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Background: Social media (SoMe) have taken a major place in the medical field, and younger generations are increasingly using them as their primary source to find information., Objective: This study aimed to describe the use of SoMe for medical education among French medical students and assess the prevalence of smartphone addiction in this population., Methods: A cross-sectional web-based survey was conducted among French medical students (second to sixth year of study). The questionnaire collected information on SoMe use for medical education and professional behavior. Smartphone addiction was assessed using the Smartphone Addiction Scale Short-Version (SAS-SV) score., Results: A total of 762 medical students responded to the survey. Of these, 762 (100%) were SoMe users, spending a median of 120 (IQR 60-150) minutes per day on SoMe; 656 (86.1%) used SoMe for medical education, with YouTube, Instagram, and Facebook being the most popular platforms. The misuse of SoMe in a professional context was also identified; 27.2% (207/762) of students posted hospital internship content, and 10.8% (82/762) searched for a patient's name on SoMe. Smartphone addiction was prevalent among 29.1% (222/762) of respondents, with a significant correlation between increased SoMe use and SAS-SV score (r=0.39, 95% CI 0.33-0.45; P<.001). Smartphone-addicted students reported a higher impact on study time (211/222, 95% vs 344/540, 63.6%; P<.001) and a greater tendency to share hospital internship content on social networks (78/222, 35.1% vs 129/540, 23.8%; P=.002)., Conclusions: Our findings reveal the extensive use of SoMe for medical education among French medical students, alongside a notable prevalence of smartphone addiction. These results highlight the need for medical schools and educators to address the responsible use of SoMe and develop strategies to mitigate the risks associated with excessive use and addiction., (© Thomas Clavier, Emma Chevalier, Zoé Demailly, Benoit Veber, Imad-Abdelkader Messaadi, Benjamin Popoff. Originally published in JMIR Medical Education (https://mededu.jmir.org).)

Background: Recent studies highlight that female anaesthesiology researchers have lower visibility on professional social networks (PSNs) than male researchers., Objective: The objective of this work was to compare the use of PSNs between women and men in critical care research., Methods: We included the first/last authors (FAs/LAs) among the most frequently cited articles in 2018 and 2019 in three critical care journals (Intensive Care Medicine, Critical Care Medicine, and Critical Care). We compared the use of three PSNs-Twitter, ResearchGate, and LinkedIn-between women and men in the FA/LA positions., Results: We analysed 494 articles, which allowed us to include 426 FAs and 383 LAs. The use of a PSN was similar between women and men (Twitter: 35 vs. 31% FA p = 0.76, 38 vs. 31% LA p = 0.24; ResearchGate: 60 vs. 70% FA p = 0.06, 67 vs. 66% LA p = 0.95; LinkedIn: 54 vs. 56% FA p = 0.25, 68 vs. 64% LA p = 0.58; respectively). On ResearchGate, women had a lower reputation score (FA group 26.4 [19.5-31.5] vs. 34.8 [27.4-41.6], p < 0.01; LA group 38.5 [30.9-43.7] vs. 42.3 [37.6-46.4], p < 0.01) and fewer followers (FA group 28.5 [19-45] vs. 68.5 [72,5-657] p < 0.01; LA group 96.5 [43,8-258] vs. 178 [76.3-313.5] p = 0.02). Female researchers were FAs in 30% of the articles and LAs in 16%., Conclusion: In the field of critical care, the visibility of female researchers on the social networks dedicated to scientific research is lower than that of male researchers., (Copyright © 2023 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: Although diarrhoea is a real source of morbidity for critically ill patients, this issue has been little studied, making it difficult to understand its mechanisms and management., Aims: We conducted a quality improvement study in an adult surgical intensive care unit before/after the implementation of a specific protocol to firstly improve diarrhoea management for patient benefit and secondly to understand the impact on caregivers., Study Design: The first part of this before/after study consisted in assessing the proportion of patients receiving an anti-diarrheal treatment before (phase I)/after (phase II) the implementation of the protocol. The second part of the study was to survey the caregivers on this topic., Results: Sixty four adults were included (33 in phase I; 31 in phase II) with 280 diarrheal episodes (129 in phase I; 151 in phase II). The proportion of patients who received at least one anti-diarrheal treatment was similar between the two phases (79% (26/33) vs. 68% (21/31), p = .40). Diarrhoea incidence was also similar (9% (33 patients/368 admissions) vs. 11% (31 patients/275 admissions), p = .35). The delay to initiate at least one treatment was significantly shorter in phase II (2 days [1-7] vs. 0 day [0-2]; p < .001). The patients' rehabilitation was no longer impacted by the occurrence of a diarrheal episode in phase II (39% (13/33) vs. 0% (0/31), p < .001). Eighty team members completed the surveys in phase I and 70 in phase II. Caregivers perceived diarrhoea like a burden and its economic impact remained high., Conclusions: The implementation of a protocol for the management of ICU diarrhoea did not increase the proportion of patients treated, but it did significantly improve the delay to initiate a treatment. The patients' rehabilitation was no longer affected by diarrhoea., Relevance to Clinical Practice: The use of specific anti-diarrhoea guidelines may help to reduce the burden of diarrhoea in an ICU., (© 2023 British Association of Critical Care Nurses.)

Objectives: The aims of the current study were 1) to provide the prevalence of five types of gender-based violence (GBV) among male and female healthcare students; 2) to describe perpetrators' status, where the GBV occurred, and psychological and behavioural impacts of the GBV; and 3) to identify factors associated with GBV., Design: A cross-sectional study was conducted among voluntary healthcare students in France., Setting: Health Campus at Rouen and nursing schools in Normandy, France., Participants: Volunteer healthcare students of 18 years and over., Data Collected: Five types of GBV were recorded: GBV1: damage to a person's image due to a sexual connotation on social networks, GBV2: sexist remarks and behaviour, GBV3: comments with sexual connotations, GBV4: sexual assaults and GBV5: rape or attempted rape. Perpetrators' status, where the GBV occurred, psychological and behavioural impacts of GBV were also recorded., Results: One thousand one hundred and fifty-two students were included. The mean age was 20.8 years (SD = 2.26), 82.6% of students were women (0.4% non-binary). Since the beginning of their healthcare study, 41.2% of students CI 95% [39.7-42.6] were victim of at least one type of GBV: 15.8% among men CI 95% [13.2-18.4] and 46.0% CI 95% [44.4-47.6] among women (p < 0.001). The perpetrators were student peers, regardless of the type of GBV, healthcare workers for the GB2 and GBV3, and patients except for GBV5. The main consequences of GBV on health was psychological and eating related. After multivariate analysis, being a woman, LGBTQ+ (Lesbian, Gay, Bi, Trans, Queer and other), a nurse, a physiotherapist student, having a job, living with roommates and year of study were risk factors for GBV., Conclusion: GBV is so common at healthcare universities and could have such severe consequences for students that more work is needed to generate a culture change and ensure safe learning environments., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Tavolacci et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: The benefit of a stay in an intensive care unit (ICU) is not certain for older patients, particularly in the surgical context., Aims: The objective of this study was to identify the factors associated with an unfavourable outcome in this population., Design: Prospective, descriptive, monocentric study conducted in the surgical ICU of a French university hospital., Methods: Patients aged ≥75 years admitted in the surgical ICU for a predicted length of stay ≥48 hours were included. Patients received an initial and a 6-months nutritional and functional assessment performed by physicians and nurses. The outcome was considered as favourable if the Katz Activities of Daily Living (ADL) variation (ADL delta = 6-months ADL - ICU admission ADL) was between 0 and -0.5 point 6 months after ICU discharge and unfavourable if the ADL delta decreased by more than 0.5 points or if the patient had died 6 months after ICU discharge., Results: Fifty-six patients-32 (57%) male-aged 79 [77; 83] y were included. ICU mortality was 19%; 6-month mortality was 22%. Median ADL delta was -0.5 [-0.5-0] points. A low ADL score (P = .0438) and a low albumin level (P = .0213) at admission were the two independent factors associated with an unfavourable outcome., Conclusion: Mortality and loss of independence were high in this elderly population during and after their surgical ICU stay. The benefit of a systematic collaboration between intensive care specialists, ICU nurses, and geriatricians, to assess and manage nutritional and functional problems and to prevent a pejorative outcome in patients over 75 years old admitted in surgical ICU needs to be studied., Relevance to Clinical Practice: There should be systematic screening for objective markers of undernutrition and frailty on ICU admission of older patients as they are associated with a poor prognosis., (© 2021 British Association of Critical Care Nurses.)

Purpose: Intensive care medicine (ICM) has the particularity of being a multidisciplinary specialty and its literature reflects this multidisciplinarity. However, the proportion of each field in this literature and its trend dynamics are not known. The objective of this study was to analyze the ICM literature, extract latent topics and search for the presence of research trends., Material and Methods: Abstracts of original articles from the top ICM journals, from their inception until December 31st, 2019, were included. This corpus was fed into a structural topic modeling algorithm to extract latent semantic topics. The temporal distribution was then analyzed and the presence of trends was searched by Mann-Kendall trends tests., Results: Finally, 49,276 articles from 10 journals were included. After topic modeling analysis and experts' feedback, 124 research topics were selected and labeled. Topics were categorized into 19 categories, the most represented being respiratory, fundamental and neurological research. Increasing trends were observed for research on mechanical ventilation and decreasing trends for cardiopulmonary resuscitation., Conclusions: This study reviewed all articles from major ICM journals in a comprehensive way. It provides a better understanding of ICM research landscape by analyzing the temporal evolution of latent research topics in the ICM literature., Competing Interests: Declaration of Competing Interest None., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Current guidelines recommend monitoring the anticoagulant effect of unfractionated heparin (UFH) by measuring anti-Xa activity rather than activated partial thromboplastin time (aPTT) in intensive care unit (ICU) patients. The primary objective of this study was to evaluate the correlation of aPTT, anti-Xa activity, and thrombin generation in UFH-treated ICU patients. A prospective observational pilot study was conducted in adult surgical ICU patients treated with UFH. aPTT and anti-Xa activity were monitored daily. The therapeutic target was aPTT between 50 s and 84 s, and/or anti-Xa between 0.3 and 0.7 U/mL. Correlation among aPTT, anti-Xa activity, and thrombin generation was determined by measuring endogenous thrombin potential (ETP), with the inflammatory response evaluated. C-reactive protein (CRP) was used as a marker of inflammatory response. The plasma of 107 samples from 30 ICU patients was analyzed. The correlation between aPTT and anti-Xa activity was 0.66, CI95% [0.54;0.76] (p < 0.0001). Although thrombin generation, aPTT, and anti-Xa were correlated with inflammatory responses, the correlation was higher with thrombin generation and anti-Xa activity compared to aPTT. When aPTT was in a therapeutic range, a low thrombin generation was observed but was 50% inhibited when anti-Xa was in a therapeutic range. Coagulation testing with aPTT, anti-Xa correlated with thrombin generation. A 50% decrease in thrombin generation was observed when anti-Xa was within a therapeutic range. Further work is needed to evaluate coagulation biomarker responses and clinical outcomes in specific ICU populations.

Purpose: Duration of antibiotic therapy for ventilator-associated pneumonia (VAP) due to non-fermenting Gram-negative bacilli (NF-GNB), including Pseudomonas aeruginosa (PA) remains uncertain. We aimed to assess the non-inferiority of a short duration of antibiotics (8 days) vs. prolonged antibiotic therapy (15 days) in VAP due to PA (PA-VAP)., Methods: We conducted a nationwide, randomized, open-labeled, multicenter, non-inferiority trial to evaluate optimal duration of antibiotic treatment in PA-VAP. Eligible patients were adults with diagnosis of PA-VAP and randomly assigned in 1:1 ratio to receive a short-duration treatment (8 days) or a long-duration treatment (15 days). A pre-specified analysis was used to assess a composite endpoint combining mortality and PA-VAP recurrence rate during hospitalization in the intensive care unit (ICU) within 90 days., Results: The study was stopped after 24 months due to slow inclusion rate. In intention-to-treat population (n = 186), the percentage of patients who reached the composite endpoint was 25.5% (N = 25/98) in the 15-day group versus 35.2% (N = 31/88) in the 8-day group (difference 9.7%, 90% confidence interval (CI) -1.9%-21.2%). The percentage of recurrence of PA-VAP during the ICU stay was 9.2% in the 15-day group versus 17% in the 8-day group. The two groups had similar median days of mechanical ventilation, of ICU stay, number of extra pulmonary infections and acquisition of multidrug-resistant (MDR) pathogens during ICU stay., Conclusions: Our study failed to show the non-inferiority of a short duration of antibiotics in the treatment of PA-VAP, compared to a long duration. The short duration strategy may be associated to an increase of PA-VAP recurrence. However, the lack of power limits the interpretation of this study., (© 2022. Springer-Verlag GmbH Germany, part of Springer Nature.)

Background and Aims: Energy metabolism (energy deficit, substrate consumption) in the early phase of septic shock is not clearly understood. The objective of this study was to describe its evolution using indirect calorimetry., Methods: Prospective observational pilot study including ventilated adult patients with septic shock admitted in a surgical intensive care unit (ICU). Metabolic data were collected using the COSMED Q-NRG + ® calorimeter: carbon dioxide production (VCO2), oxygen consumption (VO2), resting energy expenditure (REE), respiratory quotient (RQ) and the rate of substrate utilization (proteins, lipids, and carbohydrates). The main criterion was the evolution of the energy deficit (dE) from D1 to D6., Results: In total, 34 patients were included and 15 patients (age: 57.6 ± 12.8 years; Simplified Acute Physiology Score II: 52 ± 11) were eligible for final analysis. Time for initiation of nutritional support was 2.5 ± 1.5 days. The dE improved during the study period (slope = 2.9 [1.8; 4.2]; p < 0.001). The REE remained stable during the first week with no significant variation (slope = -0.16 [-1.49; 0.79]; p = 0.78). The RQ remained stable overall (slope = 0.01 [0.00; 0.03]; p = 0.10). The substrates utilization significantly changed at D3 in favor of protein consumption (slope = 6.50 [4.44; 8.85]; p < 0.001) with an overall significant decrease in the consumption of non-protein substrates., Conclusion: Energy deficit improved while REE and RQ remained relatively stable during the first week of ICU stay. The significance of the variations of substrates consumption was unclear. These preliminary results should be further explored with larger studies., (© 2021. The Author(s), under exclusive licence to Springer Nature Limited.)

Introduction: Intra-abdominal infections represent the second most frequently acquired infection in the intensive care unit (ICU), with mortality rates ranging from 20% to 50%. Candida spp. may be responsible for up to 10-30% of cases. This study assesses risk factors for development of intra-abdominal candidiasis (IAC) among patients admitted to ICU., Methods: We performed a case-control study in 26 European ICUs during the period January 2015-December 2016. Patients at least 18 years old who developed an episode of microbiologically documented IAC during their stay in the ICU (at least 48 h after admission) served as the case cohort. The control group consisted of adult patients who did not develop episodes of IAC during ICU admission. Matching was performed at a ratio of 1:1 according to time at risk (i.e. controls had to have at least the same length of ICU stay as their matched cases prior to IAC onset), ICU ward and period of study., Results: During the study period, 101 case patients with a diagnosis of IAC were included in the study. On univariate analysis, severe hepatic failure, prior receipt of antibiotics, prior receipt of parenteral nutrition, abdominal drain, prior bacterial infection, anastomotic leakage, recurrent gastrointestinal perforation, prior receipt of antifungal drugs and higher median number of abdominal surgical interventions were associated with IAC development. On multivariate analysis, recurrent gastrointestinal perforation (OR 13.90; 95% CI 2.65-72.82, p = 0.002), anastomotic leakage (OR 6.61; 95% CI 1.98-21.99, p = 0.002), abdominal drain (OR 6.58; 95% CI 1.73-25.06, p = 0.006), prior receipt of antifungal drugs (OR 4.26; 95% CI 1.04-17.46, p = 0.04) or antibiotics (OR 3.78; 95% CI 1.32-10.52, p = 0.01) were independently associated with IAC., Conclusions: Gastrointestinal perforation, anastomotic leakage, abdominal drain and prior receipt of antifungals or antibiotics may help to identify critically ill patients with higher probability of developing IAC. Prospective studies are needed to identify which patients will benefit from early antifungal treatment., (© 2022. The Author(s).)

Background and Importance: Hyperoxemia may be associated with increased mortality in emergency room or ICU patients. However, its effect during septic shock is still debated., Objective: To evaluate the effect of hyperoxemia on ICU mortality, during the first 24 h of ICU stay, in mechanically ventilated patients with septic shock according to SEPSIS-3 criteria., Design, Settings and Participants: A retrospective cohort study of ICU admissions recorded in the Medical Information Mart for Intensive Care-III, a retrospective ICU database, was performed., Intervention: Two oxygen exposures during the first 24 h were compared: average PaO2 (TWA-PaO2) between 70 and 120 mmHg in the normoxemia group and above 120 mmHg in the hyperoxemia group., Outcome Measures and Analysis: The primary outcome was mortality during ICU stay., Main Results: Four hundred eighty-eight ICU admissions met the inclusion criteria: 214 in the normoxemia group and 274 in the hyperoxemia group. The median TWA-PaO2 was 99.1 (88.9-107.6) mmHg in the normoxemia group and 151.5 (133.6-180.2) mmHg in the hyperoxemia group. ICU mortality was lower in the hyperoxemia group than in the normoxemia group in univariate analysis [29.6 vs. 39.7%, respectively; OR 0.64 (0.44-0.93); P = 0.024], but not in multivariate analysis [OR 0.98 (0.62-1.56); P = 0.93]. There was no difference between the two groups in ICU length of stay [8.0 (4.3-15.0) vs. 8.4 (4.7-15.0) days; P = 0.82]., Conclusion: We did not find any impact of early hyperoxemia on mortality in this population of mechanically ventilated patients with SEPSIS-3 septic shock criteria., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Therapeutic failure is a frequent issue in the management of post-operative peritonitis., Objectives: A post hoc analysis of the prospective, multicentre DURAPOP trial analysed the risk factors for failures in post-operative peritonitis following adequate source control and empirical antibiotic therapy in critically ill patients., Patients and Methods: Overall failures assessed post-operatively between Day 8 and Day 45 were defined as a composite of death and/or surgical and/or microbiological failures. Risk factors for failures were assessed using logistic regression analyses., Results: Among the 236 analysed patients, overall failures were reported in 141 (59.7%) patients, including 30 (12.7%) deaths, 81 (34.3%) surgical and 95 (40.2%) microbiological failures. In the multivariate analysis, the risk factors associated with overall failures were documented piperacillin/tazobactam therapy [adjusted OR (aOR) 2.10; 95% CI 1.17-3.75] and renal replacement therapy on the day of reoperation (aOR 2.96; 95% CI 1.05-8.34). The risk factors for death were age (aOR 1.08 per year; 95% CI 1.03-1.12), renal replacement therapy on reoperation (aOR 3.95; 95% CI 1.36-11.49) and diabetes (OR 6.95; 95% CI 1.34-36.03). The risk factors associated with surgical failure were documented piperacillin/tazobactam therapy (aOR 1.99; 95% CI 1.13-3.51), peritoneal cultures containing Klebsiella spp. (aOR 2.45; 95% CI 1.02-5.88) and pancreatic source of infection (aOR 2.91; 95% CI 1.21-7.01). No specific risk factors were identified for microbiological failure., Conclusions: Our data suggest a predominant role of comorbidities, the severity of post-operative peritonitis and possibly of documented piperacillin/tazobactam treatment on the occurrence of therapeutic failures, regardless of their type., (© The Author(s) 2021. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy.)

Background: Social networks are now essential tools for promoting research and researchers. However, there is no study investigating the link between presence or not on professional social networks and scientific publication or citation for a given researcher., Objective: The objective of this study was to study the link between professional presence on social networks and scientific publications/citations among anesthesia researchers., Methods: We included all the French full professors and associate professors of anesthesia. We analyzed their presence on the social networks Twitter (professional account with ≥1 tweet over the 6 previous months) and ResearchGate. We extracted their bibliometric parameters for the 2016-2020 period via the Web of Science Core Collection (Clarivate Analytics) database in the Science Citation Index-Expanded index., Results: A total of 162 researchers were analyzed; 42 (25.9%) had an active Twitter account and 110 (67.9%) a ResearchGate account. There was no difference between associate professors and full professors regarding active presence on Twitter (8/23 [35%] vs. 34/139 [24.5%], respectively; P=.31) or ResearchGate (15/23 [65%] vs. 95/139 [68.3%], respectively; P=.81). Researchers with an active Twitter account (median [IQR]) had more scientific publications (45 [28-61] vs. 26 [12-41]; P<.001), a higher h-index (12 [8-16] vs. 8 [5-11]; P<.001), a higher number of citations per publication (12.54 [9.65-21.8] vs. 10.63 [5.67-16.10]; P=.01), and a higher number of citations (563 [321-896] vs. 263 [105-484]; P<.001). Researchers with a ResearchGate account (median [IQR]) had more scientific publications (33 [17-47] vs. 26 [9-43]; P=.03) and a higher h-index (9 [6-13] vs. 8 [3-11]; P=.03). There was no difference between researchers with a ResearchGate account and those without it concerning the number of citations per publication and overall number of citations. In multivariate analysis including sex, academic status, and presence on social networks, the presence on Twitter was associated with the number of publications (β=20.2; P<.001), the number of citations (β=494.5; P<.001), and the h-index (β=4.5; P<.001)., Conclusions: Among French anesthesia researchers, an active presence on Twitter is associated with higher scientific publication and citations., (©Thomas Clavier, Emilie Occhiali, Zoé Demailly, Vincent Compère, Benoit Veber, Jean Selim, Emmanuel Besnier. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 15.10.2021.)

Background: Ventilator-associated pneumonia (VAP) is the most frequent health care-associated infection in severely ill patients, and aspiration of contaminated oropharyngeal content around the cuff of the tracheal tube is the main route of contamination., Research Question: Is continuous regulation of tracheal cuff pressure using a pneumatic device superior to manual assessment three times daily using a portable manometer (routine care) in preventing VAP in patients with severe trauma?, Study Design and Methods: In this open-label, randomized controlled superiority trial conducted in 13 French ICUs, adults (age ≥ 18 years) with severe trauma (Injury Severity Score > 15) and requiring invasive mechanical ventilation for ≥ 48 h were enrolled. Patients were randomly assigned (1:1) via a secure Web-based random number generator in permuted blocks of variable sizes to one of two groups according to the method of tracheal cuff pressure control. The primary outcome was the proportion of patients developing VAP within 28 days following the tracheal intubation, as determined by two assessors masked to group assignment, in the modified intention-to-treat population. This study is closed to new participants., Results: A total of 434 patients were recruited between July 31, 2015, and February 15, 2018, of whom 216 were assigned to the intervention group and 218 to the control group. Seventy-three patients (33.8%) developed at least one episode of VAP within 28 days following the tracheal intubation in the intervention group compared with 64 patients (29.4%) in the control group (adjusted subdistribution hazard ratio, 0.96; 95% CI, 0.76-1.20; P = .71). No serious adverse events related to the use of the pneumatic device were noted., Interpretation: Continuous regulation of cuff pressure of the tracheal tube using a pneumatic device was not superior to routine care in preventing VAP in patients with severe trauma., Clinical Trial Registration: ClinicalTrials.gov; No.: NCT02534974; URL: www.clinicaltrials.gov., (Copyright © 2021 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Controlled donation after circulatory death (cDCD) is used for "extended criteria" donors with poorer kidney transplant outcomes. The French cDCD program started in 2015 and is characterized by normothermic regional perfusion, hypothermic machine perfusion, and short cold ischemia time. We compared the outcomes of kidney transplantation from cDCD and brain-dead (DBD) donors, matching cDCD and DBD kidney transplants by propensity scoring for donor and recipient characteristics. The matching process retained 442 of 499 cDCD and 809 of 6185 DBD transplantations. The DGF rate was 20% in cDCD recipients compared with 28% in DBD recipients (adjusted relative risk [aRR], 1.43; 95% confidence interval [CI] 1.12-1.82). When DBD transplants were ranked by cold ischemia time and machine perfusion use and compared with cDCD transplants, the aRR of DGF was higher for DBD transplants without machine perfusion, regardless of the cold ischemia time (aRR with cold ischemia time <18 h, 1.57; 95% CI 1.20-2.03, vs aRR with cold ischemia time ≥18 h, 1.79; 95% CI 1.31-2.44). The 1-year graft survival rate was similar in both groups. Early outcome was better for kidney transplants from cDCD than from matched DBD transplants with this French protocol., (© 2020 The American Society of Transplantation and the American Society of Transplant Surgeons.)

Introduction: Endoplasmic reticulum stress (ERS) is involved in inflammatory organ failure. Our objective was to describe ERS, its unfolded protein response (UPR) expression/kinetics during cardiac surgery with cardiopulmonary bypass (CPB) and its association with postoperative organ failure (OF). Methods: Prospective study conducted on patients undergoing cardiac surgery with CPB. Blood samples were taken before (Pre-CPB), 2 h (H2-CPB) and 24 h (H24-CPB) after CPB. Plasma levels of 78 kDa Glucose- Regulated Protein (GRP78, final effector of UPR) were evaluated by ELISA. The expression of genes coding for key elements of UPR ( ATF6, ATF4, sXBP1, CHOP ) was evaluated by quantitative PCR performed on total blood. OF was defined as invasive mechanical ventilation and/or acute kidney injury and/or hemodynamic failure requiring catecholamines. Results: We included 46 patients, GRP78 was decreased at H2-CPB [1,328 (878-1,730) ng/ml vs. 2,348 (1,655-3,730) ng/ml Pre-CPB; p < 0.001] but returned to basal levels at H24-CPB [2,068 (1,436-3,005) ng/ml]. The genes involved in UPR had increased expression at H2 and H24. GRP78 plasma levels in patients with OF at H24-CPB ( n = 10) remained below Pre-CPB levels [-27.6 (-51.5; -24.2)%] compared to patients without OF ( n = 36) in whom GRP78 levels returned to basal levels [0.6 (-28.1; 26.6)%; p < 0.01]. H24-CPB ATF6 and CHOP expressions were lower in patients with OF than in patients without OF [2.3 (1.3-3.1) vs. 3.0 (2.7-3.7), p < 0.05 and 1.3 (0.9-2.0) vs. 2.2 (1.7-2.9), p < 0.05, respectively]. Conclusions: Low relative levels of GRP78 and weak UPR gene expression appeared associated with postoperative OF. Further studies are needed to understand ERS implication during acute organ failure in humans., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Clavier, Demailly, Semaille, Thill, Selim, Veber, Doguet, Richard, Besnier and Tamion.)

Despite efforts to develop anti-severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibody (Ab) immunoassays, reliable serological methods are still needed. We developed a multiplex addressable laser bead immunoassay (ALBIA) to detect and quantify anti-Spike S1 and nucleocapsid N Abs. Recombinant S1 and N proteins were bound to fluorescent beads (ALBIA-IgG-S1/N). Abs were revealed using class-specific anti-human Ig Abs. The performances of the test were analyzed on 575 serum samples including 192 from SARS-CoV-2 polymerase chain reaction-confirmed patients, 13 from seasonal coronaviruses, 70 from different inflammatory/autoimmune diseases, and 300 from healthy donors. Anti-S1 IgM were detected by monoplex ALBIA-IgM-S1. Comparison with chemiluminescent assays or enzyme-linked immunosorbent assays was performed using commercial tests. Multiplex ALBIA-IgG-S1/N was effective in detecting and quantifying anti-SARS-CoV-2 IgG Abs. Two weeks after first symptoms, sensitivity and specificity were 97.7 and 98.0% (anti-S1), and 100 and 98.7% (anti-N), respectively. Agreement with commercial tests was good to excellent, with a higher sensitivity of ALBIA. ALBIA-IgG-S1/N was positive in 53% of patients up to day 7, and in 75% between days 7 and 13. For ALBIA-IgM-S1, sensitivity and specificity were 74.4 and 98.7%, respectively. Patients in intensive care units had higher IgG Ab levels (Mann-Whitney test, p < 0.05). ALBIA provides a robust method for exploring humoral immunity to SARS-CoV-2. Serology should be performed after 2 weeks following first symptoms, when all COVID-19 (coronavirus disease 2019) patients had at least one anti-S1 or anti-N IgG Ab, illustrating the interest of a multiplex test., Competing Interests: LD and OB are designated as inventors for the European Patent application EP 20315157.6 filed on April 14, 2020 in the names of Inserm, Université de Rouen and CHU de Rouen and entitled “methods for detecting the presence of coronavirus-specific antibodies in a subject.” The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2020 Drouot, Hantz, Jouen, Velay, Lamia, Veber, Sibilia, Lotellier, Candon, Alain, Fafi-Kremer and Boyer.)

Background: Critical care teams are on the front line of managing the COVID-19 pandemic, which is stressful for members of these teams., Objective: Our objective was to assess whether the use of social networks is associated with increased anxiety related to the COVID-19 pandemic among members of critical care teams., Methods: We distributed a web-based survey to physicians, residents, registered and auxiliary nurses, and nurse anesthetists providing critical care (anesthesiology, intensive care, or emergency medicine) in several French hospitals. The survey evaluated the respondents' use of social networks, their sources of information on COVID-19, and their levels of anxiety and information regarding COVID-19 on analog scales from 0 to 10., Results: We included 641 respondents in the final analysis; 553 (86.3%) used social networks, spending a median time of 60 minutes (IQR 30-90) per day on these networks. COVID-19-related anxiety was higher in social network users than in health care workers who did not use these networks (median 6, IQR 5-8 vs median 5, IQR 3-7) in univariate (P=.02) and multivariate (P<.001) analyses, with an average anxiety increase of 10% in social network users. Anxiety was higher among health care workers using social networks to obtain information on COVID-19 than among those using other sources (median 6, IQR 5-8 vs median 6, IQR 4-7; P=.04). Social network users considered that they were less informed about COVID-19 than those who did not use social networks (median 8, IQR 7-9 vs median 7, IQR 6-8; P<.01)., Conclusions: Our results suggest that social networks contribute to increased anxiety in critical care teams. To protect their mental health, critical care professionals should consider limiting their use of these networks during the COVID-19 pandemic., (©Thomas Clavier, Benjamin Popoff, Jean Selim, Marion Beuzelin, Melanie Roussel, Vincent Compere, Benoit Veber, Emmanuel Besnier. Originally published in JMIR mHealth and uHealth (http://mhealth.jmir.org), 24.09.2020.)

Background: Establishing pre- and postoperative contact with patients is part of successful medical management in outpatient surgery. In France, this is mostly done via telephone. Automated information with short message service (SMS) reminders might be an interesting alternative to increase the rate of compliance with preoperative instructions, but no study has shown the safety of this approach., Objective: The objective of this study was to evaluate the impact of pre- and postoperative automated information with SMS reminders on medical safety in outpatient surgery., Methods: We conducted a retrospective, single-center, nonrandomized, controlled study with a before-after design. All adult patients who had outpatient surgery between September 2016 and December 2017 in our university hospital center were included. Before April 2017, patients were contacted by telephone by an outpatient surgery nurse. After April 2017, patients were contacted by SMS reminder. All patients were contacted the day before and the day after surgery. Patients contacted by SMS reminder were also contacted on day 7 after surgery. The primary end point was the conversion rate to full-time hospitalization. Secondary end points were hospitalization causes (anesthetic, surgical, organizational) and hospitalization costs., Results: A total of 4388 patients were included, 2160 before and 2228 after the introduction of SMS reminders. The conversion rate to full-time hospitalization was 34/4388 (0.77%) with a difference between SMS group (8/2228, 0.36%) and telephone group (26/2160, 1.20%). The cost of SMS reminders was estimated as half that of telephone calls., Conclusions: In this work, we report a decrease in the rate of conversion to full-time hospitalization with the use of pre- and postoperative SMS reminders. This new approach could represent a safe and cost-effective method in an outpatient surgery setting., (©Jeremy Peuchot, Etienne Allard, Bertrand Dureuil, Benoit Veber, Vincent Compère. Originally published in JMIR mHealth and uHealth (http://mhealth.jmir.org), 10.09.2020.)

Objectives: The world is currently facing an unprecedented healthcare crisis caused by the COVID-19 pandemic. The objective of these guidelines is to produce a framework to facilitate the partial and gradual resumption of intervention activity in the context of the COVID-19 pandemic., Methods: The group has endeavoured to produce a minimum number of recommendations to highlight the strengths to be retained in the 7 predefined areas: (1) protection of staff and patients; (2) benefit/risk and patient information; (3) preoperative assessment and decision on intervention; (4) modalities of the preanaesthesia consultation; (5) specificity of anaesthesia and analgesia; (6) dedicated circuits and (7) containment exit type of interventions., Results: The SFAR Guideline panel provides 51 statements on anaesthesia management in the context of COVID-19 pandemic. After one round of discussion and various amendments, a strong agreement was reached for 100% of the recommendations and algorithms., Conclusion: We present suggestions for how the risk of transmission by and to anaesthetists can be minimised and how personal protective equipment policies relate to COVID-19 pandemic context., (Copyright © 2020 The Author(s). Published by Elsevier Masson SAS.. All rights reserved.)

Background and Aim: The molecular adsorbent recirculating system (MARS) is the most widely used device to treat liver failure. Nevertheless, data from widespread real-life use are lacking., Methods: This was a retrospective multicenter study conducted in all French adult care centers that used MARS between 2004 and 2009. The primary objective was to evaluate patient survival according to the liver disease and listing status. Factors associated with mortality were the secondary objectives., Results: A total of 383 patients underwent 393 MARS treatments. The main indications were acute liver failure (ALF, 32.6%), and severe cholestasis (total bilirubin >340 μmol/L) (37.2%), hepatic encephalopathy (23.7%), and/or acute kidney injury-hepatorenal syndrome (22.9%) most often among patients with chronic liver disease. At the time of treatment, 34.4% of the patients were listed. Overall, the hospital survival rate was 49% (95% CI: 44-54%) and ranged from 25% to 81% depending on the diagnosis of the liver disease. In listed patients versus those not listed, the 1-year survival rate was markedly better in the setting of nonbiliary cirrhosis (59% vs 15%), early graft nonfunction (80% vs 0%), and late graft dysfunction (72% vs 0%) (all P  < 0.001). Among nonbiliary cirrhotic patients, hospital mortality was associated with the severity of liver disease (HE and severe cholestasis) and not being listed for transplant. In ALF, paracetamol etiology and ≥3 MARS sessions were associated with better transplant-free survival., Conclusion: Our study suggests that MARS should be mainly used as a bridge to liver transplantation. Survival was correlated with being listed for most etiologies and with the intensity of treatment in ALF., (© 2020 The Authors. JGH Open: An open access journal of gastroenterology and hepatology published by Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Purpose: Veno-arterial Extracoporeal Membrane Oxygenation (VA-ECMO) provides circulatory assistance for patients in cardiogenic shock. Large quantities of fluids are often required, especially during the early stages, but can result in a potentially harmful fluid-overload. The objective was to determine the association of early fluid-balance and mortality., Methods: Retrospective single-center study in 101 VA-ECMO patients between 2013 and 2016. Daily fluid-balance and weight changes over the 5 first days were observed. Analyses between survivors and non-survivors were conducted using Mann-Whitney tests and logistic regression multivariable and Cox hazard-proportional analyses to determine any association with 28-days mortality., Results: Mortality was 47.5%. The fluid-balance was higher in non-survivors at day-1 (47.3[18.1-71.9] vs. 19.3[1.5-36.2] mL/kg, P < 0.0001) and day-2 (30.6[14.8-71.0] vs. 10.1[-9.8 to 34.7] mL/kg, P = 0.025), as was the cumulative fluid-balance over the first 5 days (107.3[40.5-146.2] vs. 53.0[7.5-74.3] mL/kg, P = 0.04). The administration of unintentional fluids (used for preparation and infusion of drugs) represented an important part of the administrated fluids (15 mL/kg/d-23 mL/kg/d). A significant but moderate correlation was observed between fluid-balance and weight variations over the 5 days (r values ranging from 0.36 to 0.54). Among other parameters, day-1 fluid-balance was independently associated with mortality (OR = 14.34 [1.58-129.79], P = 0.02) and day-1 and day-2 with time to death (HR = 8.26 [1.12-60.98], P = 0.04 and 2.89 [1.26-6.65], P = 0.01). A threshold of 38.8 mL/kg predicted mortality with a sensitivity of 60% and specificity of 83% (area under the curve: 0.749)., Conclusion: Early positive fluid-balance is associated with mortality in VA-ECMO patients.

Introduction: Protein Tyrosine Phosphatase 1B (PTP1B) and endoplasmic reticulum stress (ERS) are involved in the septic inflammatory response. Their inhibition is associated with improved survival in murine models of sepsis. The objective was to describe PTP1B and ERS expression during septic shock in human. Material and Methods: Prospective study including patients admitted to intensive care unit (ICU) for septic shock. Blood samples were collected on days 1 (D1), 3 and 5 (D5). Quantitative PCR (performed from whole blood) evaluated the expression of genes coding for PTP1B ( PTPN1 ) and key elements of ERS (GRP78, ATF6, CHOP) or for endothelial dysfunction-related markers (ICAM1 and ET1). We analyzed gene variation between D5 and D1, collected glycemic parameters, insulin resistance and organ failure was evaluated by Sequential Organ Failure Assessment (SOFA) score. Results: We included 44 patients with a mean SAPS II 50 ± 16 and a mortality rate of 13.6%. Between D1 and D5, there was a significant decrease of PTPN1 ( p < 0.001) and ATF6 ( p < 0.001) expressions. Their variations of expression were correlated with SOFA variation ( PTPN1, r = 0.35, CI 95% [0.05; 0.54], p = 0.03 and ATF6, r = 0.45 CI 95% [0.20; 0.65], p < 0.001). We did not find any correlation between PTPN1 expression and insulin resistance or glycemic parameters. Between D1 and D5, ATF6 and PTPN1 expressions were correlated with that of ET1 . Conclusions: Our study has evaluated for the first time the expression of PTP1B and ERS in patients with septic shock, revealing that gene expression variation of PTPN1 and ATF6 are partly correlated with the evolution of septic organ failure and with endothelial dysfunction markers expression., (Copyright © 2019 Clavier, Grangé, Pressat-Laffouilhere, Besnier, Renet, Fraineau, Thiebaut, Richard, Veber and Tamion.)

Background: Pneumocephalus and pneumorachis, presence of air inside the skull and spinal canal, are mostly seen after neurosurgical procedures and neuraxial anesthesia. They have also been described after penetrating trauma, but never after blunt trauma without adjacent bone fractures., Case Description: We present the case of an 85-year-old white male patient admitted to our intensive care unit after a high velocity car accident. On site clinical evaluation showed normal consciousness with 15/15 Glasgow Coma Scale after a short initial loss of consciousness. The patient was first sent to a nearby hospital where a whole-body computed tomography scan revealed pneumocephalus and pneumorachis and an important left hemopneumothorax with pneumomediastinum with extensive subcutaneous emphysema. The state of the patient quickly worsened with hemorrhagic shock. The patient was sent to our intensive care unit; upon neurosurgical evaluation, no surgical indication was retained due to the absence of skull and spine fracture. A computed tomography scan performed on day 6 showed total regression of the pneumocephalus and pneumorachis. A follow-up computed tomography scan performed on day 30 revealed no intracranial bleeding or stroke, but a left pleural hernia between ribs 5 and 6. Due to respiratory complications, our patient could not be weaned from ventilator support for a proper neurological examination. Our patient's state finally worsened with septic shock due to ventilator-acquired pneumonia leading to multiple organ failure and our patient died on day 37., Conclusions: This is the first case report to describe pneumorachis and pneumocephalus following blunt trauma with pneumothorax, but no spinal or skull fractures. The mechanism that is probably involved here is a migration of air with subcutaneous emphysema and a pleural hernia into the spinal canal. However, in cases of pneumorachis or pneumocephalus, skull fractures need to be investigated as these require surgery and appropriate vaccination to prevent meningitis.

Background: The effect of personalised mechanical ventilation on clinical outcomes in patients with acute respiratory distress syndrome (ARDS) remains uncertain and needs to be evaluated. We aimed to test whether a mechanical ventilation strategy that was personalised to individual patients' lung morphology would improve the survival of patients with ARDS when compared with standard of care., Methods: We designed a multicentre, single-blind, stratified, parallel-group, randomised controlled trial enrolling patients with moderate-to-severe ARDS in 20 university or non-university intensive care units in France. Patients older than 18 years with early ARDS for less than 12 h were randomly assigned (1:1) to either the control group or the personalised group using a minimisation algorithm and stratified according to the study site, lung morphology, and duration of mechanical ventilation. Only the patients were masked to allocation. In the control group, patients received a tidal volume of 6 mL/kg per predicted bodyweight and positive end-expiratory pressure (PEEP) was selected according to a low PEEP and fraction of inspired oxygen table, and early prone position was encouraged. In the personalised group, the treatment approach was based on lung morphology; patients with focal ARDS received a tidal volume of 8 mL/kg, low PEEP, and prone position. Patients with non-focal ARDS received a tidal volume of 6 mL/kg, along with recruitment manoeuvres and high PEEP. The primary outcome was 90-day mortality as established by intention-to-treat analysis. This study is registered online with ClinicalTrials.gov, NCT02149589., Findings: From June 12, 2014, to Feb 2, 2017, 420 patients were randomly assigned to treatment. 11 patients were excluded in the personalised group and nine patients were excluded in the control group; 196 patients in the personalised group and 204 in the control group were included in the analysis. In a multivariate analysis, there was no difference in 90-day mortality between the group treated with personalised ventilation and the control group in the intention-to-treat analysis (hazard ratio [HR] 1·01; 95% CI 0·61-1·66; p=0·98). However, misclassification of patients as having focal or non-focal ARDS by the investigators was observed in 85 (21%) of 400 patients. We found a significant interaction between misclassification and randomised group allocation with respect to the primary outcome (p<0·001). In the subgroup analysis, the 90-day mortality of the misclassified patients was higher in the personalised group (26 [65%] of 40 patients) than in the control group (18 [32%] of 57 patients; HR 2·8; 95% CI 1·5-5·1; p=0·012., Interpretation: Personalisation of mechanical ventilation did not decrease mortality in patients with ARDS, possibly because of the misclassification of 21% of patients. A ventilator strategy misaligned with lung morphology substantially increases mortality. Whether improvement in ARDS phenotyping can decrease mortality should be assessed in a future clinical trial., Funding: French Ministry of Health (Programme Hospitalier de Recherche Clinique InterRégional 2013)., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: The implementation of computerized monitoring and prescription systems in intensive care has proven to be reliable in reducing the rate of medical error and increasing patient care time. They also showed a benefit in reducing the length of stay in the intensive care unit (ICU). However, this benefit has been poorly studied, with conflicting results., Objective: This study aimed to show the impact of computerization on the length of stay in ICUs., Methods: This was a before-after retrospective observational study. All patients admitted in the surgical ICU at the Rouen University Hospital were included, from June 1, 2015, to June 1, 2016, for the before period and from August 1, 2016, to August 1, 2017, for the after period. The data were extracted from the hospitalization report and included the following: epidemiological data (age, sex, weight, height, and body mass index), reason for ICU admission, severity score at admission, length of stay and mortality in ICU, mortality in hospital, use of life support during the stay, and ICU readmission during the same hospital stay. The consumption of antibiotics, biological analyses, and the number of chest x-rays during the stay were also analyzed., Results: A total of 1600 patients were included: 839 in the before period and 761 in the after period. Only the severity score Simplified Acute Physiology Score II was significantly higher in the postcomputerization period (38 [SD 20] vs 40 [SD 21]; P<.05). There was no significant difference in terms of length of stay in ICU, mortality, or readmission during the stay. There was a significant increase in the volume of prescribed biological analyses (5416 [5192-5956] biological exams prescribed in the period before Intellispace Critical Care and Anesthesia [ICCA] vs 6374 [6013-6986] biological exams prescribed in the period after ICCA; P=.002), with an increase in the total cost of biological analyses, to the detriment of hematological and biochemical blood tests. There was also a trend toward reduction in the average number of chest x-rays, but this was not significant (0.55 [SD 0.39] chest x-rays per day per patient before computerization vs 0.51 [SD 0.37] chest x-rays per day per patient after computerization; P=.05). On the other hand, there was a decrease in antibiotic prescribing in terms of cost per patient after the implementation of computerization (€149.50 [$164 USD] per patient before computerization vs €105.40 [$155 USD] per patient after computerization)., Conclusions: Implementation of an intensive care information system at the Rouen University Hospital in June 2016 did not have an impact on reducing the length of stay., (©Camille Havel, Jean Selim, Emmanuel Besnier, Philippe Gouin, Benoit Veber, Thomas Clavier. Originally published in JMIR Perioperative Medicine (http://periop.jmir.org), 04.09.2019.)

Needle-free connectors were initially designed and promoted to avoid blood exposure for healthcare workers. Some recent data suggest that the latest generation of connectors (with positive displacement) may be of interest for reducing central venous line infections. We have been using needle-free connectors for several years in our intensive care unit and here we present a protocol for installing these connectors on central venous catheters. After insertion of the catheter and control of the permeability of the lines, the connectors must be purged with 0.9% NaCl before being connected. The connectors replace all disposable caps used on infusion stopcocks and manifolds. All the connectors are changed every 7 days as recommended by the manufacturer (except when there is macroscopic contamination, which requires an immediate change of the connector). Before each injection, the connector must be disinfected for at least 3 seconds with 70% isopropyl alcohol. The connectors must not be disconnected (unless changed), as the injection is done through the device. Setting up the connectors slightly increases the total time required to place the catheter and there is no formal evidence that these connectors reduce the incidence of infectious or thrombotic complications. However, these devices simplify the management of central venous lines and prevent the catheter circuit from "opening" once it has been sterilely installed.

Background: The objective of this study was to assess the cumulative incidence of invasive candidiasis (IC) in intensive care units (ICUs) in Europe., Methods: A multinational, multicenter, retrospective study was conducted in 23 ICUs in 9 European countries, representing the first phase of the candidemia/intra-abdominal candidiasis in European ICU project (EUCANDICU)., Results: During the study period, 570 episodes of ICU-acquired IC were observed, with a cumulative incidence of 7.07 episodes per 1000 ICU admissions, with important between-center variability. Separated, non-mutually exclusive cumulative incidences of candidemia and IAC were 5.52 and 1.84 episodes per 1000 ICU admissions, respectively. Crude 30-day mortality was 42%. Age (odds ratio [OR] 1.04 per year, 95% CI 1.02-1.06, p < 0.001), severe hepatic failure (OR 3.25, 95% 1.31-8.08, p 0.011), SOFA score at the onset of IC (OR 1.11 per point, 95% CI 1.04-1.17, p 0.001), and septic shock (OR 2.12, 95% CI 1.24-3.63, p 0.006) were associated with increased 30-day mortality in a secondary, exploratory analysis., Conclusions: The cumulative incidence of IC in 23 European ICUs was 7.07 episodes per 1000 ICU admissions. Future in-depth analyses will allow explaining part of the observed between-center variability, with the ultimate aim of helping to improve local infection control and antifungal stewardship projects and interventions.

Background: The WhatsApp smartphone app is the most widely used instant messaging app in the world. Recent studies reported the use of WhatsApp for educational purposes, but there is no prospective study comparing WhatsApp's pedagogical effectiveness to that of any other teaching modality., Objective: The main objective of this study was to measure the impact of a learning program via WhatsApp on clinical reasoning in medical residents., Methods: This prospective, randomized, multicenter study was conducted among first- and second-year anesthesiology residents (offline recruitment) from four university hospitals in France. Residents were randomized in two groups of online teaching (WhatsApp and control). The WhatsApp group benefited from daily delivery of teaching documents on the WhatsApp app and a weekly clinical case supervised by a senior physician. In the control group, residents had access to the same documents via a traditional computer electronic learning (e-learning) platform. Medical reasoning was self-assessed online by a script concordance test (SCT; primary parameter), and medical knowledge was assessed using multiple-choice questions (MCQs). The residents also completed an online satisfaction questionnaire., Results: In this study, 62 residents were randomized (32 to the WhatsApp group and 30 to the control group) and 22 residents in each group answered the online final evaluation. We found a difference between the WhatsApp and control groups for SCTs (60% [SD 9%] vs 68% [SD 11%]; P=.006) but no difference for MCQs (18/30 [SD 4] vs 16/30 [SD 4]; P=.22). Concerning satisfaction, there was a better global satisfaction rate in the WhatsApp group than in the control group (8/10 [interquartile range 8-9] vs 8/10 [interquartile range 8-8]; P=.049)., Conclusions: Compared to traditional e-learning, the use of WhatsApp for teaching residents was associated with worse clinical reasoning despite better global appreciation. The use of WhatsApp probably contributes to the dispersion of attention linked to the use of the smartphone. The impact of smartphones on clinical reasoning should be studied further., (©Thomas Clavier, Julie Ramen, Bertrand Dureuil, Benoit Veber, Jean-Luc Hanouz, Hervé Dupont, Gilles Lebuffe, Emmanuel Besnier, Vincent Compere. Originally published in JMIR Mhealth and Uhealth (http://mhealth.jmir.org), 09.04.2019.)

Background: Central venous catheter-related infections (CRIs) are a complication of central venous catheters in intensive care unit (ICU). Some needle-free connectors have been designed to decrease CRI, but there is a lack of data concerning their impact on infection., Objectives: The objective was to explore the impact of MaxZero™ connectors (BD; Franklin Lakes, US) on CRI in ICU., Methods: Observational, pre-post design study (2011-2013 and 2014-2016) conducted in the surgical ICU of a tertiary care hospital (18 beds). Patients with a central venous catheter and a length of stay ≥48 h were included. The connectors replaced all disposable caps used on infusion stopcocks and ramps. The primary parameter was to compare the incidence of CRI between the "before" period and the "after" period., Results: A total of 1633 patients were included (789 "before" and 844 "after"). There was no difference between groups concerning the global duration of catheterisation (12.5 ± 11.5 days vs. 12.1 ± 10.9 days). There were 61 CRIs before and 28 CRIs after the introduction of connectors; the incidence of CRI in the "before" group was 20.33 CRI/year (6.18 CRI per 1000 catheter-days) vs. 9.33 CRI/year (2.73 CRI per 1000 catheter-days) in the "after" group (incidence rate ratio = 0.44; 95% confidence interval = 0.28-0.68, p < 0.001). However, after a global analysis of the 6-year period, when adjusting for seasonal effect and pre-existing linear trend, the effect was no longer significant (adjusted incidence rate ratio = 0.57; 95% confidence interval = 0.24-1.35, p = 0.20)., Conclusions: Our results do not allow us to conclude to a potential beneficial effect of MaxZero™ on CRI but are compatible with its prolonged and safe use in ICU. Only future prospective works will be able to confirm the value of these connectors for CRI prevention., (Copyright © 2018 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: Blended learning, which combines internet-based platform and lecturing, is used in anaesthesiology and critical care teaching. However, the benefits of this method remain unclear., Methods: We conducted a prospective, multicentre, non-randomised work between 2007 and 2014 to study the effect of blended learning on the results of first year anaesthesia and critical care residents in comparison with traditional teaching. Blended learning was implemented in Rouen University Hospital in 2011 and residents affiliated to this university corresponded as the blended learning group. The primary outcome was the resident's results as measured with multiple-choice questions between blended learning and control groups after beginning blended learning (post-interventional stage). The secondary outcomes included residents' results between pre and post-interventional stages and homework's time. Moreover, comparison between control and blended learning group before beginning blended learning (pre-interventional stage) was performed., Results: From 2007 to 2014, 308 residents were included. For the pre-interventional period, the mean score in the blended learning group (n=53) was 176 (CI 95% 163 to 188) whereas the mean score in the control group (n=106) was 167 (CI 95% 160 to 174) (no difference). For the post-interventional period, the mean score in blended learning group (n=54) was 232 on 300 (CI95% 227-237) whereas the mean score in the control group (n=95) is 215 (CI95% 209-220) (P<0.001). In the two groups, comparison between pre and post-interventional stages showed the increase of mean score, stronger for blended learning group (32% and 28% in blended learning and control group, P<0.05). The average time of homework in the blended learning group was 27h (CI 95% 18.2-35.8) and 10h in the control group (CI 95% 2-18) (P<0.05)., Conclusions: This work suggests the positive effect of blended learning (associating internet-based learning and flipped classroom) on the anaesthesia and critical care residents' knowledge by increasing their homework's time., (Copyright © 2017. Published by Elsevier Masson SAS.)

Background: The efficacy of venovenous extracorporeal membrane oxygenation (ECMO) in patients with severe acute respiratory distress syndrome (ARDS) remains controversial., Methods: In an international clinical trial, we randomly assigned patients with very severe ARDS, as indicated by one of three criteria - a ratio of partial pressure of arterial oxygen (Pao 2 ) to the fraction of inspired oxygen (Fio 2 ) of less than 50 mm Hg for more than 3 hours; a Pao 2 :Fio 2 of less than 80 mm Hg for more than 6 hours; or an arterial blood pH of less than 7.25 with a partial pressure of arterial carbon dioxide of at least 60 mm Hg for more than 6 hours - to receive immediate venovenous ECMO (ECMO group) or continued conventional treatment (control group). Crossover to ECMO was possible for patients in the control group who had refractory hypoxemia. The primary end point was mortality at 60 days., Results: At 60 days, 44 of 124 patients (35%) in the ECMO group and 57 of 125 (46%) in the control group had died (relative risk, 0.76; 95% confidence interval [CI], 0.55 to 1.04; P=0.09). Crossover to ECMO occurred a mean (±SD) of 6.5±9.7 days after randomization in 35 patients (28%) in the control group, with 20 of these patients (57%) dying. The frequency of complications did not differ significantly between groups, except that there were more bleeding events leading to transfusion in the ECMO group than in the control group (in 46% vs. 28% of patients; absolute risk difference, 18 percentage points; 95% CI, 6 to 30) as well as more cases of severe thrombocytopenia (in 27% vs. 16%; absolute risk difference, 11 percentage points; 95% CI, 0 to 21) and fewer cases of ischemic stroke (in no patients vs. 5%; absolute risk difference, -5 percentage points; 95% CI, -10 to -2)., Conclusions: Among patients with very severe ARDS, 60-day mortality was not significantly lower with ECMO than with a strategy of conventional mechanical ventilation that included ECMO as rescue therapy. (Funded by the Direction de la Recherche Clinique et du Développement and the French Ministry of Health; EOLIA ClinicalTrials.gov number, NCT01470703 .).

Purpose: Shortening the duration of antibiotic therapy (ABT) is a key measure in antimicrobial stewardship. The optimal duration of ABT for treatment of postoperative intra-abdominal infections (PIAI) in critically ill patients is unknown., Methods: A multicentre prospective randomised trial conducted in 21 French intensive care units (ICU) between May 2011 and February 2015 compared the efficacy and safety of 8-day versus 15-day antibiotic therapy in critically ill patients with PIAI. Among 410 eligible patients (adequate source control and ABT on day 0), 249 patients were randomly assigned on day 8 to either stop ABT immediately (n = 126) or to continue ABT until day 15 (n = 123). The primary endpoint was the number of antibiotic-free days between randomisation (day 8) and day 28. Secondary outcomes were death, ICU and hospital length of stay, emergence of multidrug-resistant (MDR) bacteria and reoperation rate, with 45-day follow-up., Results: Patients treated for 8 days had a higher median number of antibiotic-free days than those treated for 15 days (15 [6-20] vs 12 [6-13] days, respectively; P < 0.0001) (Wilcoxon rank difference 4.99 days [95% CI 2.99-6.00; P < 0.0001). Equivalence was established in terms of 45-day mortality (rate difference 0.038, 95% CI - 0.013 to 0.061). Treatments did not differ in terms of ICU and hospital length of stay, emergence of MDR bacteria or reoperation rate, while subsequent drainages between day 8 and day 45 were observed following short-course ABT (P = 0.041)., Conclusion: Short-course antibiotic therapy in critically ill ICU patients with PIAI reduces antibiotic exposure. Continuation of treatment until day 15 is not associated with any clinical benefit. CLINICALTRIALS., Gov Identifier: NCT01311765.

The aim of this study was to evaluate the feasibility of unilateral diaphragmatic reinnervation in humans by the inferior laryngeal nerve. This pilot study included chronically ventilated tetraplegic patients with destruction of phrenic nerve motoneurons. Five patients were included. They all had a high level of tetraplegia, with phrenic nerve motor neuron destruction. They were highly dependent on ventilation, without any possibility of weaning. They did not have other chronic pathologies, especially laryngeal disease. They all had diaphragmatic explorations to diagnose the destruction of the motoneurons of the phrenic nerves and nasoendoscopy to be sure that they did not have laryngeal or pharyngeal disease. Then, surgical anastomosis of the right phrenic nerve was performed with the inferior laryngeal nerve, by a cervical approach. A laryngeal reinnervation was performed at the same time, using the ansa hypoglossi. One patient was excluded because of a functional phrenic nerve and one patient died 6 months after the surgery of a cardiac arrest. The remaining three patients were evaluated after the anastomosis every 6 months. They did not present any swallowing or vocal alterations. In these three patients, the diaphragmatic explorations showed that there was a recovery of the diaphragmatic electromyogram of the right and left hemidiaphragms after 1 year. Two patients had surgical diaphragmatic explorations for diaphragmatic pacing 18-24 months after the reinnervation with excellent results. At 36 months, none of the patients could restore their automatic ventilation. In conclusion, this study demonstrated that diaphragmatic reinnervation by the inferior laryngeal nerve is effective, without any vocal or swallowing complications.

Introduction: Severe trauma represents the leading cause of mortality worldwide. While 80% of deaths occur within the first 24 hours after trauma, 20% occur later and are mainly due to healthcare-associated infections, including ventilator-associated pneumonia (VAP). Preventing underinflation of the tracheal cuff is recommended to reduce microaspiration, which plays a major role in the pathogenesis of VAP. Automatic devices facilitate the regulation of tracheal cuff pressure, and their implementation has the potential to reduce VAP. The objective of this work is to determine whether continuous regulation of tracheal cuff pressure using a pneumatic device reduces the incidence of VAP compared with intermittent control in severe trauma patients., Methods and Analysis: This multicentre randomised controlled and open-label trial will include patients suffering from severe trauma who are admitted within the first 24 hours, who require invasive mechanical ventilation to longer than 48 hours. Their tracheal cuff pressure will be monitored either once every 8 hours (control group) or continuously using a pneumatic device (intervention group). The primary end point is the proportion of patients that develop VAP in the intensive care unit (ICU) at day 28. The secondary end points include the proportion of patients that develop VAP in the ICU, early (≤7 days) or late (>7 days) VAP, time until the first VAP diagnosis, the number of ventilator-free days and antibiotic-free days, the length of stay in the ICU, the proportion of patients with ventilator-associated events and that die during their ICU stay., Ethics and Dissemination: This protocol has been approved by the ethics committee of Poitiers University Hospital, and will be carried out according to the principles of the Declaration of Helsinki and the Good Clinical Practice guidelines. The results of this study will be disseminated through presentation at scientific conferences and publication in peer-reviewed journals., Trial Registration: Clinical Trials NCT02534974., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Conflicting results have been reported on the influence of Polymyxin-B hemoperfusion treatment on systemic inflammation markers. The aim of the study was to assess in a randomized control trial the influence on plasma cytokine concentrations of Polymyxin-B hemoperfusion in septic shock due to peritonitis. A panel of 10 pro- or anti-inflammatory cytokines was measured in 213 patients with peritonitis-induced septic shock enrolled in the randomized trial ABDOMIX testing the impact of 2 Polymyxin-B hemoperfusion sessions with standard treatment. Gram-negative bacteria were identified in 69% of patients. In the overall population, baseline plasma cytokine concentrations were not different between the two groups. Circulating tumor necrosis factor-α, interleukin (IL)-1β, IL-10, IL-6, and IL-1RA decreased significantly over time in both groups (P <0.0001 for all in controls, and P = 0.0002, 0.003, and <0.0001 in patients treated with Polymyxin-B hemoperfusion). IL-17A decreased significantly in patients treated with Polymyxin B hemoperfusion (P = 0.045) but not in controls. At the end of the second Polymyxin-B hemoperfusion session or at corresponding time in controls, plasma levels of cytokines did not differ between the two groups. Similar results were found in the subgroup of patients with gram-negative peritonitis who completed two Polymyxin-B hemoperfusion sessions. These results do not support a significant influence of Polymyxin-B hemoperfusion on circulating cytokines assessed except for IL-17A which clinical significance remains to be elucidated.

Background: Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is an emerging curative treatment option for patients with peritoneal carcinomatosis. It has a long-term survival benefit but is associated with high rates of morbidity, ranging from 12 % to 65 %, mainly due to infectious complications. We sought to evaluate the clinical relevance of routine intraoperative bacteriological sampling following CRS/HIPEC., Study Design: Between November 2010 and December 2014, every patients receiving CRS/HIPEC were included. Three samples were routinely collected from standardized locations for intraperitoneal rinsing liquid bacteriological analysis (RLBA) after completion of HIPEC. The clinical and surgical features, bacteriological results, and short-term outcomes were retrospectively reviewed., Results: The overall mortality and morbidity rates were 5 and 45 %, respectively. Among the 75 included patients, 40 % (n = 30) had at least one positive bacterial culture. Risk factors for a positive culture were colorectal resection (adjusted hazard ratio [HR] = 3.072, 95 % CI 1.843-8.004; p = 0.009) and blood loss >1000 mL (HR = 4.272, 95 % CI 1.080-18.141; p = 0.031). Among 26 (35 %) patients with abdominal infectious complications, 13 (17 %) experienced isolated complications. A positive RLBA result was independently associated with abdominal infectious complications (HR = 5.108, 95 % CI 1.220-16.336; p = 0.024) and isolated abdominal infectious complications (HR = 4.199, 95 % CI 1.064-15.961; p = 0.04)., Conclusions: Forty percent of the RLBA samples obtained following CRS/HIPEC tested positive for bacteria. Bacterial sampling of rinsing liquid should be systematically performed. An aggressive and immediate antibiotic strategy needs to be evaluated.

Objective: Despite recent efforts, most people are not trained in cardiopulmonary resuscitation (CPR), which has a major impact on survival following cardiac arrest (CA). We have set up a dispatcher-assisted CPR protocol at our call centre, based on international guidelines issued in 2010. The aim of our study was to evaluate the impact of this protocol on CA diagnosis and quantity of recommendations given by telephone dispatchers to untrained witnesses., Methods: We performed a 'before and after' monocentric observational study. Data were compared before and a short time after (2 months) implementation of the protocol. We included patients presenting as an out-of-hospital CA in the presence of a witness untrained in CPR. Fisher's test was used to compare periods. P < 0.05 was considered significant., Results: During the 8 month period before the protocol, 115 victims were potentially eligible for CPR. Diagnosis was achieved in 63.5% of cases and CPR recommendations given in 6.1%. After implementation of the protocol, 130 victims were potentially eligible for CPR. Frequency of CA diagnosis was significantly higher after the protocol with 76% of cases (P = 0.0359). Frequency of CPR recommendations given to witnesses was also significantly higher after the protocol, with a fivefold increase up to 29.2% (P < 0.0001)., Conclusion: Implementation of a dispatcher-assisted CPR protocol was efficient in improving both CA diagnosis and CPR recommendations given to untrained witnesses for out-of-hospital CA with a very short time of dispatcher training. It is a simple and efficacious measure, at no additional cost and with the promises of improving prognosis following cardiac arrest in a centre not equipped with computerised dispatcher support programmes., (© 2015 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.)

Purpose: To test whether the polymyxin B hemoperfusion (PMX HP) fiber column reduces mortality and organ failure in peritonitis-induced septic shock (SS) from abdominal infections., Method: Prospective, multicenter, randomized controlled trial in 18 French intensive care units from October 2010 to March 2013, enrolling 243 patients with SS within 12 h after emergency surgery for peritonitis related to organ perforation. The PMX HP group received conventional therapy plus two sessions of PMX HP. Primary outcome was mortality on day 28; secondary outcomes were mortality on day 90 and a reduction in the severity of organ failures based on Sequential Organ Failure Assessment (SOFA) scores., Primary Outcome: day 28 mortality in the PMX HP group (n = 119) was 27.7 versus 19.5% in the conventional group (n = 113), p = 0.14 (OR 1.5872, 95% CI 0.8583-2.935). Secondary endpoints: mortality rate at day 90 was 33.6% in PMX-HP versus 24% in conventional groups, p = 0.10 (OR 1.6128, 95% CI 0.9067-2.8685); reduction in SOFA score from day 0 to day 7 was -5 (-11 to 6) in PMX-HP versus -5 (-11 to 9), p = 0.78. Comparable results were observed in the predefined subgroups (presence of comorbidity; adequacy of surgery, <2 sessions of hemoperfusion) and for SOFA reduction from day 0 to day 3., Conclusion: This multicenter randomized controlled study demonstrated a non-significant increase in mortality and no improvement in organ failure with PMX HP treatment compared to conventional treatment of peritonitis-induced SS.

Introduction: Recent work has shown that benzodiazepines interact with the immune system and exhibit anti-inflammatory effects. By using in vitro models, researchers in several studies have shown that the peptidergic endogenous ligands of benzodiazepine receptors, named endozepines, are involved in the immune response. All endozepines identified so far derive from diazepam-binding inhibitor (DBI), which generates several biologically active fragments. The aim of the present study was to measure plasma levels of DBI-like immunoreactivity (DBI-LI) in a rat model of sepsis and in patients with systemic inflammation from septic or non-septic origin., Methods: Cecal ligation and puncture (CLP) or sham surgery was performed in rats. Blood samples were taken from animals, patients hospitalized for digestive surgery with inflammatory diseases, and healthy volunteers. Measurements of plasma DBI-related peptides were carried out by radioimmunoassay in animal and human samples., Results: In the rats, CLP provoked an increase of plasma DBI-LI (+37%) 6 hours postsurgery. In humans, DBI-LI levels were significantly higher in the systemic inflammation group than in the healthy volunteer group (48.6 (32.7 to 77.7) pg/ml versus 11.1 (5.9 to 35.3) pg/ml, P <  .001). We found a positive correlation between endozepine levels and Acute Physiology and Chronic Health Evaluation II score (r s = 0.33 (0.026 to 0.58), P < 0.05) and tumor necrosis factor α levels (r s = 0.43 (0.14 to 0.65), P < 0.01). The area under the receiver operating characteristic curve for endozepines was 0.842 (95% CI (0.717 to 0.966), P < 0.0001) for discriminating patients with inflammation from healthy volunteers., Conclusions: Endozepines might be involved in the inflammatory response in patients with systemic inflammation.

Objective: To evaluate the efficacy and safety of oral care with povidone-iodine on the occurrence of ventilator-associated pneumonia in a high-risk population., Design: A multicenter, placebo-controlled, randomized, double-blind, two-parallel-group trial performed between May 2008 and May 2011., Setting: Six ICUs in France., Patients: One hundred seventy-nine severely brain-injured patients (Glasgow Coma Scale ≤ 8) or cerebral hemorrhage expected to be mechanically ventilated for more than 24 hours., Interventions: Participants were randomly assigned to receive oropharyngeal care with povidone-iodine (n = 91) or placebo (n = 88) six times daily until mechanical ventilation withdrawal., Measurements and Main Results: Primary endpoint was the rate of ventilator-associated pneumonia. Secondary endpoint included the rates of ventilator-associated tracheobronchitis and acute respiratory distress syndrome and patient's outcome. The number of patients evaluable for the primary endpoint (preplanned modified intention-to-treat population) was 150 (78 in the povidone-iodine group, 72 in the placebo group). Ventilator-associated pneumonia occurred in 24 patients (31%) in the povidone-iodine group and 20 (28%) in the placebo group (relative risk, 1.11 [95% CI, 0.67-1.82]; p = 0.69). There was no significant difference between the two groups for ventilator-associated tracheobronchitis: eight patients (10%) in the povidone-iodine group and five patients (7%) in the placebo group (relative risk, 1.48 [95% CI, 0.51-4.31]; p = 0.47). Acute respiratory distress syndrome occurred in five patients in the povidone-iodine group but not in the placebo group (p = 0.06). There was no difference between groups for ICU and hospital lengths of stay, as well as ICU and 90-day mortality., Conclusions: There is no evidence to recommend oral care with povidone-iodine to prevent ventilator-associated pneumonia in high-risk patients. Furthermore, this strategy seems to increase the rate of acute respiratory distress syndrome.

Background: Hyperthermic intraperitoneal chemotherapy (HIPEC) improves the survival of select patients with peritoneal carcinomatosis. Hemophagocytic syndrome (HS) is a rare and potentially fatal disease. We describe our experience with five patients who developed HS following oxaliplatin HIPEC and propose a management procedure., Methods: Hyperthermic intraperitoneal chemotherapy was performed using the open-abdomen technique (43 °C) with oxaliplatin (460 mg/m (2) ) for 30 min. If thrombocytopenia occurred from days 5 to 14, heparin-induced thrombocytopenia was evaluated. For thrombocytopenia with unknown etiology, we performed a bone marrow analysis (BMA). A BMA indicating HS stimulated an extensive infectious disease workup. Herein, we describe "reactive septic HS" and HS of unknown origin., Results: We documented five patients with HS as a result of severe thrombocytopenia. Underlying infections were present in two patients who were treated with antibiotics and survived. For the remaining three patients, we found no underlying etiology of HS; multidisciplinary staff adapted the clinical management daily. Two patients died on postoperative days 40 and 29. The third patient survived after several operations and treatment with the VAC abdominal dressing system., Conclusions: We present these cases to ensure that physicians are aware of the symptoms of HS after HIPEC, which are important for initiating immediate life-saving therapy. This condition is a diagnostic and therapeutic emergency. When HS complicates HIPEC, aggressive, early medical, and surgical management is required. However, the optimal management has not been defined.

Objective: D-lactate is the enantiomer of L-lactate, which is measured routinely in clinical practice to assess cell hypoxia. D-lactate has been proposed as a specific marker of gut ischemia-reperfusion (IR), particularly during surgery for ruptured abdominal aortic aneurysms. The aim of this study was to compare the use of D-lactate measurement and colonic tonometry (taken as a reference method) for gut IR detection during elective infrarenal aortic aneurysm (IrAA) surgery., Design: Prospective, monocenter, observational study., Setting: Vascular surgery unit, university hospital., Participants: Candidates for elective IrAA surgery., Interventions: Patients without (controls) and with gut IR (defined as ΔCO2>2.6 kPa) were compared retrospectively., Measurement and Main Results: D-lactate levels were compared with colonic perfusion levels (ΔCO2), as assessed by colonic tonometry, at 7 time points during surgery and until 24 hours after surgery. D-lactate also was measured in mesenteric vein blood before and after gut reperfusion. Plasma TNF-α level was measured at the same time points to assess systemic inflammatory response. Eighteen patients requiring elective IrAA surgery were included. The ΔCO2 and TNF-α level varied significantly over time. There was a significant ΔCO2 peak at the end of clamping (2.6±1.8 kPa, p = 0.006) and a significant peak in TNF-α level after 1 hour of reperfusion (183±53 ng/L, p = 0.05). D-lactate levels were undetectable in systemic and mesenteric blood in all the patients throughout the study period. Gut IR patients (n = 6) experienced a longer overall duration of intraoperative hypotensive episodes and received more catecholamines than the controls (n = 12)., Conclusions: Compared with colonic tonometry, D-lactate was not a reliable biomarker of gut IR during elective IrAA surgery., (Copyright © 2013 Elsevier Inc. All rights reserved.)