Impact of Country Income Level on Outcomes in Patients with Acute Brain Injury Requiring Invasive Mechanical Ventilation: A Secondary Analysis of the ENIO Study

Shi Nan Feng; Camilo Diaz-Cruz; Raphael Cinotti; Karim Asehnoune; Marcus J Schultz; Gentle S Shrestha; Paula R Sanches; Chiara Robba; Sung-Min Cho; ENIO collaborators

doi:10.1007/s12028-024-02198-6

Impact of Country Income Level on Outcomes in Patients with Acute Brain Injury Requiring Invasive Mechanical Ventilation: A Secondary Analysis of the ENIO Study

Neurocrit Care. 2025 Jan 7. doi: 10.1007/s12028-024-02198-6. Online ahead of print.

Authors

Shi Nan Feng¹, Camilo Diaz-Cruz², Raphael Cinotti^{3

4}, Karim Asehnoune³, Marcus J Schultz^{5

6

7}, Gentle S Shrestha⁸, Paula R Sanches⁹, Chiara Robba^{10

11}, Sung-Min Cho¹²; ENIO collaborators

Affiliations

¹ Division of Neuroscience Critical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
² Department of Neurology, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
³ Department of Anesthesia and Critical Care, Centre Hospitalier Universitaire Nantes, Nantes Université, Hôtel Dieu, Nantes, France.
⁴ Unité Mixte de Recherche 1246 Methods in Patient-Centered Outcomes & Health Research, University of Nantes, University of Tours, Institut National de La Santé et de La Recherche Médicale, Nantes, France.
⁵ Department of Clinical Medicine, University of Oxford Nufeld, Oxford, UK.
⁶ Department of Intensive Care, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands.
⁷ Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand.
⁸ Department of Critical Care Medicine, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal.
⁹ Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil.
¹⁰ Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Policlinico San Martino, Genoa, Italy.
¹¹ Department of Surgical Science and Integrated Diagnostic, University of Genova, Genoa, Italy.
¹² Division of Neuroscience Critical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA. csungmi1@jhmi.edu.

PMID: 39776347
DOI: 10.1007/s12028-024-02198-6

Abstract

Background: Invasive mechanical ventilation can present complex challenges for patients with acute brain injury (ABI) in middle-income countries (MICs). We characterized the impact of country income level on weaning strategies and outcomes in patients with ABI.

Methods: A secondary analysis was performed on a registry of critically ill patients with ABI admitted to 73 intensive care units (ICUs) in 18 countries from 2018 to 2020. Patients were classified as high-income country (HIC) or MIC. The primary outcome was ICU mortality. Secondary outcomes were days to first extubation, tracheostomy, extubation failure, ICU length of stay, and hospital mortality. Multivariable analyses were adjusted for clinically preselected covariates such as age, sex, body mass index, neurological severity, comorbidities, and ICU management. Extubation and tracheostomy outcomes were also adjusted for arterial blood gas values and ventilatory settings.

Results: Of 1512 patients (median age = 54 years, 66% male), 1170 (77%) were from HICs, and 342 (23%) were from MICs. Median age was significantly lower in MICs [35 (range 26-52) vs. 58 (range 45-68) years in HICs]. Neurosurgical procedures (47.7% vs. 38.2%) and decompressive craniectomy (30.7% vs. 15.9%) were more common in MICs, whereas intracranial pressure monitoring (12.0% vs. 51.5%) and external ventricular drain (7.6% vs. 35.6%) were less common. Compared with HICs, patients from MICs had 2.27 times the odds of ICU mortality [p = 0.009, 95% confidence interval (CI) 1.22-4.21]. Frequency of extubation failure was lower in MICs but not significant after adjustment. Patients from MICs had 3.38 times the odds of tracheostomy (p ≤ 0.001, 95% CI 2.28-5.01), 5.59 days shorter mean ICU stay (p < 0.001, 95% CI - 7.82 to - 3.36), and 1.96 times the odds of hospital mortality (p = 0.011, 95% CI 1.17-3.30).

Conclusions: In an international registry of patients with ABI requiring invasive mechanical ventilation, MICs had higher odds of ICU mortality, tracheostomy placement, and hospital mortality compared with HICs, which may be due to difference in neurocritical care resources and management.

Keywords: Acute brain injury; Country income level; Extubation failure; Intensive care unit; Invasive mechanical ventilation; Mortality; Neurocritical care; Tracheostomy.