Conflict of interest statement. PLM, AR, EC, MSM, OM, GLG, DS, CC, FF, YM, and PS declare that they have no conflicts of interest. SL has received consulting fees from Viforpharma. KA has received lecturing and consulting fees from Braun, Astellas, and Fresenius. AbstractPurpose: Frailty is a recent concept used for evaluating elderly individuals. Our study determined the prevalence of frailty in intensive care unit (ICU) patients and its impact on the rate of mortality. Methods:A multicenter, prospective, observational study performed in four ICUs in France included 196 patients aged ≥65 years hospitalized for >24 hours during a 6-month study period. Frailty was determined using the frailty phenotype (FP) and the clinical frailty score (CFS). The patients were separated as follows: FP score <3 or ≥3 and CFS < 5 or ≥ 5.Results: Frailty was observed in 41% and 23% of patients based on a FP score ≥3 and a CFS ≥5, respectively. At admission to the ICU, the Simplified Acute Physiology Score II (SAPS II) and Sequential Organ Failure Assessment (SOFA) scores did not differ between the frail and nonfrail patients. In the multivariate analysis, the risk factors for ICU mortality were FP score ≥3 (hazard ratio [HR], 3.3; 95% confidence interval [CI], 1.6-6.6; p<0.001), male gender (HR, 2.4; 95% CI, 1.1-5.3; p=0.026), cardiac arrest before admission (HR, 2.8; 95% CI, 1.1-7.4; p=0.036), SAPS II score ≥ 46 (HR, 2.6; 95% CI, 1.2-5.3; p=0.011), and brain injury before admission (HR, 3.5; 95% CI, 1.6-7.7; p=0.002). The risk factors for 6-month mortality were a CFS ≥5 (HR, 2.4; 95% CI, 1.49-3.87; p<0.001) and a SOFA score ≥7 (HR, 2.2; 95% CI, 1.35-3.64; p=0.002). An increased CFS was associated with significant incremental hospital and 6-month mortalities. Conclusions:Frailty is a frequent occurrence and is independently associated with increased ICU and 6-month mortalities.Notably, the CFS predicts outcomes more effectively than the commonly used ICU illness scores.

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.

Background Patients with brain injury are at high risk of extubation failure. Methods We conducted a prospective observational cohort study in four intensive care units of three university hospitals. The aim of the study was to create a score that could predict extubation success in patients with brain injury. Results A total of 437 consecutive patients with brain injury were included, and 338 patients (77.3%) displayed successful extubation. In the multivariate analysis, four features were associated with success the day of extubation: age less than 40 yr, visual pursuit, swallowing attempts, and a Glasgow coma score greater than 10. In the score, each item counted as one. A score of 3 or greater was associated with 90% extubation success. The area under the receiver–operator curve was 0.75 (95% CI, 0.69 to 0.81). After internal validation by bootstrap, the area under the receiver–operator curve was 0.73 (95% CI, 0.68 to 0.79). Extubation success was significantly associated with shorter duration of mechanical ventilation (11 [95% CI, 5 to 17 days] vs. 22 days [95% CI, 13 to 29 days]; P &lt; 0.0001), shorter intensive care unit length of stay (15 [95% CI, 9 to 23 days] vs. 27 days [95% CI, 21 to 36 days]; P &lt; 0.0001), and lower in-intensive care unit mortality (4 [1.2%] vs. 11 [11.1%]; P &lt; 0.0001). Conclusions Our score exploring both airway functions and neurologic status may increase the probability of successful extubation in patients with severe brain injury.

BackgroundIn obese patients, preoxygenation with non-invasive ventilation (NIV) was reported to improve outcomes compared with facemask. In this setting, high-flow nasal cannulae (HFNC) used before and during intubation has never been studied against NIV.MethodsThe PREOPTIPOP study is a randomised, single-centre, open-labelled, controlled trial including obese patients requiring intubation before scheduled surgery. Patients were randomised to receive preoxygenation by HFNC or NIV. HFNC was maintained throughout intubation whereas NIV was removed when apnea occurred to perform laryngoscopy. The study was designed to assess the superiority of HNFC. The primary outcome was the lowest level of end-tidal oxygen concentration (EtO2) within 2 min after intubation. Secondary outcomes included drop in pulse oximetry and complications related to intubation.Main findingsA total of 100 patients were randomised. The intent-to-treat analysis found median [IQR] lowest EtO2 of 76% [66–82] for HFNC and 88% [82–90] for NIV (mean difference − 12·1 [− 15·1 to − 8·5], p < 0·0001). Mild desaturation below 95% was more frequent with HFNC (30%) than with NIV (12%) (relative risk 2·5, IC 95% [1·1 to 5·9], p = 0·03) and median lowest SpO2 during intubation was 98% [93–99] in HFNC vs. 99% [97–100] in NIV (p = 0·03). Severe and moderate complications were not different but patients reported more discomfort with NIV (28%) vs. HFNC (4%), p = 0·001.InterpretationCompared with NIV, preoxygenation with HFNC in obese patients provided lower EtO2 after intubation and a higher rate of desaturation < 95%.FundingInstitutional funding, additional grant from Fisher & Paykel.Trial RegistrationClinical trial Submission: April 10, 2017.Registry name: Preoxygenation Optimization in Obese Patients: High-flow Nasal Cannulae Oxygen Versus Non-invasive Ventilation: A Single-centre Randomised Controlled Study. The PREOPTIPOP Study.Clinicaltrials.govidentifier:NCT03106441N°ID RCB: 2017-A00305–48.Institutional review Board: CPP Nord-Ouest I, registration number 019/2017.URL registry:https://clinicaltrials.gov/ct2/show/NCT03106441