Zhejiang P.R. China
| | - Yanfei Shen
- grid.417400.60000 0004 1799 0055Department of Intensive Care, Zhejiang Hospital, Gudun Road 1229, 310013 Hangzhou, Zhejiang P.R. China
| | - Huijuan Zhang
- grid.417400.60000 0004 1799 0055Department of Intensive Care, Zhejiang Hospital, Gudun Road 1229, 310013 Hangzhou, Zhejiang P.R. China
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