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Chest. Ventilator-associated pneumonia during weaning from mechanical ventilation: role of fluid management

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  • Chest. Ventilator-associated pneumonia during weaning from mechanical ventilation: role of fluid management

    [Source: Chest, full page: (LINK). Abstract, edited.]


    Original Research | March 20, 2014

    Ventilator-associated pneumonia during weaning from mechanical ventilation: role of fluid management

    Armand Mekontso Dessap, M.D., Ph.D.; Sandrine Katsahian, M.D.; Ferran Roche-Campo, M.D., Ph.D.; Hugo Varet, Ph.D.; Achille Kouatchet, M.D.; Vinko Tomicic, M.D.; Gaetan Beduneau, M.D.; Romain Sonneville, M.D., Ph.D.; Samir Jaber, M.D., Ph.D.; Michael Darmon, M.D., Ph.D.; Diego Castanares-Zapatero, M.D.; Laurent Brochard, M.D.; Christian Brun-Buisson, M.D.

    Author and Funding Information: AP-HP, CHU Henri Mondor, Service de Réanimation Médicale, Créteil, F-94010 France (Dessap, Roche-Campo, Brun-Buisson); Université Paris Est Créteil, Faculté de Médecine, Créteil, F-94010, France (Dessap, Brun-Buisson); INSERM, Unité U955, Créteil, F-94010, France (Dessap, Brun-Buisson); AP-HP, CHU Henri Mondor, Unité de Recherche Clinique, Créteil, F-94010 France (Katsahian, Varet); Hospital de Sant Pau, Servei de Medicina Intensiva, Barcelona, Spain (Roche-Campo); CHU d’Angers, Service de Réanimation Médicale, Angers, France (Kouatchet); Clinica Alemana, Departamento de Paciente Crítico, Santiago de Chile, Chile (Tomicic); CHU de Rouen, Service de Réanimation Médicale and UPRES-EA 3830, Rouen, France (Beduneau); AP-HP, CHU Bichat-Claude Bernard, Service de Réanimation Médicale et des Maladies Infectieuses, Univ Paris Diderot, Sorbonne Paris Cité, Paris, France (Sonneville); CHU Saint Eloi, Réanimation DAR B, INSERM U1046, Montpellier, France (Jaber); AP-HP, CHU Saint Louis, Service de Réanimation Médicale, Paris, France (Darmon); Hôpital Universitaire Saint-Luc, Service de Soins Intensifs, Bruxelles, Belgium (Castanares-Zapatero); Critical Care Department, St Michael’s Hospital, Toronto; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada (Brochard)

    Correspondence to: Armand Mekontso Dessap, MD, PhD, Service de Réanimation Médicale, Centre Hospitalo-Universitaire Henri Mondor, 51, avenue du Mal de Lattre de Tassigny 94 010 Créteil Cedex, France; E-mail: armand.dessap@hmn.aphp.fr.

    Funding: The project was funded by the French Ministry of Health research program (Programme Hospitalier de Recherche Clinique, contract N°05104).

    Chest. 2014. doi:10.1378/chest.13-2564 / Published online


    Abstract

    Background:

    Pulmonary edema may alter alveolar bacterial clearance and infectivity. Manipulation of fluid balance aimed at reducing fluid overload may therefore influence ventilator-associated pneumonia (VAP) occurrence in intubated patients. The objective of the present study was to assess the impact of a depletive fluid management strategy on ventilator-associated complication (VAC) and VAP occurrence during weaning from mechanical ventilation.


    Methods:

    We used data from the B-type natriuretic peptide for the fluid Management of Weaning (BMW) randomized controlled trial performed in nine intensive care units across Europe and America. We compared the cumulative incidence of VAC and VAP between the biomarker-driven depletive fluid management group and the usual care group during the 14 days following randomization, using specific competing risk methods (Fine and Gray model).


    Results:

    Among the 304 patients analyzed, 41 experienced VAP, including 27 (17.8%) in the usual care group vs. 14 (9.2%) in the interventional group (p=0.03). From the Fine and Gray model, the probabilities of VAC and VAP occurrence were both significantly reduced with the interventional strategy while adjusting for weaning outcome as a competing event [sub-hazard ratios of 0.44 (0.22-0.87), p=0.02 and 0.50 (0.25-0.96), p=0.03, respectively].


    Conclusions:

    Using proper competing risk analyses, we found that a depletive fluid management strategy when initiating the weaning process has the potential for lowering VAP risk in mechanically ventilated patients.


    Clinical Trial Registration: www.clinicaltrials.gov (NCT00473148).


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