Nurse-to-Nurse Familiarity and Mortality in the Critically Ill: A Multicenter Observational Study.

Rationale: Nurse-to-nurse familiarity at work should strengthen the components of teamwork and enhance its efficiency. However, its impact on patient outcomes in critical care remains poorly investigated. Objectives: To explore the role of nurse-to-nurse familiarity on inpatient deaths during ICU stay. Methods: This was a retrospective observational study in eight adult academic ICUs between January 1, 2011 and December 31, 2016. Measurements and Main Results: Nurse-to-nurse familiarity was measured across day and night 12-hour daily shifts as the mean number of previous collaborations between each nursing team member during previous shifts within the given ICU (suboptimal if <50). Primary outcome was a shift with at least one inpatient death, excluding death of patients with a decision to forego life-sustaining therapy. A multiple modified Poisson regression was computed to identify the determinants of mortality per shift, taking into account ICU, patient characteristics, patient-to-nurse and patient-to-assistant nurse ratios, nurse experience length, and workload. A total of 43,479 patients were admitted, of whom 3,311 (8%) died. The adjusted model showed a lower risk of a shift with mortality when nurse-to-nurse familiarity increased in the shift (relative risk, 0.90; 95% confidence interval per 10 shifts, 0.82-0.98; P = 0.012). Low nurse-to-nurse familiarity during the shift combined with suboptimal patient-to-nurse and patient-to-assistant nurse ratios (suboptimal if >2.5 and >4, respectively) were associated with increased risk of shift with mortality (relative risk, 1.84; 95% confidence interval, 1.15-2.96; P < 0.001). Conclusions: Shifts with low nurse-to-nurse familiarity were associated with an increased risk of patient deaths.

[18F]F13640: a selective agonist PET radiopharmaceutical for imaging functional 5-HT1A receptors in humans.

PURPOSE: F13640 (a.k.a. befiradol, NLX-112) is a highly selective 5-HT1A receptor ligand that was selected as a PET radiopharmaceutical-candidate based on animal studies. Due to its high efficacy agonist properties, [18F]F13640 binds preferentially to functional 5-HT1A receptors, which are coupled to intracellular G-proteins. Here, we characterize brain labeling of 5-HT1A receptors by [18F]F13640 in humans and describe a simplified model for its quantification. METHODS: PET/CT and PET-MRI scans were conducted in a total of 13 healthy male volunteers (29 ± 9 years old), with arterial input functions (AIF) (n = 9) and test-retest protocol (n = 8). Several kinetic models were compared (one tissue compartment model, two-tissue compartment model, and Logan); two models with reference region were also evaluated: simplified reference tissue model (SRTM) and the logan reference model (LREF). RESULTS: [18F]F13640 showed high uptake values in raphe nuclei and cortical regions. SRTM and LREF models showed a very high correlation with kinetic models using AIF. As concerns test-retest parameters and the prolonged binding kinetics of [18F]F13640, better reproducibility, and reliability were found with the LREF method. Cerebellum white matter and frontal lobe white matter stand out as suitable reference regions. CONCLUSION: The favorable brain labeling and kinetic profile of [18F]F13640, its high receptor specificity and its high efficacy agonist properties open new perspectives for studying functionally active 5-HT1A receptors, unlike previous radiopharmaceuticals that act as antagonists. [18F]F13640's kinetic properties allow injection outside of the PET scanner with delayed acquisitions, facilitating the design of innovative longitudinal protocols in neurology and psychiatry. TRIAL REGISTRATION: Trial Registration EudraCT 2017-002,722-21.

The post-resuscitation VASOGRADE: a more accurate scale to predict delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage.

BACKGROUND: Predicting the occurrence of delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage is of interest to adjust the level of care. The VASOGRADE, a simple grading scale using admission World Federation of Neurosurgical Societies (WFNS) grading score and modified Fisher scale (mFS) on first CT scan, could help to select patients at risk of DCI. However, using data after initial resuscitation (initial complication treatment, aneurysm exclusion) may be more relevant. METHODS: We calculated a post-resuscitation VASOGRADE (prVG) using WFNS grade and mFS after early brain injury treatment and aneurysm exclusion (or at day 3). Patients were categorized as green, yellow, or red. RESULTS: Using our prospective observational registry, 566 patients were included in the study. Two hundred six (36.4%) were classified as green, 208 (36.7%) as yellow, and 152 (26.9%) as red, and DCI was experienced in 22 (10.7%), 67 (32.2%), and 45 (29.6%) cases respectively. Patients classified as yellow had higher risk of developing DCI (OR 3.94, 95% CI 2.35-6.83). Risk was slightly lower in red patients (OR 3.49, 95% CI 2.00-6.24). The AUC for prediction was higher with prVG (0.62, 95% CI 0.58-0.67) than with VASOGRADE (0.56, 95% CI 0.51-0.60) (p < 0.01). CONCLUSION: By using simple clinical and radiological scale evaluated at subacute stage, prVG is more accurate to predict the occurrence of DCI.

Nicotine Replacement Therapy Does Not Reduce Headaches Following Subarachnoid Hemorrhage: A Propensity Score-Matched Study.

BACKGROUND: A significant number of patients admitted for aneurysmal subarachnoid hemorrhage (aSAH) are active smokers and are at risk of developing nicotine withdrawal symptoms (e.g., cravings, irritability, insomnia, headaches, etc.). This study aimed to evaluate the use of nicotine replacement therapy (NRT) regarding headache severity and analgesics consumption. METHODS: A retrospective study was conducted using prospectively collected data from 2014 to 2019 in the neurointensive care unit of the Hospices Civils in Lyon, France. We performed a propensity score matching analysis. The covariables used were age, sex, initial World Federation of Neurosurgical Societies score, Hijdra sum score, and factors associated with pain following aSAH (history of chronic pain, anxiety, or depression). Smokers received NRT through a transdermal device. The primary end point was headache control. Secondary end points were mean numerical pain rating scale score and analgesics consumption. RESULTS: One hundred and fifty-five patients were included among 523 patients hospitalized for aSAH. Fifty-one patients underwent nicotine substitution and were matched to 51 unsubstituted patients. The headache control rate was not different between the two groups (43.1% vs. 31.4%, p = 0.736). The mean numeric pain rating scale score in the substituted group was 2.2 (1.1-3.5) and 2.4 (1.6-3.1) in the unsubstituted group (p = 0.533). The analgesics consumption (acetaminophen, tramadol, and morphine) was the same in the two groups. CONCLUSIONS: The use of NRT in the acute phase of aSAH does not seem to have an impact on the intensity of headaches or analgesics consumption.

Cortical Spreading Depolarizations in Aneurysmal Subarachnoid Hemorrhage: An Overview of Current Knowledge and Future Perspectives.

Despite significant advances in the management of aneurysmal subarachnoid hemorrhage (SAH), morbidity and mortality remain devastating particularly for high-grade SAH. Poor functional outcome usually results from delayed cerebral ischemia (DCI). The pathogenesis of DCI during aneurysmal SAH has historically been attributed to cerebral vasospasm, but spreading depolarizations (SDs) are now considered to play a central role in DCI. During SAH, SDs may produce an inverse hemodynamic response leading to spreading ischemia. Several animal models have contributed to a better understanding of the pathogenesis of SDs during aneurysmal SAH and provided new therapeutic approaches including N-methyl-D-aspartate receptor antagonists and phosphodiesterase inhibitors. Herein we review the current knowledge in the field of SDs' pathogenesis and we detail the key experimental and clinical studies that have opened interesting new therapeutic approaches to prevent DCI in aneurysmal SAH.

A retrospective comparison of COVID-19 and seasonal influenza mortality and outcomes in the ICUs of a French university hospital.

BACKGROUND: SARS-Cov-2 (COVID-19) has become a major worldwide health concern since its appearance in China at the end of 2019. OBJECTIVE: To evaluate the intrinsic mortality and burden of COVID-19 and seasonal influenza pneumonia in ICUs in the city of Lyon, France. DESIGN: A retrospective study. SETTING: Six ICUs in a single institution in Lyon, France. PATIENTS: Consecutive patients admitted to an ICU with SARS-CoV-2 pneumonia from 27 February to 4 April 2020 (COVID-19 group) and seasonal influenza pneumonia from 1 November 2015 to 30 April 2019 (influenza group). A total of 350 patients were included in the COVID-19 group (18 refused to consent) and 325 in the influenza group (one refused to consent). Diagnosis was confirmed by RT-PCR. Follow-up was completed on 1 April 2021. MAIN OUTCOMES AND MEASURES: Differences in 90-day adjusted-mortality between the COVID-19 and influenza groups were evaluated using a multivariable Cox proportional hazards model. RESULTS: COVID-19 patients were younger, mostly men and had a higher median BMI, and comorbidities, including immunosuppressive condition or respiratory history were less frequent. In univariate analysis, no significant differences were observed between the two groups regarding in-ICU mortality, 30, 60 and 90-day mortality. After Cox modelling adjusted on age, sex, BMI, cancer, sepsis-related organ failure assessment (SOFA) score, simplified acute physiology score SAPS II score, chronic obstructive pulmonary disease and myocardial infarction, the probability of death associated with COVID-19 was significantly higher in comparison to seasonal influenza [hazard ratio 1.57, 95% CI (1.14 to 2.17); P = 0.006]. The clinical course and morbidity profile of both groups was markedly different; COVID-19 patients had less severe illness at admission (SAPS II score, 37 [28 to 48] vs. 48 [39 to 61], P < 0.001 and SOFA score, 4 [2 to 8] vs. 8 [5 to 11], P < 0.001), but the disease was more severe considering ICU length of stay, duration of mechanical ventilation, PEEP level and prone positioning requirement. CONCLUSION: After ICU admission, COVID-19 was associated with an increased risk of death compared with seasonal influenza. Patient characteristics, clinical course and morbidity profile of these diseases is markedly different.

Ultrasound guidance for urgent arterial and venous catheterisation: randomised controlled study.

BACKGROUND: Haemodynamically unstable patients often require arterial and venous catheter insertion urgently. We hypothesised that ultrasound-guided arterial and venous catheterisation would reduce mechanical complications. METHODS: We performed a prospective RCT, where patients requiring both urgent arterial and venous femoral catheterisation were randomised to either ultrasound-guided or landmark-guided catheterisation. Complications and characteristics of catheter insertion (procedure duration, number of punctures, and procedure success) were recorded at the time of insertion (immediate complications). Late complications were investigated by ultrasound examination performed between the third and seventh days after randomisation. Primary outcome was the proportion of patients with at least one mechanical complication (immediate or late), by intention-to-treat analysis. Secondary outcomes included success rate, procedure time, and number of punctures. RESULTS: We analysed 136 subjects (102 [75%] male; age range: 27-62 yr) by intention to treat. The proportion of subjects with one or more complications was lower in 22/67 (33%) subjects undergoing ultrasound-guided catheterisation compared with landmark-guided catheterisation (40/69 [58%]; odds ratio: 0.35 [95% confidence interval: 0.18-0.71]; P=0.003). Ultrasound-guided catheterisation reduced both immediate (27%, compared with 51% in the landmark approach group; P=0.004) and late (10%, compared with 23% in the landmark approach group; P=0.047) complications. Ultrasound guidance also reduced the proportion of patients who developed deep vein thrombosis (4%, compared with 22% following landmark approach; P=0.012), and achieved a higher procedural success rate (96% vs 78%; P=0.004). CONCLUSIONS: An ultrasound-guided approach reduced mechanical complications after urgent femoral arterial and venous catheterisation, while increasing procedural success. CLINICAL TRIAL REGISTRATION: NCT02820909.

Is circadian rhythmicity a prerequisite to coma recovery? Circadian recovery concomitant to cognitive improvement in two comatose patients.

Circadian rhythmicity (CR) is involved in the regulation of all integrated functions, from sleep-wake cycle regulation to metabolic function, mood and cognition. However, the interdependence of CR, cognition and consciousness has been poorly addressed. To clarify the state of CR in coma and to determine the chronological relationship between its recovery and consciousness after brain lesions, we conducted a longitudinal observational study investigating how the state of CR was chronologically related with the recovery of behavioural wakefulness, cognition and/or awareness. Among 16 acute comatose patients, we recruited two 37-year-old patients with a persistent disorder of consciousness, presenting diencephalic lesions caused by severe traumatic brain injuries. Two biological urinary markers of CR were explored every 2 hours during 24 hours (6-sulfatoxymelatonin, free cortisol) with a dedicated methodology to extract the endogenous component of rhythmicity (environmental light recording, near-constant-routine protocol, control of beta-blockers). They presented an initial absence of rhythmic secretions and a recovered CR 7-8 months later. This recovery was not associated with the restoration of behavioural wakefulness, but with an improvement of cognition and awareness (up to the minimally conscious state). MRI showed a lesion pattern compatible with the interruption of either the main hypothalamic-sympathetic pathway or the accessory habenular pathway. These results suggest that CR may be a prerequisite for coma recovery with a potential but still unproven favourable effect on brain function of the resorted circadian melatonin secretion and/or the functional recovery of the suprachiasmatic nucleus (SCN). Assessing circadian functions by urinary melatonin should be further explored as a biomarker of cognition reappearance and investigated to prognosticate functional recovery.

Influence of vascular access devices upon efficiency of therapeutic plasma exchange.

BACKGROUND: An efficient vascular access is mandatory for the proper conduction of therapeutic plasma exchanges (TPE). Peripheral and central venous catheters may be used, with respective advantages and limitations. In this study, vascular access devices (IV catheter, dialysis cannula, central venous catheter) and anatomic vein characteristics were evaluated. METHOD: From January to June 2016, 162 TPE in 29 patients were reviewed. Only TPE using centrifugation method (Spectra Optia apheresis system) were evaluated. Volume exchanged, procedure duration, mean flow rate, number of inlet, and return pressure pauses were recorded. Site, width, and depth of punctured veins were studied. RESULTS: Median exchange volume planned was 3500 mL, and 152 (94%) procedures could be completed. Peripheral venous catheter was inserted in 103 (64%) cases (IV catheter: 61, dialysis cannulae: 42). Ultrasound guidance was used in 12 (11%) cases. Median procedure duration was shorter with central venous catheter (94 minutes), rather than dialysis cannula (133 minutes) or IV catheter (133 minutes). Median numbers of inlet pressure pauses were lower with central venous catheter (0) and dialysis cannulae (6), rather than IV catheter (10). There were no complications with peripheral venous access. There were no anatomic differences between catheterized veins with IV catheter or dialysis cannula. CONCLUSION: The use of peripheral venous access is possible in most of TPE, for emergency and during maintenance therapy. Dialysis cannulae are good compromise between classic IV catheters and central venous catheters, as it allows high flow rates, are easy to insert and associated with few complications.

Anti-N-Methyl-d-Aspartate Receptor Encephalitis in Adult Patients Requiring Intensive Care.

RATIONALE: Encephalitis caused by anti-N-methyl-d-aspartate receptor (NMDAR) antibodies is the leading cause of immune-mediated encephalitis. There are limited data on intensive care unit (ICU) management of these patients. OBJECTIVES: To identify prognostic factors of good neurologic outcome in patients admitted to an ICU with anti-NMDAR encephalitis. METHODS: This was an observational multicenter study of all consecutive adult patients diagnosed with anti-NMDAR encephalitis at the French National Reference Centre, admitted to an ICU between 2008 and 2014. The primary outcome was a good neurologic outcome at 6 months after ICU admission, defined by a modified Rankin Scale score of 0-2. MEASUREMENTS AND MAIN RESULTS: Seventy-seven patients were included from 52 ICUs. First-line immunotherapy consisted of steroids (n = 61/74; 82%), intravenous immunoglobulins (n = 71/74; 96%), and plasmapheresis (n = 17/74; 23%). Forty-five (61%) patients received second-line immunotherapy (cyclophosphamide, rituximab, or both). At 6 months, 57% of patients had a good neurologic outcome. Independent factors of good neurologic outcome were early (≤8 d after ICU admission) immunotherapy (odds ratio, 16.16; 95% confidence interval, 3.32-78.64; for combined first-line immunotherapy with steroids and intravenous immunoglobulins vs. late immunotherapy), and a low white blood cell count on the first cerebrospinal examination (odds ratio, 9.83 for <5 vs. >50 cells/mm3; 95% confidence interval, 1.07-90.65). Presence of nonneurologic organ failures at ICU admission and occurrence of status epilepticus during ICU stay were not associated with neurologic outcome. CONCLUSIONS: The prognosis of adult patients with anti-NMDAR encephalitis requiring intensive care is good, especially when immunotherapy is initiated early, advocating for prompt diagnosis and early aggressive treatment.

Hyperchloremic metabolic acidosis following plasma exchange during myasthenia gravis crisis.

BACKGROUND: Therapeutic plasma exchanges are increasingly used, notably during myasthenia gravis crisis. Repeated exchanges may induce severe adverse events. CASE: We reported a case of symptomatic hyperchloremic metabolic acidosis following a therapeutic plasma exchange. Analysis of 4% albumin substitution solution revealed a chloride concentration of 145 mmol/L, which could explain this acidosis. DISCUSSION: Infusion of high volume of 4% albumin during plasma exchanges may produce hyerchloremic metabolic acidosis. CONCLUSION: Special attention should be paid when repeated plasma exchanges are performed. J. Clin. Apheresis 31:479-480, 2016. © 2015 Wiley Periodicals, Inc.

Risk factors for intraoperative allogeneic blood transfusion during craniotomy for brain tumor removal in children.

BACKGROUND: Several clinical and surgical factors can influence the occurrence of allogeneic blood transfusion (ABT) during oncologic neurosurgery. OBJECTIVES: To identify the potential predictive factors of ABT during craniotomy for the removal of brain tumors in children and the potential impact of intraoperative ABT on early postoperative outcome. METHODS: A retrospective study was performed in all pediatric patients younger than 18 years who underwent craniotomy for brain tumor removal from December 2009 to December 2012 in our institution. Pre-, intra-, and postoperative data were collected from medical and stored electronic anesthesia records. The predictors of intraoperative ABT were determined using multivariate logistic regression. RESULTS: A total of 110 patients were included. Twenty-seven patients (25%) received intraoperative ABT with a volume of 16 ± 8 ml·kg(-1) . On multivariate analysis, an age <4 years, a duration of surgery >270 min, and a preoperative hemoglobin <12.2 g·dl(-1) were independently associated with the need for intraoperative ABT. We did not show any significant difference concerning postoperative early outcome and length of stay between the transfused and non-transfused patients except for the duration of postoperative mechanical ventilation that was significantly higher in the transfused group (P = 0.04). CONCLUSION: In children, craniotomy for brain tumor removal is at risk of intraoperative ABT. An age <4 years, a duration of surgery >270 min, and a preoperative hemoglobin <12.2 g·dl(-1) are the main factors associated with intraoperative ABT during this surgery.

Patient Mortality Is Associated With Staff Resources and Workload in the ICU: A Multicenter Observational Study.

OBJECTIVE: Matching healthcare staff resources to patient needs in the ICU is a key factor for quality of care. We aimed to assess the impact of the staffing-to-patient ratio and workload on ICU mortality. DESIGN: We performed a multicenter longitudinal study using routinely collected hospital data. SETTING: Information pertaining to every patient in eight ICUs from four university hospitals from January to December 2013 was analyzed. PATIENTS: A total of 5,718 inpatient stays were included. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We used a shift-by-shift varying measure of the patient-to-caregiver ratio in combination with workload to establish their relationships with ICU mortality over time, excluding patients with decision to forego life-sustaining therapy. Using a multilevel Poisson regression, we quantified ICU mortality-relative risk, adjusted for patient turnover, severity, and staffing levels. The risk of death was increased by 3.5 (95% CI, 1.3-9.1) when the patient-to-nurse ratio was greater than 2.5, and it was increased by 2.0 (95% CI, 1.3-3.2) when the patient-to-physician ratio exceeded 14. The highest ratios occurred more frequently during the weekend for nurse staffing and during the night for physicians (p < 0.001). High patient turnover (adjusted relative risk, 5.6 [2.0-15.0]) and the volume of life-sustaining procedures performed by staff (adjusted relative risk, 5.9 [4.3-7.9]) were also associated with increased mortality. CONCLUSIONS: This study proposes evidence-based thresholds for patient-to-caregiver ratios, above which patient safety may be endangered in the ICU. Real-time monitoring of staffing levels and workload is feasible for adjusting caregivers' resources to patients' needs.

Ruptured brain arteriovenous malformations associated with aneurysms: safety and efficacy of selective embolization in the acute phase of hemorrhage.

INTRODUCTION: The impact of targeted embolization of ruptured cerebral arteriovenous malformation (AVM)-associated arterial aneurysms in the acute phase of bleeding is not well known. The objective of our study was to analyze the safety and efficacy of this treatment strategy with special emphasis on its protective effect against rebleeding. METHODS: From a prospective database, all patients presenting between December 2005 and March 2012 with a ruptured cerebral AVM associated with arterial aneurysms contiguous to the hemorrhage were selected. Hemorrhagic stroke severity and clinical outcome were measured using, respectively, Glasgow Coma Scale (GCS) and modified Rankin Scale (mRS) scores. RESULTS: Twenty-five patients with ruptured cerebral AVMs associated with 31 arterial aneurysms contiguous with the hemorrhage were included. In the first group of 17 patients, the mean time to treatment was 30.1 h, while in the second group with 1 patient in poor initial clinical conditions and 7 admitted 7 to 28 days after bleeding, it was 17 days. All arterial aneurysms were totally occluded. Four patients presented rebleeding before treatment (mean interval 9.6 days) and four had rebleeding after treatment (mean interval 8.25 months). At a mean follow-up of 56 months, 21 patients were alive (19 mRS ≤ 2, 2 mRS > 2). Three patients died 2 days, 9 days, and 2 months after bleeding and another died of rebleeding of her residual AVM 19 months after treatment. Treatment-related morbidity and mortality were, respectively, 4 and 0%. CONCLUSION: Selective embolization of arterial aneurysms associated with ruptured AVMs is a safe procedure and could lower the immediate risk of rebleeding.

Trajectory of mean platelet volume changes after aneurysmal subarachnoid hemorrhage in patients with or without delayed cerebral ischemia.

The morbidity of aneurysmal subarachnoid hemorrhage (aSAH) remains high, particularly because of secondary cerebral lesions that significantly aggravate the primary lesions. The main type of secondary lesions is delayed cerebral ischemia (DCI), in which platelets (PLT) appear to play a key role. Mean platelet volume (MPV) is an indirect marker of platelet activation. We aimed to determine the individual trajectories of MPV over time in patients with and without DCI during the course of aSAH. This is a single-center, retrospective, longitudinal analysis of individual trajectories of MPV over time, in a cohort of aSAH patients included in the Prospective, Observational Registry of Patient with Subarachnoid Hemorrhage in Neurocritical Care Unit (ProReSHA). A mixed-effects linear regression model was used to compare the trajectories of MPV and MPV/PLT ratio between patients who developed a DCI and those who did not. A total of 3634 MPV values were collected in 587 patients. The analysis of MPV as a function of DCI occurrence showed a significant difference in the trajectory over time between patients with DCI and those without, with an estimate of 0.02 (95%CI 0.01, 0.04, p = 0.009). The analysis of the MPV/PLT ratio as a function of DCI occurrence and other covariates showed a significant difference in the trajectory over time only for patients with a modified Fisher score less than 3, with an estimate of -0.59 (95%CI: -0.94, -0.23, p = 0.001). The individual trajectories of MPV over time differ between patients with DCI and those without. However, MPV values vary greatly over time and between patients. Thus it does not appear as a reliable biomarker for stratifying patients based on their specific risk of developing DCI. ClinicalTrials.gov identifier: (NCT02890004), registered in August 2016.

Monitoring monocyte HLA-DR expression and CD4 + T lymphocyte count in dexamethasone-treated severe COVID-19 patients.

BACKGROUND: A 10-day dexamethasone regimen has emerged as the internationally adopted standard-of-care for severe COVID-19 patients. However, the immune response triggered by SARS-CoV-2 infection remains a complex and dynamic phenomenon, leading to various immune profiles and trajectories. The immune status of severe COVID-19 patients following complete dexamethasone treatment has yet to be thoroughly documented. RESULTS: To analyze monocyte HLA-DR expression (mHLA-DR) and CD4 + T lymphocyte count (CD4) in critically ill COVID-19 patients after a dexamethasone course and evaluate their association with 28-day ICU mortality, adult COVID-19 patients (n = 176) with an ICU length of stay of at least 10 days and under dexamethasone treatment were included. Associations between each biomarker value (or in combination) measured at day 10 after ICU admission and 28-day mortality in ICU were evaluated. At day 10, the majority of patients presented decreased values of both parameters. A significant association between low mHLA-DR and 28-day mortality was observed. This association remained significant in a multivariate analysis including age, comorbidities or pre-existing immunosuppression (adjusted Hazard ratio (aHR) = 2.86 [1.30-6.32], p = 0.009). Similar results were obtained with decreased CD4 + T cell count (aHR = 2.10 [1.09-4.04], p = 0.027). When combining these biomarkers, patients with both decreased mHLA-DR and low CD4 presented with an independent and significant elevated risk of 28-day mortality (i.e., 60%, aHR = 4.83 (1.72-13.57), p = 0.001). CONCLUSIONS: By using standardized immunomonitoring tools available in clinical practice, it is possible to identify a subgroup of patients at high risk of mortality at the end of a 10-day dexamethasone treatment. This emphasizes the significance of integrating immune monitoring into the surveillance of intensive care patients in order to guide further immumodulation approaches.