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Invasive fungal infections are common, and severe complications can occur in immunocompromised patients, especially in patients with hematologic malignancies who require intensive care unit (ICU) admission (2,2). Invasive fusariosis is [...]

Purpose Compliance to the Surviving Sepsis Campaign (SSC) guidelines is limited. This is known to be associated with increased mortality. The aim of this retrospective cohort study was to identify among the SCC guidelines the optimal bundle of recommendations that minimize 28-day mortality. Methods We used a training cohort to identify, using a least absolute shrinkage and selection operator penalized machine learning model, this bundle. Patients with sepsis/septic shock admitted to the intensive care unit (ICU) were extracted from two US databases, the Medical Information Mart for Intensive Care-IV (MIMIC-IV) database (training and internal validation cohorts) and the eICU Collaborative Research Database (eICU-CRD) (external validation cohort). In the validation cohorts, we defined a bundle group that includes patients who were treated with at least all the recommendations selected in our bundle and a no-bundle group that includes patients in whom at least one recommendation from our bundle was omitted. Results All-cause 28-day mortality was the primary outcome measure. A total of 42,735 patients were included. Six recommendations (antimicrobials, balanced crystalloid, insulin therapy, corticosteroids, vasopressin, and bicarbonate therapy) were identified from the training cohort to be included in our bundle. In the propensity score-(PS)-matched internal validation cohort, the bundle group was associated with a lower mortality (OR 0.41 [0.33-0.53]; p < 0.001) compared to the no-bundle group. This was confirmed in the PS-matched external validation cohort (OR 0.75 [0.60-0.94]; p 0.02). Conclusion Our bundle of six recommendations is associated with a dramatic reduction in mortality in sepsis and septic shock. This bundle needs to be evaluated prospectively., Author(s): Alexandre Kalimouttou [sup.1] [sup.2], Ivan Lerner [sup.2] [sup.3] [sup.4], Chérifa Cheurfa [sup.5], Anne-Sophie Jannot [sup.2] [sup.3] [sup.4], Romain Pirracchio [sup.1] [sup.6] Author Affiliations: (1) grid.508487.6, 0000 0004 7885 7602, [...]

Purpose The aim of this study was to perform a systematic review and meta-analysis to investigate the incidence rate of cardiac arrest and severe complications occurring under non-invasive ventilation (NIV). Methods We performed a systematic review and meta-analysis of studies between 1981 and 2020 that enrolled adults in whom NIV was used to treat acute respiratory failure (ARF). We generated the pooled incidence and confidence interval (95% CI) of NIV-related cardiac arrest per patient (primary outcome) and performed a meta-regression to assess the association with study characteristics. We also generated the pooled incidences of NIV failure and hospital mortality. Results Three hundred and eight studies included a total of 7,601,148 participants with 36,326 patients under NIV (8187 in 138 randomized controlled trials, 9783 in 99 prospective observational studies, and 18,356 in 71 retrospective studies). Only 19 (6%) of the analyzed studies reported the rate of NIV-related cardiac arrest. Forty-nine cardiac arrests were reported. The pooled incidence was 0.01% (95% CI 0.00-0.02, I.sup.2 = 0% (0-15)). NIV failure was reported in 4371 patients, with a pooled incidence of 11.1% (95% CI 9.0-13.3). After meta-regression, NIV failure and the study period (before 2010) were significantly associated with NIV-related cardiac arrest. The hospital mortality pooled incidence was 6.0% (95% CI 4.4-7.9). Conclusion Cardiac arrest related to NIV occurred in one per 10,000 patients under NIV for ARF treatment. NIV-related cardiac arrest was associated with NIV failure., Author(s): Amélie Rolle [sup.1] [sup.2], Audrey De Jong [sup.1] [sup.3], Elsa Vidal [sup.1] [sup.2], Nicolas Molinari [sup.4], Elie Azoulay [sup.5], Samir Jaber [sup.1] [sup.3] Author Affiliations: (1) grid.121334.6, 0000 0001 [...]

Elasmobranchs make up a significant part of by catch in pelagic longline fisheries, whose induced mortality can be a major threat to endangered species. It is therefore crucial to understand the drivers of at-vessel mortality (AVM) for this fishing gear to enhance postrelease survival. To this end, we analysed scientific data collected during monitored longline fishing experiments conducted in French Polynesia to (i) estimate AVM for each species based on bootstrapped samples and (ii) to assess AVM drivers using multivariate logistic regression models for the blue shark (Prionace glauca) and oceanic whitetip shark (Carcharhinus longimanus). We found that AVM varies widely between species. Oceanic whitetip sharks are more likely to die when caught in waters outside their comfort temperature range, and their odds of survival increase with body length. For the blue shark, the only driver related to AVM is hooking duration. These results indicate that to reduce the AVM of these two species, the vertical distribution of hooks and soak duration should be considered as mitigation measures related to pelagic longlining. Les elasmobranches representent une part significative des prises accessoires des pecheries palangrieres pelagiques, dont la mortalite induite peut constituer une menace importante pour des especes vulnerables ou en danger. La comprehension des facteurs de mortalite au virage (MAV) pour cet engin est donc cruciale pour ameliorer la survie apres remise a l'eau. Pour cela, nous avons analyse des donnees recueillies durant des campagnes scientifiques de peche avec une palangre instrumentee menees en Polynesie francaise afin (i) d'estimer la MAV pour chaque espece sur la base d'echantillons bootstrappes et (ii) d'evaluer les facteurs influencant la MAV a l'aide de modeles de regression logistique multivariee pour le requin peau bleue (Prionace glauca) et le requin longimane (Carcharhinus longimanus). Nous avons constate que la MAV differe grandement entre les especes. Les requins longimanes sont plus susceptibles de mourir quand ils sont captures dans des eaux en dehors de leur intervalle de temperatures de confort et leur probabilite de survie augmente avec la taille des individus. Pour le requin peau bleue, le seul facteur qui influence la MAV est la duree d'hameconnage. Ces resultats indiquent que, pour reduire la MAV de ces deux especes, la repartition verticale des hamecons et le temps d'immersion de la palangre devraient etre considerees comme mesures d'attenuation dans la peche palangriere pelagique. [Traduit par la Redaction], 1. Introduction Across the globe, fishing activities unintentionally catch nontarget species--i.e., bycatch--and are therefore considered one of the greatest threats to marine populations, especially pelagic sharks (Dulvy et al. 2014). [...]

Purpose Epidemiologic studies have documented lower rates of active smokers compared to former or non-smokers in symptomatic patients affected by coronavirus disease 2019 (COVID-19). We assessed the efficacy and safety of nicotine administered by a transdermal patch in critically ill patients with COVID-19 pneumonia. Methods In this multicentre, double-blind, placebo-controlled trial conducted in 18 intensive care units in France, we randomly assigned adult patients (non-smokers, non-vapers or who had quit smoking/vaping for at least 12 months) with proven COVID-19 pneumonia receiving invasive mechanical ventilation for up to 72 h to receive transdermal patches containing either nicotine at a daily dose of 14 mg or placebo until 48 h following successful weaning from mechanical ventilation or for a maximum of 30 days, followed by 3-week dose tapering by 3.5 mg per week. Randomization was stratified by centre, non- or former smoker status and Sequential Organ Function Assessment score (< or [greater than or equal to] 7). The primary outcome was day-28 mortality. Main prespecified secondary outcomes included 60-day mortality, time to successful extubation, days alive and free from mechanical ventilation, renal replacement therapy, vasopressor support or organ failure at day 28. Results Between November 6th 2020, and April 2nd 2021, 220 patients were randomized from 18 active recruiting centers. After excluding 2 patients who withdrew consent, 218 patients (152 [70%] men) were included in the analysis: 106 patients to the nicotine group and 112 to the placebo group. Day-28 mortality did not differ between the two groups (30 [28%] of 106 patients in the nicotine group vs 31 [28%] of 112 patients in the placebo group; odds ratio 1.03 [95% confidence interval, CI 0.57-1.87]; p = 0.46). The median number of day-28 ventilator-free days was 0 (IQR 0-14) in the nicotine group and 0 (0-13) in the placebo group (with a difference estimate between the medians of 0 [95% CI -3-7]). Adverse events likely related to nicotine were rare (3%) and similar between the two groups. Conclusion In patients having developed severe COVID-19 pneumonia requiring invasive mechanical ventilation, transdermal nicotine did not significantly reduce day-28 mortality. There is no indication to use nicotine in this situation., Author(s): Guylaine Labro [sup.1], Florence Tubach [sup.2], Lisa Belin [sup.2], Jean-Louis Dubost [sup.3], David Osman [sup.4], Grégoire Muller [sup.5], Jean-Pierre Quenot [sup.6] [sup.7] [sup.8], Daniel Da Silva [sup.9], Jonathan Zarka [...]

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., Author(s): Adrien Bouglé [sup.1], Sophie Tuffet [sup.2], Laura Federici [sup.3], Marc Leone [sup.4], Antoine Monsel [sup.5], Thomas Dessalle [sup.1], Julien Amour [sup.1], Claire Dahyot-Fizelier [sup.6], François Barbier [sup.7], Charles-Edouard Luyt [...]

Purpose The Coronavirus disease 2019 (COVID-19) has led to an unparalleled influx of patients. Prognostic scores could help optimizing healthcare delivery, but most of them have not been comprehensively validated. We aim to externally validate existing prognostic scores for COVID-19. Methods We used 'COVID-19 Evidence Alerts' (McMaster University) to retrieve high-quality prognostic scores predicting death or intensive care unit (ICU) transfer from routinely collected data. We studied their accuracy in a retrospective multicenter cohort of adult patients hospitalized for COVID-19 from January 2020 to April 2021 in the Greater Paris University Hospitals. Areas under the receiver operating characteristic curves (AUC) were computed for the prediction of the original outcome, 30-day in-hospital mortality and the composite of 30-day in-hospital mortality or ICU transfer. Results We included 14,343 consecutive patients, 2583 (18%) died and 5067 (35%) died or were transferred to the ICU. We examined 274 studies and found 32 scores meeting the inclusion criteria: 19 had a significantly lower AUC in our cohort than in previously published validation studies for the original outcome; 25 performed better to predict in-hospital mortality than the composite of in-hospital mortality or ICU transfer; 7 had an AUC > 0.75 to predict in-hospital mortality; 2 had an AUC > 0.70 to predict the composite outcome. Conclusion Seven prognostic scores were fairly accurate to predict death in hospitalized COVID-19 patients. The 4C Mortality Score and the ABCS stand out because they performed as well in our cohort and their initial validation cohort, during the first epidemic wave and subsequent waves, and in younger and older patients., Author(s): Yannis Lombardi [sup.1], Loris Azoyan [sup.1], Piotr Szychowiak [sup.2] [sup.3], Ali Bellamine [sup.4], Guillaume Lemaitre [sup.5], Mélodie Bernaux [sup.6], Christel Daniel [sup.7], Judith Leblanc [sup.8] [sup.9], Quentin Riller [sup.1], [...]

Purpose Hyperglycaemia is an adaptive response to stress commonly observed in critical illness. Its management remains debated in the intensive care unit (ICU). Individualising hyperglycaemia management, by targeting the patient's pre-admission usual glycaemia, could improve outcome. Methods In a multicentre, randomized, double-blind, parallel-group study, critically-ill adults were considered for inclusion. Patients underwent until ICU discharge either individualised glucose control by targeting the pre-admission usual glycaemia using the glycated haemoglobin A1c level at ICU admission (IC group), or conventional glucose control by maintaining glycaemia below 180 mg/dL (CC group). A non-commercial web application of a dynamic sliding-scale insulin protocol gave to nurses all instructions for glucose control in both groups. The primary outcome was death within 90 days. Results Owing to a low likelihood of benefit and evidence of the possibility of harm related to hypoglycaemia, the study was stopped early. 2075 patients were randomized; 1917 received the intervention, 942 in the IC group and 975 in the CC group. Although both groups showed significant differences in terms of glycaemic control, survival probability at 90-day was not significantly different (IC group: 67.2%, 95% CI [64.2%; 70.3%]; CC group: 69.6%, 95% CI [66.7%; 72.5%]). Severe hypoglycaemia (below 40 mg/dL) occurred in 3.9% of patients in the IC group and in 2.5% of patients in the CC group (p = 0.09). A post hoc analysis showed for non-diabetic patients a higher risk of 90-day mortality in the IC group compared to the CC group (HR 1.3, 95% CI [1.05; 1.59], p = 0.018). Conclusion Targeting an ICU patient's pre-admission usual glycaemia using a dynamic sliding-scale insulin protocol did not demonstrate a survival benefit compared to maintaining glycaemia below 180 mg/dL., Author(s): Julien Bohé [sup.1], Hassane Abidi [sup.1], Vincent Brunot [sup.2], Amna Klich [sup.3] [sup.4] [sup.5] [sup.6], Kada Klouche [sup.2] [sup.7], Nicholas Sedillot [sup.8], Xavier Tchenio [sup.8], Jean-Pierre Quenot [sup.9] [sup.10] [...]

Author(s): Antoine Guillon [sup.1], Emeline Laurent [sup.2] [sup.3], Lucile Godillon [sup.2], Antoine Kimmoun [sup.4], Leslie Grammatico-Guillon [sup.2] [sup.5] [sup.6] Author Affiliations: (1) grid.12366.30, 0000 0001 2182 6141, Intensive Care Unit, [...]

Author(s): Antoine Guillon [sup.1], Emeline Laurent [sup.2] [sup.3], Lucile Godillon [sup.2], Antoine Kimmoun [sup.4], Leslie Grammatico-Guillon [sup.2] [sup.5] Author Affiliations: (1) Intensive Care Unit, Tours University Hospital, Research Center for [...]

Purpose Invasive pulmonary aspergillosis (IPA) is a dreadful event in patients with hematological malignancies (HM). Recent advances have standardized diagnostic, prophylactic and curative therapeutic strategies. We sought to assess whether these advances actually translate into improved survival in critically ill patients with acute respiratory failure and IPA. Methods This was a retrospective, multicenter study. Adult patients with HM, IPA, admitted to the ICU for acute respiratory failure over a 20-year period (January 1998-December 2017) were included. A cox regression model was used to identify variables independently associated with day-90 survival. Results Overall, 219 patients were included [138 (63%) men, median age 55 (IQR 44-64)]. Acute myeloid leukemia (30.1%) and non-Hodgkin lymphoma (22.8%) were the most frequent malignancies, and 53 (24.2%) were allogeneic stem cell recipients. Day-1 SOFA score was 9 [7 (See CR7)-12 (See CR12)]. Most patients presented with probable IPA, whereas 15 (7%) underwent lung biopsies or pleurocentesis and met criteria for proven IPA. Overall ICU and day-90 mortality were, respectively, 58.4% and 75.2% (80.4% if invasive mechanical ventilation) without any significant improvement over time. By multivariable analysis adjusted on day-1 SOFA score and ventilation strategies, voriconazole use (HR 0.49, CI 95 0.34-0.73, p < 0.001) and an ICU admission after 2010 (HR 0.67, 0.45-0.99, p = 0.042) were associated with increased survival, whereas a diffuse radiologic pattern (HR 2.07, CI 95 1.33-3.24, p = 0.001) and delayed admission to the ICU (HR 1.51, CI 95 1.05-2.16, p = 0.026) were independently associated with increased mortality. Conclusions IPA is associated with high mortality rates in critically ill patients with acute respiratory failure. Routine voriconazole and prompt ICU admission are warranted., Author(s): Emmanuel Pardo [sup.1], Virginie Lemiale [sup.1], Djamel Mokart [sup.2], Annabelle Stoclin [sup.3], Anne-Sophie Moreau [sup.4], Lionel Kerhuel [sup.1], Laure Calvet [sup.1], Sandrine Valade [sup.1], Audrey De Jong [sup.1], Michael [...]

Purpose Data on the benefit or or harmful effects of oxygen level on ischemic reperfusion injuries in cardiac surgery are insufficient. We hypothesized that hyperoxia during cardiopulmonary bypass decreases the incidence of postoperative atrial fibrillation (POAF) and ventricular fibrillation, and therefore decreases cardiovascular morbidity (CARDIOX study). Methods An open-label, randomized clinical trial including adults undergoing elective cardiac surgery, i.e. cardiopulmonary bypass (CPB) randomized 1:1 to an intervention group or standard group at two French University Hospitals from June 2016 to October 2018. The intervention consisted in delivering of an inspired fraction of oxygen of one to one during CPB. The standard care consisted in delivering oxygen to achieve a partial arterial blood pressure less than 150 mmHg. The primary endpoint was the occurrence of POAF and/or ventricular tachycardia/ventricular fibrillation (VT/VF) within the 15 days following cardiac surgery. The secondary endpoint was the occurrence of major adverse cardiovascular events (MACCE: in-hospital mortality, stroke, cardiac arrest, acute kidney injury, and mesenteric ischemia). Results 330 patients were randomly assigned to either the intervention group (n = 161) or the standard group (n = 163). Mean PaO.sub.2 was 447 ± 98 mmHg and 161 ± 60 mmHg during CPB, for the intervention and standard group (p < 0.0001) respectively. The incidence of POAF or VT/VF were similar in the intervention group and the standard group (30% [49 of 161 patients] and 30% [49 of 163 patients], absolute risk reduction 0.4%; 95% CI, - 9.6-10.4; p = 0.94). MACCE was similar between groups with, an occurrence of 24% and 21% for the intervention group and the standard groups (absolute risk reduction 3.4%; 95% CI, - 5.7-12.5; p = 0.47) respectively. After adjustment, the primary and secondary endpoints remained similar for both groups. Conclusion Hyperoxia did not decrease POAF and cardiovascular morbidity following cardiac surgery with CPB. Clinicaltrial.gov identifier NCT02819739., Author(s): Osama Abou-Arab [sup.1] [sup.2], Pierre Huette [sup.1], Lucie Martineau [sup.1], Clémence Beauvalot [sup.3], Christophe Beyls [sup.1], Estelle Josse [sup.4], Gilles Touati [sup.5], Olivier Bouchot [sup.6], Belaïd Bouhemad [sup.3], Momar [...]

Purpose Mechanisms of circulatory failure are complex and frequently intricate in septic shock. Better characterization could help to optimize hemodynamic support. Methods Two published prospective databases from 12 different ICUs including echocardiographic monitoring performed by a transesophageal route at the initial phase of septic shock were merged for post hoc analysis. Hierarchical clustering in a principal components approach was used to define cardiovascular phenotypes using clinical and echocardiographic parameters. Missing data were imputed. Findings A total of 360 patients (median age 64 [55; 74]) were included in the analysis. Five different clusters were defined: patients well resuscitated (cluster 1, n = 61, 16.9%) without left ventricular (LV) systolic dysfunction, right ventricular (RV) failure or fluid responsiveness, patients with LV systolic dysfunction (cluster 2, n = 64, 17.7%), patients with hyperkinetic profile (cluster 3, n = 84, 23.3%), patients with RV failure (cluster 4, n = 81, 22.5%) and patients with persistent hypovolemia (cluster 5, n = 70, 19.4%). Day 7 mortality was 9.8%, 32.8%, 8.3%, 27.2%, and 23.2%, while ICU mortality was 21.3%, 50.0%, 23.8%, 42.0%, and 38.6% in clusters 1, 2, 3, 4, and 5, respectively (p < 0.001 for both). Conclusion Our clustering approach on a large population of septic shock patients, based on clinical and echocardiographic parameters, was able to characterize five different cardiovascular phenotypes. How this could help physicians to optimize hemodynamic support should be evaluated in the future., Author(s): Guillaume Geri [sup.1] [sup.2] [sup.3], Philippe Vignon [sup.4] [sup.5] [sup.6], Alix Aubry [sup.1] [sup.2], Anne-Laure Fedou [sup.4], Cyril Charron [sup.1], Stein Silva [sup.7], Xavier Repessé [sup.1], Antoine Vieillard-Baron [sup.1] [...]

Purpose Prognosis of solid organ transplant (SOT) recipients has improved, mainly because of better prevention of rejection by immunosuppressive therapies. However, SOT recipients are highly susceptible to conventional and opportunistic infections, which represent a major cause of morbidity, graft dysfunction and mortality. Methods Narrative review. Results We cover the current epidemiology and main aspects of infections in SOT recipients including risk factors such as postoperative risks and specific risks for different transplant recipients, key points on anti-infective prophylaxis as well as diagnostic and therapeutic approaches. We provide an up-to-date guide for management of the main syndromes that can be encountered in SOT recipients including acute respiratory failure, sepsis or septic shock, and central nervous system infections as well as bacterial infections with multidrug-resistant strains, invasive fungal diseases, viral infections and less common pathogens that may impact this patient population. Conclusion We provide state-of the art review of available knowledge of critically ill SOT patients with infections., Author(s): Jean-François Timsit [sup.1] [sup.2], Romain Sonneville [sup.3] [sup.4], Andre C. Kalil [sup.5], Matteo Bassetti [sup.6], Ricard Ferrer [sup.7], Samir Jaber [sup.8], Fanny Lanternier [sup.9] [sup.10], Charles-Edouard Luyt [sup.11] [sup.12], [...]

Author(s): Thomas Rimmelé [sup.1] [sup.2], Léa Pascal [sup.3] [sup.4], Stéphanie Polazzi [sup.3] [sup.4], Antoine Duclos [sup.3] [sup.4] Author Affiliations: (1) grid.412180.e, 0000 0001 2198 4166, Anesthesiology and Critical Care Medicine, [...]

Purpose Intensive care unit survivors suffer from prolonged impairment, reduced quality of life, and higher mortality rates after discharge compared to the general population. Socioeconomic status may play a partial but important role in mortality and recovery. Therefore, the detection of factors that are responsible for poor long-term outcomes would be beneficial in designing targeted interventions for at-risk populations. Methods For an endpoint analysis, 1834 intensive care unit patients with known French Deprivation Index (FDep) scores were included from the French and euRopean Outcome reGistry in Intensive Care Units (FROG-ICU) study, which was a prospective, observational, multicenter cohort study performed in 20 French intensive care units in 13 different hospitals. Socioeconomic status was defined by using the FDep score [represented as quintiles when referring to the general French population, as quintiles when referring to the FROG-ICU cohort, or as dichotomized data (which was defined as a FDep [less than or equal to] 0 for nondeprived patients)] and by using a detailed social questionnaire that was completed 3 months after discharge. The primary outcome included an all-cause, 1-year mortality after ICU discharge when regarding socioeconomic status. The secondary outcomes included both ICU and hospital lengths of stay, both short- and medium-term mortality, and the quality of life, as assessed during the 1-year follow-up by using the Medical Outcome Survey Short Form-36 (SF-36). The Revised Impact of Event Scale (IES-R) was used to evaluate the symptoms of post-traumatic stress disorder, and the Hospital Anxiety and Depression Scale (HADS) was used to screen for anxiety and depression. Results Of the 1447 patients who were discharged alive from the ICU, 19.2% died over the following year. No association was found between 1-year mortality and socioeconomic status, regardless of whether this association was analyzed in quintiles (p = 0.911 in the quintiles of the general French population; p = 0.589 in the quintiles of the FROG-ICU cohort itself) or as dichotomized data [nondeprived (n = 177; 1-year mortality of 18.2%) versus deprived (n = 97; 1-year mortality of 20.5%; p = 0.304)]. Moreover, no differences were found between the nondeprived and the deprived patients in the ICU and hospital lengths of stay, ICU mortalities, in-hospital mortalities, or 28-day mortalities. The SF-36 was below the score for the normal French population throughout the follow-up period. Socially deprived patients showed significantly lower median scores in the physical function subscale [55, interquartile range (IQR) (28.8-80) vs. 65, IQR (35-90); p = 0.014], the physical role subscale [25, IQR (0-75) vs. 33.3, IQR (0-100); p = 0.022], and the overall physical component scale [47.5, IQR (30-68.8) vs. 54.4, IQR (35-78.8); p = 0.010]. Up to 31.6% of survivors presented symptoms that indicated post-traumatic stress disorder, and up to 31.5% of survivors reported clinically meaningful symptoms of anxiety or depression. Conclusions A lower socioeconomic status was associated with lower self-reported physical component scores in the nondeprived patients. Psychiatric symptoms are frequently reported after an ICU stay, and subsequent interventions should target those fields. Trial registration ClinicalTrials.gov NCT01367093; registered on June 6, 2011., Author(s): Kathleen Bastian [sup.1] [sup.2] [sup.3], Alexa Hollinger [sup.1] [sup.2] [sup.3], Alexandre Mebazaa [sup.1] [sup.2] [sup.4], Elie Azoulay [sup.1] [sup.4], Elodie Féliot [sup.1], Karine Chevreul [sup.5] [sup.6], Marie-Céline Fournier [sup.1] [...]

Purpose To assess the relative importance of host and bacterial factors associated with hospital mortality in patients admitted to the intensive care unit (ICU) for pneumococcal community-acquired pneumonia (PCAP). Methods Immunocompetent Caucasian ICU patients with PCAP documented by cultures and/or pneumococcal urinary antigen (UAg Sp) test were included in this multicenter prospective study between 2008 and 2012. All pneumococcal strains were serotyped. Logistic regression analyses were performed to identify risk factors for hospital mortality. Results Of the 614 patients, 278 (45%) had septic shock, 270 (44%) had bacteremia, 307 (50%) required mechanical ventilation at admission, and 161 (26%) had a diagnosis based only on the UAg Sp test. No strains were penicillin-resistant, but 23% had decreased susceptibility. Of the 36 serotypes identified, 7 accounted for 72% of the isolates, with different distributions according to age. Although antibiotics were consistently appropriate and were started within 6 h after admission in 454 (74%) patients, 116 (18.9%) patients died. Independent predictors of hospital mortality in the adjusted analysis were platelets [less than or equal to] 100 x 10.sup.9/L (OR, 7.7; 95% CI, 2.8-21.1), McCabe score [greater than or equal to] 2 (4.58; 1.61-13), age > 65 years (2.92; 1.49-5.74), lactates > 4 mmol/L (2.41; 1.27-4.56), male gender and septic shock (2.23; 1.30-3.83 for each), invasive mechanical ventilation (1.78; 1-3.19), and bilateral pneumonia (1.59; 1.02-2.47). Women with platelets [less than or equal to] 100 x 10.sup.9/L had the highest mortality risk (adjusted OR, 7.7; 2.8-21). Conclusions In critically ill patients with PCAP, age, gender, and organ failures at ICU admission were more strongly associated with hospital mortality than were comorbidities. Neither pneumococcal serotype nor antibiotic regimen was associated with hospital mortality., Author(s): Jean-Pierre Bedos [sup.1], Emmanuelle Varon [sup.2] [sup.3], Raphael Porcher [sup.4], Pierre Asfar [sup.5], Yves Le Tulzo [sup.6], Bruno Megarbane [sup.7], Armelle Mathonnet [sup.8], Anthony Dugard [sup.9], Anne Veinstein [sup.10], [...]

Purpose Thrombocytopenia is a frequent and serious adverse event in patients treated with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for refractory cardiogenic shock. Similarly to postcardiac surgery patients, heparin-induced thrombocytopenia (HIT) could represent the causative underlying mechanism. However, the epidemiology as well as related mortality regarding HIT and VA-ECMO remains largely unknown. We aimed to define the prevalence and associated 90-day mortality of HIT diagnosed under VA-ECMO. Methods This retrospective study included patients under VA-ECMO from 20 French centers between 2012 and 2016. Selected patients were hospitalized for more than 3 days with high clinical suspicion of HIT and positive anti-PF4/heparin antibodies. Patients were classified according to results of functional tests as having either Confirmed or Excluded HIT. Results A total of 5797 patients under VA-ECMO were screened; 39/5797 met the inclusion criteria, with HIT confirmed in 21/5797 patients (0.36% [95% CI] [0.21-0.52]). Fourteen of 39 patients (35.9% [20.8-50.9]) with suspected HIT were ultimately excluded because of negative functional assays. Drug-induced thrombocytopenia tended to be more frequent in Excluded HIT at the time of HIT suspicion (p = 0.073). The platelet course was similar between Confirmed and Excluded HIT (p = 0.65). Mortality rate was 33.3% [13.2-53.5] in Confirmed and 50% [23.8-76.2] in Excluded HIT (p = 0.48). Conclusions Prevalence of HIT among patients under VA-ECMO is extremely low at 0.36% with an associated mortality rate of 33.3%, which appears to be in the same range as that observed in patients treated with VA-ECMO without HIT. In addition, HIT was ultimately ruled out in one-third of patients with clinical suspicion of HIT and positive anti-PF4/heparin antibodies., Author(s): Antoine Kimmoun [sup.1], Walid Oulehri [sup.2], Romain Sonneville [sup.3], Paul-Henri Grisot [sup.1], Elie Zogheib [sup.4], Julien Amour [sup.5], Nadia Aissaoui [sup.6], Bruno Megarbane [sup.7], Nicolas Mongardon [sup.8], Amelie Renou [...]

Purpose Data on purpura fulminans (PF) in adult patients are scarce and mainly limited to meningococcal infections. Our aim has been to report the clinical features and outcomes of adult patients admitted in the intensive care unit (ICU) for an infectious PF, as well as the predictive factors for limb amputation and mortality. Methods A 17-year national multicenter retrospective cohort study in 55 ICUs in France from 2000 to 2016, including adult patients admitted for an infectious PF defined by a sudden and extensive purpura, together with the need for vasopressor support. Primary outcome variables included hospital mortality and amputation during the follow-up period (time between ICU admission and amputation, death or end of follow-up). Results Among the 306 included patients, 126 (41.2%; 95% CI 35.6-46.9) died and 180 (58.8%; 95% CI 53.3-64.3) survived during the follow-up period [13 (3-24) days], including 51/180 patients (28.3%, 95% CI 21.9-35.5) who eventually required limb amputations, with a median number of 3 (1-4) limbs amputated. The two predominantly identified microorganisms were Neisseria meningitidis (63.7%) and Streptococcus pneumoniae (21.9%). By multivariable Cox model, SAPS II [hazard-ratio (HR) = 1.03 (1.02-1.04); p < 0.001], lower leucocytes [HR 0.83 (0.69-0.99); p = 0.034] and platelet counts [HR 0.77 (0.60-0.91); p = 0.007], and arterial blood lactate levels [HR 2.71 (1.68-4.38); p < 0.001] were independently associated with hospital death, while a neck stiffness [HR 0.51 (0.28-0.92); p = 0.026] was a protective factor. Infection with Streptococcus pneumoniae [sub-hazard ratio 1.89 (1.06-3.38); p = 0.032], together with arterial lactate levels and ICU admission temperature, was independently associated with amputation by a competing risks analysis. Conclusion Purpura fulminans carries a high mortality and morbidity. Pneumococcal PF leads to a higher risk of amputation. Trials registration NCT03216577., Author(s): Damien Contou [sup.1] [sup.2], Romain Sonneville [sup.3], Florence Canoui-Poitrine [sup.4] [sup.5], Gwenhaël Colin [sup.6], Rémi Coudroy [sup.7] [sup.8], Frédéric Pène [sup.9], Jean-Marc Tadié [sup.10], Martin Cour [sup.11], Gaëtan Béduneau [...]

Purpose Respiratory complications are the leading causes of morbidity and mortality after lung cancer surgery. We hypothesized that oropharyngeal and nasopharyngeal decontamination with chlorhexidine gluconate (CHG) would be an effective method to reduce these complications as reported in cardiac surgery. Methods In this multicenter parallel-group randomized double-blind placebo-controlled trial, we enrolled consecutive adults scheduled for anatomical pulmonary resection for lung cancer. Perioperative decontamination consisted in oropharyngeal rinse solution (0.12% CHG) and nasopharyngeal soap (4% CHG) or a placebo. The primary outcome measure was the proportion of patients requiring postoperative invasive and/or noninvasive mechanical ventilation (MV). Secondary outcome measures included occurrence of respiratory and non-respiratory healthcare-associated infections (HAIs) and outcomes within 90 days. Results Between July 2012 and April 2015, 474 patients were randomized. Of them, 24 had their surgical procedure cancelled or withdrew consent. The remaining 450 patients were included in a modified intention-to-treat analysis: 226 were allocated to CHG and 224 to the placebo. Proportions of patients requiring postoperative MV were not significantly different [CHG 14.2%; placebo 15.2%; relative risks (RRs) 0.93; 95% confidence interval (CI) 0.59-1.45; P = 0.76]. Neither of the proportions of patients with respiratory HAIs were different (CHG 13.7%; placebo 12.9%; RRs 1.06; 95% CI 0.66-1.69; P = 0.81). The CHG group had significantly decreased incidence of bacteremia, surgical-site infection and overall Staphylococcus aureus infections. However, there were no significant between-group differences for hospital stay length, change in tracheal microbiota, postoperative antibiotic utilization and outcomes by day 90. Conclusions CHG decontamination decreased neither MV requirements nor respiratory infections after lung cancer surgery. Additionally, CHG did not change tracheal microbiota or postoperative antibiotic utilization. Trial Registration This study is registered on ClinicalTrials.gov, number NCT01613365., Author(s): Xavier Benoit D'Journo [sup.1] [sup.6], Pierre-Emmanuel Falcoz [sup.2], Marco Alifano [sup.3], Jean-Philippe Le Rochais [sup.4], Thomas D'Annoville [sup.5], Gilbert Massard [sup.2], Jean Francois Regnard [sup.3], Philippe Icard [sup.4], Charles [...]

Purpose Acute kidney injury (AKI) is associated with the activation of the renin-angiotensin system. Whether angiotensin-converting enzyme inhibitors (ACEi) or angiotensin-receptor blockers (ARB) improve outcome in patients recovering from AKI remains unexplored. The purpose was to investigate the association between prescription of ACEi/ARB at intensive care unit (ICU) discharge and 1-year outcome in patients recovering from AKI. Methods Association between ACEi/ARB and 1-year mortality rate was explored in 1551 patients discharged from 21 European ICUs in an observational cohort. One-year all-cause mortality after ICU discharge was the primary endpoint. AKI was defined using the kidney disease improvement global outcome definition. Propensity score matching was used to consider the probability to receive ACEi/ARB at ICU discharge and included chronic heart failure, ACEi/ARB on ICU admission, Charlson Comorbidity Index, age, diabetes mellitus, chronic kidney disease, estimated glomerular filtration rate and arterial blood pressure at ICU discharge vasopressors and renal replacement therapy. Results Overall, 1-year mortality was 28 and 15% in patients with AKI (n = 611, 39%) and without AKI (n = 940), respectively. In patients with AKI, unadjusted, adjusted and propensity-score matched 1-year mortality rates were lower in patients treated with ACEi/ARB at ICU discharge [HR of 0.55 (0.35-0.89), HR of 0.45 (0.27-0.75), and HR of 0.48 (0.27-0.85, p < 0.001), respectively]. These results were consistent across sensitivity analysis. No association was observed in patients without AKI. Conclusions In patients discharged alive from the ICU after experiencing AKI, ACEi/ARB prescription at discharge is associated with a decrease in 1-year mortality. Trial registration ClinicalTrials.gov NCT01367093. Registered on 6 June 2011., Author(s): Etienne Gayat [sup.1] [sup.2] [sup.3], Alexa Hollinger [sup.1] [sup.2] [sup.4], Alain Cariou [sup.5], Nicolas Deye [sup.2] [sup.6], Antoine Vieillard-Baron [sup.7] [sup.8] [sup.9], Samir Jaber [sup.10], Benjamin G. Chousterman [sup.1], [...]

Purpose To compare the efficacy of an antibiotic protocol guided by serum procalcitonin (PCT) with that of standard antibiotic therapy in severe acute exacerbations of COPD (AECOPDs) admitted to the intensive care unit (ICU). Methods We conducted a multicenter, randomized trial in France. Patients experiencing severe AECOPDs were assigned to groups whose antibiotic therapy was guided by (1) a 5-day PCT algorithm with predefined cutoff values for the initiation or stoppage of antibiotics (PCT group) or (2) standard guidelines (control group). The primary endpoint was 3-month mortality. The predefined noninferiority margin was 12%. Results A total of 302 patients were randomized into the PCT (n = 151) and control (n = 151) groups. Thirty patients (20%) in the PCT group and 21 patients (14%) in the control group died within 3 months of admission (adjusted difference, 6.6%; 90% CI - 0.3 to 13.5%). Among patients without antibiotic therapy at baseline (n = 119), the use of PCT significantly increased 3-month mortality [19/61 (31%) vs. 7/58 (12%), p = 0.015]. The in-ICU and in-hospital antibiotic exposure durations, were similar between the PCT and control group (5.2 ± 6.5 days in the PCT group vs. 5.4 ± 4.4 days in the control group, p = 0.85 and 7.9 ± 8 days in the PCT group vs. 7.7 ± 5.7 days in the control group, p = 0.75, respectively). Conclusion The PCT group failed to demonstrate non-inferiority with respect to 3-month mortality and failed to reduce in-ICU and in-hospital antibiotic exposure in AECOPDs admitted to the ICU., Author(s): Cédric Daubin [sup.1], Xavier Valette [sup.1], Fabrice Thiollière [sup.2], Jean-Paul Mira [sup.3], Pascal Hazera [sup.4], Djillali Annane [sup.5] [sup.6], Vincent Labbe [sup.7], Bernard Floccard [sup.8], François Fournel [sup.9], Nicolas [...]

Purpose Identifying modifiable factors for sepsis-associated encephalopathy may help improve patient care and outcomes. Methods We conducted a retrospective analysis of a prospective multicenter database. Sepsis-associated encephalopathy (SAE) was defined by a score on the Glasgow coma scale (GCS) Results We included 2513 patients with sepsis at ICU admission, of whom 1341 (53%) had sepsis-associated encephalopathy. After adjusting for baseline characteristics, site of infection, and type of admission, the following factors remained independently associated with sepsis-associated encephalopathy: acute renal failure [adjusted odds ratio (aOR) = 1.41, 95% confidence interval (CI) 1.19-1.67], hypoglycemia 10 mmol/l (aOR = 1.37, 95% CI 1.09-1.72), hypercapnia >45 mmHg (aOR = 1.91, 95% CI 1.53-2.38), hypernatremia >145 mmol/l (aOR = 2.30, 95% CI 1.48-3.57), and S. aureus (aOR = 1.54, 95% CI 1.05-2.25). Sepsis-associated encephalopathy was associated with higher mortality, higher use of ICU resources, and longer hospital stay. After adjusting for age, comorbidities, year of admission, and non-neurological SOFA score, even mild alteration of mental status (i.e., a score on the GCS of 13-14) remained independently associated with mortality (adjusted hazard ratio = 1.38, 95% CI 1.09-1.76). Conclusions Acute renal failure and common metabolic disturbances represent potentially modifiable factors contributing to sepsis-associated encephalopathy. However, a true causal relationship has yet to be demonstrated. Our study confirms the prognostic significance of mild alteration of mental status in patients with sepsis., Author(s): Romain Sonneville [sup.1] [sup.2], Etienne de Montmollin [sup.3] [sup.4], Julien Poujade [sup.1], Maïté Garrouste-Orgeas [sup.3] [sup.5], Bertrand Souweine [sup.6], Michael Darmon [sup.8] [sup.9], Eric Mariotte [sup.7], Laurent Argaud [sup.10], [...]

Purpose In this era of rising antimicrobial resistance, slowly refilling antibiotic development pipelines, and an aging population, we need to ensure that randomized clinical trials (RCTs) determine the added benefit of new antibiotic agents effectively and in a valid way, especially for severely ill patients. Unfortunately, universally accepted endpoints for the evaluation of new drugs in severe infections are lacking. Methods We review and discuss the current practices and challenges regarding endpoints in RCTs in this field and propose novel approaches. Results Usual endpoints actually recommended for drug development suffer from important flaws. Mortality requires large sample size and only partly related to the infectious process. Clinical cure rate is highly subjective in critically ill patients where symptoms may be related to other intercurrent events. Currently, composite endpoints, hierarchical nested designs, and competing risks analysis seem to be the most promising new tools for designing and analyzing clinical trials in this area, although they require further validation. Conclusion Regulatory authorities, pharmaceutical companies, and clinicians need to agree on the most appropriate clinical endpoints for severe infections to ensure efficient approval of new, effective antibiotic agents., Author(s): Jean-François Timsit [sup.1] [sup.2], Marlieke E. A. de Kraker [sup.3], Harriet Sommer [sup.4], Emmanuel Weiss [sup.5] [sup.6], Esther Bettiol [sup.3], Martin Wolkewitz [sup.4], Stavros Nikolakopoulos [sup.7], David Wilson [sup.8], [...]

Purpose To assess the risk factors and outcomes associated with fungemia caused by the six most commonly occurring Candida species in patients with and without malignancies. Methods Analysis of the episodes of fungemia due to common Candida species in adults, based on an active hospital-based surveillance program (Paris area, France, 2002 to 2014). Results Of the 3417 patients (3666 isolates), 1164 (34.1%) had a solid tumor (45.7% digestive tract) and 586 (17.1%) a hematological malignancy (41.8% lymphoma, 33.5% acute leukemia). The hematology patients were significantly younger, more often pre-exposed to antifungals, more often infected by C. tropicalis, C. krusei, or C. kefyr, and more often treated in the first instance with an echinocandin. Compared with inpatients who were not in ICU at the time of fungemia, those in ICU were less frequently infected by C. parapsilosis (p < 0.02), had more recent surgery (p < 0.03), and died more frequently before day 8 and day 30 (p < 0.0001). An increase in crude mortality over time in ICU was observed only in oncology patients (p < 0.04). For all patients, lack of prescription of antifungals despite knowledge of positive blood culture increased the risk of death. The odds of being infected by a given Candida species compared with C. albicans were uneven regarding age, gender, type of malignancy, hospitalization in ICU, central venous catheter, HIV status, intravenous drug addiction, and previous exposure to antifungal drugs. Compared with C. albicans, C. glabrata (OR = 0.69 [0.54-0.89]) and C. parapsilosis (OR = 0.49 [0.35-0.67]) were associated with a decreased risk of death by day 8 and day 30. Conclusion The clinical context of underlying malignancy and hospitalization in ICU may be relevant to the initial management of candidemia., Author(s): Olivier Lortholary [sup.1] [sup.2], Charlotte Renaudat [sup.1], Karine Sitbon [sup.1], Marie Desnos-Ollivier [sup.1], Stéphane Bretagne [sup.1] [sup.3], Françoise Dromer [sup.1] Author Affiliations: (1) grid.428999.7, 0000 0001 2353 6535, Institut [...]

Purpose Phase angle as measured by bioelectrical impedance analysis reflects fat-free mass. Fat-free mass loss relates to worse prognosis in chronic diseases. Primary aim of this study was: to determine the association between fat-free mass at intensive care unit admission and 28-day mortality. Methods Ten centres in nine countries participated in this multicentre prospective observational study. The inclusion criteria were age >18 years; expected length of stay >48 h; absence of pacemaker, heart defibrillator implant, pregnancy and lactation. Fat-free mass was assessed by measurement of the 50-kHz phase angle at admission. The primary endpoint was 28-day mortality. The area under the receiver operating characteristic curve (AUC) was used to assess prediction of 28-day mortality by fat-free mass at ICU admission. The variables associated with 28-day mortality were analysed by means of multivariable logistic regression. Results Of the 3605 patients screened, 931 were analysed: age 61 ± 16 years, male 60 %, APACHE II 19 ± 9, body mass index 26 ± 6, day 1 phase angle 4.5° ± 1.9°. Day 1 phase angle was lower in patients who eventually died than in survivors (4.1° ± 2.0° vs. 4.6° ± 1.8°, P = 0.001). The day 1 phase angle AUC for 28-day mortality was 0.63 [0.58-0.67]. In multivariable analysis, the following were independently associated with 28-day mortality: age (adjusted odds ratio (aOR) 1.014 [95 % confidence interval 1.002-1.027], P = 0.03), day 1 phase angle (aOR 0.86 [0.78-0.96], P = 0.008), APACHE II (aOR 1.08 [1.06-1.11], P < 0.001), surgical patient (aOR 0.51 [0.33-0.79], P = 0.002), and admission for other diagnosis (aOR 0.39 [0.21-0.72], P = 0.003). A multivariable combined score improved the predictability of 28-day mortality: AUC = 0.79 [0.75-0.82]. Conclusion Low fat-free mass at ICU admission is associated with 28-day mortality. A combined score improves mortality predictability. Trial registration: NCT01907347 (http://www.clinicaltrials.gov)., Author(s): Ronan Thibault [sup.1] [sup.2], Anne-Marie Makhlouf [sup.1], Aurélien Mulliez [sup.3], M. Cristina Gonzalez [sup.4], Gintautas Kekstas [sup.5], Nada Rotovnik Kozjek [sup.6], Jean-Charles Preiser [sup.7], Isabel Ceniceros Rozalen [sup.8], Sylvain [...]

Purpose The best renal replacement therapy (RRT) modality remains controversial. We compared mortality and short- and long-term renal recovery between patients treated with continuous RRT and intermittent hemodialysis. Methods Patients of the prospective observational multicenter cohort database OUTCOMEREA[TM] were included if they underwent at least one RRT session between 2004 and 2014. Differences in patients' baseline and daily characteristics between treatment groups were taken into account by using a marginal structural Cox model, allowing one to substantially reduce the bias resulting from confounding factors in observational longitudinal data analysis. The composite primary endpoint was 30-day mortality and dialysis dependency. Results Among 1360 included patients with RRT, 544 (40.0 %) and 816 (60.0 %) were initially treated by continuous RRT and intermittent hemodialysis, respectively. At day 30, 39.6 % patients were dead. Among survivors, 23.8 % still required RRT. There was no difference between groups for the primary endpoint in global population (HR 1.00, 95 % CI 0.77-1.29; p = 0.97). In patients with higher weight gain at RRT initiation, mortality and dialysis dependency were significantly lower with continuous RRT (HR 0.54, 95 % CI 0.29-0.99; p = 0.05). Conversely, this technique appeared to be deleterious in patients without shock (HR 2.24, 95 % CI 1.24-4.04; p = 0.01). Six-month mortality and persistent renal dysfunction were not influenced by the RRT modality in patients with dialysis dependence at ICU discharge. Conclusion Continuous RRT did not appear to improve 30-day and 6-month patient outcomes. It seems beneficial for patients with fluid overload, but might be deleterious in the absence of hemodynamic failure., Author(s): Anne-Sophie Truche [sup.1] [sup.2] [sup.3], Michael Darmon [sup.4] [sup.5], Sébastien Bailly [sup.1] [sup.6], Christophe Clec'h [sup.1] [sup.7] [sup.8], Claire Dupuis [sup.1] [sup.9], Benoit Misset [sup.10] [sup.11], Elie Azoulay [sup.12] [...]

Purpose Although rapid response systems are known to reduce in-hospital cardiac arrest rate, their effect on mortality remains debated. The present study aimed to evaluate the effect of implementing an intensivist-led rapid response team (RRT) on mortality in hospitalized patients. Methods An implementation of an intervention and a comparison with retrospective data analysis were performed in the four hospitals of Montpellier regional healthcare centre, in France. An intensivist-led RRT was implemented on a 24/7 basis along with educational modules, publicity and bedside simulation-based training in only one of the four hospitals from January 2012 to June 2012. A single activation criterion (heart rate below 40/min or above 140/min, systolic blood pressure below 80 mmHg, cardiac arrest, respiratory rate below 8/min or above 30/min, pulse oximetry below 90 % with O.sub.2 above 6 l/min, respiratory distress in a tracheotomised patient, respiratory arrest, coma or sudden change in level of consciousness, seizure) allowed any caregiver to directly contact the RRT using a dedicated cell phone number. Patients over 18 years admitted for more than 24 h in the medical-surgical wards from July 2010 to December 2011 (pre-RRT period) and from July 2012 to December 2013 (RRT period) were included. The main outcome was unexpected mortality. Analyses of data from one RRT hospital and three control hospitals (no RRT hospital) were performed. Results RRT implementation was associated with a decrease in unexpected mortality rate in the hospital that implemented RRT (from 21.9 to 17.4 per 1000 discharges; p = 0.002). Reduction in unexpected mortality associated with RRT implementation could be estimated at 1.5 lives saved per week in the RRT hospital. In the three other hospitals, mortality rate was not significantly modified (from 19.5 to 19.9 per 1000 discharges; p = 0.69). Overall mortality decreased from 39.6 to 34.6 per 1000 discharges between the pre-RRT and RRT period in the RRT hospital (p = 0.012), but did not significantly change in the other hospitals. Patients in the RRT hospital were more frequently admitted to the intensive care unit (ICU) during the RRT period (45.8 vs 52.9 per 1000; p = 0.002), and their sequential organ failure assessment (SOFA) score upon ICU admission significantly decreased from 7 (4-10) to 5 (2-9); p < 0.001. Conclusions In the present retrospective study, implementation of an intensivist-led RRT along with educational modules, publicity and bedside simulation-based training was associated with a significant decrease in unexpected and overall mortality of inpatients., Author(s): Boris Jung [sup.1] [sup.2], Aurelien Daurat [sup.1], Audrey De Jong [sup.1] [sup.2], Gerald Chanques [sup.1] [sup.2], Martin Mahul [sup.1], Marion Monnin [sup.1], Nicolas Molinari [sup.3], Samir Jaber [sup.1] [sup.2] [...]

Purpose This study was designed to identify factors associated with in-intensive care unit (ICU) death and develop a practical mortality risk score for venoarterial-extracorporeal membrane oxygenation (VA-ECMO)-treated acute myocardial infarction (AMI) patients. Long-term survivors' health-related quality of life (HRQOL), anxiety, depression, and post-traumatic stress disorder (PTSD) frequencies were also assessed. Methods Data from 138 ECMO-treated AMI patients admitted to two French ICUs (2008-2013) were analyzed. ICU survivors contacted >6 months post-ICU discharge were assessed for HRQOL, psychological and PTSD status. Results Sixty-five patients (47 %) survived to ICU discharge. On the basis of multivariable logistic regression analyses, the ENCOURAGE score was constructed with seven pre-ECMO parameters: age >60, female sex, body mass index >25 kg/m.sup.2, Glasgow coma score 150 [mu]mol/L, lactate (8 mmol/L), and prothrombin activity Conclusions The ENCOURAGE score might be a useful tool to predict mortality of severe cardiogenic shock AMI patients who received VA-ECMO. However, it now needs prospective validation on other populations of AMI patients., Author(s): Grégoire Muller [sup.1], Erwan Flecher [sup.3], Guillaume Lebreton [sup.2], Charles-Edouard Luyt [sup.1], Jean-Louis Trouillet [sup.1], Nicolas Bréchot [sup.1], Matthieu Schmidt [sup.1], Ciro Mastroianni [sup.2], Jean Chastre [sup.1], Pascal Leprince [...]

Purpose Over the last two decades, noninvasive ventilation (NIV) has been proposed in various causes of acute respiratory failure (ARF) but some indications are debated. Current trends in NIV use are unknown. Methods Comparison of three multicenter prospective audits including all patients receiving mechanical ventilation and conducted in 1997, 2002, and 2011 in francophone countries. Results Among the 4132 patients enrolled, 2094 (51 %) required ventilatory support for ARF and 2038 (49 %) for non-respiratory conditions. Overall NIV use was markedly increased in 2010/11 compared to 1997 and 2002 (37 % of mechanically ventilated patients vs. 16 % and 28 %, P < 0.05). In 2010/11, the use of first-line NIV for ARF had reached a plateau (24 % vs. 16 % and 23 %, P < 0.05) whereas pre-ICU and post-extubation NIV had substantially increased (11 % vs. 4 % and 11 % vs. 7 %, respectively, P < 0.05). First-line NIV remained stable in acute-on-chronic RF, continued to increase in cardiogenic pulmonary edema, but decreased in de novo ARF (16 % in 2010/11 vs. 23 % in 2002, P < 0.05). The NIV success rate increased from 56 % in 2002 to 70 % in 2010/11 and remained the lowest in de novo ARF. NIV failure in de novo ARF was associated with increased mortality in 2002 but not in 2010/11. Mortality decreased over time, and overall, NIV use was associated with a lower mortality. Conclusion Increases in NIV use and success rate, an overall decrease in mortality, and a decrease of the adverse impact NIV failure has in de novo ARF suggest better patient selection and greater proficiency of staff in administering NIV. Trial registration Clinicaltrials.gov Identifier NCT01449331., Author(s): Alexandre Demoule [sup.1] [sup.2], Sylvie Chevret [sup.3], Annalisa Carlucci [sup.4], Achille Kouatchet [sup.5], Samir Jaber [sup.6], Ferhat Meziani [sup.7], Matthieu Schmidt [sup.1] [sup.2], David Schnell [sup.8], Céline Clergue [sup.9], [...]

Purpose Systemic antifungal therapy (SAT) of invasive candidiasis needs to be initiated immediately upon clinical suspicion. Controversies exist about adequate time and potential harm of antifungal de-escalation (DE) in documented and suspected candidiasis in ICU patients. Our objective was to investigate whether de-escalation within 5 days of antifungal initiation is associated with an increase of the 28-day mortality in SAT-treated non-neutropenic adult ICU patients. Methods From the 835 non-neutropenic adults recruited in the multicenter prospective observational AmarCAND2 study, we selected the patients receiving systemic antifungal therapy for a documented or suspected invasive candidiasis in the ICU and who were still alive 5 days after SAT initiation. They were included into two groups according to the occurrence of observed SAT de-escalation before day 6. The average causal SAT de-escalation effect on 28-day mortality was evaluated by using a double robust estimation. Results Among the 647 included patients, early de-escalation at day 5 after antifungal initiation occurred in 142 patients (22 %), including 48 (34 %) patients whose SAT was stopped before day 6. After adjustment for the baseline confounders, early SAT de-escalation was the solely factor not associated with increased 28-day mortality (RR 1.12, 95 % CI 0.76-1.66). Conclusion In non-neutropenic critically ill adult patients with documented or suspected invasive candidiasis, SAT de-escalation within 5 days was not related to increased day-28 mortality but it was associated with decreased SAT consumption. These results suggest for the first time that SAT de-escalation may be safe in these patients., Author(s): Sébastien Bailly [sup.1] [sup.2], Olivier Leroy [sup.3], Philippe Montravers [sup.4], Jean-Michel Constantin [sup.5], Hervé Dupont [sup.6], Didier Guillemot [sup.7], Olivier Lortholary [sup.8] [sup.9], Jean-Paul Mira [sup.10] [sup.11], Pierre-François Perrigault [...]

Purpose To assess the prevalence of decisions to forgo life-sustaining treatment (DFLST), the patients characteristics, and to estimate the impact of DFLST stages on mortality. Methods Observational study of a prospective database between 2005 and 2012 from 13 ICUs. DFLST were defined as follows: no escalation of treatment (stage 1), not to start or escalate treatment even if such treatment is considered in the future; withholding (stage 2), not to start or escalate necessary treatment; withdrawal (stage 3), to stop necessary treatment. The impact of daily DFLST stage on day-30 hospital mortality was tested with a discrete-time Cox's model and adjusted for admission severity and daily SOFA score. Results Of 10,080 patients, 1290 (13 %) made DFLST. The highest DFLST stage during the ICU stay was no escalation of treatment in 339 (26 %) patients, withholding in 502 (39 %) patients, and withdrawal in 449 (35 %) patients. Older patients, patients with at least one chronic disease, and patients with greater ICU severity were significantly more numerous in the DFLST group. Day-30 mortality was 13 % for non-DFLST patients, 35 % for no escalation of treatment, 75 % for withholding, 93 % for withdrawal. After adjustment, an increase in day-30 mortality was associated with withholding and withdrawal (hazard ratio 95 % CI 5.93 [4.95-7.12] and 20.05 [15.58-25.79], P < 0.0001), but not with no escalation of treatment (HR 1.14 [0.91-1.44], P = 0.25). Conclusions DFLST were made in 13 % of ICU patients. Withholding, withdrawal, older age, more comorbidities, and higher severity of illness were associated with higher mortality. No escalation of treatment was not associated with increased mortality., Author(s): Alexandre Lautrette [sup.1] [sup.2], Maïté Garrouste-Orgeas [sup.3], Pierre-Marie Bertrand [sup.1], Dany Goldgran-Toledano [sup.4], Samir Jamali [sup.5], Virginie Laurent [sup.6], Laurent Argaud [sup.7], Carole Schwebel [sup.8], Bruno Mourvillier [sup.9], Michaël [...]

Purpose We previously showed that external cooling decreases day 14 mortality in febrile septic shock. Because cooling may participate in heart rate control, we studied the respective impact of heart rate and temperature lowering on mortality. Methods Post hoc analysis of the Sepsiscool randomized controlled trial database (NCT00527007). Cooling was applied to maintain normothermia (36.5-37 °C) during 48 h. We assessed the time spent below different thresholds of temperature and heart rate on day 14 mortality. The best threshold was selected by AUC-ROC and tested as a potential mediator of mortality reduction. Mediation analysis was adjusted for severity and treatments influencing temperature and heart rate evolution. Sensitivity analysis was done using only patients with appropriate antimicrobial therapy. Results A total of 197/200 patients with adequate heart rate and temperature monitoring were analyzed. The best threshold differentiating survivors and nonsurvivors was 38.4 °C for temperature and 95 b/min for heart rate. During the 48 h of intervention, cooling significantly increased the time spent with a temperature below 38.4 °C, p = 0.001, and with a heart rate below 95 b/min, p < 0.01. The longer was the time spent with a temperature below 38.4 °C, the lower was the mortality [adjOR 0.17 (0.06-0.49), p = 0.001]. The time spent with a heart rate below 95 b/min was similar in survivors and nonsurvivors [adjOR 0.68 (0.27-1.72), p = 0.42]. Mediation analysis showed that the time spent with a temperature below 38.4 °C was a significant mediator of mortality. Conclusion The time spent with a temperature below 38.4 °C was independently associated with patient's outcome and explained 73 % of the effect of the randomization on the day 14 mortality. Heart rate lowering was not a mediator of mortality., Author(s): Frédérique Schortgen [sup.1], Anaïs Charles-Nelson [sup.2] [sup.7], Lila Bouadma [sup.3], Geoffray Bizouard [sup.4], Laurent Brochard [sup.5] [sup.6], Sandrine Katsahian [sup.2] [sup.7] Author Affiliations: (1) grid.412116.1, 0000000122921474, Réanimation médicale, Hôpital [...]

Purpose Characteristics of acute kidney injury (AKI) occurring after out-of-hospital cardiac arrest (OHCA) are incompletely described. We aimed to evaluate the prevalence of AKI, identifying risk factors and assessing the impact of AKI on outcome after OHCA. Methods Single-center study between 2007 and 2012 in a cardiac arrest center in Paris, France. All consecutive OHCA patients with at least one weight measurement and one serum creatinine level available and treated by therapeutic hypothermia were included, except those with chronic kidney disease and those dead on arrival. AKI was defined as stage 3 of the Acute Kidney Injury Network (AKIN) classification. Main outcome was day-30 mortality. Factors associated with AKI occurrence and day-30 mortality were evaluated by logistic regression. Results 580 patients (71.3 % male, median age 59.3 years, initial shockable rhythm in 56.9 % of cases) were included in the analysis. AKI stage 3 occurred in 280 (48.3 %) patients. Age, male gender, resuscitation duration, post-resuscitation shock, public setting, and initial rhythm were associated with AKI stage 3. AKI stage 3 was associated with a significantly higher day-30 mortality rate [OR 1.60; 95 % CI (1.05, 2.43); p = 0.03]. No independent association between AKI and neurologic outcome was observed. At day 30, 67 patients had a normal kidney function (eGFR >75 mL/min/1.73 m.sup.2), and five remained dialysis-dependent. Patients with eGFR higher than 75 mL/min/1.73 m.sup.2 at day 30 were younger and more frequently male. Conclusion AKI stage 3 was frequent after OHCA and was associated with poorer outcome. Improvement strategies in post-resuscitation care should consider AKI as a potential target of treatment., Author(s): Guillaume Geri [sup.1] [sup.3] [sup.4], Lucie Guillemet [sup.1], Florence Dumas [sup.2] [sup.3] [sup.4], Julien Charpentier [sup.1], Marion Antona [sup.5], Virginie Lemiale [sup.6], Wulfran Bougouin [sup.1] [sup.3] [sup.4], Lionel Lamhaut [...]

Purpose Cervical necrotizing fasciitis (CNF) is a severe and debilitating disease that requires intensive care unit (ICU) management and prompt surgical treatment to reduce morbidity and mortality. The aim of this study was to estimate the incidence and factors associated with severe complications of CNF. Methods We reviewed the medical records of consecutive patients hospitalized in an ICU from 2007 to 2012. The data were collected retrospectively; initial cervical and thoracic computed tomography (CT) scans, performed on admission, were reviewed by an experienced and blinded radiologist to determine CNF complications. Results A cohort of 160 patients admitted for CNF was included. The following complications of CNF were found: bilateral extension of CNF (28 %), internal jugular vein thrombosis (21 %), descending necrotic effusion (14 %), mediastinitis (24 %), and mortality (4 %); 53 % had at least one complication, and 48 % had at least one cervical complication. On the basis of a univariate analysis, the significant independent factors are odynophagia, dyspnea, oral glucocorticoids intake before admission, and pharyngeal source. Oral nonsteroidal anti-inflammatory drug intake before admission does not have any impact. The initial CNF complications increased both the duration of mechanical ventilation and the length of stay in the ICU. On the basis of a multivariate analysis, the independent factors for severe complications are pharyngeal CNF and oral glucocorticoid intake before admission. Conclusions Our study demonstrated that an initial cervico-thoracic CT scan revealed a high incidence of cervical and mediastinal CNF complications that all needed immediate management. Those severe complications might be avoidable as they were associated, at least partially, with prehospital oral glucocorticoid intake., Author(s): Hélène Nougué [sup.1], Anne-Laure Le Maho [sup.1], Mourad Boudiaf [sup.2], Jean-Philippe Blancal [sup.3], Etienne Gayat [sup.1], Mathieu Le Dorze [sup.1], Fabrice Vallée [sup.1], Benjamin Verillaud [sup.3], Joaquim Mateo [sup.1], [...]

Purpose To assess the evolution of patient deep colonization by Candida spp. in a surgical ICU over an 8-year period. Methods This retrospective, observational study included all patients hospitalized for more than 2 days in a surgical and trauma ICU of a university hospital, from 2005 to 2012. Mycological samples were monitored weekly from five sites (oropharyngeal, rectal, gastric, tracheal and urinary). Preemptive fluconazole therapy was started in patients highly colonized with Candida albicans. The evolution in Candida spp. involved in the deep colonization sites distribution over the study period (main outcome measure, trend chi-square and time-series analysis), antifungal consumption, ICU-acquired candidemia and mortality were determined. Results Among the 3029 patients with ICU stay >48 h, 2651 had at least one set of mycological sampling. Thirty percent of the 31,171 samples were positive to Candida spp. Caspofungin consumption increased over the years, whereas fluconazole consumption decreased. No trend in C. albicans colonization was observed, after adjusting on colonization risk-factors. A significant increase of acquired C. glabrata colonization was observed, whereas the clearing of C. parapsilosis colonization significantly decreased. No significant shift of colonization to other Candida spp. and mortality was observed. Conclusions Preemptive strategy of antifungal drug prescriptions in highly colonized ICU patients induced an increase in C. glabrata colonization without significant shift of colonization to other Candida spp. in surgical ICU patients. However, the potential detrimental impact of fluconazole on Candida ecology in ICU and/or on Candida susceptibility to antifungal drugs should be considered, and deserves further studies., Author(s): David Ferreira [sup.1], Frederic Grenouillet [sup.2] [sup.3], Gilles Blasco [sup.1], Emmanuel Samain [sup.1] [sup.4], Thierry Hénon [sup.5], Alain Dussaucy [sup.6], Laurence Millon [sup.2] [sup.3], Mariette Mercier [sup.7] [sup.8], Sebastien [...]

Background In the intensive care unit (ICU), the outcomes of patients with acute mesenteric ischemia (AMI) are poorly documented. This study aimed to determine the risk factors for death in ICU patients with AMI. Methods A retrospective, observational, non-interventional, multicenter study was conducted in 43 ICUs of 38 public institutions in France. From January 2008 to December 2013, all adult patients with a diagnosis of AMI during their hospitalization in ICU were included in a database. The diagnosis was confirmed by at least one of three procedures (computed tomography scan, gastrointestinal endoscopy, or upon surgery). To determine factors associated with ICU death, we established a logistic regression model. Recursive partitioning analysis was applied to construct a decision tree regarding risk factors and their interactions most critical to determining outcomes. Results The death rate of the 780 included patients was 58 %. Being older, having a higher sequential organ failure assessment (SOFA) severity score at diagnosis, and a plasma lactate concentration over 2.7 mmol/l at diagnosis were independent risk factors of ICU mortality. In contrast, having a prior history of peripheral vascular disease or an initial surgical treatment were independent protective factors against ICU mortality. Using age and SOFA severity score, we established an ICU mortality score at diagnosis based on the cutoffs provided by recursive partitioning analysis. Probability of survival was statistically different (p < 0.001) between patients with a score from 0 to 2 and those with a score of 3 and 4. Conclusion Acute mesenteric ischemia in ICU patients was associated with a 58 % ICU death rate. Age and SOFA severity score at diagnosis were risk factors for mortality. Plasma lactate concentration over 2.7 mmol/l was also an independent risk factor, but values in the normal range did not exclude the diagnosis of AMI., Author(s): Marc Leone [sup.6], Carole Bechis [sup.6], Karine Baumstarck [sup.7], Alexandre Ouattara [sup.8], Olivier Collange [sup.9], Pascal Augustin [sup.10], Djillali Annane [sup.11] [sup.12], Charlotte Arbelot [sup.13], Karim Asehnoune [sup.14], Olivier [...]

Purpose Skin mottling is frequent and can be associated with an increased mortality rate in ICU patients with septic shock. Its overall incidence in ICU and its impact on outcome is unknown. We aimed to assess the incidence of skin mottling over the knee among all critically ill patients admitted in ICU and its role on their outcome. Methods An observational study over a 1-year period in a 15-bed medical ICU of a teaching hospital. Skin mottling over the knee was prospectively and qualitatively assessed by trained nurses. Results Incidence of skin mottling was 29% (230 of 791 patients) in overall, and 49% (32 of 65 patients) in the subset of patients admitted for septic shock. Skin mottling was present on the day on admission in 65% of patients and persisted more than 6 h in 59% of cases. In-ICU mortality was 8% in patients without mottling, 30% in patients with short skin mottling and 40% in patients with persistent skin mottling (p < 0.01 between all groups). In the overall population, skin mottling over the knee was associated with in-ICU mortality independently from SAPS II (aOR 3.29 [95% CI, 2.08-5.19], p < 0.0001). Among patients with skin mottling over the knee, persistence of skin mottling remained associated with increased in-ICU mortality independently of organ dysfunctions at the mottling onset (OR 2.77 [95% CI, 1.34-5.72], p = 0.004). Conclusions Skin mottling is frequent in the general population of patients admitted in ICU. Occurrence and persistence of skin mottling are independently associated with in-ICU mortality., Author(s): Rémi Coudroy [sup.1] [sup.2], Angéline Jamet [sup.1], Jean-Pierre Frat [sup.1] [sup.3], Anne Veinstein [sup.1], Delphine Chatellier [sup.1], Véronique Goudet [sup.1], Severin Cabasson [sup.1], Arnaud W. Thille [sup.1] [sup.3], René [...]

Patients with psychiatric disorders who were hospitalized for COVID-19 experienced higher mortality rates, but not due to their underlying psychiatric disorders, study results show. The study, led by Nicolas Hoertel, [...]

Author(s): José-Artur Paiva [sup.1] [sup.2], Pierre-Emmanuel Charles [sup.3] Author Affiliations: (1) 0000 0001 1503 7226, grid.5808.5, Department of Emergency and Intensive Care, Centro Hospitalar São Joao, Faculdade de Medicina, Universidade [...]

Introduction Although the recent literature contains plenty of studies concerning all aspects of infective endocarditis (IE), very few focus on severe IE requiring admission to the ICU. Results In 2004, we published a report on the clinical spectrum and prognostic factors in 228 consecutive critically ill patients with IE. Septic shock, neurological complications and immunocompromised state were independently associated with in-hospital mortality. Cardiac surgery during the acute phase of EI was associated with better survival. A lot of information has been accumulated during the past 10 years on management of IE. Although three sets of blood cultures allow the identification of about 90 % of cases, culture-negative IE still remains a diagnostic challenge. Blood-polymerase chain reaction in valve tissue may yield a microbiologic diagnosis. New imaging techniques such as positron emission tomography computed tomography (PET-CT) have shown additive value in patients with an intracardiac device or valvular prosthesis. Systematic cerebral magnetic resonance imaging can lead to modification of therapeutic plans. The decision to operate and the timing of cardiac surgery should take into account the presence of congestive heart failure, neurological complications, renal failure and multiorgan dysfunction syndrome. In 2011 and 2013, we published the results of a multicentre prospective observational study of 198 ICU patients with left-sided IE and confirmed that cardiac surgery was associated with better outcome. The strongest independent predictor of post-operative mortality was the pre-operative multiorgan failure score. Neurological failure also represented a major determinant of mortality, regardless of the mechanism of neurological complication. Conclusion In the present paper, we propose algorithms to optimize the medico-surgical approach., Author(s): Michel Wolff [sup.1] [sup.2], Bruno Mourvillier [sup.1] [sup.2], Romain Sonneville [sup.1] [sup.2], Jean-François Timsit [sup.1] [sup.2] [sup.3] Author Affiliations: (1) grid.50550.35, 0000000121754109, Service de Réanimation, Medical Intensive Care Unit, [...]

Background In patients with severe sepsis, no randomized clinical trial has tested the concept of de-escalation of empirical antimicrobial therapy. This study aimed to compare the de-escalation strategy with the continuation of an appropriate empirical treatment in those patients. Methods This was a multicenter non-blinded randomized noninferiority trial of patients with severe sepsis who were randomly assigned to de-escalation or continuation of empirical antimicrobial treatment. Recruitment began in February 2012 and ended in April 2013 in nine intensive care units (ICUs) in France. Patients with severe sepsis were assigned to de-escalation (n = 59) or continuation of empirical antimicrobial treatment (n = 57). The primary outcome was to measure the duration of ICU stay. We defined a noninferiority margin of 2 days. If the lower boundary of the 95 % confidence interval (CI) for the difference in patients assigned to the de-escalation group was less than 2 days, as compared with that of patients assigned to the continuation group, de-escalation was considered to be noninferior to the continuation strategy. Secondary outcomes included mortality at 90 days, occurrence of organ failure, number of superinfections, and number of days with antibiotics during the ICU stay. Results The median duration of ICU stay was 9 [interquartile range (IQR) 5-22] days in the de-escalation group and 8 [IQR 4-15] days in the continuation group, respectively (P = 0.71). The mean difference was 3.4 (95 % CI -1.7 to 8.5). A superinfection occurred in 16 (27 %) patients in the de-escalation group and six (11 %) patients in the continuation group (P = 0.03). The numbers of antibiotic days were 9 [7-15] and 7.5 [6-13] in the de-escalation group and continuation group, respectively (P = 0.03). Mortality was similar in both groups. Conclusion As compared to the continuation of the empirical antimicrobial treatment, a strategy based on de-escalation of antibiotics resulted in prolonged duration of ICU stay. However, it did not affect the mortality rate., Author(s): Marc Leone [sup.1] [sup.2], Carole Bechis [sup.1], Karine Baumstarck [sup.3], Jean-Yves Lefrant [sup.4], Jacques Albanèse [sup.5], Samir Jaber [sup.6], Alain Lepape [sup.7], Jean-Michel Constantin [sup.8], Laurent Papazian [sup.2] [sup.9], [...]

Background During septic shock management, the evaluation of microvascular perfusion by skin analysis is of interest. We aimed to study the skin capillary refill time (CRT) in a selected septic shock population. Methods We conducted a prospective observational study in a tertiary teaching hospital. After a preliminary study to calculate CRT reproducibility, all consecutive patients with septic shock during a 10-month period were included. After initial resuscitation at 6 h (H6), we recorded hemodynamic parameters and analyzed their predictive value on 14-day mortality. CRT was measured on the index finger tip and on the knee area. Results CRT was highly reproducible with an excellent inter-rater concordance calculated at 80 % [73-86] for index CRT and 95 % [93-98] for knee CRT. A total of 59 patients were included, SOFA score was 10 [7-14], SAPS II was 61 [50-78] and 14-day mortality rate was 36 %. CRT measured at both sites was significantly higher in non-survivors compared to survivors (respectively 5.6 ± 3.5 vs 2.3 ± 1.8 s, P < 0.0001 for index CRT and 7.6 ± 4.6 vs 2.9 ± 1.7 s, P < 0.0001 for knee CRT). The CRT at H6 was strongly predictive of 14-day mortality as the area under the curve was 84 % [75-94] for the index measurement and was 90 % [83-98] for the knee area. A threshold of index CRT at 2.4 s predicted 14-day outcome with a sensitivity of 82 % (95 % CI [60-95]) and a specificity of 73 % (95 % CI [56-86]). A threshold of knee CRT at 4.9 s predicted 14-day outcome with a sensitivity of 82 % (95 % CI [60-95]) and a specificity of 84 % (95 % CI [68-94]). CRT was significantly related to tissue perfusion parameters such as arterial lactate level and SOFA score. Finally, CRT changes during shock resuscitation were significantly associated with prognosis. Conclusion CRT is a clinical reproducible parameter when measured on the index finger tip or the knee area. After initial resuscitation of septic shock, CRT is a strong predictive factor of 14-day mortality., Author(s): H. Ait-Oufella [sup.1] [sup.2] [sup.4], N. Bige [sup.1], P. Y. Boelle [sup.3] [sup.4] [sup.5], C. Pichereau [sup.1] [sup.4], M. Alves [sup.1] [sup.4], R. Bertinchamp [sup.1], J. L. Baudel [sup.1], [...]

Purpose Noninvasive ventilation (NIV) had proven benefits in clinical trials that included selected patients admitted to highly skilled centers. Whether these benefits apply to every patient and in everyday practice deserves appraisal. The aim of the study was to assess the use and outcomes of NIV over the last 15 years. Methods Multicenter database study of critically ill patients who required ventilatory support for acute respiratory failure between 1997 and 2011. The impact of first-line NIV on 60-day mortality was evaluated using a marginal structural model. Follow-up was censored on day 60. Results Of 3,163 patients, 1,232 (39 %) received NIV. Over the study period, first-line NIV increased from 29 to 42 %, and NIV success rates increased from 69 to 84 %. NIV decreased 60-day mortality [adjusted hazard ratio (aHR), 0.75; 95 % confidence interval (95 % CI), 0.68-0.83; P < 0.0001]. This protective effect was observed in patients with acute-on-chronic respiratory failure (aHR, 0.71; 95 % CI, 0.57-0.90; P = 0.004), but not in patients with cardiogenic pulmonary edema (aHR, 0.85; 95 % CI, 0.70-1.03; P = 0.10) or in patients with hypoxemic ARF, either immunocompetent (aHR, 1.18; 95 % CI, 0.87-1.59; P = 0.30) or immunocompromised (aHR, 0.89; 95 % CI, 0.70-1.13; P = 0.35). NIV failure was an independent time-dependent risk factor for mortality (aHR, 4.2; 95 % CI, 2.8-6.2; P < 0.0001). Conclusions The use of NIV increased steadily over the study period. First-line NIV was associated with better 60-day survival and fewer ICU-acquired infections compared to first-line intubation. Survival benefits from NIV occurred only in patients with acute-on-chronic respiratory failure and immunocompromised patients., Author(s): David Schnell [sup.1] [sup.2], Jean-François Timsit [sup.3] [sup.4], Michael Darmon [sup.5] [sup.6], Aurélien Vesin [sup.4], Dany Goldgran-Toledano [sup.7], Anne-Sylvie Dumenil [sup.8], Maite Garrouste-Orgeas [sup.4] [sup.9], Christophe Adrie [sup.10], Lila [...]

Objectives To investigate whether prophylactic postoperative NIV prevents respiratory complications following lung resection surgery in COPD patients. Methods In seven thoracic surgery departments, 360 COPD patients undergoing lung resection surgery were randomly assigned to two groups: conventional postoperative treatment without (n = 179) or with (n = 181) prophylactic NIV, applied intermittently during 6 h per day for 48 h following surgery. The primary endpoint was the rate of acute respiratory events (ARE) at 30 days postoperatively (ITT analysis). Secondary endpoints were acute respiratory failure (ARF), intubation rate, mortality rate, infectious and non-infectious complications, and duration of ICU and hospital stay. Measurements and main results ARE rates did not differ between the prophylactic NIV and control groups (57/181, 31.5 vs. 55/179, 30.7 %, p = 0.93). ARF rate was 18.8 % in the prophylactic NIV group and 24.5 % in controls (p = 0.20). Re-intubation rates were similar in the prophylactic NIV and control group [10/181 (5.5 %) and 13/179 (7.2 %), respectively, p = 0.53]. Mortality rates were 5 and 2.2 % in the control and prophylactic NIV groups, respectively (p = 0.16). Infectious and non-infectious complication rates, and duration of ICU and hospital stays were similar between groups. Conclusions Prophylactic postoperative NIV did not reduce the rate of ARE in COPD patients undergoing lung resection surgery and did not influence other postoperative complications rates, mortality rates, and duration of ICU and hospital stay., Author(s): Christine Lorut [sup.1], Aurélie Lefebvre [sup.1], Benjamin Planquette [sup.4], Laurent Quinquis [sup.3], Hervé Clavier [sup.6], Nicola Santelmo [sup.8], Halim Abou Hanna [sup.9], François Bellenot [sup.10], Jean-François Regnard [sup.2], Marc [...]

Purpose The blood glucose target range and optimal method to reach this range remain a matter of debate in the intensive care unit (ICU). A computer decision support system (CDSS) might improve the outcome of ICU patients through facilitation of a tighter blood glucose control. Methods We conducted a multi-center randomized trial in 34 French ICU. Adult patients expected to require treatment in the ICU for at least 3 days were randomly assigned without blinding to undergo tight computerized glucose control with the CDSS (TGC) or conventional glucose control (CGC), with blood glucose targets of 4.4-6.1 and Results Of the 2,684 patients who underwent randomization to the TGC and CGC treatment groups, primary outcome was available for 1,335 and 1,311 patients, respectively. The baseline characteristics of these treatment groups were similar in terms of age (61 ± 16 years), SAPS II (51 ± 19), percentage of surgical admissions (40.0 %) and proportion of diabetic patients (20.3 %). A total of 431 (32.3 %) patients in the TGC group and 447 (34.1 %) in the CGC group had died by day 90 (odds ratio for death in the TGC 0.92; 95 % confidence interval 0.78-1.78; p = 0.32). Severe hypoglycemia ( Conclusions Tight computerized glucose control with the CDSS did not significantly change 90-day mortality and was associated with more frequent severe hypoglycemia episodes in comparison with conventional glucose control., Author(s): Pierre Kalfon [sup.1] [sup.2], Bruno Giraudeau [sup.3], Carole Ichai [sup.4], Alexandre Guerrini [sup.5] [sup.6], Nicolas Brechot [sup.7], Raphaël Cinotti [sup.8], Pierre-François Dequin [sup.9], Béatrice Riu-Poulenc [sup.10], Philippe Montravers [sup.11], [...]

Author(s): Dominique D. Benoit [sup.1], Gordon Doig [sup.2], Jean-Francois Timsit [sup.3] Author Affiliations: (1) grid.410566.0, 0000000406263303, Department of Intensive Care, Ghent University Hospital, , Ghent, Belgium (2) grid.1013.3, 000000041936834X, Northern [...]

Author(s): Audrey De Jong [sup.1], Boris Jung [sup.1] [sup.2], Aurelien Daurat [sup.1], Gerald Chanques [sup.1] [sup.2], Martin Mahul [sup.1], Marion Monnin [sup.1], Nicolas Molinari [sup.3], Samir Jaber [sup.1] [sup.2] Author [...]

Objective Brain injury is well established as a cause of early mortality after out-of-hospital cardiac arrest (OHCA), but postresuscitation shock also contributes to these deaths. This study aims to describe the respective incidence, risk factors, and relation to mortality of post-cardiac arrest (CA) shock and brain injury. Design Retrospective analysis of an observational cohort. Setting 24-bed medical intensive care unit (ICU) in a French university hospital. Patients All consecutive patients admitted following OHCA were considered for analysis. Post-CA shock was defined as a need for infusion of vasoactive drugs after resuscitation. Death related to brain injury included brain death and care withdrawal for poor neurological evolution. Intervention None. Measurements and main results Between 2000 and 2009, 1,152 patients were admitted after OHCA. Post-CA shock occurred in 789 (68 %) patients. Independent factors associated with its onset were high blood lactate and creatinine levels at ICU admission. During the ICU stay, 269 (34.8 %) patients died from post-CA shock and 499 (65.2 %) from neurological injury. Age, raised blood lactate and creatinine values, and time from collapse to restoration of spontaneous circulation increased the risk of ICU mortality from both shock and brain injury, whereas a shockable rhythm was associated with reduced risk of death from these causes. Finally, bystander cardiopulmonary resuscitation (CPR) decreased the risk of death from neurological injury. Conclusions Brain injury accounts for the majority of deaths, but post-CA shock affects more than two-thirds of OHCA patients. Mortality from post-CA shock and brain injury share similar risk factors, which are related to the quality of the rescue process., Author(s): Virginie Lemiale [sup.1] [sup.5] [sup.7], Florence Dumas [sup.2] [sup.6], Nicolas Mongardon [sup.1] [sup.5], Olivier Giovanetti [sup.6], Julien Charpentier [sup.1] [sup.5], Jean-Daniel Chiche [sup.1] [sup.5], Pierre Carli [sup.4] [sup.5], Jean-Paul [...]

Introduction The prognosis of thrombotic thrombocytopenic purpura (TTP) has considerably improved since the introduction of plasma exchange (PEX) therapy. However, unresponsive thrombotic thrombocytopenic purpura (Un-TTP) still carries high morbidity and mortality rates, indicating a need for early specific treatments. Patients and Methods In a retrospective study including consecutive adults with TTP admitted between January 1997 and January 2011 in a teaching hospital intensive care unit (ICU), our objective here is to identify early clinical and laboratory features predicting Un-TTP. Patients who responded to plasma exchange and steroids (N = 49) were compared with patients with unresponsive TTP defined as requirement for other treatments, protracted course, or death (N = 37, 43 %). Results Hospital mortality was 24.3 % in the Un-TTP group. Variables associated with Un-TTP on univariate logistic regression were older age, cardiac involvement, neurological involvement, higher anti-a disintegrin and metalloproteinase with thrombospondin motifs (ADAMTS13) immunoglobulin G (IgG) titer, lower platelet counts starting on day 2, higher Sequential Organ Failure Assessment (SOFA) scores starting on day 3, need for higher plasma volumes to obtain remission, and greater use of adjuvant treatments and life-sustaining interventions. Multivariate logistic regression identified four factors independently associated with Un-TTP: age over 60 years [odds ratio (OR) 7.90; 95 % confidence interval (95 % CI) 1.06-78.34], cardiac (OR 5.17; 95 % CI 1.63-16.39) or neurological (OR 8.04; 95 % CI 1.27-51.03) manifestations at diagnosis, and day 2 platelet count less than 15 G/l (OR 3.88; 95 % CI 1.30-11.62). Conclusion Therapeutic intensification starting on day 3 or even earlier in patients with the independent risk factors for unresponsive TTP identified in our study deserves evaluation in a multicenter prospective study., Author(s): Eric Mariotte [sup.1], Alice Blet [sup.1], Lionel Galicier [sup.2], Michael Darmon [sup.3], Nathalie Parquet [sup.4], Etienne Lengline [sup.5], David Boutboul [sup.2], Emmanuel Canet [sup.1], Richard Traineau [sup.4], Benoît Schlemmer [...]