Utilization of mechanical power and associations with clinical outcomes in brain injured patients: a secondary analysis of the extubation strategies in neuro-intensive care unit patients and associations with outcome (ENIO) trial
Authors: Wahlster Sarah , Sharma Monisha , Taran Shaurya , Town James A. , Stevens Robert D. , Cinotti Raphaël , Asehoune Karim , Pelosi Paolo , Robba Chiara ,   ENIO Study Group Collaborators, Abback Paër-sélim , Codorniu Anaïs , Citerio Giuseppe , Sala Vittoria Ludovica , Astuto Marinella , Tringali Eleonora , Alampi Daniela , Rocco Monica , Maugeri Jessica Giuseppina , Bellissima Agrippino , Filippini Matteo , Lazzeri Nicoletta , Cortegiani Andrea , Ippolito Mariachiara , Battaglini Denise , Biston Patrick , Al-Gharyani Mohamed Fathi , Chabanne Russell , Astier Léo , Soyer Benjamin , Gaugain Samuel , Zimmerli Alice , Pietsch Urs , Filipovic Miodrag , Brandi Giovanna , Bicciato Giulio , Serrano Ainhoa , Monleon Berta , van Vliet Peter , Gerretsen Benjamin Marcel , Ortiz-Macias Iris Xochitl , Oto Jun , Enomoto Noriya , Matsuda Tomomichi , Masui Nobutaka , Garçon Pierre , Zarka Jonathan , Vermeijden Wytze J. , Cornet Alexander Daniel , Inurrigarro Sergio Reyes , Domínguez Rafael Cirino Lara , Bellini Maria Mercedes , Gomez Haedo Maria Milagros , Lamot Laura , Orquera Jose , Biais Matthieu , Georges Delphine , Baronia Arvind , Miranda-Ackerman Roberto Carlos , Barbosa-Camacho Francisco José , Porter John , Lopez-Morales Miguel , Geeraerts Thomas , Compagnon Baptiste , Pérez-Torres David , Prol-Silva Estefanía , Yahya Hana Basheer , Khaled Ala , Ghula Mohamed , Andrea Cracchiolo Neville , Daniela Palma Maria , Deana Cristian , Vetrugno Luigi , Chavez Manuel J. Rivera , Trujillo Rocio Mendoza , Legros Vincent , Brochet Benjamin , Huet Olivier , Geslain Marie , van der Jagt Mathieu , van Steenkiste Job , Ahmed Hazem , Coombs Alexander Edward , Welbourne Jessie , Velarde Pineda Ana Alicia , Nubert Castillo Víctor Hugo , Azab Mohammed A. , Azzam Ahmed Y. , van Meenen David Michael Paul , Gasca Gilberto Adrian , Arellano Alfredo , Galicia-Espinosa Forttino , García-Ramos José Carlos , Yadav Ghanshyam , Jha Amarendra Kumar , Robert-Edan Vincent , Rodie-Talbere Pierre-Andre , Jain Gaurav , Panda Sagarika , Agarwal Sonika , Deewan Yashbir , Gasca Gilberto Adrian , Arellano Alfredo , Reza Syed Tariq , Hossain Md.Mozaffer , Papadas Christos , Chantziara Vasiliki , Sklavou Chrysanthi , Hourmant Yannick , Grillot Nicolas , van Steenkiste Job , van der Jagt Mathieu , Pirracchio Romain , Akkari Abdelraouf , Abdelaty Mohamed , Hashim Ahmed , Launey Yoann , Masseret Elodie , Lasocki Sigismond , Gergaud Soizic , Mouclier Nicolas , Saxena Sulekha , Agrawal Avinash , Mishra Shakti Bedanta , Samal Samir , Mijangos Julio Cesar , Haënggi Mattias , Gurjar Mohan , Schultz Marcus J. , Kaye Callum , Godoy Daniela Agustin , Alvarez Pablo , Ioakeimidou Aikaterini , Ueno Yoshitoyo , Badenes Rafael , Suei Elbuzidi Abdurrahmaan Ali , Piagnerelli Michaël , Elhadi Muhammed , Reza Syed Tariq , Digitale Jean Catherine , Fong Nicholas , Cerda Ricardo Campos , de la Torre Peredo Norma 
Published: April 2023

Abstract
Background
There is insufficient evidence to guide ventilatory targets in acute brain injury (ABI). Recent studies have shown associations between mechanical power (MP) and mortality in critical care populations. We aimed to describe MP in ventilated patients with ABI, and evaluate associations between MP and clinical outcomes.

Methods
In this preplanned, secondary analysis of a prospective, multi-center, observational cohort study (ENIO, NCT03400904), we included adult patients with ABI (Glasgow Coma Scale ≤ 12 before intubation) who required mechanical ventilation (MV) ≥ 24 h. Using multivariable log binomial regressions, we separately assessed associations between MP on hospital day (HD)1, HD3, HD7 and clinical outcomes: hospital mortality, need for reintubation, tracheostomy placement, and development of acute respiratory distress syndrome (ARDS).

Results
We included 1217 patients (mean age 51.2 years [SD 18.1], 66% male, mean body mass index [BMI] 26.3 [SD 5.18]) hospitalized at 62 intensive care units in 18 countries. Hospital mortality was 11% (n = 139), 44% (n = 536) were extubated by HD7 of which 20% (107/536) required reintubation, 28% (n = 340) underwent tracheostomy placement, and 9% (n = 114) developed ARDS. The median MP on HD1, HD3, and HD7 was 11.9 J/min [IQR 9.2–15.1], 13 J/min [IQR 10–17], and 14 J/min [IQR 11–20], respectively. MP was overall higher in patients with ARDS, especially those with higher ARDS severity. After controlling for same-day pressure of arterial oxygen/fraction of inspired oxygen (P/F ratio), BMI, and neurological severity, MP at HD1, HD3, and HD7 was independently associated with hospital mortality, reintubation and tracheostomy placement. The adjusted relative risk (aRR) was greater at higher MP, and strongest for: mortality on HD1 (compared to the HD1 median MP 11.9 J/min, aRR at 17 J/min was 1.22, 95% CI 1.14–1.30) and HD3 (1.38, 95% CI 1.23–1.53), reintubation on HD1 (1.64; 95% CI 1.57–1.72), and tracheostomy on HD7 (1.53; 95%CI 1.18–1.99). MP was associated with the development of moderate-severe ARDS on HD1 (2.07; 95% CI 1.56–2.78) and HD3 (1.76; 95% CI 1.41–2.22).

Conclusions
Exposure to high MP during the first week of MV is associated with poor clinical outcomes in ABI, independent of P/F ratio and neurological severity. Potential benefits of optimizing ventilator settings to limit MP warrant further investigation.