Résumé
Purpose: safety of weaning critically ill patients from mechanical ventilation while receiving vasopressor is uncertain. The present emulated trial compares four a priori vasopressor discontinuation strategies in critically ill adult medical patients undergoing weaning from mechanical ventilation.Methods: we performed an emulated trial with consecutive observational data from patients admitted to the intensive care units at Beth Israel Deaconess Medical Center from January 2011 to June 2022. We compared the risk of death or reintubation within 7 days of weaning among four a priori defined weaning strategies: delayed weaning after vasopressor discontinuation, early weaning, low-dose, and high-dose vasopressor infusion.Results: the estimated excess of deaths or reintubations for the early strategy, compared to the delayed strategy, if every patient had followed the early strategy, was 35 (95% CI, 14.8 to 55) per 1,000 patients (Risk Difference [RD]=0.035, 95% CI, 0.015 to 0.055). The estimated excess cases were 30 (95% CI, 4 to 56) per 1,000 patients (RD=0.030, 95% CI, 0.004 to 0.056) for the low-dose strategy in comparison with the delayed strategy. The highest estimated excess case number was in the high-dose vasopressor strategy, with excess cases of 95 (95% CI, 60 to 130) per 1,000 patients (RD=0.095, 95% CI, 0.060 to 0.130).Conclusions: in medical critically ill patients, the safest strategy to limit death or reintubation by day 7 was todiscontinue vasopressors at least 24h before weaning. Weaning medical critically ill patients with a low-dose of vasopressors was associated with a shorter overall duration of mechanical ventilation and had a modestly increased risk of weaning failure, while the high-dose strategy had the highest risk of weaning failure.