ABSTRACT
BACKGROUND: Spontaneous breathing trials (SBT) can be exhausting, but the preventive role of rest has never been studied. This study aimed to evaluate whether reconnection to mechanical ventilation (MV) for 1 h after the effort of a successful SBT could reduce the need for reintubation in critically ill patients. METHODS: Randomized multicenter trial conducted in 17 Spanish medical-surgical intensive care units (Oct 2013-Jan 2015). Patients under MV for longer than 12 h who fulfilled criteria for planned extubation were randomly allocated after a successful SBT to direct extubation (control group) or reconnection to the ventilator for a 1-h rest before extubation (rest group). The primary outcome was reintubation within 48 h. Analysis was by intention to treat. RESULTS: We recruited 243 patients randomized to the control group and 227 to the rest group. Median time from intubation to SBT did not differ between groups [5.5 (2.7, 9.6) days in the control group vs. 5.7 (2.7, 10.6) in the rest group; p = 0.85]. Reintubation within 48 h after extubation was more common in the control than in the rest group [35 (14%) vs. 12 (5%) patients; OR 0.33; 95% CI 0.16-0.65; p < 0.001]. A multivariable regression model demonstrated that the variables independently associated with reintubation were rest [OR 0.34 (95%CI 0.17-0.68)], APACHE II [OR 1.04 (1.002-1.077)], and days of MV before SBT [OR 1.04 (1.001-1.073)], whereas age, reason for admission, and type and duration of SBT were not. CONCLUSION: One-hour rest after a successful SBT reduced the rates of reintubation within 48 h after extubation in critically ill patients. Trial registration Clinicaltrials.gov identifier NCT01915563.
Subject(s)
Airway Extubation/methods , Respiration, Artificial/methods , Respiratory Insufficiency/therapy , Ventilator Weaning/methods , APACHE , Aged , Airway Extubation/adverse effects , Critical Illness/therapy , Female , Humans , Intensive Care Units , Intention to Treat Analysis , Intubation, Intratracheal , Male , Middle Aged , Multivariate Analysis , Prospective Studies , Respiration, Artificial/adverse effects , Respiratory Insufficiency/etiology , Severity of Illness Index , Time FactorsABSTRACT
BACKGROUND: There is considerable interest in the research of molecules modulating the acute inflammatory response in patients with sepsis. Paraoxonases (PON) are antioxidant and anti-inflammatory enzymes that inhibit the production of the monocyte chemoattractant protein-1 (MCP-1). This preliminary study investigated changes in PON status and MCP-1 concentrations in critically ill patients with severe sepsis treated in an ICU and their relationship with the evolution of disease. METHODS: This was a longitudinal, prospective and observational study on 15 patients with sepsis, studied at baseline and on days 1, 2, 5, 7 and 10 of their stay in the ICU. In all the patients we measured serum PON1 and PON3 concentrations, PON1 paraoxonase and lactonase activities, serum MCP-1 concentrations, and several standard biochemical and haematological parameters. RESULTS: MCP-1 concentration significantly decreased with the resolution of sepsis, and this decrease was especially important during the first 5 days of hospitalisation. PON1 and PON3 tended to decrease during the first 5 days in ICU and significantly increased in days 7 and 10. Linear regression analysis showed significant and direct correlations among serum MCP-1 concentration and lactate levels at baseline. At the end of stay, PON1 paraoxonase and lactonase activities were significantly correlated with organ system function measurements. CONCLUSIONS: We observed an inverse pattern between changes in MCP-1, and PON1 and PON3 levels in patients with sepsis, this was related to the resolution of their infection after receiving treatment in an ICU.