Biblio du mois : Juin 2017
2 juillet 2017
Après la belle journée dédiée au Don d’Organes du 1er juillet (retransmission vidéo bientôt disponible), nous vous donnons vos petites lectures pour l’été avec la Biblio du Mois de l’AJAR !
Au programme, ce mois-ci, beaucoup d’études intéressantes comme l’évaluation du flair médical et paramédical ou l’outil AKIprédictor qui va sans doute vous rappeler Akinator…
Comme c’est l’été, vous aurez aussi l’occasion de discuter du nouveau cocktail B1 C Cortico pour vos patients.
Entre le bad beat pour la FAST et l’évaluation cardiaque sur iPhone, une étude vous propose peut-être d’instaurer de la VNI à domicile pour moins revoir vos sortants d’énième hospitalisation pour exacerbation de BPCO…
On parlera même de physiologie, d’acupuncture, de statistique avec l’équipe comprenant le Pr Timsit qui nous propose de meilleurs moyens satistiques d’évaluation de l’antibiothérapie, de nombreuses méta-analyses dont une discutant de la prévention d’ulcère « de stress ».
VNI à domicile vs OLD après une exacerbation de BPCO
Murphy et al., JAMA, 2017
Importance Outcomes after exacerbations of chronic obstructive pulmonary disease (COPD) requiring acute noninvasive ventilation (NIV) are poor and there are few treatments to prevent hospital readmission and death.
Objective To investigate the effect of home NIV plus oxygen on time to readmission or death in patients with persistent hypercapnia after an acute COPD exacerbation.
Design, Setting, and Participants A randomized clinical trial of patients with persistent hypercapnia (Paco2 >53 mm Hg) 2 weeks to 4 weeks after resolution of respiratory acidemia, who were recruited from 13 UK centers between 2010 and 2015. Exclusion criteria included obesity (body mass index [BMI] >35), obstructive sleep apnea syndrome, or other causes of respiratory failure. Of 2021 patients screened, 124 were eligible.
Interventions There were 59 patients randomized to home oxygen alone (median oxygen flow rate, 1.0 L/min [interquartile range {IQR}, 0.5-2.0 L/min]) and 57 patients to home oxygen plus home NIV (median oxygen flow rate, 1.0 L/min [IQR, 0.5-1.5 L/min]). The median home ventilator settings were an inspiratory positive airway pressure of 24 (IQR, 22-26) cm H2O, an expiratory positive airway pressure of 4 (IQR, 4-5) cm H2O, and a backup rate of 14 (IQR, 14-16) breaths/minute.
Main Outcomes and Measures Time to readmission or death within 12 months adjusted for the number of previous COPD admissions, previous use of long-term oxygen, age, and BMI.
Results A total of 116 patients (mean [SD] age of 67 [10] years, 53% female, mean BMI of 21.6 [IQR, 18.2-26.1], mean [SD] forced expiratory volume in the first second of expiration of 0.6 L [0.2 L], and mean [SD] Paco2 while breathing room air of 59 [7] mm Hg) were randomized. Sixty-four patients (28 in home oxygen alone and 36 in home oxygen plus home NIV) completed the 12-month study period. The median time to readmission or death was 4.3 months (IQR, 1.3-13.8 months) in the home oxygen plus home NIV group vs 1.4 months (IQR, 0.5-3.9 months) in the home oxygen alone group, adjusted hazard ratio of 0.49 (95% CI, 0.31-0.77; P = .002). The 12-month risk of readmission or death was 63.4% in the home oxygen plus home NIV group vs 80.4% in the home oxygen alone group, absolute risk reduction of 17.0% (95% CI, 0.1%-34.0%). At 12 months, 16 patients had died in the home oxygen plus home NIV group vs 19 in the home oxygen alone group.
Conclusions and Relevance Among patients with persistent hypercapnia following an acute exacerbation of COPD, adding home noninvasive ventilation to home oxygen therapy prolonged the time to readmission or death within 12 months.
Performances pronostiques à 6 mois des médecins et IDE à l’admission en Réanimation
Detsky et al, JAMA, 2017
Importance Predictions of long-term survival and functional outcomes influence decision making for critically ill patients, yet little is known regarding their accuracy.
Objective To determine the discriminative accuracy of intensive care unit (ICU) physicians and nurses in predicting 6-month patient mortality and morbidity, including ambulation, toileting, and cognition.
Design, Setting, and Participants Prospective cohort study conducted in 5 ICUs in 3 hospitals in Philadelphia, Pennsylvania, and enrolling patients who spent at least 3 days in the ICU from October 2013 until May 2014 and required mechanical ventilation, vasopressors, or both. These patients’ attending physicians and bedside nurses were also enrolled. Follow-up was completed in December 2014.
Main Outcomes and Measures ICU physicians’ and nurses’ binary predictions of in-hospital mortality and 6-month outcomes, including mortality, return to original residence, ability to toilet independently, ability to ambulate up 10 stairs independently, and ability to remember most things, think clearly, and solve day-to-day problems (ie, normal cognition). For each outcome, physicians and nurses provided a dichotomous prediction and rated their confidence in that prediction on a 5-point Likert scale. Outcomes were assessed via interviews with surviving patients or their surrogates at 6 months. Discriminative accuracy was measured using positive and negative likelihood ratios (LRs), C statistics, and other operating characteristics.
Results Among 340 patients approached, 303 (89%) consented (median age, 62 years [interquartile range, 53-71]; 57% men; 32% African American); 6-month follow-up was completed for 299 (99%), of whom 169 (57%) were alive. Predictions were made by 47 physicians and 128 nurses. Physicians most accurately predicted 6-month mortality (positive LR, 5.91 [95% CI, 3.74-9.32]; negative LR, 0.41 [95% CI, 0.33-0.52]; C statistic, 0.76 [95% CI, 0.72-0.81]) and least accurately predicted cognition (positive LR, 2.36 [95% CI, 1.36-4.12]; negative LR, 0.75 [95% CI, 0.61-0.92]; C statistic, 0.61 [95% CI, 0.54-0.68]). Nurses most accurately predicted in-hospital mortality (positive LR, 4.71 [95% CI, 2.94-7.56]; negative LR, 0.61 [95% CI, 0.49-0.75]; C statistic, 0.68 [95% CI, 0.62-0.74]) and least accurately predicted cognition (positive LR, 1.50 [95% CI, 0.86-2.60]; negative LR, 0.88 [95% CI, 0.73-1.06]; C statistic, 0.55 [95% CI, 0.48-0.62]). Discriminative accuracy was higher when physicians and nurses were confident about their predictions (eg, for physicians’ confident predictions of 6-month mortality: positive LR, 33.00 [95% CI, 8.34-130.63]; negative LR, 0.18 [95% CI, 0.09-0.35]; C statistic, 0.90 [95% CI, 0.84-0.96]). Compared with a predictive model including objective clinical variables, a model that also included physician and nurse predictions had significantly higher discriminative accuracy for in-hospital mortality, 6-month mortality, and return to original residence (P < .01 for all).
Conclusions and Relevance ICU physicians’ and nurses’ discriminative accuracy in predicting 6-month outcomes of critically ill patients varied depending on the outcome being predicted and confidence of the predictors. Further research is needed to better understand how clinicians derive prognostic estimates of long-term outcomes.
Evaluation de la FAST-écho chez l’enfant
Holmes et al., JAMA, 2017
http://jamanetwork.com/journals/jama/article-abstract/2631528
Importance The utility of the focused assessment with sonography for trauma (FAST) examination in children is unknown.
Objective To determine if the FAST examination during initial evaluation of injured children improves clinical care.
Design, Setting, and Participants A randomized clinical trial (April 2012-May 2015) that involved 975 hemodynamically stable children and adolescents younger than 18 years treated for blunt torso trauma at the University of California, Davis Medical Center, a level I trauma center.
Interventions Patients were randomly assigned to a standard trauma evaluation with the FAST examination by the treating ED physician or a standard trauma evaluation alone.
Main Outcomes and Measures Coprimary outcomes were rate of abdominal computed tomographic (CT) scans in the ED, missed intra-abdominal injuries, ED length of stay, and hospital charges.
Results Among the 925 patients who were randomized (mean [SD] age, 9.7 [5.3] years; 575 males [62%]), all completed the study. A total of 50 patients (5.4%, 95% CI, 4.0% to 7.1%) were diagnosed with intra-abdominal injuries, including 40 (80%; 95% CI, 66% to 90%) who had intraperitoneal fluid found on an abdominal CT scan, and 9 patients (0.97%; 95% CI, 0.44% to 1.8%) underwent laparotomy. The proportion of patients with abdominal CT scans was 241 of 460 (52.4%) in the FAST group and 254 of 465 (54.6%) in the standard care–only group (difference, −2.2%; 95% CI, −8.7% to 4.2%). One case of missed intra-abdominal injury occurred in a patient in the FAST group and none in the control group (difference, 0.2%; 95% CI, −0.6% to 1.2%). The mean ED length of stay was 6.03 hours in the FAST group and 6.07 hours in the standard care–only group (difference, −0.04 hours; 95% CI, −0.47 to 0.40 hours). Median hospital charges were $46 415 in the FAST group and $47 759 in the standard care–only group (difference, −$1180; 95% CI, −$6651 to $4291).
Conclusions and Relevance Among hemodynamically stable children treated in an ED following blunt torso trauma, the use of FAST compared with standard care only did not improve clinical care, including use of resources; ED length of stay; missed intra-abdominal injuries; or hospital charges. These findings do not support the routine use of FAST in this setting.
Acupuncture : entre efficacité et futilité ?
Xia-ke, et al. JAMA, 2017
http://jamanetwork.com/journals/jama/article-abstract/2633915
Zhishun et al., JAMA, 2017
http://jamanetwork.com/journals/jama/article-abstract/2633916
Méta-analyse sur l’Early, Goal-Directed Therapy dans le choc septique
PRISM investigators
http://www.nejm.org/doi/full/10.1056/NEJMoa1701380
DOI: 10.1056/NEJMoa1701380
Background
After a single-center trial and observational studies suggesting that early, goal-directed therapy (EGDT) reduced mortality from septic shock, three multicenter trials (ProCESS, ARISE, and ProMISe) showed no benefit. This meta-analysis of individual patient data from the three recent trials was designed prospectively to improve statistical power and explore heterogeneity of treatment effect of EGDT.
Methods
We harmonized entry criteria, intervention protocols, outcomes, resource-use measures, and data collection across the trials and specified all analyses before unblinding. After completion of the trials, we pooled data, excluding the protocol-based standard-therapy group from the ProCESS trial, and resolved residual differences. The primary outcome was 90-day mortality. Secondary outcomes included 1-year survival, organ support, and hospitalization costs. We tested for treatment-by-subgroup interactions for 16 patient characteristics and 6 care-delivery characteristics.
Results
We studied 3723 patients at 138 hospitals in seven countries. Mortality at 90 days was similar for EGDT (462 of 1852 patients [24.9%]) and usual care (475 of 1871 patients [25.4%]); the adjusted odds ratio was 0.97 (95% confidence interval, 0.82 to 1.14; P=0.68). EGDT was associated with greater mean (±SD) use of intensive care (5.3±7.1 vs. 4.9±7.0 days, P=0.04) and cardiovascular support (1.9±3.7 vs. 1.6±2.9 days, P=0.01) than was usual care; other outcomes did not differ significantly, although average costs were higher with EGDT. Subgroup analyses showed no benefit from EGDT for patients with worse shock (higher serum lactate level, combined hypotension and hyperlactatemia, or higher predicted risk of death) or for hospitals with a lower propensity to use vasopressors or fluids during usual resuscitation.
Conclusions
In this meta-analysis of individual patient data, EGDT did not result in better outcomes than usual care and was associated with higher hospitalization costs across a broad range of patient and hospital characteristics.
On se repose la tête dans l’AVC ischémique ?
Anderson et al., NEJM, 2017
http://www.nejm.org/doi/full/10.1056/NEJMoa1615715
DOI: 10.1056/NEJMoa1615715
Background
The role of supine positioning after acute stroke in improving cerebral blood flow and the countervailing risk of aspiration pneumonia have led to variation in head positioning in clinical practice. We wanted to determine whether outcomes in patients with acute ischemic stroke could be improved by positioning the patient to be lying flat (i.e., fully supine with the back horizontal and the face upwards) during treatment to increase cerebral perfusion.
Methods
In a pragmatic, cluster-randomized, crossover trial conducted in nine countries, we assigned 11,093 patients with acute stroke (85% of the strokes were ischemic) to receive care in either a lying-flat position or a sitting-up position with the head elevated to at least 30 degrees, according to the randomization assignment of the hospital to which they were admitted; the designated position was initiated soon after hospital admission and was maintained for 24 hours. The primary outcome was degree of disability at 90 days, as assessed with the use of the modified Rankin scale (scores range from 0 to 6, with higher scores indicating greater disability and a score of 6 indicating death).
Results
The median interval between the onset of stroke symptoms and the initiation of the assigned position was 14 hours (interquartile range, 5 to 35). Patients in the lying-flat group were less likely than patients in the sitting-up group to maintain the position for 24 hours (87% vs. 95%, P<0.001). In a proportional-odds model, there was no significant shift in the distribution of 90-day disability outcomes on the global modified Rankin scale between patients in the lying-flat group and patients in the sitting-up group (unadjusted odds ratio for a difference in the distribution of scores on the modified Rankin scale in the lying-flat group, 1.01; 95% confidence interval, 0.92 to 1.10; P=0.84). Mortality within 90 days was 7.3% among the patients in the lying-flat group and 7.4% among the patients in the sitting-up group (P=0.83). There were no significant between-group differences in the rates of serious adverse events, including pneumonia.
Conclusions
Disability outcomes after acute stroke did not differ significantly between patients assigned to a lying-flat position for 24 hours and patients assigned to a sitting-up position with the head elevated to at least 30 degrees for 24 hours.
DFG sur néphron unique > DFG global en prédictif ?
Denic et al., NEJM, 2017
http://www.nejm.org/doi/full/10.1056/NEJMoa1614329
DOI: 10.1056/NEJMoa1614329
Background
The glomerular filtration rate (GFR) assesses the function of all nephrons, and the single-nephron GFR assesses the function of individual nephrons. How the single-nephron GFR relates to demographic and clinical characteristics and kidney-biopsy findings in humans is unknown.
Methods
We identified 1388 living kidney donors at the Mayo Clinic and the Cleveland Clinic who underwent a computed tomographic (CT) scan of the kidney with the use of contrast material and an iothalamate-based measurement of the GFR during donor evaluation and who underwent a kidney biopsy at donation. The mean single-nephron GFR was calculated as the GFR divided by the number of nephrons (calculated as the cortical volume of both kidneys as assessed on CT times the biopsy-determined glomerular density). Demographic and clinical characteristics and biopsy findings were correlated with the single-nephron GFR.
Results
A total of 58% of the donors were women, and the mean (±SD) age of the donors was 44±12 years. The mean GFR was 115±24 ml per minute, the mean number of nephrons was 860,000±370,000 per kidney, and the mean single-nephron GFR was 80±40 nl per minute. The single-nephron GFR did not vary significantly according to age (among donors <70 years of age), sex, or height (among donors ≤190 cm tall). A higher single-nephron GFR was independently associated with larger nephrons on biopsy and more glomerulosclerosis and arteriosclerosis than would be expected for age. A higher single-nephron GFR was associated with a height of more than 190 cm, obesity, and a family history of end-stage renal disease.
Conclusions
Among healthy adult kidney donors, the single-nephron GFR was fairly constant with regard to age, sex, and height (if ≤190 cm). A higher single-nephron GFR was associated with certain risk factors for chronic kidney disease and certain kidney-biopsy findings.
Intérêt de réhospitalisation dans le même hôpital sur la mortalité ?
Hua et al., AJRCCM, 2017
http://www.atsjournals.org/doi/full/10.1164/rccm.201605-0912OC
https://doi.org/10.1164/rccm.201605-0912OC
Rationale: Intensive care unit (ICU) patients who receive mechanical ventilation are at high risk for early rehospitalization. Given the medical complexity of these patients, a lack of continuity of care may adversely affect their outcomes during rehospitalization.
Objectives: To determine whether outcomes differ for patients who are rehospitalized at a different hospital versus the hospital of their index ICU stay.
Methods: We conducted a retrospective cohort study of mechanically ventilated ICU patients rehospitalized within 30 days in New York State hospitals between 2008 and 2013.
Measurements and Main Results: We measured frequency of rehospitalization at a different hospital, mortality, length of stay, and costs during rehospitalization. Of 26,947 mechanically ventilated ICU patients rehospitalized within 30 days of discharge, 8,443 (31.3%) were rehospitalized at a different hospital than that of the index ICU stay. For patients at a different hospital, 13.7% died during rehospitalization versus 11.1% who died at the index hospital (adjusted rate ratio [aRR], 1.11; 95% confidence interval [CI], 1.03–1.20; P = 0.009). Patients who died at a different hospital had shorter length of stay (aRR, 0.80; 95% CI, 0.70–0.92; P = 0.001) and decreased costs (adjusted mean difference, −$9,632.73; 95% CI, −$16,387.60 to −$2,877.88; P = 0.005), whereas survivors of rehospitalization at a different hospital had a modest increase in length of stay (aRR, 1.06; 95% CI, 1.01–1.11; P = 0.009) and increased costs of care (adjusted mean difference, $1,665.34; 95% CI, $602.12–$2,728.56; P = 0.002).
Conclusions: Almost one-third of mechanically ventilated critically ill patients were rehospitalized at a different hospital than that of the index ICU stay. This care discontinuity was associated with increased mortality.
Rôle du diaphragme contre le dérecrutement alvéolaire ?
Pellegrini et al., AJRCCM, 2017
http://www.atsjournals.org/doi/full/10.1164/rccm.201605-0992OC
https://doi.org/10.1164/rccm.201605-0992OC
Rationale: The diaphragm is the major inspiratory muscle and is assumed to relax during expiration. However, electrical postinspiratory activity has been observed. Whether there is an expiratory diaphragmatic contraction that preserves lung patency has yet to be explored.
Objectives: We hypothesized the occurrence of an expiratory diaphragmatic contraction directed at stabilizing peripheral airways and preventing or reducing cyclic expiratory lung collapse.
Methods: Mild acute respiratory distress syndrome was induced in 10 anesthetized, spontaneously breathing pigs. Lung volume was decreased by lowering end-expiratory airway pressure in a stepwise manner. We recorded the diaphragmatic electric activity during expiration, dynamic computed tomographic scans, and respiratory mechanics. In five pigs, the same protocol was repeated during mechanical ventilation after muscle paralysis.
Measurements and Main Results: Diaphragmatic electric activity during expiration increased by decreasing end-expiratory lung volume during spontaneous breathing. This enhanced the diaphragm muscle force, to a greater extent with lower lung volume, indicating a diaphragmatic electromechanical coupling during spontaneous expiration. In turn, the resulting diaphragmatic contraction delayed and reduced the expiratory collapse and increased lung aeration compared with mechanical ventilation with muscle paralysis and absence of diaphragmatic activity.
Conclusions: The diaphragm is an important regulator of expiration. Its expiratory activity seems to preserve lung volume and to protect against lung collapse. The loss of diaphragmatic expiratory contraction during mechanical ventilation and muscle paralysis may be a contributing factor to unsuccessful respiratory support.
Effets d’une incitation financière à des tests de VS quotidien aux USA
Barbash et al., AJRCCM, 2017
http://www.atsjournals.org/doi/full/10.1164/rccm.201607-1505OC
https://doi.org/10.1164/rccm.201607-1505OC
Rationale: Pay for performance is an increasingly common quality improvement strategy despite the absence of robust supporting evidence.
Objectives: To determine the impact of a financial incentive program rewarding physicians for the completion of daily spontaneous breathing trials (SBTs) in three academic hospitals.
Methods: We compared data from mechanically ventilated patients from 6 months before to 2 years after introduction of a financial incentive program that provided annual payments to critical care physicians contingent on unit-level SBT completion rates. We used Poisson regression to compare the frequency of days on which SBTs were completed among eligible patients and days on which patients were excluded from SBT eligibility among all mechanically ventilated patients. We used multivariate regression to compare risk-adjusted duration of mechanical ventilation and in-hospital mortality.
Measurements and Main Results: The cohort included 7,291 mechanically ventilated patients with 75,621 ventilator days. Baseline daily SBT rates were 96.8% (hospital A), 16.4% (hospital B), and 74.7% (hospital C). In hospital A, with the best baseline performance, there was no change in SBT rates, exclusion rates, or duration of mechanical ventilation across time periods. In hospitals B and C, with lower SBT completion rates at baseline, there was an increase in daily SBT completion rates and a concomitant increase in exclusions from eligibility. Duration of mechanical ventilation decreased in hospital C but not in hospital B. Mortality was unchanged for all hospitals.
Conclusions: In hospitals with low baseline SBT completion, physician-targeted financial incentives were associated with increased SBT rates driven in part by increased exclusion rates, without consistent improvements in outcome.
Utilisation d’une échelle de fragilité comme score pronostique ?
Brummel et al., AJRCCM, 2017
http://www.atsjournals.org/doi/full/10.1164/rccm.201605-0939OC
https://doi.org/10.1164/rccm.201605-0939OC
Rationale: The prevalence of frailty (diminished physiologic reserve) and its effect on outcomes for those aged 18 years and older with critical illness is unclear.
Objectives: We hypothesized greater frailty would be associated with subsequent mortality, disability, and cognitive impairment, regardless of age.
Methods: At enrollment, we measured frailty using the Clinical Frailty Scale (range, 1 [very fit] to 7 [severely frail]). At 3 and 12 months post-discharge, we assessed vital status, instrumental activities of daily living, basic activities of daily living, and cognition. We used multivariable regression to analyze associations between Clinical Frailty Scale scores and outcomes, adjusting for age, sex, education, comorbidities, baseline disability, baseline cognition, severity of illness, delirium, coma, sepsis, mechanical ventilation, and sedatives/opiates.
Measurements and Main Results: We enrolled 1,040 patients who were a median (interquartile range) of 62 (53–72) years old and who had a median Clinical Frailty Scale score of 3 (3–5). Half of those with clinical frailty (i.e., Clinical Frailty Scale score ≥5) were younger than 65 years old. Greater Clinical Frailty Scale scores were independently associated with greater mortality (P = 0.01 at 3 mo and P < 0.001 at 12 mo) and with greater odds of disability in instrumental activities of daily living (P = 0.04 at 3 mo and P = 0.002 at 12 mo). Clinical Frailty Scale scores were not associated with disability in basic activities of daily living or with cognition.
Conclusions: Frailty is common in critically ill adults aged 18 years and older and is independently associated with increased mortality and greater disability. Future studies should explore routine screening for clinical frailty in critically ill patients of all ages. Interventions to reduce mortality and disability among patients with heightened vulnerability should be developed and tested.
Infections pneumococciques invasives versus non invasives
Ceccato et al., Chest, 2017
http://journal.publications.chestnet.org/article.aspx?articleid=2598977
doi:10.1016/j.chest.2017.01.005
Background The burden of pneumococcal disease is measured only through patients with invasive pneumococcal disease. The urinary antigen test (UAT) for pneumococcus has exhibited high sensitivity and specificity. We aimed to compare the pneumococcal pneumonias diagnosed as invasive disease with pneumococcal pneumonias defined by UAT results.
Methods A prospective observational study of consecutive nonimmunosuppressed patients with community-acquired pneumonia was performed from January 2000 to December 2014. Patients were stratified into two groups: invasive pneumococcal pneumonia (IPP) defined as a positive blood culture or pleural fluid culture result and noninvasive pneumococcal pneumonia (NIPP) defined as a positive UAT result with negative blood or pleural fluid culture result.
Results We analyzed 779 patients (15%) of 5,132, where 361 (46%) had IPP and 418 (54%) had NIPP. Compared with the patients with IPP, those with NIPP presented more frequent chronic pulmonary disease and received previous antibiotics more frequently. Patients with IPP presented more severe community-acquired pneumonia, higher levels of inflammatory markers, and worse oxygenation at admission; more pulmonary complications; greater extrapulmonary complications; longer time to clinical stability; and longer length of hospital stay compared with the NIPP group. Age, chronic liver disease, mechanical ventilation, and acute renal failure were independent risk factors for 30-day crude mortality. Neither IPP nor NIPP was an independent risk factor for 30-day mortality.
Conclusions A high percentage of confirmed pneumococcal pneumonia is diagnosed by UAT. Despite differences in clinical characteristics and outcomes, IPP is not an independent risk factor for 30-day mortality compared with NIPP, reinforcing the importance of NIPP for pneumococcal pneumonia.
Vitamine C, Hydrocortisone, Thiamine : QUID de la supplémentation systématique dans le sepsis ?
Background The global burden of sepsis is estimated as 15 to 19 million cases annually, with a mortality rate approaching 60% in low-income countries.Methods In this retrospective before-after clinical study, we compared the outcome and clinical course of consecutive septic patients treated with intravenous vitamin C, hydrocortisone, and thiamine during a 7-month period (treatment group) with a control group treated in our ICU during the preceding 7 months. The primary outcome was hospital survival. A propensity score was generated to adjust the primary outcome.Results There were 47 patients in both treatment and control groups, with no significant differences in baseline characteristics between the two groups. The hospital mortality was 8.5% (4 of 47) in the treatment group compared with 40.4% (19 of 47) in the control group (P < .001). The propensity adjusted odds of mortality in the patients treated with the vitamin C protocol was 0.13 (95% CI, 0.04-0.48; P = .002). The Sepsis-Related Organ Failure Assessment score decreased in all patients in the treatment group, with none developing progressive organ failure. All patients in the treatment group were weaned off vasopressors, a mean of 18.3 ± 9.8 h after starting treatment with the vitamin C protocol. The mean duration of vasopressor use was 54.9 ± 28.4 h in the control group (P < .001).
Conclusions Our results suggest that the early use of intravenous vitamin C, together with corticosteroids and thiamine, are effective in preventing progressive organ dysfunction, including acute kidney injury, and in reducing the mortality of patients with severe sepsis and septic shock. Additional studies are required to confirm these preliminary findings.
ATB inhalés : IASIS is good ? Not better…
Background Clinical failures in ventilator-associated pneumonia (VAP) caused by gram-negative bacteria are common and associated with substantial morbidity, mortality, and resource utilization.Methods We assessed the safety and efficacy of the amikacin fosfomycin inhalation system (AFIS) for the treatment of gram-negative bacterial VAP in a randomized double-blind, placebo-controlled, parallel group, phase 2 study between May 2013 and March 2016. We compared standard of care in each arm plus 300 mg amikacin/120 mg fosfomycin or placebo (saline), delivered by aerosol twice daily for 10 days (or to extubation if < 10 days) via the investigational eFlow Inline System (PARI GmbH). The primary efficacy end point was change from baseline in the Clinical Pulmonary Infection Score (CPIS) during the randomized course of AFIS/placebo, using the subset of patients with microbiologically proven baseline infections with gram-negative bacteria.Results There were 143 patients randomized: 71 to the AFIS group, and 72 to the placebo group. Comparison of CPIS change from baseline between treatment groups was not different (P = .70). The secondary hierarchical end point of no mortality and clinical cure at day 14 or earlier was also not significant (P = .68) nor was the hierarchical end point of no mortality and ventilator-free days (P = .06). The number of deaths in the AFIS group was 17 (24%) and 12 (17%) in the placebo group (P = .32). The AFIS group had significantly fewer positive tracheal cultures on days 3 and 7 than placebo.
Conclusions In this trial of adjunctive aerosol therapy compared with standard of care IV antibiotics in patients with gram-negative VAP, the AFIS was ineffective in improving clinical outcomes despite reducing bacterial burden.
Oxygène per-op : point trop n’en faut ?
Staehr-Rye, et al., ICM, 2017
Background. High inspiratory oxygen fraction (FIO2) may improve tissue oxygenation but also impair pulmonary function. We aimed to assess whether the use of high intraoperative FIO2increases the risk of major respiratory complications.
Methods. We studied patients undergoing non-cardiothoracic surgery involving mechanical ventilation in this hospital-based registry study. The cases were divided into five groups based on the median FIO2
between intubation and extubation. The primary outcome was a composite of major respiratory complications (re-intubation, respiratory failure, pulmonary oedema, and pneumonia) developed within 7 days after surgery. Secondary outcomes included 30-day mortality. Several predefined covariates were included in a multivariate logistic regression model.
Results. The primary analysis included 73 922 cases, of whom 3035 (4.1%) developed a major respiratory complication within 7 days of surgery. For patients in the high- and low-oxygen groups, the median FIO2
was 0.79 [range 0.64–1.00] and 0.31 [0.16–0.34], respectively. Multivariate logistic regression analysis revealed that the median FIO2 was associated in a dose-dependent manner with increased risk of respiratory complications (adjusted odds ratio for high vs low FIO2 1.99, 95% confidence interval [1.72–2.31], P-value for trend <0.001). This finding was robust in a series of sensitivity analyses including adjustment for intraoperative oxygenation. High median FIO2 was also associated with 30-day mortality (odds ratio for high vs low FIO21.97, 95% confidence interval [1.30–2.99], P-value for trend <0.001).
Conclusions. In this analysis of administrative data on file, high intraoperative FIO2
was associated in a dose-dependent manner with major respiratory complications and with 30-day mortality. The effect remained stable in a sensitivity analysis controlled for oxygenation.
Compétences non techniques altérées en sortie de garde ?
Background. Sleep deprivation is common in anaesthesia residents, but its impact on performance remains uncertain. Non-technical skills (team working, situation awareness, decision making, and task management) are key components of quality of care in anaesthesia, particularly in crisis situations occurring in the operating room. The impact of sleep deprivation on non-technical skills is unknown. We tested the hypothesis that in anaesthesia residents sleep deprivation is associated with impaired non-technical skills.
Methods. Twenty anaesthesia residents were randomly allocated to undergo a simulation session after a night shift [sleep-deprived (SLD) group, n=10] or after a night of rest [rested (R) group, n=10] from January to March 2015. The simulated scenario was a situation of crisis management in the operating room. The primary end point was a composite score of anaesthetists’ non-technical skills (ANTS) assessed by two blinded evaluators.
Results. Non-technical skills were significantly impaired in the SLD group [ANTS score 12.2 (interquartile range 10.5–13)] compared with the R group [14.5 (14–15), P<0.02]. This difference was mainly accounted for by a difference in the team working item. On the day of simulation, the SLD group showed increased sleepiness and decreased confidence in anaesthesia skills.
Conclusions. In this randomized pilot trial, sleep deprivation was associated with impaired non-technical skills of anaesthesia residents in a simulated anaesthesia intraoperative crisis scenario.
Hypotension à l’induction :
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Non prédictive de la performance de l’anesthésiste ?
Epstein et al., BJA, 2017
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Etude des facteurs de risque
Südfeld et al., BJA, 2017
Solutés hypotoniques > isotoniques en perfusion ?
van Rogenmortel et al., BJA, 2017
Background. Daily and globally, millions of adult hospitalized patients are exposed to maintenance i.v. fluid solutions supported by limited scientific evidence. In particular, it remains unclear whether fluid tonicity contributes to the recently established detrimental effects of fluid, sodium, and chloride overload.
Methods. This crossover study consisted of two 48 h study periods, during which 12 fasting healthy adults were treated with a frequently prescribed solution (NaCl 0.9% in glucose 5% supplemented by 40 mmol litre−1 of potassium chloride) and a premixed hypotonic fluid (NaCl 0.32% in glucose 5% containing 26 mmol litre−1 of potassium) at a daily rate of 25 ml kg−1 of body weight. The primary end point was cumulative urine volume; fluid balance was thus calculated. We also explored the physiological mechanisms behind our findings and assessed electrolyte concentrations.
Results. After 48 h, 595 ml (95% CI: 454–735) less urine was voided with isotonic fluids than hypotonic fluids (P<0.001), or 803 ml (95% CI: 692–915) after excluding an outlier with ‘exaggerated natriuresis of hypertension’. The isotonic treatment was characterized by a significant decrease in aldosterone (P<0.001). Sodium concentrations were higher in the isotonic arm (P<0.001), but all measurements remained within the normal range. Potassium concentrations did not differ between the two solutions (P=0.45). Chloride concentrations were higher with the isotonic treatment (P<0.001), even causing hyperchloraemia.
Conclusions. Even at maintenance rate, isotonic solutions caused lower urine output, characterized by decreased aldosterone concentrations indicating (unintentional) volume expansion, than hypotonic solutions and were associated with hyperchloraemia. Despite their lower sodium and potassium content, hypotonic fluids were not associated with hyponatraemia or hypokalaemia.
Nouveaux modèles AIVOC :
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De Propofol pour les plus maigres
Lee et al., BJA, 2017
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De Rémifentanil pour les plus gros
Kyun Kim et al., Anesthesiology, 2017
http://anesthesiology.pubs.asahq.org/article.aspx?articleid=2627516
doi:10.1097/ALN.0000000000001635
Retarder les chirurgies après un AVC ischémique ?
Christiansen et al., Anesthesiology, 2017
http://anesthesiology.pubs.asahq.org/article.aspx?articleid=2628648
doi:10.1097/ALN.0000000000001685
Background: The outcomes of emergent noncardiac, nonintracranial surgery in patients with previous stroke remain unknown.
Methods: All emergency surgeries performed in Denmark (2005 to 2011) were analyzed according to time elapsed between previous ischemic stroke and surgery. The risks of 30-day mortality and major adverse cardiovascular events were estimated as odds ratios (ORs) and 95% CIs using adjusted logistic regression models in a priori defined groups (reference was no previous stroke). In patients undergoing surgery immediately (within 1 to 3 days) or early after stroke (within 4 to 14 days), propensity-score matching was performed.
Results: Of 146,694 nonvascular surgeries (composing 98% of all emergency surgeries), 5.3% had previous stroke (mean age, 75 yr [SD = 13]; 53% women, 50% major orthopedic surgery). Antithrombotic treatment and atrial fibrillation were more frequent and general anesthesia less frequent in patients with previous stroke (all P < 0.001). Risks of major adverse cardiovascular events and mortality were high for patients with stroke less than 3 months (20.7 and 16.4% events; OR = 4.71 [95% CI, 4.18 to 5.32] and 1.65 [95% CI, 1.45 to 1.88]), and remained increased for stroke within 3 to 9 months (10.3 and 12.3%; OR = 1.93 [95% CI, 1.55 to 2.40] and 1.20 [95% CI, 0.98 to 1.47]) and stroke more than 9 months (8.8 and 11.7%; OR = 1.62 [95% CI, 1.43 to 1.84] and 1.20 [95% CI, 1.08 to 1.34]) compared with no previous stroke (2.3 and 4.8% events). Major adverse cardiovascular events were significantly lower in 323 patients undergoing immediate surgery (21%) compared with 323 successfully propensity-matched early surgery patients (29%; P = 0.029).
Conclusions: Adverse cardiovascular outcomes and mortality were greatly increased among patients with recent stroke. However, events were higher 4 to 14 days after stroke compared with 1 to 3 days after stroke.
Etude randomisée sur une sortie de SSPI sans récupération motrice après une Rachianesthésie
http://anesthesiology.pubs.asahq.org/article.aspx?articleid=2618832
doi:10.1097/ALN.0000000000001629
Background: Postanesthesia care unit (PACU) discharge without observation of lower limb motor function after spinal anesthesia has been suggested to significantly reduce PACU stay and enhance resource optimization and early rehabilitation but without enough data to allow clinical recommendations.
Methods: A multicenter, semiblinded, noninferiority randomized controlled trial of discharge from the PACU with or without assessment of lower limb motor function after elective total hip or knee arthroplasty under spinal anesthesia was undertaken. The primary outcome was frequency of a successful fast-track course (length of stay 4 days or less and no 30-day readmission). Noninferiority would be declared if the odds ratio (OR) for a successful fast-track course was no worse for those patients receiving no motor function assessment versus those patients receiving motor function assessment by OR = 0.68.
Results: A total of 1,359 patients (98.8% follow-up) were available for analysis (93% American Society of Anesthesiologists class 1 to 2). The primary outcome occurred in 92.2% and 92.0%, corresponding to no motor function assessment being noninferior to motor function assessment with OR 0.97 (95% CI, 0.70 to 1.35). Adverse events in the ward during the first 24 h occurred in 5.8% versus 7.4% with or without motor function assessment, respectively (OR, 0.77; 95% CI, 0.5 to 1.19, P = 0.24).
Conclusions: PACU discharge without assessment of lower limb motor function after spinal anesthesia for total hip or knee arthroplasty was noninferior to motor function assessment in achieving length of stay 4 days or less or 30-day readmissions. Because a nonsignificant tendency toward increased adverse events during the first 24 h in the ward was discovered, further safety data are needed in patients without assessment of lower limb motor function before PACU discharge.
Analgésie : KT fémoral + bloc sciatique versus KT péri-articulaire & Ropi versus Bupi liposomale
Amundson et al., Anesthesiology, 2017
http://anesthesiology.pubs.asahq.org/article.aspx?articleid=2608336
doi:10.1097/ALN.0000000000001586
Background: Multimodal analgesia is standard practice for total knee arthroplasty; however, the role of regional techniques in improved perioperative outcomes remains unknown. The authors hypothesized that peripheral nerve blockade would result in lower pain scores and opioid consumption than two competing periarticular injection solutions.
Methods: This three-arm, nonblinded trial randomized 165 adults undergoing unilateral primary total knee arthroplasty to receive (1) femoral catheter plus sciatic nerve blocks, (2) ropivacaine-based periarticular injection, or (3) liposomal bupivacaine-based periarticular injection. Primary outcome was maximal pain during postoperative day 1 (0 to 10, numerical pain rating scale) in intention-to-treat analysis. Additional outcomes included pain scores and opioid consumption for postoperative days 0 to 2 and 3 months.
Results: One hundred fifty-seven study patients received peripheral nerve block (n = 50), ropivacaine (n = 55), or liposomal bupivacaine (n = 52) and reported median maximal pain scores on postoperative day 1 of 3, 4, and 4.5 and on postoperative day 0 of 1, 4, and 5, respectively (average pain scores for postoperative day 0: 0.6, 1.7, and 2.4 and postoperative day 1: 2.5, 3.5, and 3.7). Postoperative day 1 median maximal pain scores were significantly lower for peripheral nerve blockade compared to liposomal bupivacaine-based periarticular injection (P = 0.016; Hodges–Lehmann median difference [95% CI] = −1 [−2 to 0]). After postanesthesia care unit discharge, postoperative day 0 median maximal and average pain scores were significantly lower for peripheral nerve block compared to both periarticular injections (ropivacaine: maximal −2 [−3 to −1]; P < 0.001; average −0.8 [−1.3 to −0.2]; P = 0.003; and liposomal bupivacaine: maximal −3 [−4 to −2]; P < 0.001; average −1.4 [−2.0 to −0.8]; P < 0.001).
Conclusions: Ropivacaine-based periarticular injections provide pain control comparable on postoperative days 1 and 2 to a femoral catheter and single-injection sciatic nerve block. This study did not demonstrate an advantage of liposomal bupivacaine over ropivacaine in periarticular injections for total knee arthroplasty.
AKIpredictor : Insuffisance rénale tu auras ou pas ?
Flechet et al., ICM, 2017
Purpose
Early diagnosis of acute kidney injury (AKI) remains a major challenge. We developed and validated AKI prediction models in adult ICU patients and made these models available via an online prognostic calculator. We compared predictive performance against serum neutrophil gelatinase-associated lipocalin (NGAL) levels at ICU admission.
Methods
Analysis of the large multicenter EPaNIC database. Model development (n = 2123) and validation (n = 2367) were based on clinical information available (1) before and (2) upon ICU admission, (3) after 1 day in ICU and (4) including additional monitoring data from the first 24 h. The primary outcome was a comparison of the predictive performance between models and NGAL for the development of any AKI (AKI-123) and AKI stages 2 or 3 (AKI-23) during the first week of ICU stay.
Results
Validation cohort prevalence was 29% for AKI-123 and 15% for AKI-23. The AKI-123 model before ICU admission included age, baseline serum creatinine, diabetes and type of admission (medical/surgical, emergency/planned) and had an AUC of 0.75 (95% CI 0.75–0.75). The AKI-23 model additionally included height and weight (AUC 0.77 (95% CI 0.77–0.77)). Performance consistently improved with progressive data availability to AUCs of 0.82 (95% CI 0.82–0.82) for AKI-123 and 0.84 (95% CI 0.83–0.84) for AKI-23 after 24 h. NGAL was less discriminant with AUCs of 0.74 (95% CI 0.74–0.74) for AKI-123 and 0.79 (95% CI 0.79–0.79) for AKI-23.
Conclusions
AKI can be predicted early with models that only use routinely collected clinical information and outperform NGAL measured at ICU admission. The AKI-123 models are available at
Impact & coût après un séjour en réa pour :
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SDRA :
Parker Ruhl et al., ICM, 2017
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> 24h de ventilation mécanique :
Hogdson et al., ICM, 2017
Admission directement en Réa après une chirurgie : inutile ?
Kahan et al., ICM, 2017
Purpose
As global initiatives increase patient access to surgical treatments, there is a need to define optimal levels of perioperative care. Our aim was to describe the relationship between the provision and use of critical care resources and postoperative mortality.
Methods
Planned analysis of data collected during an international 7-day cohort study of adults undergoing elective in-patient surgery. We used risk-adjusted mixed-effects logistic regression models to evaluate the association between admission to critical care immediately after surgery and in-hospital mortality. We evaluated hospital-level associations between mortality and critical care admission immediately after surgery, critical care admission to treat life-threatening complications, and hospital provision of critical care beds. We evaluated the effect of national income using interaction tests.
Results
44,814 patients from 474 hospitals in 27 countries were available for analysis. Death was more frequent amongst patients admitted directly to critical care after surgery (critical care: 103/4317 patients [2%], standard ward: 99/39,566 patients [0.3%]; adjusted OR 3.01 [2.10–5.21]; p < 0.001). This association may differ with national income (high income countries OR 2.50 vs. low and middle income countries OR 4.68; p = 0.07). At hospital level, there was no association between mortality and critical care admission directly after surgery (p = 0.26), critical care admission to treat complications (p = 0.33), or provision of critical care beds (p = 0.70). Findings of the hospital-level analyses were not affected by national income status. A sensitivity analysis including only high-risk patients yielded similar findings.
Conclusions
We did not identify any survival benefit from critical care admission following surgery.
Vers de nouvelles méthodes d’évaluation des antibiothérapies ?
Timsit et al., ICM, 2017
Purpose
In this era of rising antimicrobial resistance, slowly refilling antibiotic development pipelines, and an aging population, we need to ensure that randomized clinical trials (RCTs) determine the added benefit of new antibiotic agents effectively and in a valid way, especially for severely ill patients. Unfortunately, universally accepted endpoints for the evaluation of new drugs in severe infections are lacking.
Methods
We review and discuss the current practices and challenges regarding endpoints in RCTs in this field and propose novel approaches.
Results
Usual endpoints actually recommended for drug development suffer from important flaws. Mortality requires large sample size and only partly related to the infectious process. Clinical cure rate is highly subjective in critically ill patients where symptoms may be related to other intercurrent events. Currently, composite endpoints, hierarchical nested designs, and competing risks analysis seem to be the most promising new tools for designing and analyzing clinical trials in this area, although they require further validation.
Conclusion
Regulatory authorities, pharmaceutical companies, and clinicians need to agree on the most appropriate clinical endpoints for severe infections to ensure efficient approval of new, effective antibiotic agents.
Vers des modèles PK/PD personnalisés pour soigner les infections en réa ?
Tängdén et al., ICM, 2017
Agressions rénales aux produits de contraste :
– Revue et méta-analyse bayésienne :
Ehrmann et al., ICM, 2017
– Score de propension :
McDonald (miam !) et al., ICM, 2017
Revue sur la gestion du remplissage dans l’insuffisance rénale aigue
Perner et al., ICM, 2017
DOI: 10.1007/s00134-017-4817-x
Mesure de la FEVG par iPhone ?
Pahlevan et al., CCM, 2017
doi: 10.1097/CCM.0000000000002459
Objective: The study is based on previously reported mathematical analysis of arterial waveform that extracts hidden oscillations in the waveform that we called intrinsic frequencies. The goal of this clinical study was to compare the accuracy of left ventricular ejection fraction derived from intrinsic frequencies noninvasively versus left ventricular ejection fraction obtained with cardiac MRI, the most accurate method for left ventricular ejection fraction measurement.
Design: After informed consent, in one visit, subjects underwent cardiac MRI examination and noninvasive capture of a carotid waveform using an iPhone camera (The waveform is captured using a custom app that constructs the waveform from skin displacement images during the cardiac cycle.). The waveform was analyzed using intrinsic frequency algorithm.
Setting: Outpatient MRI facility.
Subjects: Adults able to undergo MRI were referred by local physicians or self-referred in response to local advertisement and included patients with heart failure with reduced ejection fraction diagnosed by a cardiologist.
Interventions: Standard cardiac MRI sequences were used, with periodic breath holding for image stabilization. To minimize motion artifact, the iPhone camera was held in a cradle over the carotid artery during iPhone measurements.
Measurements and Main Results: Regardless of neck morphology, carotid waveforms were captured in all subjects, within seconds to minutes. Seventy-two patients were studied, ranging in age from 20 to 92 years old. The main endpoint of analysis was left ventricular ejection fraction; overall, the correlation between ejection fraction–iPhone and ejection fraction–MRI was 0.74 (r = 0.74; p < 0.0001; ejection fraction–MRI = 0.93 × [ejection fraction–iPhone] + 1.9).
Conclusions: Analysis of carotid waveforms using intrinsic frequency methods can be used to document left ventricular ejection fraction with accuracy comparable with that of MRI. The measurements require no training to perform or interpret, no calibration, and can be repeated at the bedside to generate almost continuous analysis of left ventricular ejection fraction without arterial cannulation.
SDRA chez l’enfant : plus une question de P/F que de volume courant ?
Yehya et al, CCM, 2017
doi: 10.1097/CCM.0000000000002406
Objectives: Both oxygenation and peak inspiratory pressure are associated with mortality in pediatric acute respiratory distress syndrome. Since oxygenation and respiratory mechanics are linked, it is difficult to identify which variables, pressure or oxygenation, are independently associated with outcome. We aimed to determine whether respiratory mechanics (peak inspiratory pressure, positive end-expiratory pressure, ΔP [PIP minus PEEP], tidal volume, dynamic compliance [Cdyn]) or oxygenation (PaO2/FIO2) was associated with mortality.
Design: Prospective, observational, cohort study.
Setting: University affiliated PICU.
Patients: Mechanically ventilated children with acute respiratory distress syndrome (Berlin).
Interventions: None.
Measurements and Main Results: Peak inspiratory pressure, positive end-expiratory pressure, ΔP, tidal volume, Cdyn, and PaO2/FIO2 were collected at acute respiratory distress syndrome onset and at 24 hours in 352 children between 2011 and 2016. At acute respiratory distress syndrome onset, neither mechanical variables nor PaO2/FIO2 were associated with mortality. At 24 hours, peak inspiratory pressure, positive end-expiratory pressure, ΔP were higher, and Cdyn and PaO2/FIO2 lower, in nonsurvivors. In multivariable logistic regression, PaO2/FIO2 at 24 hours and ΔPaO2/FIO2 (change in PaO2/FIO2 over the first 24 hr) were associated with mortality, whereas pressure variables were not. Both oxygenation and pressure variables were associated with duration of ventilation in multivariable competing risk regression.
Conclusions: Improvements in oxygenation, but not in respiratory mechanics, were associated with lower mortality in pediatric acute respiratory distress syndrome. Future trials of mechanical ventilation in children should focus on oxygenation (higher PaO2/FIO2) rather than lower peak inspiratory pressure or ΔP, as oxygenation was more consistently associated with outcome.
ETT post-ACR : dilatation du VD peu prédictif d’embolie pulmonaire ?
Aagaard et al., CCM, 2017
doi: 10.1097/CCM.0000000000002334
Objectives: The aim of this study was to test the hypothesis that the right ventricle is more dilated during resuscitation from cardiac arrest caused by pulmonary embolism, compared with hypoxia and primary arrhythmia.
Design: Twenty-four pigs were anesthetized and cardiac arrest was induced using three different methods. Pigs were resuscitated after 7 minutes of untreated cardiac arrest. Ultrasonographic images were obtained and the right ventricular diameter was measured.
Setting: University hospital animal laboratory.
Subjects: Female crossbred Landrace/Yorkshire/Duroc pigs (27–32 kg).
Interventions: Pigs were randomly assigned to cardiac arrest induced by pulmonary embolism, hypoxia, or primary arrhythmia.
Measurements and Main Results: There was no difference at baseline. During induction of cardiac arrest, the right ventricle dilated in all groups (p < 0.01 for all). The primary endpoint was right ventricle diameter at the third rhythm analysis: 32 mm (95% CI, 29–36) for pulmonary embolism which was significantly larger than both hypoxia: 23 mm (95% CI, 20–27) and primary arrhythmia: 25 mm (95% CI, 22–28)—the absolute difference was 7–9 mm. Physicians with basic training in focused cardiac ultrasonography were able to detect a difference in right ventricle diameter of approximately 10 mm with a sensitivity of 79% (95% CI, 64–94) and a specificity of 68% (95% CI, 56–80).
Conclusions: The right ventricle was more dilated during resuscitation when cardiac arrest was caused by pulmonary embolism compared with hypoxia and primary arrhythmia. However, the right ventricle was dilated, irrespective of the cause of arrest, and diagnostic accuracy by physicians with basic training in focused cardiac ultrasonography was modest. These findings challenge the paradigm that right ventricular dilatation on ultrasound during cardiopulmonary resuscitation is particularly associated with pulmonary embolism.
Repenser le planning de garde pour avoir plus de liberté ?
Geva et al., CCM, 2017
doi: 10.1097/CCM.0000000000002319
Objective: Despite widespread adoption of in-house call for ICU attendings, there is a paucity of research on optimal scheduling of intensivists to provide continuous on-site coverage. Overnight call duties have traditionally been added onto 7 days of continuous daytime clinical service. We designed an alternative ICU staffing model to increase continuity of attending physician care for patients while also decreasing interruptions to attendings’ nonclinical weeks.
Design: Computer-based simulation of a 1-year schedule.
Setting: A simulated ICU divided into two daytime teams each covered by a different attending and both covered by one overnight on-call attending.
Subjects: Simulated patients were randomly admitted on different service days to assess continuity of care.
Interventions: A “shared service schedule” was compared to a standard “7 days on schedule.” For the 7 days on schedule, an attending covered a team for 7 consecutive days and off-service attendings cross-covered each night. For the shared schedule, four attendings shared the majority of daytime and nighttime service for two teams over 2 weeks, with recovery periods built into the scheduled service time.
Measurements and Main Results: Continuity of care as measured by the Continuity of Attending Physician Index increased by 9% with the shared schedule. Annually, the shared service schedule was predicted to increase free weekends by 3.4 full weekends and 1.3 weekends with either Saturday or Sunday off. Full weeks without clinical obligations increased by 4 weeks. Mean time between clinical obligations increased by 5.8 days.
Conclusions: A shared service schedule is predicted to improve continuity of care while increasing free weekends and continuity of uninterrupted nonclinical weeks for attendings. Computer-based simulation allows assessment of benefits and tradeoffs of the alternative schedule without disturbing existing clinical systems.
Méta-analyse sur la prévention d’ulcère de stress : Pas de quoi stresser !
Alhazzzani, et al., CCM, 2017
doi: 10.1097/CCM.0000000000002461
Corticoïdes dans le SDRA : toujours pas !
Takaki et al., CC, 2017
https://ccforum.biomedcentral.com/articles/10.1186/s13054-017-1723-0
DOI: 10.1186/s13054-017-1723-0
Background
The efficacy of corticosteroid use in acute respiratory distress syndrome (ARDS) remains controversial. Generally, short-term high-dose corticosteroid therapy is considered to be ineffective in ARDS. On the other hand, low-dose, long-term use of corticosteroids has been reported to be effective since they provide continued inhibition of the systemic inflammatory response syndrome (SIRS) that accompanies ARDS. Thus far, no reports have been published on the efficacy of initiating treatment with a high-dose corticosteroid regimen with tapering.
Methods
We conducted a retrospective observational study involving 186 patients treated at a teaching hospital (68% had sepsis, pneumonia, or aspiration pneumonia). ARDS was diagnosed according to the Berlin definition. Patients were divided into a high-dose (n = 21) or low-dose corticosteroid group (n = 165) to compare the effectiveness of a down-titration regimen. The primary medical team chose which treatment a patient would receive. We were careful to conduct a differential diagnosis of interstitial pneumonia (e.g., acute eosinophilic pneumonia) since corticosteroid treatment has been proven effective in that patient population. The primary outcome was the 60-day mortality rate. The secondary outcome was the number of ventilator-free days (VFD).
Results
Those started on a high-dose regimen had a significantly higher 60-day mortality rate (P = 0.031) with significantly fewer VFD (P = 0.021). Propensity scores were used to adjust patient backgrounds in a variable analysis that also showed the high-dose regimen was a factor in decreasing VFD (OR, 95.63; 95% CI, 1.74–5271.07; P = 0.026) and worsening the 60-day mortality rate (OR, 2.54; 95% CI, 0.92–7.02; P = 0.072).
Conclusions
A tapering regimen after high-dose corticosteroids is likely to increase ventilator dependency and might aggravate the prognosis of patients with ARDS diagnosed according to the Berlin definition.
Cohorte sur les pneumonies sévères à VZV
Mirouse et al., CC, 2017
https://ccforum.biomedcentral.com/articles/10.1186/s13054-017-1731-0
Background
Pneumonia is a dreaded complication of varicella-zoster virus (VZV) infection in adults; however, the data are limited. Our objective was to investigate the clinical features, management, and outcomes of critically ill patients with VZV-related community-acquired pneumonia (VZV-CAP).
Methods
This was an observational study of patients with VZV-CAP admitted to 29 intensive care units (ICUs) from January 1996 to January 2015.
Results
One hundred and two patients with VZV-CAP were included. Patients were young (age 39 years (interquartile range 32–51)) and 53 (52%) were immunocompromised. Time since respiratory symptom onset was 2 (1–3) days. There was a seasonal distribution of the disease, with more cases during spring and winter time. All but four patients presented with typical skin rash on ICU admission. Half the patients received mechanical ventilation within 1 (1–2) day following ICU admission (the ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FiO2) = 150 (80–284), 80% with acute respiratory distress syndrome (ARDS)). Sequential Organ Failure Assessment (SOFA) score on day 1 (odds ratio (OR) 1.90 (1.33–2.70); p < 0.001), oxygen flow at ICU admission (OR 1.25 (1.08–1.45); p = 0.004), and early bacterial co-infection (OR 14.94 (2.00–111.8); p = 0.009) were independently associated with the need for mechanical ventilation. Duration of mechanical ventilation was 14 (7–21) days. ICU and hospital mortality rates were 17% and 24%, respectively. All patients were treated with aciclovir and 10 received adjunctive therapy with steroids. Compared to 60 matched steroid-free controls, patients treated with steroids had a longer mechanical ventilation duration, ICU length of stay, and a similar hospital mortality, but experienced more ICU-acquired infections.
Conclusions
Severe VZV-CAP is responsible for an acute pulmonary involvement associated with a significant morbidity and mortality. Steroid therapy did not influence mortality, but increased the risk of superinfection.
Bénéfice potentiel d’hémoperfusion de Polymixine B dans le choc septique ?
Nakamura et al., CC, 2017
https://ccforum.biomedcentral.com/articles/10.1186/s13054-017-1712-3
DOI: 10.1186/s13054-017-1712-3
Background
The purpose of this study was to investigate whether polymyxin B hemoperfusion (PMX-HP) improves the survival of patients with septic shock.
Methods
This was a retrospective, multicenter study conducted on patients treated during a 3-year period. We performed propensity-score analyses of the Japan Septic Disseminated Intravascular Coagulation (JSEPTIC DIC) study database. The study included data on 1723 patients with septic shock aged 16 years or older. Furthermore, we divided patients into to PMX-HP- and non-PMX-HP-treated groups. The primary endpoint was all-cause hospital mortality; secondary endpoints included intensive care unit (ICU) mortality and number of ICU-free days (ICUFDs) in the first 28 days.
Results
Of 1,723 eligible patients, 522 had received PMX-HP. Propensity score matching created 262 matched pairs (i.e., 262 patients in each of the non-PMX-HP and PMX-HP groups). The proportion of all-cause hospital mortality was significantly lower in the PMX-HP group than in the non-PMX-HP group (32.8% vs. 41.2%; odds ratio (OR): 0.681; 95% confidence interval (CI): 0.470–0.987; P = 0.042). The number of ICUFD in the first 28 days was significantly higher in the PMX-HP group than in the non-PMX-HP group (18 (0-22) vs. 14 (0-22) days, respectively; P = 0.045). On the other hand, there was no significant difference in ICU mortality between the two groups (21.8% vs. 24.4%; OR: 0.844; CI: 0.548–1.300; P = 0.443).
Conclusions
Our results strongly suggest that PMX-HP reduces all-cause hospital mortality and length of ICU stay in patients with septic shock.
Nutrition entérale : pas de différence entre les produits ?
Jakob et al., CC, 2017
https://ccforum.biomedcentral.com/articles/10.1186/s13054-017-1730-1
DOI: 10.1186/s13054-017-1730-1
Background
Diarrhea is frequent in patients in intensive care units (ICU) and is associated with discomfort and complications and may increase the length of stay and nursing workload.
Methods
This was a prospective, double-blind, randomized, controlled single-center pilot study to assess the incidence and frequency of diarrhea and the respective effects of a modified enteral diet (intervention: Peptamen® AF, rich in proteins, medium chain triglycerides and fish oil) compared to a standard diet (control: Isosource® Energy) in 90 randomized adult patients (intervention, n = 46; control, n = 44) with an ICU stay ≥5 days and tube feeding ≥3 days. Tube feeding was initiated within 72 h of ICU admission and continued up to 10 days. The caloric goal was adjusted to needs by indirect calorimetry. Gastrointestinal function, nutritional intake, and nursing workload were recorded. Follow-up was until 28 days after randomization.
Results
Median age was 63.3 (interquartile range (IQR) 51.0–73.2) years and Simplified Acute Physiology Score (SAPS) II was 61.0 (IQR 47.8–74). Time to reach caloric goal (intervention: 2.2 (0.8–3.7) days (median, IQR); control: 2.0 (1.3–2.7) days; p = 0.16), length of time on study nutrition (intervention: 5.0 (3.6–6.4) days; control: 7.0 (5.3–8.7) days; p = 0.26), and calorie intake (intervention: 18.0 (12.5–20.9) kcal/kg/day; control 19.7 (17.3–23.1) kcal/kg/day; p = 0.08) did not differ between groups, with a higher protein intake for Peptamen® group (1.13 (0.78–1.31) g/kg/day vs 0.80 (0.70–0.94); p < 0.001). No difference in diarrhea incidence (intervention group: 29 (64%); control group: 31 (70%); p = 0.652), use of fecal collectors (23 (51%) vs. 24 (55%); p = 0.83), or diarrhea-free days (161 (64%) vs 196 (68%); p = 0.65) was found. Nursing workload and cost for diarrhea care were not different between the groups. In a post-hoc analysis, adjusted for treatment group, age, sex, and SAPS II score, diarrhea was associated with length of mechanical ventilation (9.5 (6.0–13.1) vs. 3.9 (3.2–4.6) days; p = 0.006) and length of ICU stay (11.0 (8.9–13.1) vs. 5.0 (3.8–6.2) days; p = 0.001).
Conclusions
In this pilot study, we found a high incidence of diarrhea, which was not attenuated by Peptamen® AF. Patients with diarrhea stayed longer in the ICU.
Méta-analyse sur les alternatives aux épreuves de VS
Burns et al., CC, 2017
https://ccforum.biomedcentral.com/articles/10.1186/s13054-017-1698-x
DOI: 10.1186/s13054-017-1698-x
Retour d’expérience sur l’ECMO chez les > 70ans pour choc cardiogénique
Pontailler et al., ASAIO journal, 2017
DOI: 10.1097/MAT.0000000000000484
Étiquettes :