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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.

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%. Candidaspp. 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.

Dans la majorité des cas, les décisions de limitation ou d’arrêt de traitement en réanimation sont prises en accord avec la famille du patient. Néanmoins, il arrive que la famille ne soit pas d’accord avec le projet de soins. Cette situation amène alors des discussions et des questionnements éthiques qui permettent avec le temps de faire émerger une solution. Mais ce désaccord peut aussi évoluer vers un vrai conflit. Plusieurs affaires médiatisées et judiciarisées ces dernières années nous ont montré à quel point ces conflits pouvaient être destructeurs et combien il est important d’empêcher la judiciarisation. Pour éviter l’escalade, il est nécessaire de comprendre les raisons de ces conflits, leur origine et ce qui les favorise. Il faut également sortir du questionnement « qui décide pour le patient qui n’est pas en mesure d’exprimer sa volonté ? », opposant famille et corps médical. La question n’est pas « qui », mais « comment ». Les soignants doivent se positionner en aidants, et établir une relation de confiance. En écoutant et en accompagnant les proches, ils doivent avoir pour objectif commun de s’accorder sur une décision qui réponde au mieux à ce qu’aurait souhaité le patient ou, en pédiatrie, à ce que des parents considèrent comme acceptable pour leur enfant et qu’ils soient capables de supporter. L’établissement de cette relation de confiance nécessite une implication forte des soignants dans la relation, la connaissance des enjeux communicationnels, ainsi que le respect d’une temporalité propre à chaque cas.

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. A nationwide protocol for kidneys from controlled donation after circulatory death donors, characterized by systematic normothermic regional perfusion after death until kidney recovery, hypothermic machine perfusion until transplantation, and short cold ischemia times, is associated with significantly lower risk of delayed graft function and comparable 1‐year graft and patient survival rates, compared to kidneys from brain death donors.

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.

The Radiographic Assessment of Lung Edema (RALE) score is associated with the severity of ARDS, and treatments targeted at reducing pulmonary edema such as conservative fluid management cause a reduction in RALE score over time.

La loi Claeys–Leonetti a donné le droit à « une sédation profonde et continue provoquant une altération de la conscience maintenue jusqu’au décès (SPCMD) ». Chaque situation de sa mise en œuvre soulève des questions éthiques, morales, mais aussi pratiques, techniques et organisationnelles. Comment s’approprier la SPCMD dans le contexte particulier de la réanimation ? Comment définir les contours de cette pratique sédative à visée palliative ? Quelles sont les modalités décisionnelles et pratiques de sa mise en œuvre ? La SPCMD se distingue des autres pratiques sédatives à visée palliative : elle consiste à rendre le patient inconscient sans communication possible ; son intention dès l’initiation est d’être poursuivie jusqu’au décès, l’inconscience provoquée est quant à elle l’objectif, et non pas l’effet indésirable. La SPCMD se distingue également de l’euthanasie : si la distinction peut parfois paraître complexe et ambiguë lorsqu’elle s’accompagne en réanimation de l’arrêt d’un traitement de maintien en vie, les intentions restent radicalement différentes. Si les modalités décisionnelles sont clairement précisées dans la loi, les étapes du processus décisionnel continuent de questionner les équipes de réanimation. Et les modalités d’application pratique sont moins claires, particulièrement dans le contexte de la réanimation. Si la loi actuelle est probablement insuffisamment connue et mise en œuvre, elle permet de soigner les patients en fin de vie, tout en respectant leur dignité.

La consultation préanesthésique (CPA) améliore la qualité et la sécurité des soins prodigués en anesthésie-réanimation. L’objectif de cette étude était d’évaluer l’enseignement de cette activité pendant l’internat d’anesthésie-réanimation en France, du point de vue des internes (DESAR) et des responsables de l’enseignement de la discipline.

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.

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.

Recent studies highlight that female anesthesiology researchers have lower visibility on professional social networks (PSN) than male. The objective of this work was to compare the use of PSN between women and men in critical care research.

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.

We report the case of a 77-year-old male who had elective duodenopancreatectomy surgery. As part of a multimodal analgesia strategy a continuous infusion of lidocaine was administered peri-operatively. Surgery was uneventful. On admission to post-operative Intensive Care Unit (ICU), the patient presented with progressive neurological and haemodynamic failure due to a lidocaine overdose made by an error in the continuous systemic administration. Once the diagnosis was established, an infusion of lipid emulsion resulted in almost immediate haemodynamic recovery; full neurological recovery was however delayed for some hours. Continuous intravenous infusions of lidocaine can lead to systemic toxicity, therefore training in lidocaine administration, diagnosis of toxicity and its management are essential for all staff involved in the care of these patients.

The open repair of suprarenal aortic aneurysm requires supraceliac aortic cross-clamping and separate renal artery reconstruction. The aim of this study was to determine the intraoperative factors responsible for postoperative renal dysfunction.

Objective.To establish whether continuous subglottic suctioning (CSS) could be cost-effective.Design.Cost-benefit analysis, based on a hypothetical replacement of conventional ventilation (CV) with CSS.Setting.A surgical intensive care unit (SICU) of a tertiary care university hospital in France.Patients.All consecutive patients receiving ventilation in the SICU in 2006.Methods.Efficacy data for CSS were obtained from the literature and applied to the SICU of our hospital. Costs for CV and CSS were provided by the hospital pharmacy; costs for ventilator-associated pneumonia (VAP) were obtained from the literature. The cost per averted VAP episode was calculated, and a sensitivity analysis was performed on VAP incidence and on the number of tubes required for each patient.Results.At our SICU in 2006, 416 patients received mechanical ventilation for 3,487 ventilation-days, and 32 VAP episodes were observed (7.9 episodes per 100 ventilated patients; incidence density, 9.2 episodes per 10,000 ventilation-days). Based on the hypothesis of a 29% reduction in the risk of VAP with CSS than CV, 9 VAP episodes could have been averted. The additional cost of CSS for 2006 was estimated to be €10,585.34. The cost per averted VAP episode was €1,176.15. Assuming a VAP cost of €4,387, a total of 3 averted VAP episodes would neutralize the additional cost. For a low VAP incidence of 6.6%, the cost per averted VAP would be €1,323. If each patient required 2 tubes during ventilation, the cost would be €1,383.69 per averted VAP episode.Conclusion.Replacement of CV with CSS was cost-effective even when assuming the most pessimistic scenario of VAP incidence and costs.

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.

Cerebral aspergillosis carries a mortality rate close to 100%, especially in immunocompromised patients. We describe 3 patients who contracted cerebral aspergillosis after neurosurgery, 2 of whom survived after exhaustive surgical treatment and medical treatment with high doses of amphotericin B (once liposomal), 5-fluorocytosine and itraconazole. We review the few non-fatal cases of cerebral aspergillosis reported. We consider that surgical excision must be complete and repeated if necessary, always in combination with medical treatment.

L’association CEFOTAXIME-FOSFOMYCINE a été validée par Portier et al. dans le traitement des méningites nosocomiales de l’adulte [1]. Cette association a été pourtant remise en cause du fait de son risque d’inefficacité [2]amenant même à l’émission de recommandations à l’étranger préconisant l’utilisation d’une antibiothérapie probabiliste à plus large spectre. Nous avons voulu évaluer la sensibilité à cette antibiothérapie probabiliste des souches bactériennes retrouvées dans les infections neuroméningées nosocomiales au sein de l’unité de neuroréanimation du CHU de Rouen.

Le médecin anesthésiste-réanimateur (MAR) est rarement, voire exceptionnellement confronté à certaines urgences vitales au bloc opératoire. Ces situations requièrent un rappel immédiat de connaissances parfois anciennes, l’analyse dynamique d’une situation complexe et une prise de décision efficace dans un contexte souvent stressant. L’utilisation de checklists est recommandée afin d’optimiser leur contrôle et de prévenir le risque d’erreurs médicales [1]. Cette étude visait à évaluer le bénéfice de la fiche d’urgence « Hyperthermie maligne » (HTM) de la Société française d’anesthésie-réanimation (SFAR) sur la prise en charge d’une crise d’HTM simulée.