Importance In the intensive care unit (ICU), orotracheal intubation can be associated with increased risk of complications because the patient may be acutely unstable, requiring prompt intervention, often by a practitioner with nonexpert skills. Video laryngoscopy may decrease this risk by improving glottis visualization. Objective To determine whether video laryngoscopy increases the frequency of successful first-pass orotracheal intubation compared with direct laryngoscopy in ICU patients. Design, Setting, and Participants Randomized clinical trial of 371 adults requiring intubation while being treated at 7 ICUs in France between May 2015 and January 2016; there was 28 days of follow-up. Interventions Intubation using a video laryngoscope (n = 186) or direct laryngoscopy (n = 185). All patients received general anesthesia. Main Outcomes and Measures The primary outcome was the proportion of patients with successful first-pass intubation. The secondary outcomes included time to successful intubation and mild to moderate and severe life-threatening complications. Results Among 371 randomized patients (mean [SD] age, 62.8 [15.8] years; 136 [36.7%] women), 371 completed the trial. The proportion of patients with successful first-pass intubation did not differ significantly between the video laryngoscopy and direct laryngoscopy groups (67.7% vs 70.3%; absolute difference, −2.5% [95% CI, −11.9% to 6.9%];P = .60). The proportion of first-attempt intubations performed by nonexperts (primarily residents, n = 290) did not differ between the groups (84.4% with video laryngoscopy vs 83.2% with direct laryngoscopy; absolute difference 1.2% [95% CI, −6.3% to 8.6%];P = .76). The median time to successful intubation was 3 minutes (range, 2 to 4 minutes) for both video laryngoscopy and direct laryngoscopy (absolute difference, 0 [95% CI, 0 to 0];P = .95). Video laryngoscopy was not associated with life-threatening complications (24/180 [13.3%] vs 17/179 [9.5%] for direct laryngoscopy; absolute difference, 3.8% [95% CI, −2.7% to 10.4%];P = .25). In post hoc analysis, video laryngoscopy was associated with severe life-threatening complications (17/179 [9.5%] vs 5/179 [2.8%] for direct laryngoscopy; absolute difference, 6.7% [95% CI, 1.8% to 11.6%];P = .01) but not with mild to moderate life-threatening complications (10/181 [5.4%] vs 14/181 [7.7%]; absolute difference, −2.3% [95% CI, −7.4% to 2.8%];P = .37). Conclusions and Relevance Among patients in the ICU requiring intubation, video laryngoscopy compared with direct laryngoscopy did not improve first-pass orotracheal intubation rates and was associated with higher rates of severe life-threatening complications. Further studies are needed to assess the comparative effectiveness of these 2 strategies in different clinical settings and among operators with diverse skill levels. Trial Registration clinicaltrials.gov Identifier:NCT02413723

Adrenomedullin (ADM) regulates vascular tone and endothelial permeability during sepsis. Levels of circulating biologically active ADM (bio-ADM) show an inverse relationship with blood pressure and a direct relationship with vasopressor requirement. In the present prospective observational multinational Adrenomedullin and Outcome in Sepsis and Septic Shock 1 (, AdrenOSS-1) study, we assessed relationships between circulating bio-ADM during the initial intensive care unit (ICU) stay and short-term outcome in order to eventually design a biomarker-guided randomized controlled trial. AdrenOSS-1 was a prospective observational multinational study. The primary outcome was 28-day mortality. Secondary outcomes included organ failure as defined by Sequential Organ Failure Assessment (SOFA) score, organ support with focus on vasopressor/inotropic use, and need for renal replacement therapy. AdrenOSS-1 included 583 patients admitted to the ICU with sepsis or septic shock. Circulating bio-ADM levels were measured upon admission and at day 2. Median bio-ADM concentration upon admission was 80.5 pg/ml [IQR 41.5–148.1 pg/ml]. Initial SOFA score was 7 [IQR 5–10], and 28-day mortality was 22%. We found marked associations between bio-ADM upon admission and 28-day mortality (unadjusted standardized HR 2.3 [CI 1.9–2.9]; adjusted HR 1.6 [CI 1.1–2.5]) and between bio-ADM levels and SOFA score (p < 0.0001). Need of vasopressor/inotrope, renal replacement therapy, and positive fluid balance were more prevalent in patients with a bio-ADM > 70 pg/ml upon admission than in those with bio-ADM ≤ 70 pg/ml. In patients with bio-ADM > 70 pg/ml upon admission, decrease in bio-ADM below 70 pg/ml at day 2 was associated with recovery of organ function at day 7 and better 28-day outcome (9.5% mortality). By contrast, persistently elevated bio-ADM at day 2 was associated with prolonged organ dysfunction and high 28-day mortality (38.1% mortality, HR 4.9, 95% CI 2.5–9.8). AdrenOSS-1 shows that early levels and rapid changes in bio-ADM estimate short-term outcome in sepsis and septic shock. These data are the backbone of the design of the biomarker-guided AdrenOSS-2 trial. ClinicalTrials.gov, NCT02393781 . Registered on March 19, 2015.

Introduction: In septic shock patients, the prevalence of low (<70%) central venous oxygen saturation (ScvO2) on admission to the intensive care unit (ICU) and its relationship to outcome are unknown. The objectives of the present study were to estimate the prevalence of low ScvO2 in the first hours of ICU admission and to assess its potential association with mortality in patients with severe sepsis or septic shock. Methods: This was a prospective, multicentre, observational study conducted over a one-year period in ten French ICUs. Clinicians were asked to include patients with severe sepsis or septic shock preferably within 6 hours of ICU admission and as soon as possible without changing routine practice. ScvO2 was measured at inclusion and 6 hours later (H6), by blood sampling. Results: We included 363 patients. Initial ScvO2 below 70% was present in 111 patients and the pooled estimate for its prevalence was 27% (95% Confidence interval (95%CI): 18% to 37%). At time of inclusion, among 166 patients with normal lactate concentration (≤2 mmol/L), 55 (33%) had a low initial ScvO2 (<70%), and among 136 patients who had already reached the classic clinical endpoints for mean arterial pressure (≥65 mmHg), central venous pressure (≥8 mmHg), and urine output (≥0.5 mL/Kg of body weight), 43 (32%) had a low initial ScvO2 (<70%). Among them, 49% had lactate below 2 mmol/L. The day-28 mortality was higher in case of low initial ScvO2 (37.8% versus 27.4%; P = 0.049). When adjusted for confounders including the Simplified Acute Physiology Score and initial lactate concentration, a low initial ScvO2 (Odds ratio (OR) = 3.60, 95%CI: 1.76 to 7.36; P = 0.0004) and a low ScvO2 at H6 (OR = 2.18, 95%CI: 1.12 to 4.26; P = 0.022) were associated with day-28 mortality by logistic regression. Conclusions: Low ScvO2 was common in the first hours of admission to the ICU for severe sepsis or septic shock even when clinical resuscitation endpoints were achieved and even when arterial lactate was normal. A ScvO2 below 70% in the first hours of ICU admission and six hours later was associated with day-28 mortality.

Intubation is frequently required for patients in the intensive care unit (ICU) but is associated with high morbidity and mortality mainly in emergency procedures and in the presence of severe organ failures. Improving the intubation procedure is a major goal for all ICU physicians worldwide, and videolaryngoscopy may play a relevant role. Videolaryngoscopes are a heterogeneous entity, including Macintosh blade-shaped optical laryngoscopes, anatomically shaped blade without a tube guide and anatomically shaped blade with a tube guide, which might have theoretical benefits and pitfalls. Videolaryngoscope/videolaryngoscopy improves glottis view and allows supervision by an expert during the intubation process; however, randomized controlled trials in the ICU suggest that the systematic use of videolaryngoscopes for every intubation cannot yet be recommended, especially in non-expert hands. Nevertheless, a videolaryngoscope should be available in all ICUs as a powerful tool to rescue difficult intubation or unsuccessful first-pass laryngoscopy, especially in expert hands. The use of associated devices such as bougie or stylet, glottis view needed (full vs incomplete) and patient position during intubation (ramped, sniffed position) should be further evaluated. Future trials will better define the role of videolaryngoscopy in ICU.