The prevalence of vitamin deficiencies is underes- timated. Risk factors for these deficiencies s... more The prevalence of vitamin deficiencies is underes- timated. Risk factors for these deficiencies should be reco- gnized in the intensive care unit. Some among these defi- ciencies can be fatal including Wernicke encephalopathy, shoshin beriberi, and scurvy; however they may recover dra- matically with appropriate supplementation.
Third-generation cephalosporins (3GCs) are recommended for empirical antibiotic therapy of commun... more Third-generation cephalosporins (3GCs) are recommended for empirical antibiotic therapy of community-acquired pneumonia (CAP) in patients requiring ICU admission. However, their extensive use could promote the emergence of extended-spectrum beta-lactamases-producing Enterobacteriaceae. Our aim was to assess whether the use of 3GCs in patients with CAP requiring ICU admission was justified. We assessed all patients with CAP who required ICU admission during a 7-year period. We recorded empirical and definitive antibiotic therapies and susceptibility of causative pathogens. Amoxicillin, amoxicillin/clavulanate (A/C) susceptibilities as well as amikacin susceptibility of A/C-resistant strains were recorded. From January 2007 to March 2014, 391 patients were included in the study. Empirical 3GCs were used in 215 patients (55%). Among 267 patients with microbiologically documented CAP (68%), 241 received a beta-lactam as definitive therapy, and of those, 3CGs were chosen for 43 patients ...
The best predictors of short- and medium-term mortality of cirrhotic patients receiving intensive... more The best predictors of short- and medium-term mortality of cirrhotic patients receiving intensive care support are unknown. We conducted meta-analyses from 13 studies (2523 cirrhotics) after selection of original articles and response to a standardized questionnaire by the corresponding authors. End-points were in-ICU, in-hospital, and 6-month mortality in ICU survivors. A total of 301 pooled analyses, including 95 analyses restricted to 6-month mortality among ICU survivors, were conducted considering 249 variables (including reason for admission, organ replacement therapy, and composite prognostic scores). In-ICU, in-hospital, and 6-month mortality was 42.7, 54.1, and 75.1%, respectively. Forty-eight patients (3.8%) underwent liver transplantation during follow-up. In-ICU mortality was lower in patients admitted for variceal bleeding (OR 0.46; 95% CI 0.36-0.59; p < 0.001) and higher in patients with SOFA > 19 at baseline (OR 8.54; 95% CI 2.09-34.91; p < 0.001; PPV = 0.93)...
Microcirculatory disorders leading to tissue hypoperfusion play a central role in the pathophysio... more Microcirculatory disorders leading to tissue hypoperfusion play a central role in the pathophysiology of organ failure in severe sepsis and septic shock. As microcirculatory disorders have been identified as strong predictive factors of unfavourable outcome, there is a need to develop accurate parameters at the bedside to evaluate tissue perfusion. We evaluated whether different body temperature gradients could relate to sepsis severity and could predict outcome in critically ill patients with severe sepsis and septic shock. We conducted a prospective observational study in a tertiary teaching hospital in France. During a 10-month period, all consecutive adult patients with severe sepsis or septic shock who required ICU admission were included. Six hours after initial resuscitation (H6), we recorded the hemodynamic parameters and four temperature gradients: central-to-toe, central-to-knee, toe-to-room and knee-to-room. We evaluated 40 patients with severe sepsis (40/103, 39 %) and 6...
ABSTRACT Au cours des trente dernières années, les inégalités d’accès aux soins se sont renforcée... more ABSTRACT Au cours des trente dernières années, les inégalités d’accès aux soins se sont renforcées. La précarité est associée à une réduction de l’accès aux soins primaires, une augmentation des consultations en urgence, des pathologies plus graves et une espérance de vie plus courte. Elle pourrait donc influencer l’épidémiologie et le pronostic des patients admis en réanimation. Les données de la littérature, majoritairement issues d’études rétrospectives, suggèrent que la précarité augmente le risque d’admission en réanimation. Les patients sans couverture sociale, sans domicile fixe (SDF) ou issus d’un milieu défavorisé sont plus jeunes et sont hospitalisés pour des motifs divers, plus souvent médicaux ou chirurgicaux urgents qu’après une chirurgie programmée. Aux États-Unis, l’absence de couverture sociale est associée à une réduction de l’intensité des soins et à une augmentation de la mortalité. En revanche, la plupart des études européennes montrent que les patients bénéficient du même niveau de soins, quel que soit leur niveau socio-économique, mais que les patients en situation de précarité ont des durées de séjour plus longues. La mortalité hospitalière ne semble pas influencée par le niveau socio-économique. Cependant, au sein des patients SDF, ceux vivant dans la rue ont une mortalité hospitalière plus élevée que ceux ayant un hébergement. La précarité étant une notion économique et sociale complexe, une étude prospective semble nécessaire pour confirmer ces résultats et déterminer si certaines de ses caractéristiques sont associées au pronostic. Enfin, l’isolement social soulève des questions éthiques à l’heure où l’accent est mis sur les directives anticipées et la personne de confiance.
Annual Update in Intensive Care and Emergency Medicine 2011, 2011
Among the investigations performed daily in the intensive care unit (ICU), bedside chest x-rays (... more Among the investigations performed daily in the intensive care unit (ICU), bedside chest x-rays (CXRs) are trivialized. However, they are a source of discomfort and irradiation for the patients, and carry a potential risk of accidental removal of devices (catheters, tubes) and microbial dissemination, all resulting in additional cost for the community. It is, therefore, essential to assess current practices in order to establish recommendations for prescription of CXRs and to determine whether it is possible to reduce the number of CXRs performed during an ICU stay without impairing quality of care. We will discuss alternatives to CXRs in specific situations (such as placement of feeding tubes and central venous lines). We will also consider bedside CXR prescription strategies, without considering medico-economic aspects such as the possible savings resulting from a reduction in the number of CXRs performed in the ICU. Indeed, the real cost of performing a bedside CXR is unknown because it integrates multiple parameters, such as cost of consumables, depreciation of equipment, working time of the x-ray technician and logistical costs.
Background: We assessed the potential impact of infusion tubing on blood glucose imbalance in ICU... more Background: We assessed the potential impact of infusion tubing on blood glucose imbalance in ICU patients given intensive insulin therapy (IIT). We compared the incidence of blood glucose imbalance in patients equipped, in a nonrandomized fashion, with either conventional tubing or with a multiport infusion device. Methods: We retrospectively analyzed the nursing files of 35 patients given IIT through the distal line of a doublelumen central venous catheter. A total of 1389 hours of IIT were analyzed for occurrence of hypoglycemic events [defined as arterial blood glucose below 90 mg/dL requiring discontinuation of insulin]. Results: Twenty-one hypoglycemic events were noted (density of incidence 15 for 1000 hours of ITT). In 17 of these 21 events (81%), medication had been administered during the previous hour through the line connected to the distal lumen of the catheter. Conventional tubing use was associated with a higher density of incidence of hypoglycemic events than multiport infusion device use (23 vs. 2 for 1,000 hours of IIT; rate ratio = 11.5; 95% confidence interval, 2.71-48.8; p < 0.001). Conclusions: The administration of on-demand medication through tubing carrying other medications can lead to the delivery of significant amounts of unscheduled products. Hypoglycaemia observed during IIT could be related to this phenomenon. The use of a multiport infusion device with a limited dead volume could limit hypoglycemia in patients on IIT.
During septic shock management, the evaluation of microvascular perfusion by skin analysis is of ... more During septic shock management, the evaluation of microvascular perfusion by skin analysis is of interest. We aimed to study the skin capillary refill time (CRT) in a selected septic shock population. We conducted a prospective observational study in a tertiary teaching hospital. After a preliminary study to calculate CRT reproducibility, all consecutive patients with septic shock during a 10-month period were included. After initial resuscitation at 6 h (H6), we recorded hemodynamic parameters and analyzed their predictive value on 14-day mortality. CRT was measured on the index finger tip and on the knee area. CRT was highly reproducible with an excellent inter-rater concordance calculated at 80% [73-86] for index CRT and 95% [93-98] for knee CRT. A total of 59 patients were included, SOFA score was 10 [7-14], SAPS II was 61 [50-78] and 14-day mortality rate was 36%. CRT measured at both sites was significantly higher in non-survivors compared to survivors (respectively 5.6 ± 3.5 vs 2.3 ± 1.8 s, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001 for index CRT and 7.6 ± 4.6 vs 2.9 ± 1.7 s, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001 for knee CRT). The CRT at H6 was strongly predictive of 14-day mortality as the area under the curve was 84% [75-94] for the index measurement and was 90% [83-98] for the knee area. A threshold of index CRT at 2.4 s predicted 14-day outcome with a sensitivity of 82% (95% CI [60-95]) and a specificity of 73% (95% CI [56-86]). A threshold of knee CRT at 4.9 s predicted 14-day outcome with a sensitivity of 82% (95% CI [60-95]) and a specificity of 84% (95% CI [68-94]). CRT was significantly related to tissue perfusion parameters such as arterial lactate level and SOFA score. Finally, CRT changes during shock resuscitation were significantly associated with prognosis. CRT is a clinical reproducible parameter when measured on the index finger tip or the knee area. After initial resuscitation of septic shock, CRT is a strong predictive factor of 14-day mortality.
Skin perfusion alterations are early and strong predictors of death in patients with septic shock... more Skin perfusion alterations are early and strong predictors of death in patients with septic shock. Cirrhosis is associated with systemic vasodilation and increases mortality from septic shock. We aimed at assessing whether the mottling score and tissue oxygen saturation (StO2) could be used as early predictors of death in cirrhotic patients with septic shock. This observational study included cirrhotic patients with septic shock. Each 6h during the first 24h, we collected data reflecting macrocirculation (mean arterial pressure, heart rate, central venous pressure, and cardiac output) and organ perfusion (arterial lactate, urinary output, ScvO2, mottling score, thenar, and knee StO2). Data of 75 non-cirrhotic patients with previously reported septic shock were used as control. 42 cirrhotic patients were included. Mortality at day 14 was 71%. At H6, parameters reflecting macrocirculation were not associated with mortality, whereas higher arterial lactate and mottling score were associated with death. Mottling score was the strongest predictor of mortality (sensitivity=0.63, specificity=1, OR=42.4 (2.3-785.9)). At H6, knee StO2 decreased in non-survivors and predicted death (sensitivity=0.45, specificity=1). In comparison with control, mottling kinetic was different in cirrhotic patients (delayed mottling appearance in non-survivors, earlier mottling disappearance in survivors). Knee StO2 and skin perfusion, assessed by laser-Doppler, were higher in cirrhotic patients. Mottling score and knee StO2 at H6 were very specific predictors of death in patients with cirrhosis and septic shock. Their sensitivity was lower in cirrhotic patients due to delayed mottling appearance and higher knee StO2 related to higher skin perfusion.
A 79 year-old patient with prostate cancer related Cushing's syndrome was referred to ICU for acu... more A 79 year-old patient with prostate cancer related Cushing's syndrome was referred to ICU for acute respiratory distress occurring two days after introduction of mifepristone. Pneumocystis jirovecii pneumonia was diagnosed. Despite anti pneumocystis therapy and supportive treatment, the patient died of multiple organ failure. The relationship between mifepristone and Cushing's syndrome and potential implications are discussed.
Background: Little is known about the efficacy of management of iatrogenic pneumothoraces with sm... more Background: Little is known about the efficacy of management of iatrogenic pneumothoraces with small-bore chest tubes. The aim of this study was to assess the outcome of iatrogenic pneumothoraces requiring drainage managed with a small-bore chest tube and to compare the results to spontaneous pneumothoraces treated in the same unit with the same device. The primary outcome was requirement of video-assisted thoracoscopic surgery for drainage failure; secondary outcomes were length of drainage and number of inserted chest tubes. Methods: Patients with pneumothorax admitted between 1997 and 2007 were retrospectively identified. Traumatic pneumothoraces and those occurring under mechanical ventilation were excluded. All pneumothoraces were drained using the same small-bore chest tube (8 French) according to our local protocol. Results: Five hundred sixty-one pneumothoraces were analysed, 431 (76.8%) were spontaneous pneumothoraces and 130 (23.2%) were iatrogenic. Iatrogenic pneumothoraces were associated with less requirement of video-assisted thoracoscopic surgery for drainage failure [adjusted odds ratio= 0.24 (0.04, 0.86)]. Length of drainage of iatrogenic pneumothoraces was longer than for primary spontaneous pneumothoraces (3.8 Ϯ 3.1 vs. 2.7 Ϯ 1.8 days, P < 0.001) and shorter than for secondary spontaneous pneumothoraces (4.6 Ϯ 2.3 days, P = 0.004). Number of inserted chest tubes per patient was not significantly different according to pneumothoraces' aetiology. Conclusion: Small-bore chest tubes are feasible for treatment of iatrogenic pneumothoraces and have a better rate of success and slightly longer drainage duration than when used for spontaneous pneumothoraces.
We read with great interest the article by Stepanova et al. 1 In this report from the United Stat... more We read with great interest the article by Stepanova et al. 1 In this report from the United States with 10,582 eligible individuals (1.52% of whom were positive for hepatitis C virus [HCV] antibody [anti-HCV]), the rate of insurance coverage was significantly lower in patients with HCV infection (61.2%), particularly in 66.7% patients who could be candidates for treatment (54.3%), than in subjects without HCV infection (81.2%). Only 36.3% of HCV-infected patients were potentially eligible for treatment and had health insurance. The authors considered that access to care for patients infected with HCV is critical, and their results can have important implications for health insurance coverage of HCV-infected patients and should be considered under the new health care reform legislation. With the current standard-of-care (SOC) regimen with a combination of pegylated interferon-alfa (PegIFN) and ribavirin, sustained virological response (SVR) rates in Western countries were around 50% and 83% for genotype 1 and 2/3 patients, respectively. 2,3 In addition to the well-known adverse effects of the PegIFN/ribavirin, which might terrify both physicians and patients and need careful monitoring as well as management, another important barrier that prevents patients from receiving SOC is the high cost of treatment of HCV, which the authors estimate is up to $48,000 per year in the United States. Insurance coverage to reduce the economic impact is critical in these patients, given the inability of most to afford the treatment. Recently, Yan et al. also reported that concern about cost is one of the most common causes (37%) for nontreatment before the government reimbursed all treatment for chronic hepatitis C (CHC) in Hong Kong. 4 Reduction of the economic burden for HCV therapy helps improve the treatment uptake of patients with CHC. In Taiwan, patients with CHC who are infected with genotype 1 and 2, and who are treated with PegIFN/ribavirin, achieve high SVR rates in our previous randomized trials (80% and 95%, respectively). 5,6 In addition, Asian patients had the highest frequency of the advantageous allele in the gene for interleukin-28B, with up to 88% of Taiwanese patients with CHC having the rs8099917 TT genotype in our reports, 7,8 which has been shown to be an important predictor of response. It seems reasonable to encourage Taiwanese patients with CHC to undertake the SOC regimen. In Taiwan, National Health Insurance (NHI) commenced in 1995, with a very high universal coverage rate of 99.5% by the end of 2008, resulting in a narrowed disparity in health care between the wealthy and the poor. 9 The reimbursement for anti-HCV therapy by the Taiwanese NHI started in 2003 if patients meet all the criteria: (1) positive for anti-HCV; (2) the alanine aminotransferase levels !2Â upper limit of normal on two occasions 3 months apart during the 6-month period; and (3) fibrosis stage !2 (revised to stage 1 or greater since 2004). The criteria were further revised in 2009: (1) patients with positive anti-HCV and serum HCV RNA and (2) abnormal alanine aminotransferase levels. Accordingly, more Taiwanese patients with CHC can be expected to receive therapy under this permitted reimbursement claim. We have constructed the ''roadmap'' concept with the determined duration of therapy in Taiwan 10 and using the strategy to truncate treatment, the estimated cost saving of drugs achieves 11.8% and 29% per SVR for HCV genotype 1/4 and genotype 2/ 3 patients, respectively. We can make more efforts to help patients. For instance, the NHI program in Taiwan, which is given unanimous praise, does not yet reimburse the use of hematopoietic agents such as erythropoietin or granulocyte colony stimulating factor in treating anemia or neutropenia caused by PegIFN/ribavirin. Here, we share the status of Taiwan's NHI, which has made Taiwanese patients with CHC more fortunate than patients in nations that have a lower rate of insurance coverage. When welcoming the new era of emergence of direct-acting antivirals that effectively enhance SVR rates when combined with SOC, we have tried our best to remove all barriers for receiving therapy, particularly the insurance obstacle in terms of financial burden for patients.
Objectives: To reassess the prognosis of patients with cirrhosis admitted to the intensive care u... more Objectives: To reassess the prognosis of patients with cirrhosis admitted to the intensive care unit. Design: A retrospective study in a medical intensive care unit in a teaching hospital in France. Patients: All patients with cirrhosis without previous liver transplantation admitted in the period from 2005 to 2008. Interventions: None. Main Results: One hundred thirty-eight patients were studied. Survival rates in the intensive care unit, in hospital, and at 6 months were 59% (95% confidence interval, 50%-67%), 46% (95% confidence interval, 38%-54%), and 38% (95% confidence interval, 30%-47%), respectively. In-hospital survival rates for patients requiring vasopressors, mechanical ventilation, or renal replacement therapy were 20%, 33%, and 31%, respectively. On day 1, independent risk factors for inhospital mortality were age, albuminemia, international normalized ratio, and the Sequential Organ Failure Assessment score computed after discarding points for hematologic failure (modified Sequential Organ Failure Assessment score). Liver disease severity, assessed using a clinical classification, did not correlate with inhospital mortality. In patients still alive after 3 days, the only prog-nostic factor was the modified Sequential Organ Failure Assessment score computed after 3 days. To predict inhospital mortality, the modified Sequential Organ Failure Assessment score on day 1 had a greater area under the receiver operating characteristic curve (0.84) than the Simplified Acute Physiology Score II (0.78), the Child-Pugh score (0.76), the model for end-stage liver disease score (0.77), or the model for end-stage liver disease-natremia score (0.75). The inhospital mortality rate with three or four nonhematologic organ failures on day 1 was not >70%, whereas it was 89% with three nonhematologic organ failures after 3 days spent in the intensive care unit. Conclusion: In-hospital survival rate of intensive care unitadmitted cirrhotic patients seemed acceptable, even in patients requiring life-sustaining treatments and/or with multiple organ failure on admission. The most important risk factor for inhospital mortality was the severity of nonhematologic organ failure, as best assessed after 3 days. A trial of unrestricted intensive care for a few days could be proposed for select critically ill cirrhotic patients. (Crit Care Med 2010; 38:2108-2116) KEY WORDS: liver cirrhosis; prognosis; critical care; critical illness; intensive care units; mechanical ventilation LEARNING OBJECTIVES After participating in this educational activity, the participant should be better able to: 1. Evaluate the usefulness of factors that influence outcome when triaging cirrhotic patients. 2. Analyze factors that influence outcome when triaging cirrhotic patients. 3. Assess risk factors for inhospital mortality in patients with cirrhosis. Unless otherwise noted, the faculty's, staff's, and authors' spouse(s)/life partner(s) (if any) have nothing to disclose. The authors have disclosed that they have no financial relationships with, or financial interests in, any commercial companies pertaining to this educational activity. All faculty and staff in a position to control the content of this CME activity have disclosed that they have no financial relationship with, or financial interests in, any commercial companies pertaining to this educational activity. Visit the Critical Care Medicine Web site (www.ccmjournal.org) for information on obtaining continuing medical education credit.
Background The death rate in intensive care units (ICUs) can reach 20%. More than half occurs aft... more Background The death rate in intensive care units (ICUs) can reach 20%. More than half occurs after a decision of care withholding/withdrawal. We aimed at describing and evaluating the experience of ICU physicians and nurses involved in the end-of-life (EOL) procedure. Primary objective was the evaluation of the experience of EOL assessed by the CAESAR questionnaire. Secondary objectives were to describe factors associated with a low or high score and to examine the association between Numeric Analogic Scale and quality of EOL. Methods Consecutive adult patients deceased in 52 ICUs were included between April and June 2018. Characteristics of patients and caregivers, therapeutics and care involved after withdrawal were recorded. CAESAR score included 15 items, rated from 1 (traumatic experience) to 5 (comforting experience). The sum was rated from 15 to 75 (the highest, the best experience). Numeric Analogic Scale was rated from 0 (worst EOL) to 10 (optimal EOL). Results Five hundre...
Background Intensive care unit (ICU) patients age 90 years or older represent a growing subgroup ... more Background Intensive care unit (ICU) patients age 90 years or older represent a growing subgroup and place a huge financial burden on health care resources despite the benefit being unclear. This leads to ethical problems. The present investigation assessed the differences in outcome between nonagenarian and octogenarian ICU patients. Methods We included 7900 acutely admitted older critically ill patients from two large, multinational studies. The primary outcome was 30-day-mortality, and the secondary outcome was ICU-mortality. Baseline characteristics consisted of frailty assessed by the Clinical Frailty Scale (CFS), ICU-management, and outcomes were compared between octogenarian (80–89.9 years) and nonagenarian (> 90 years) patients. We used multilevel logistic regression to evaluate differences between octogenarians and nonagenarians. Results The nonagenarians were 10% of the entire cohort. They experienced a higher percentage of frailty (58% vs 42%; p
BackgroundThe COVID-19 pandemic has led highly developed healthcare systems to the brink of colla... more BackgroundThe COVID-19 pandemic has led highly developed healthcare systems to the brink of collapse due to the large numbers of patients being admitted into hospitals. One of the potential prognostic indicators in patients with COVID-19 is frailty. The degree of frailty could be used to assist both the triage into intensive care, and decisions regarding treatment limitations. Our study sought to determine the interaction of frailty and age in elderly COVID-19 ICU patients.MethodsA prospective multi-centre study of COVID-19 patients ≥ 70 years admitted to intensive care in 138 ICUs from 28 countries was conducted. The primary endpoint was 30-day mortality. Frailty was assessed using the Clinical Frailty Scale (CFS). Additionally, comorbidities, management strategies and treatment limitations were recorded.ResultsThe study included 1346 patients (28% female) with a median age of 75 years (IQR 72-78, range 70-96), 16.3% were older than 80 years and 21% of the patients were frail. The ...
Purpose Lactate is an established prognosticator in critical care. However, there still is insuff... more Purpose Lactate is an established prognosticator in critical care. However, there still is insufficient evidence about its role in predicting outcome in COVID-19. This is of particular concern in older patients who have been mostly affected during the initial surge in 2020. Methods This prospective international observation study (The COVIP study) recruited patients aged 70 years or older (ClinicalTrials.gov ID: NCT04321265) admitted to an intensive care unit (ICU) with COVID-19 disease from March 2020 to February 2021. In addition to serial lactate values (arterial blood gas analysis), we recorded several parameters, including SOFA score, ICU procedures, limitation of care, ICU- and 3-month mortality. A lactate concentration ≥ 2.0 mmol/L on the day of ICU admission (baseline) was defined as abnormal. The primary outcome was ICU-mortality. The secondary outcomes 30-day and 3-month mortality. Results In total, data from 2860 patients were analyzed. In most patients (68%), serum lacta...
The prevalence of vitamin deficiencies is underes- timated. Risk factors for these deficiencies s... more The prevalence of vitamin deficiencies is underes- timated. Risk factors for these deficiencies should be reco- gnized in the intensive care unit. Some among these defi- ciencies can be fatal including Wernicke encephalopathy, shoshin beriberi, and scurvy; however they may recover dra- matically with appropriate supplementation.
Third-generation cephalosporins (3GCs) are recommended for empirical antibiotic therapy of commun... more Third-generation cephalosporins (3GCs) are recommended for empirical antibiotic therapy of community-acquired pneumonia (CAP) in patients requiring ICU admission. However, their extensive use could promote the emergence of extended-spectrum beta-lactamases-producing Enterobacteriaceae. Our aim was to assess whether the use of 3GCs in patients with CAP requiring ICU admission was justified. We assessed all patients with CAP who required ICU admission during a 7-year period. We recorded empirical and definitive antibiotic therapies and susceptibility of causative pathogens. Amoxicillin, amoxicillin/clavulanate (A/C) susceptibilities as well as amikacin susceptibility of A/C-resistant strains were recorded. From January 2007 to March 2014, 391 patients were included in the study. Empirical 3GCs were used in 215 patients (55%). Among 267 patients with microbiologically documented CAP (68%), 241 received a beta-lactam as definitive therapy, and of those, 3CGs were chosen for 43 patients ...
The best predictors of short- and medium-term mortality of cirrhotic patients receiving intensive... more The best predictors of short- and medium-term mortality of cirrhotic patients receiving intensive care support are unknown. We conducted meta-analyses from 13 studies (2523 cirrhotics) after selection of original articles and response to a standardized questionnaire by the corresponding authors. End-points were in-ICU, in-hospital, and 6-month mortality in ICU survivors. A total of 301 pooled analyses, including 95 analyses restricted to 6-month mortality among ICU survivors, were conducted considering 249 variables (including reason for admission, organ replacement therapy, and composite prognostic scores). In-ICU, in-hospital, and 6-month mortality was 42.7, 54.1, and 75.1%, respectively. Forty-eight patients (3.8%) underwent liver transplantation during follow-up. In-ICU mortality was lower in patients admitted for variceal bleeding (OR 0.46; 95% CI 0.36-0.59; p < 0.001) and higher in patients with SOFA > 19 at baseline (OR 8.54; 95% CI 2.09-34.91; p < 0.001; PPV = 0.93)...
Microcirculatory disorders leading to tissue hypoperfusion play a central role in the pathophysio... more Microcirculatory disorders leading to tissue hypoperfusion play a central role in the pathophysiology of organ failure in severe sepsis and septic shock. As microcirculatory disorders have been identified as strong predictive factors of unfavourable outcome, there is a need to develop accurate parameters at the bedside to evaluate tissue perfusion. We evaluated whether different body temperature gradients could relate to sepsis severity and could predict outcome in critically ill patients with severe sepsis and septic shock. We conducted a prospective observational study in a tertiary teaching hospital in France. During a 10-month period, all consecutive adult patients with severe sepsis or septic shock who required ICU admission were included. Six hours after initial resuscitation (H6), we recorded the hemodynamic parameters and four temperature gradients: central-to-toe, central-to-knee, toe-to-room and knee-to-room. We evaluated 40 patients with severe sepsis (40/103, 39 %) and 6...
ABSTRACT Au cours des trente dernières années, les inégalités d’accès aux soins se sont renforcée... more ABSTRACT Au cours des trente dernières années, les inégalités d’accès aux soins se sont renforcées. La précarité est associée à une réduction de l’accès aux soins primaires, une augmentation des consultations en urgence, des pathologies plus graves et une espérance de vie plus courte. Elle pourrait donc influencer l’épidémiologie et le pronostic des patients admis en réanimation. Les données de la littérature, majoritairement issues d’études rétrospectives, suggèrent que la précarité augmente le risque d’admission en réanimation. Les patients sans couverture sociale, sans domicile fixe (SDF) ou issus d’un milieu défavorisé sont plus jeunes et sont hospitalisés pour des motifs divers, plus souvent médicaux ou chirurgicaux urgents qu’après une chirurgie programmée. Aux États-Unis, l’absence de couverture sociale est associée à une réduction de l’intensité des soins et à une augmentation de la mortalité. En revanche, la plupart des études européennes montrent que les patients bénéficient du même niveau de soins, quel que soit leur niveau socio-économique, mais que les patients en situation de précarité ont des durées de séjour plus longues. La mortalité hospitalière ne semble pas influencée par le niveau socio-économique. Cependant, au sein des patients SDF, ceux vivant dans la rue ont une mortalité hospitalière plus élevée que ceux ayant un hébergement. La précarité étant une notion économique et sociale complexe, une étude prospective semble nécessaire pour confirmer ces résultats et déterminer si certaines de ses caractéristiques sont associées au pronostic. Enfin, l’isolement social soulève des questions éthiques à l’heure où l’accent est mis sur les directives anticipées et la personne de confiance.
Annual Update in Intensive Care and Emergency Medicine 2011, 2011
Among the investigations performed daily in the intensive care unit (ICU), bedside chest x-rays (... more Among the investigations performed daily in the intensive care unit (ICU), bedside chest x-rays (CXRs) are trivialized. However, they are a source of discomfort and irradiation for the patients, and carry a potential risk of accidental removal of devices (catheters, tubes) and microbial dissemination, all resulting in additional cost for the community. It is, therefore, essential to assess current practices in order to establish recommendations for prescription of CXRs and to determine whether it is possible to reduce the number of CXRs performed during an ICU stay without impairing quality of care. We will discuss alternatives to CXRs in specific situations (such as placement of feeding tubes and central venous lines). We will also consider bedside CXR prescription strategies, without considering medico-economic aspects such as the possible savings resulting from a reduction in the number of CXRs performed in the ICU. Indeed, the real cost of performing a bedside CXR is unknown because it integrates multiple parameters, such as cost of consumables, depreciation of equipment, working time of the x-ray technician and logistical costs.
Background: We assessed the potential impact of infusion tubing on blood glucose imbalance in ICU... more Background: We assessed the potential impact of infusion tubing on blood glucose imbalance in ICU patients given intensive insulin therapy (IIT). We compared the incidence of blood glucose imbalance in patients equipped, in a nonrandomized fashion, with either conventional tubing or with a multiport infusion device. Methods: We retrospectively analyzed the nursing files of 35 patients given IIT through the distal line of a doublelumen central venous catheter. A total of 1389 hours of IIT were analyzed for occurrence of hypoglycemic events [defined as arterial blood glucose below 90 mg/dL requiring discontinuation of insulin]. Results: Twenty-one hypoglycemic events were noted (density of incidence 15 for 1000 hours of ITT). In 17 of these 21 events (81%), medication had been administered during the previous hour through the line connected to the distal lumen of the catheter. Conventional tubing use was associated with a higher density of incidence of hypoglycemic events than multiport infusion device use (23 vs. 2 for 1,000 hours of IIT; rate ratio = 11.5; 95% confidence interval, 2.71-48.8; p < 0.001). Conclusions: The administration of on-demand medication through tubing carrying other medications can lead to the delivery of significant amounts of unscheduled products. Hypoglycaemia observed during IIT could be related to this phenomenon. The use of a multiport infusion device with a limited dead volume could limit hypoglycemia in patients on IIT.
During septic shock management, the evaluation of microvascular perfusion by skin analysis is of ... more During septic shock management, the evaluation of microvascular perfusion by skin analysis is of interest. We aimed to study the skin capillary refill time (CRT) in a selected septic shock population. We conducted a prospective observational study in a tertiary teaching hospital. After a preliminary study to calculate CRT reproducibility, all consecutive patients with septic shock during a 10-month period were included. After initial resuscitation at 6 h (H6), we recorded hemodynamic parameters and analyzed their predictive value on 14-day mortality. CRT was measured on the index finger tip and on the knee area. CRT was highly reproducible with an excellent inter-rater concordance calculated at 80% [73-86] for index CRT and 95% [93-98] for knee CRT. A total of 59 patients were included, SOFA score was 10 [7-14], SAPS II was 61 [50-78] and 14-day mortality rate was 36%. CRT measured at both sites was significantly higher in non-survivors compared to survivors (respectively 5.6 ± 3.5 vs 2.3 ± 1.8 s, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001 for index CRT and 7.6 ± 4.6 vs 2.9 ± 1.7 s, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001 for knee CRT). The CRT at H6 was strongly predictive of 14-day mortality as the area under the curve was 84% [75-94] for the index measurement and was 90% [83-98] for the knee area. A threshold of index CRT at 2.4 s predicted 14-day outcome with a sensitivity of 82% (95% CI [60-95]) and a specificity of 73% (95% CI [56-86]). A threshold of knee CRT at 4.9 s predicted 14-day outcome with a sensitivity of 82% (95% CI [60-95]) and a specificity of 84% (95% CI [68-94]). CRT was significantly related to tissue perfusion parameters such as arterial lactate level and SOFA score. Finally, CRT changes during shock resuscitation were significantly associated with prognosis. CRT is a clinical reproducible parameter when measured on the index finger tip or the knee area. After initial resuscitation of septic shock, CRT is a strong predictive factor of 14-day mortality.
Skin perfusion alterations are early and strong predictors of death in patients with septic shock... more Skin perfusion alterations are early and strong predictors of death in patients with septic shock. Cirrhosis is associated with systemic vasodilation and increases mortality from septic shock. We aimed at assessing whether the mottling score and tissue oxygen saturation (StO2) could be used as early predictors of death in cirrhotic patients with septic shock. This observational study included cirrhotic patients with septic shock. Each 6h during the first 24h, we collected data reflecting macrocirculation (mean arterial pressure, heart rate, central venous pressure, and cardiac output) and organ perfusion (arterial lactate, urinary output, ScvO2, mottling score, thenar, and knee StO2). Data of 75 non-cirrhotic patients with previously reported septic shock were used as control. 42 cirrhotic patients were included. Mortality at day 14 was 71%. At H6, parameters reflecting macrocirculation were not associated with mortality, whereas higher arterial lactate and mottling score were associated with death. Mottling score was the strongest predictor of mortality (sensitivity=0.63, specificity=1, OR=42.4 (2.3-785.9)). At H6, knee StO2 decreased in non-survivors and predicted death (sensitivity=0.45, specificity=1). In comparison with control, mottling kinetic was different in cirrhotic patients (delayed mottling appearance in non-survivors, earlier mottling disappearance in survivors). Knee StO2 and skin perfusion, assessed by laser-Doppler, were higher in cirrhotic patients. Mottling score and knee StO2 at H6 were very specific predictors of death in patients with cirrhosis and septic shock. Their sensitivity was lower in cirrhotic patients due to delayed mottling appearance and higher knee StO2 related to higher skin perfusion.
A 79 year-old patient with prostate cancer related Cushing's syndrome was referred to ICU for acu... more A 79 year-old patient with prostate cancer related Cushing's syndrome was referred to ICU for acute respiratory distress occurring two days after introduction of mifepristone. Pneumocystis jirovecii pneumonia was diagnosed. Despite anti pneumocystis therapy and supportive treatment, the patient died of multiple organ failure. The relationship between mifepristone and Cushing's syndrome and potential implications are discussed.
Background: Little is known about the efficacy of management of iatrogenic pneumothoraces with sm... more Background: Little is known about the efficacy of management of iatrogenic pneumothoraces with small-bore chest tubes. The aim of this study was to assess the outcome of iatrogenic pneumothoraces requiring drainage managed with a small-bore chest tube and to compare the results to spontaneous pneumothoraces treated in the same unit with the same device. The primary outcome was requirement of video-assisted thoracoscopic surgery for drainage failure; secondary outcomes were length of drainage and number of inserted chest tubes. Methods: Patients with pneumothorax admitted between 1997 and 2007 were retrospectively identified. Traumatic pneumothoraces and those occurring under mechanical ventilation were excluded. All pneumothoraces were drained using the same small-bore chest tube (8 French) according to our local protocol. Results: Five hundred sixty-one pneumothoraces were analysed, 431 (76.8%) were spontaneous pneumothoraces and 130 (23.2%) were iatrogenic. Iatrogenic pneumothoraces were associated with less requirement of video-assisted thoracoscopic surgery for drainage failure [adjusted odds ratio= 0.24 (0.04, 0.86)]. Length of drainage of iatrogenic pneumothoraces was longer than for primary spontaneous pneumothoraces (3.8 Ϯ 3.1 vs. 2.7 Ϯ 1.8 days, P < 0.001) and shorter than for secondary spontaneous pneumothoraces (4.6 Ϯ 2.3 days, P = 0.004). Number of inserted chest tubes per patient was not significantly different according to pneumothoraces' aetiology. Conclusion: Small-bore chest tubes are feasible for treatment of iatrogenic pneumothoraces and have a better rate of success and slightly longer drainage duration than when used for spontaneous pneumothoraces.
We read with great interest the article by Stepanova et al. 1 In this report from the United Stat... more We read with great interest the article by Stepanova et al. 1 In this report from the United States with 10,582 eligible individuals (1.52% of whom were positive for hepatitis C virus [HCV] antibody [anti-HCV]), the rate of insurance coverage was significantly lower in patients with HCV infection (61.2%), particularly in 66.7% patients who could be candidates for treatment (54.3%), than in subjects without HCV infection (81.2%). Only 36.3% of HCV-infected patients were potentially eligible for treatment and had health insurance. The authors considered that access to care for patients infected with HCV is critical, and their results can have important implications for health insurance coverage of HCV-infected patients and should be considered under the new health care reform legislation. With the current standard-of-care (SOC) regimen with a combination of pegylated interferon-alfa (PegIFN) and ribavirin, sustained virological response (SVR) rates in Western countries were around 50% and 83% for genotype 1 and 2/3 patients, respectively. 2,3 In addition to the well-known adverse effects of the PegIFN/ribavirin, which might terrify both physicians and patients and need careful monitoring as well as management, another important barrier that prevents patients from receiving SOC is the high cost of treatment of HCV, which the authors estimate is up to $48,000 per year in the United States. Insurance coverage to reduce the economic impact is critical in these patients, given the inability of most to afford the treatment. Recently, Yan et al. also reported that concern about cost is one of the most common causes (37%) for nontreatment before the government reimbursed all treatment for chronic hepatitis C (CHC) in Hong Kong. 4 Reduction of the economic burden for HCV therapy helps improve the treatment uptake of patients with CHC. In Taiwan, patients with CHC who are infected with genotype 1 and 2, and who are treated with PegIFN/ribavirin, achieve high SVR rates in our previous randomized trials (80% and 95%, respectively). 5,6 In addition, Asian patients had the highest frequency of the advantageous allele in the gene for interleukin-28B, with up to 88% of Taiwanese patients with CHC having the rs8099917 TT genotype in our reports, 7,8 which has been shown to be an important predictor of response. It seems reasonable to encourage Taiwanese patients with CHC to undertake the SOC regimen. In Taiwan, National Health Insurance (NHI) commenced in 1995, with a very high universal coverage rate of 99.5% by the end of 2008, resulting in a narrowed disparity in health care between the wealthy and the poor. 9 The reimbursement for anti-HCV therapy by the Taiwanese NHI started in 2003 if patients meet all the criteria: (1) positive for anti-HCV; (2) the alanine aminotransferase levels !2Â upper limit of normal on two occasions 3 months apart during the 6-month period; and (3) fibrosis stage !2 (revised to stage 1 or greater since 2004). The criteria were further revised in 2009: (1) patients with positive anti-HCV and serum HCV RNA and (2) abnormal alanine aminotransferase levels. Accordingly, more Taiwanese patients with CHC can be expected to receive therapy under this permitted reimbursement claim. We have constructed the ''roadmap'' concept with the determined duration of therapy in Taiwan 10 and using the strategy to truncate treatment, the estimated cost saving of drugs achieves 11.8% and 29% per SVR for HCV genotype 1/4 and genotype 2/ 3 patients, respectively. We can make more efforts to help patients. For instance, the NHI program in Taiwan, which is given unanimous praise, does not yet reimburse the use of hematopoietic agents such as erythropoietin or granulocyte colony stimulating factor in treating anemia or neutropenia caused by PegIFN/ribavirin. Here, we share the status of Taiwan's NHI, which has made Taiwanese patients with CHC more fortunate than patients in nations that have a lower rate of insurance coverage. When welcoming the new era of emergence of direct-acting antivirals that effectively enhance SVR rates when combined with SOC, we have tried our best to remove all barriers for receiving therapy, particularly the insurance obstacle in terms of financial burden for patients.
Objectives: To reassess the prognosis of patients with cirrhosis admitted to the intensive care u... more Objectives: To reassess the prognosis of patients with cirrhosis admitted to the intensive care unit. Design: A retrospective study in a medical intensive care unit in a teaching hospital in France. Patients: All patients with cirrhosis without previous liver transplantation admitted in the period from 2005 to 2008. Interventions: None. Main Results: One hundred thirty-eight patients were studied. Survival rates in the intensive care unit, in hospital, and at 6 months were 59% (95% confidence interval, 50%-67%), 46% (95% confidence interval, 38%-54%), and 38% (95% confidence interval, 30%-47%), respectively. In-hospital survival rates for patients requiring vasopressors, mechanical ventilation, or renal replacement therapy were 20%, 33%, and 31%, respectively. On day 1, independent risk factors for inhospital mortality were age, albuminemia, international normalized ratio, and the Sequential Organ Failure Assessment score computed after discarding points for hematologic failure (modified Sequential Organ Failure Assessment score). Liver disease severity, assessed using a clinical classification, did not correlate with inhospital mortality. In patients still alive after 3 days, the only prog-nostic factor was the modified Sequential Organ Failure Assessment score computed after 3 days. To predict inhospital mortality, the modified Sequential Organ Failure Assessment score on day 1 had a greater area under the receiver operating characteristic curve (0.84) than the Simplified Acute Physiology Score II (0.78), the Child-Pugh score (0.76), the model for end-stage liver disease score (0.77), or the model for end-stage liver disease-natremia score (0.75). The inhospital mortality rate with three or four nonhematologic organ failures on day 1 was not >70%, whereas it was 89% with three nonhematologic organ failures after 3 days spent in the intensive care unit. Conclusion: In-hospital survival rate of intensive care unitadmitted cirrhotic patients seemed acceptable, even in patients requiring life-sustaining treatments and/or with multiple organ failure on admission. The most important risk factor for inhospital mortality was the severity of nonhematologic organ failure, as best assessed after 3 days. A trial of unrestricted intensive care for a few days could be proposed for select critically ill cirrhotic patients. (Crit Care Med 2010; 38:2108-2116) KEY WORDS: liver cirrhosis; prognosis; critical care; critical illness; intensive care units; mechanical ventilation LEARNING OBJECTIVES After participating in this educational activity, the participant should be better able to: 1. Evaluate the usefulness of factors that influence outcome when triaging cirrhotic patients. 2. Analyze factors that influence outcome when triaging cirrhotic patients. 3. Assess risk factors for inhospital mortality in patients with cirrhosis. Unless otherwise noted, the faculty's, staff's, and authors' spouse(s)/life partner(s) (if any) have nothing to disclose. The authors have disclosed that they have no financial relationships with, or financial interests in, any commercial companies pertaining to this educational activity. All faculty and staff in a position to control the content of this CME activity have disclosed that they have no financial relationship with, or financial interests in, any commercial companies pertaining to this educational activity. Visit the Critical Care Medicine Web site (www.ccmjournal.org) for information on obtaining continuing medical education credit.
Background The death rate in intensive care units (ICUs) can reach 20%. More than half occurs aft... more Background The death rate in intensive care units (ICUs) can reach 20%. More than half occurs after a decision of care withholding/withdrawal. We aimed at describing and evaluating the experience of ICU physicians and nurses involved in the end-of-life (EOL) procedure. Primary objective was the evaluation of the experience of EOL assessed by the CAESAR questionnaire. Secondary objectives were to describe factors associated with a low or high score and to examine the association between Numeric Analogic Scale and quality of EOL. Methods Consecutive adult patients deceased in 52 ICUs were included between April and June 2018. Characteristics of patients and caregivers, therapeutics and care involved after withdrawal were recorded. CAESAR score included 15 items, rated from 1 (traumatic experience) to 5 (comforting experience). The sum was rated from 15 to 75 (the highest, the best experience). Numeric Analogic Scale was rated from 0 (worst EOL) to 10 (optimal EOL). Results Five hundre...
Background Intensive care unit (ICU) patients age 90 years or older represent a growing subgroup ... more Background Intensive care unit (ICU) patients age 90 years or older represent a growing subgroup and place a huge financial burden on health care resources despite the benefit being unclear. This leads to ethical problems. The present investigation assessed the differences in outcome between nonagenarian and octogenarian ICU patients. Methods We included 7900 acutely admitted older critically ill patients from two large, multinational studies. The primary outcome was 30-day-mortality, and the secondary outcome was ICU-mortality. Baseline characteristics consisted of frailty assessed by the Clinical Frailty Scale (CFS), ICU-management, and outcomes were compared between octogenarian (80–89.9 years) and nonagenarian (> 90 years) patients. We used multilevel logistic regression to evaluate differences between octogenarians and nonagenarians. Results The nonagenarians were 10% of the entire cohort. They experienced a higher percentage of frailty (58% vs 42%; p
BackgroundThe COVID-19 pandemic has led highly developed healthcare systems to the brink of colla... more BackgroundThe COVID-19 pandemic has led highly developed healthcare systems to the brink of collapse due to the large numbers of patients being admitted into hospitals. One of the potential prognostic indicators in patients with COVID-19 is frailty. The degree of frailty could be used to assist both the triage into intensive care, and decisions regarding treatment limitations. Our study sought to determine the interaction of frailty and age in elderly COVID-19 ICU patients.MethodsA prospective multi-centre study of COVID-19 patients ≥ 70 years admitted to intensive care in 138 ICUs from 28 countries was conducted. The primary endpoint was 30-day mortality. Frailty was assessed using the Clinical Frailty Scale (CFS). Additionally, comorbidities, management strategies and treatment limitations were recorded.ResultsThe study included 1346 patients (28% female) with a median age of 75 years (IQR 72-78, range 70-96), 16.3% were older than 80 years and 21% of the patients were frail. The ...
Purpose Lactate is an established prognosticator in critical care. However, there still is insuff... more Purpose Lactate is an established prognosticator in critical care. However, there still is insufficient evidence about its role in predicting outcome in COVID-19. This is of particular concern in older patients who have been mostly affected during the initial surge in 2020. Methods This prospective international observation study (The COVIP study) recruited patients aged 70 years or older (ClinicalTrials.gov ID: NCT04321265) admitted to an intensive care unit (ICU) with COVID-19 disease from March 2020 to February 2021. In addition to serial lactate values (arterial blood gas analysis), we recorded several parameters, including SOFA score, ICU procedures, limitation of care, ICU- and 3-month mortality. A lactate concentration ≥ 2.0 mmol/L on the day of ICU admission (baseline) was defined as abnormal. The primary outcome was ICU-mortality. The secondary outcomes 30-day and 3-month mortality. Results In total, data from 2860 patients were analyzed. In most patients (68%), serum lacta...
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