National Institute for Health Research.

PURPOSE:Mechanical power (MP) may unify variables known to be related with development of ventilator-induced lung injury. The aim of this study is to examine the association between MP and mortality in critically ill patients receiving invasive ventilation for at least 48 hours. METHODS:This is an analysis of data stored in the databases of the MIMIC-III, and eICU. Critically ill patients receiving invasive ventilation for at least 48 hours were included. The exposure of interest was MP. The primary outcome was in-hospital mortality. RESULTS:In total, 8,207 patients were analyzed. Median MP during the second 24 hours was 21.4 (16.2 to 28.1) J/min in MIMIC-III and 16.0 (11.7 to 22.1) J/min in eICU. MP was independently associated with in-hospital mortality (odds ratio per 5 J/min increase [OR] 1.06 [95% confidence interval [CI] 1.01 to 1.11]; p = 0.021 in MIMIC-III, and 1.10 [1.02 to 1.18]; p = 0.010 in eICU). MP was also associated with ICU-mortality, 30-day mortality, and with ventilator-free days, ICU and hospital length of stay. Even at low tidal volume, high MP was associated with in-hospital mortality (OR 1.70 [1.32 to 2.18]; p < 0.001) and other secondary outcomes. Finally, there is a consistent increase in the risk of death with MP higher than 17.0 J/min. CONCLUSION:High MP of ventilation is independently associated with higher inhospital mortality and several other outcomes in ICU patients receiving invasive ventilation for at least 48 hours.

This updated meta-analysis of individual participant data from 12 countries shows that the use of procalcitonin to guide initiation and duration of antibiotic treatment results in lower risks of mortality, lower antibiotic consumption, and lower risk for antibiotic-related side effects. Results were similar for different clinical settings and types of ARIs, thus supporting the use of procalcitonin in the context of antibiotic stewardship in people with ARIs. Future high-quality research is needed to confirm the results in immunosuppressed patients and patients with non-respiratory infections.

BackgroundThe clinical utility of serum procalcitonin levels in guiding antibiotic treatment decisions in patients with sepsis remains unclear. This patient-level meta-analysis based on 11 randomized trials investigates the impact of procalcitonin-guided antibiotic therapy on mortality in intensive care unit (ICU) patients with infection, both overall and stratified according to sepsis definition, severity, and type of infection.MethodsFor this meta-analysis focusing on procalcitonin-guided antibiotic management in critically ill patients with sepsis of any type, in February 2018 we updated the database of a previous individual patient data meta-analysis which was limited to patients with respiratory infections only. We used individual patient data from 11 trials that randomly assigned patients to receive antibiotics based on procalcitonin levels (the “procalcitonin-guided” group) or the current standard of care (the “controls”). The primary endpoint was mortality within 30 days. Secondary endpoints were duration of antibiotic treatment and length of stay.ResultsMortality in the 2252 procalcitonin-guided patients was significantly lower compared with the 2230 control group patients (21.1% vs 23.7%; adjusted odds ratio 0.89, 95% confidence interval (CI) 0.8 to 0.99; p = 0.03). These effects on mortality persisted in a subgroup of patients meeting the sepsis 3 definition and based on the severity of sepsis (assessed on the basis of the Sequential Organ Failure Assessment (SOFA) score, occurrence of septic shock or renal failure, and need for vasopressor or ventilatory support) and on the type of infection (respiratory, urinary tract, abdominal, skin, or central nervous system), with interaction for each analysis being > 0.05. Procalcitonin guidance also facilitated earlier discontinuation of antibiotics, with a reduction in treatment duration (9.3 vs 10.4 days; adjusted coefficient −1.19 days, 95% CI −1.73 to −0.66; p <  0.001).ConclusionProcalcitonin-guided antibiotic treatment in ICU patients with infection and sepsis patients results in improved survival and lower antibiotic treatment duration.Electronic supplementary materialThe online version of this article (10.1186/s13054-018-2125-7) contains supplementary material, which is available to authorized users.