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1. Regional Practice Variation and Outcomes in the Standard Versus Accelerated Initiation of Renal Replacement Therapy in Acute Kidney Injury (STARRT-AKI) Trial: A Post Hoc Secondary Analysis

Author: Suvi T. Vaara, MD, PhD, Ary Serpa Neto, MD, PhD, Rinaldo Bellomo, MD, PhD, Neill K. J. Adhikari, MDCM, MSc, Didier Dreyfuss, MD, PhD, Martin Gallagher, MD, PhD, Stephane Gaudry, MD, PhD, Eric Hoste, MD, PhD, Michael Joannidis, MD, Ville Pettilä, MD, PhD, Amanda Y. Wang, MD, PhD, Kianoush Kashani, MD, PhD, Ron Wald, MDCM, MPH, Sean M. Bagshaw, MD, MSc, Marlies Ostermann, MD, PhD, and Sean M Bagshaw
Subjects: Medical emergencies. Critical care. Intensive care. First aid, RC86-88.9
Abstract: OBJECTIVES:. Among patients with severe acute kidney injury (AKI) admitted to the ICU in high-income countries, regional practice variations for fluid balance (FB) management, timing, and choice of renal replacement therapy (RRT) modality may be significant. DESIGN:. Secondary post hoc analysis of the STandard vs. Accelerated initiation of Renal Replacement Therapy in Acute Kidney Injury (STARRT-AKI) trial (ClinicalTrials.gov number NCT02568722). SETTING:. One hundred-fifty-three ICUs in 13 countries. PATIENTS:. Altogether 2693 critically ill patients with AKI, of whom 994 were North American, 1143 European, and 556 from Australia and New Zealand (ANZ). INTERVENTIONS:. None. MEASUREMENTS AND MAIN RESULTS:. Total mean FB to a maximum of 14 days was +7199 mL in North America, +5641 mL in Europe, and +2211 mL in ANZ (p < 0.001). The median time to RRT initiation among patients allocated to the standard strategy was longest in Europe compared with North America and ANZ (p < 0.001; p < 0.001). Continuous RRT was the initial RRT modality in 60.8% of patients in North America and 56.8% of patients in Europe, compared with 96.4% of patients in ANZ (p < 0.001). After adjustment for predefined baseline characteristics, compared with North American and European patients, those in ANZ were more likely to survive to ICU (p < 0.001) and hospital discharge (p < 0.001) and to 90 days (for ANZ vs. Europe: risk difference [RD], –11.3%; 95% CI, –17.7% to –4.8%; p < 0.001 and for ANZ vs. North America: RD, –10.3%; 95% CI, –17.5% to –3.1%; p = 0.007). CONCLUSIONS:. Among STARRT-AKI trial centers, significant regional practice variation exists regarding FB, timing of initiation of RRT, and initial use of continuous RRT. After adjustment, such practice variation was associated with lower ICU and hospital stay and 90-day mortality among ANZ patients compared with other regions.
Published: 2024
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2. Long-term outcomes after severe acute kidney injury in critically ill patients: the SALTO study

Author: Khalil Chaïbi, Franck Ehooman, Bertrand Pons, Laurent Martin-Lefevre, Eric Boulet, Alexandre Boyer, Guillaume Chevrel, Nicolas Lerolle, Dorothée Carpentier, Nicolas de Prost, Alexandre Lautrette, Anne Bretagnol, Julien Mayaux, Saad Nseir, Bruno Megarbane, Marina Thirion, Jean-Marie Forel, Julien Maizel, Hodane Yonis, Philippe Markowicz, Guillaume Thiery, Frédérique Schortgen, Cécile Couchoud, Didier Dreyfuss, and Stephane Gaudry
Subjects: Acute kidney injury, Renal replacement therapy, Long-term outcomes, Worsening renal failure, Medical emergencies. Critical care. Intensive care. First aid, RC86-88.9
Abstract: Abstract Background The extent of the consequences of an episode of severe acute kidney injury (AKI) on long-term outcome of critically ill patients remain debated. We conducted a prospective follow-up of patients included in a large multicenter clinical trial of renal replacement therapy (RRT) initiation strategy during severe AKI (the Artificial Kidney Initiation in Kidney Injury, AKIKI) to investigate long-term survival, renal outcome and health related quality of life (HRQOL). We also assessed the influence of RRT initiation strategy on these outcomes. Results Follow-up of patients extended from 60 days to a median of 3.35 years [interquartile range (IQR), 1.89 to 4.09] after the end of initial study. Of the 619 patients included in the AKIKI trial, 316 survived after 60 days. The overall survival rate at 3 years from inclusion was 39.4% (95% CI 35.4 to 43.4). A total of 46 patients (on the 175 with available data on long-term kidney function) experienced worsening of renal function (WRF) at the time of follow-up [overall incidence of 26%, cumulative incidence at 4 years: 20.6% (CI 95% 13.0 to 28.3)]. Fifteen patients required chronic dialysis (5% of patients who survived after day 90). Among the 226 long-term survivors, 80 (35%) answered the EQ-5D questionnaire. The median index value reported was 0.67 (IQR 0.40 to 1.00) indicating a noticeable alteration of quality of life. Initiation strategy for RRT had no effect on any long-term outcome. Conclusion Severe AKI in critically ill patients was associated with a high proportion of death within the first 2 months but less so during long-term follow-up. A quarter of long-term survivors experienced a WRF and suffered from a noticeable impairment of quality of life. Renal replacement therapy initiation strategy was not associated with mortality outcome. Graphical Abstract
Published: 2023
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3. Impact of renal replacement therapy strategy on beta-lactam plasma concentrations: the BETAKIKI study—an ancillary study of a randomized controlled trial

Author: Damien Roux, Nicolas Benichou, David Hajage, Laurent Martin-Lefèvre, Nicolas de Prost, Nicolas Lerolle, Dimitri Titeca-Beauport, Eric Boulet, Julien Mayaux, Bruno Mégarbane, Khaoula Mahjoub, Dorothée Carpentier, Saad Nseir, Florence Tubach, Jean-Damien Ricard, Didier Dreyfuss, Stéphane Gaudry, and for the AKIKI Study group
Subjects: Acute kidney injury, Beta-lactam, Concentration, Septic shock, Renal replacement therapy, Antibiotic, Medical emergencies. Critical care. Intensive care. First aid, RC86-88.9
Abstract: Abstract Background Sepsis prognosis correlates with antibiotic adequacy at the early phase. This adequacy is dependent on antibacterial spectrum, bacterial resistance profile and antibiotic dosage. Optimal efficacy of beta-lactams mandates concentrations above the minimal inhibitory concentration (MIC) of the targeted bacteria for the longest time possible over the day. Septic acute kidney injury (AKI) is the most common AKI syndrome in ICU and often mandates renal replacement therapy (RRT) initiation. Both severe AKI and RRT may increase outside target antibiotic concentrations and ultimately alter patient’s prognosis. Patients and methods This is a secondary analysis of a randomized controlled trial that compared an early RRT initiation strategy with a delayed one in 620 critically ill patients undergoing severe AKI (defined by KDIGO 3). We compared beta-lactam trough concentrations between the two RRT initiation strategies. The primary outcome was the proportion of patients with sufficient trough plasma concentration of beta-lactams defined by trough concentration above 4 times the MIC. We hypothesized that early initiation of RRT could be associated with an insufficient antibiotic plasma trough concentration compared to patients allocated to the delayed strategy. Results One hundred and twelve patients were included: 53 in the early group and 59 in the delayed group. Eighty-three patients (74%) had septic shock on inclusion. Trough beta-lactam plasma concentration was above 4 times the MIC breakpoint in 80.4% (n = 90) of patients of the whole population, without differences between the early and the delayed groups (79.2% vs. 81.4%, respectively, p = 0.78). On multivariate analysis, the presence of septic shock and a higher mean arterial pressure were significantly associated with a greater probability of adequate antibiotic trough concentration [OR 3.95 (1.14;13.64), p = 0.029 and OR 1.05 (1.01;1.10), p = 0.013, respectively). Evolution of procalcitonin level and catecholamine-free days as well as mortality did not differ whether beta-lactam trough concentration was above 4 times the MIC or not. Conclusions In this secondary analysis of a randomized controlled trial, renal replacement therapy initiation strategy did not significantly influence plasma trough concentrations of beta-lactams in ICU patients with severe AKI. Presence of septic shock on inclusion was the main variable associated with a sufficient beta-lactam concentration. Trial registration: The AKIKI trial was registered on ClinicalTrials.gov (Identifier: NCT01932190) before the inclusion of the first patient.
Published: 2023
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4. Continuous renal replacement therapy versus intermittent hemodialysis as first modality for renal replacement therapy in severe acute kidney injury: a secondary analysis of AKIKI and IDEAL-ICU studies

Author: Stéphane Gaudry, François Grolleau, Saber Barbar, Laurent Martin-Lefevre, Bertrand Pons, Éric Boulet, Alexandre Boyer, Guillaume Chevrel, Florent Montini, Julien Bohe, Julio Badie, Jean-Philippe Rigaud, Christophe Vinsonneau, Raphaël Porcher, Jean-Pierre Quenot, and Didier Dreyfuss
Subjects: Renal replacement therapy, Acute kidney injury, Critical care, Medical emergencies. Critical care. Intensive care. First aid, RC86-88.9
Abstract: Abstract Background Intermittent hemodialysis (IHD) and continuous renal replacement therapy (CRRT) are the two main RRT modalities in patients with severe acute kidney injury (AKI). Meta-analyses conducted more than 10 years ago did not show survival difference between these two modalities. As the quality of RRT delivery has improved since then, we aimed to reassess whether the choice of IHD or CRRT as first modality affects survival of patients with severe AKI. Methods This is a secondary analysis of two multicenter randomized controlled trials (AKIKI and IDEAL-ICU) that compared an early RRT initiation strategy with a delayed one. We included patients allocated to the early strategy in order to emulate a trial where patients would have been randomized to receive either IHD or CRRT within twelve hours after the documentation of severe AKI. We determined each patient’s modality group as the first RRT modality they received. The primary outcome was 60-day overall survival. We used two propensity score methods to balance the differences in baseline characteristics between groups and the primary analysis relied on inverse probability of treatment weighting. Results A total of 543 patients were included. Continuous RRT was the first modality in 269 patients and IHD in 274. Patients receiving CRRT had higher cardiovascular and total-SOFA scores. Inverse probability weighting allowed to adequately balance groups on all predefined confounders. The weighted Kaplan–Meier death rate at day 60 was 54·4% in the CRRT group and 46·5% in the IHD group (weighted HR 1·26, 95% CI 1·01–1·60). In a complementary analysis of less severely ill patients (SOFA score: 3–10), receiving IHD was associated with better day 60 survival compared to CRRT (weighted HR 1.82, 95% CI 1·01–3·28; p
Published: 2022
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5. Personalization of renal replacement therapy initiation: a secondary analysis of the AKIKI and IDEAL-ICU trials

Author: François Grolleau, Raphaël Porcher, Saber Barbar, David Hajage, Abderrahmane Bourredjem, Jean-Pierre Quenot, Didier Dreyfuss, and Stéphane Gaudry
Subjects: Acute kidney injury, Renal replacement therapy, Heterogeneity of treatment effect, Personalized medicine, Medical emergencies. Critical care. Intensive care. First aid, RC86-88.9
Abstract: Abstract Background Trials comparing early and delayed strategies of renal replacement therapy in patients with severe acute kidney injury may have missed differences in survival as a result of mixing together patients at heterogeneous levels of risks. Our aim was to evaluate the heterogeneity of treatment effect on 60-day mortality from an early vs a delayed strategy across levels of risk for renal replacement therapy initiation under a delayed strategy. Methods We used data from the AKIKI, and IDEAL-ICU randomized controlled trials to develop a multivariable logistic regression model for renal replacement therapy initiation within 48 h after allocation to a delayed strategy. We then used an interaction with spline terms in a Cox model to estimate treatment effects across the predicted risks of RRT initiation. Results We analyzed data from 1107 patients (619 and 488 in the AKIKI and IDEAL-ICU trial respectively). In the pooled sample, we found evidence for heterogeneous treatment effects (P = 0.023). Patients at an intermediate-high risk of renal replacement therapy initiation within 48 h may have benefited from an early strategy (absolute risk difference, − 14%; 95% confidence interval, − 27% to − 1%). For other patients, we found no evidence of benefit from an early strategy of renal replacement therapy initiation but a trend for harm (absolute risk difference, 8%; 95% confidence interval, − 5% to 21% in patients at intermediate-low risk). Conclusions We have identified a clinically sound heterogeneity of treatment effect of an early vs a delayed strategy of renal replacement therapy initiation that may reflect varying degrees of kidney demand-capacity mismatch.
Published: 2022
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6. Vascular access for renal replacement therapy among 459 critically ill patients: a pragmatic analysis of the randomized AKIKI trial

Author: Nicolas Benichou, Saïd Lebbah, David Hajage, Laurent Martin-Lefèvre, Bertrand Pons, Eric Boulet, Alexandre Boyer, Guillaume Chevrel, Nicolas Lerolle, Dorothée Carpentier, Nicolas de Prost, Alexandre Lautrette, Anne Bretagnol, Julien Mayaux, Saad Nseir, Bruno Megarbane, Marina Thirion, Jean-Marie Forel, Julien Maizel, Hodane Yonis, Philippe Markowicz, Guillaume Thiery, Frederique Schortgen, Florence Tubach, Jean-Damien Ricard, Didier Dreyfuss, and Stéphane Gaudry
Subjects: Renal replacement therapy, Acute kidney injury, Vascular access, Catheter, Critical care, Medical emergencies. Critical care. Intensive care. First aid, RC86-88.9
Abstract: Abstract Background Vascular access for renal replacement therapy (RRT) is routine question in the intensive care unit. Randomized trials comparing jugular and femoral sites have shown similar rate of nosocomial events and catheter dysfunction. However, recent prospective observational data on RRT catheters use are scarce. We aimed to assess the site of RRT catheter, the reasons for catheter replacement, and the complications according to site in a large population of critically ill patients with acute kidney injury. Patients and methods We performed an ancillary study of the AKIKI study, a pragmatic randomized controlled trial, in which patients with severe acute kidney injury (KDIGO 3 classification) with invasive mechanical ventilation, catecholamine infusion or both were randomly assigned to either an early or a delayed RRT initiation strategy. The present study involved all patients who underwent at least one RRT session. Number of RRT catheters, insertion sites, factors potentially associated with the choice of insertion site, duration of catheter use, reason for catheter replacement, and complications were prospectively collected. Results Among the 619 patients included in AKIKI, 462 received RRT and 459 were finally included, with 598 RRT catheters. Femoral site was chosen preferentially (n = 319, 53%), followed by jugular (n = 256, 43%) and subclavian (n = 23, 4%). In multivariate analysis, continuous RRT modality was significantly associated with femoral site (OR = 2.33 (95% CI (1.34–4.07), p = 0.003) and higher weight with jugular site [88.9 vs 83.2 kg, OR = 0.99 (95% CI 0.98–1.00), p = 0.03]. Investigator site was also significantly associated with the choice of insertion site (p = 0.03). Cumulative incidence of catheter replacement did not differ between jugular and femoral site [sHR 0.90 (95% CI 0.64—1.25), p = 0.67]. Catheter dysfunction was the main reason for replacement (n = 47), followed by suspected infection (n = 29) which was actually seldom proven (n = 4). No mechanical complication (pneumothorax or hemothorax) occurred. Conclusion Femoral site was preferentially used in this prospective study of RRT catheters in 31 French intensive care units. The choice of insertion site depended on investigating center habits, weight, RRT modality. A high incidence of catheter infection suspicion led to undue replacement.
Published: 2021
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7. The Artificial Kidney Initiation in Kidney Injury 2 (AKIKI2): study protocol for a randomized controlled trial

Author: Stéphane Gaudry, David Hajage, Laurent Martin-Lefevre, Guillaume Louis, Sébastien Moschietto, Dimitri Titeca-Beauport, Béatrice La Combe, Bertrand Pons, Nicolas de Prost, Sébastien Besset, Alain Combes, Adrien Robine, Marion Beuzelin, Julio Badie, Guillaume Chevrel, Jean Reignier, Julien Bohé, Elisabeth Coupez, Nicolas Chudeau, Saber Barbar, Christophe Vinsonneau, Jean-Marie Forel, Didier Thevenin, Eric Boulet, Karim Lakhal, Nadia Aissaoui, Steven Grange, Marc Leone, Guillaume Lacave, Saad Nseir, Florent Poirson, Julien Mayaux, Karim Asehnoune, Guillaume Geri, Kada Klouche, Guillaume Thiery, Laurent Argaud, Jean-Damien Ricard, Jean-Pierre Quenot, and Didier Dreyfuss
Subjects: Acute kidney injury, Critical care, Renal replacement therapy, Treatment outcome, Medicine (General), R5-920
Abstract: Abstract Background The Artificial Kidney Initiation in Kidney Injury (AKIKI) trial showed that a delayed renal replacement therapy (RRT) strategy for severe acute kidney injury (AKI) in critically ill patients was safe and associated with major reduction in RRT initiation compared with an early strategy. The five criteria which mandated RRT initiation in the delayed arm were: severe hyperkalemia, severe acidosis, acute pulmonary edema due to fluid overload resulting in severe hypoxemia, serum urea concentration > 40 mmol/l and oliguria/anuria > 72 h. However, duration of anuria/oliguria and level of blood urea are still criteria open to debate. The objective of the study is to compare the delayed strategy used in AKIKI (now termed “standard”) with another in which RRT is further delayed for a longer period (termed “delayed strategy”). Methods/design This is a prospective, multicenter, open-label, two-arm randomized trial. The study is composed of two stages (observational and randomization stages). At any time, the occurrence of a potentially severe condition (severe hyperkalemia, severe metabolic or mixed acidosis, acute pulmonary edema due to fluid overload resulting in severe hypoxemia) suggests immediate RRT initiation. Patients receiving (or who have received) intravenously administered catecholamines and/or invasive mechanical ventilation and presenting with AKI stage 3 of the KDIGO classification and with no potentially severe condition are included in the observational stage. Patients presenting a serum urea concentration > 40 mmol/l and/or an oliguria/anuria for more than 72 h are randomly allocated to a standard (RRT is initiated within 12 h) or a delayed RRT strategy (RRT is initiated only if an above-mentioned potentially severe condition occurs or if the serum urea concentration reaches 50 mmol/l). The primary outcome will be the number of RRT-free days at day 28. One interim analysis is planned. It is expected to include 810 patients in the observational stage and to randomize 270 subjects. Discussion The AKIKI2 study should improve the knowledge of RRT initiation criteria in critically ill patients. The potential reduction in RRT use allowed by a delayed RRT strategy might be associated with less invasive care and decreased costs. Enrollment is ongoing. Inclusions are expected to be completed by November 2019. Trial registration ClinicalTrials.gov, ID: NCT03396757. Registered on 11 January 2018.
Published: 2019
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8. Interpreting trials on renal replacement therapy initiation: beware of methodologic issues

Author: Stéphane Gaudry, Paul M. Palevsky, and Didier Dreyfuss
Subjects: Medical emergencies. Critical care. Intensive care. First aid, RC86-88.9
Published: 2020
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9. Initial management of diabetic ketoacidosis and prognosis according to diabetes type: a French multicentre observational retrospective study

Author: Adrien Balmier, Fadia Dib, Arnaud Serret-Larmande, Etienne De Montmollin, Victorine Pouyet, Benjamin Sztrymf, Bruno Megarbane, Abirami Thiagarajah, Didier Dreyfuss, Jean-Damien Ricard, and Damien Roux
Subjects: Diabetic ketoacidosis, Hypoglycaemia, Hypokalaemia, Insulin, Critical care, Type 1 diabetes, Medical emergencies. Critical care. Intensive care. First aid, RC86-88.9
Abstract: Abstract Background Guidelines for the management of diabetic ketoacidosis (DKA) do not consider the type of underlying diabetes. We aimed to compare the occurrence of metabolic adverse events and the recovery time for DKA according to diabetes type. Methods Multicentre retrospective study conducted at five adult intermediate and intensive care units in Paris and its suburbs, France. All patients admitted for DKA between 2013 and 2014 were included. Patients were grouped and compared according to the underlying type of diabetes into three groups: type 1 diabetes, type 2 or secondary diabetes, and DKA as the first presentation of diabetes. Outcomes of interest were the rate of metabolic complications (hypoglycaemia or hypokalaemia) and the recovery time. Results Of 122 patients, 60 (49.2%) had type 1 diabetes, 28 (22.9%) had type 2 or secondary diabetes and 34 (27.9%) presented with DKA as the first presentation of diabetes (newly diagnosed diabetes). Despite having received lower insulin doses, hypoglycaemia was more frequent in patients with type 1 diabetes (76.9%) than in patients with type 2 or secondary diabetes (50.0%) and in patients with newly diagnosed diabetes (54.6%) (p = 0.026). In contrast, hypokalaemia was more frequent in the latter group (82.4%) than in patients with type 1 diabetes (57.6%) and type 2 or secondary diabetes (51.9%) (p = 0.022). The median recovery times were not significantly different between groups. Conclusions Rates of metabolic complications associated with DKA treatment differ significantly according to underlying type of diabetes. Decreasing insulin dose may limit those complications. DKA treatment recommendations should take into account the type of diabetes.
Published: 2019
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10. Formal guidelines: management of acute respiratory distress syndrome

Author: Laurent Papazian, Cécile Aubron, Laurent Brochard, Jean-Daniel Chiche, Alain Combes, Didier Dreyfuss, Jean-Marie Forel, Claude Guérin, Samir Jaber, Armand Mekontso-Dessap, Alain Mercat, Jean-Christophe Richard, Damien Roux, Antoine Vieillard-Baron, and Henri Faure
Subjects: Medical emergencies. Critical care. Intensive care. First aid, RC86-88.9
Abstract: Abstract Fifteen recommendations and a therapeutic algorithm regarding the management of acute respiratory distress syndrome (ARDS) at the early phase in adults are proposed. The Grade of Recommendation Assessment, Development and Evaluation (GRADE) methodology has been followed. Four recommendations (low tidal volume, plateau pressure limitation, no oscillatory ventilation, and prone position) had a high level of proof (GRADE 1 + or 1 −); four (high positive end-expiratory pressure [PEEP] in moderate and severe ARDS, muscle relaxants, recruitment maneuvers, and venovenous extracorporeal membrane oxygenation [ECMO]) a low level of proof (GRADE 2 + or 2 −); seven (surveillance, tidal volume for non ARDS mechanically ventilated patients, tidal volume limitation in the presence of low plateau pressure, PEEP > 5 cmH2O, high PEEP in the absence of deleterious effect, pressure mode allowing spontaneous ventilation after the acute phase, and nitric oxide) corresponded to a level of proof that did not allow use of the GRADE classification and were expert opinions. Lastly, for three aspects of ARDS management (driving pressure, early spontaneous ventilation, and extracorporeal carbon dioxide removal), the experts concluded that no sound recommendation was possible given current knowledge. The recommendations and the therapeutic algorithm were approved by the experts with strong agreement.
Published: 2019
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11. Intensive care units, the Achilles heel of France in the COVID-19 battle

Author: Djillali Annane, Laura Federici, Jean-Luc Chagnon, Jean Luc Diehl, Didier Dreyfuss, Philippe Guiot, Etienne Javouhey, Nicolas Joram, Olivier Lesieur, Jean Philippe Rigaud, Hervé Outin, Arnaud Sement, Chantal Sevens, Didier Thévenin, Samia Touati, and Nicolas Terzi
Subjects: Public aspects of medicine, RA1-1270
Published: 2021
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12. Clinical impact of upper gastrointestinal endoscopy in critically ill patients with suspected bleeding

Author: Sylvain Jean-Baptiste, Jonathan Messika, David Hajage, Stéphane Gaudry, Julie Barbieri, Henri Duboc, Didier Dreyfuss, Benoit Coffin, and Jean-Damien Ricard
Subjects: Upper gastrointestinal endoscopy, Intensive care unit, Profitability, Medical emergencies. Critical care. Intensive care. First aid, RC86-88.9
Abstract: Abstract Background and Aims Upper gastrointestinal endoscopies’ (UGE) profitability is undisputable in patients admitted for an overt upper digestive tract bleeding. In critically ill subjects admitted for other causes, its performances have scarcely been investigated despite its broad use. We sought to question the performance of bedside UGE in intensive care unit (ICU) patients, admitted for another reason than overt bleeding. Methods This was a six-year (January 2007–December 2012) retrospective observational study of all UGE performed in a medico-surgical ICU. Exclusion of those performed: in patients admitted for a patent upper digestive bleeding; for a second-look gastroscopy of a known lesion; as a planned interventional procedure. Main demographic and clinical data were recorded; UGE indication and profitability were rated according to its findings and therapeutic impact. Operative values of the indications of UGE were calculated. This study received approval from the Ethics Committee of the French Society of Intensive Care (n° 12-363). Results Eighty-four patients (74% male, mean age 61 ± 14 years) underwent a diagnostic UGE, all for a suspected upper digestive tract bleeding. The main symptoms justifying the procedure were anemia (52%), digestive bleeding (27%), vomiting (15%), hemodynamic instability (3%) and hyperuremia (3%). The profitability of UGE was rated as major (n = 5; 5.8%); minor (n = 34; 40.5%); or null (n = 45; 53.6%). Conclusions When ICU admission is not warranted by a digestive bleeding, UGE has limited diagnostic and therapeutic interest, despite being often performed.
Published: 2018
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13. Renin-angiotensin-aldosterone system blockers after KDIGO stage 3 acute kidney injury: use and impact on 2-year mortality in the AKIKI trial

Author: Mathilde Scarton, Anne Oppenheimer, Khalil Chaïbi, Didier Dreyfuss, and Stéphane Gaudry
Subjects: Medical emergencies. Critical care. Intensive care. First aid, RC86-88.9
Published: 2019
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14. Loxapine to control agitation during weaning from mechanical ventilation

Author: Stéphane Gaudry, Benjamin Sztrymf, Romain Sonneville, Bruno Megarbane, Guillaume Van Der Meersch, Dominique Vodovar, Yves Cohen, Jean-Damien Ricard, David Hajage, Laurence Salomon, and Didier Dreyfuss
Subjects: Mechanical ventilation, Ventilation weaning, Agitation, Intensive care unit, Medical emergencies. Critical care. Intensive care. First aid, RC86-88.9
Abstract: Abstract Background Weaning from mechanical ventilation (MV) may be impeded by the occurrence of agitation. Loxapine has the ability to control agitation without affecting spontaneous ventilation. The aim of this study was to establish whether loxapine would reduce MV weaning duration in agitated patients. Methods We performed a multicentre, double-blind, placebo-controlled, parallel group, randomised trial. Patients who were potential candidates for weaning but exhibited agitation (Richmond Agitation-Sedation Scale score ≥ 2) after sedation withdrawal were randomly assigned to receive either loxapine or placebo. In case of severe agitation, conventional sedation was immediately resumed. The primary endpoint was the time between first administration of loxapine or placebo and successful extubation. Results The trial was discontinued after 102 patients were enrolled because of an insufficient inclusion rate. Median times to successful extubation were 3.2 days in the loxapine group and 5 days in the placebo group (relative risk 1.2, 95% CI 0.75–1.88, p = 0.45). During the first 24 h, sedation was more frequently resumed in the placebo group (44% vs 17%, p = 0.01). Conclusions In this prematurely stopped trial, loxapine did not significantly shorten weaning from MV. However, loxapine reduced the need for resuming sedation. Trial registration Clinicaltrials.gov, NCT01193816 . Registered on 26 August 2010.
Published: 2017
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15. Albumin infusion in spontaneous bacterial peritonitis: another brick off the wall?

Author: Damien Roux, Richard Moreau, and Didier Dreyfuss
Subjects: Medical emergencies. Critical care. Intensive care. First aid, RC86-88.9
Published: 2018
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16. Renal replacement therapy after cardiac surgery: do not ask 'When', ask 'Why'

Author: Stéphane Gaudry, David Hajage, and Didier Dreyfuss
Subjects: Medical emergencies. Critical care. Intensive care. First aid, RC86-88.9
Published: 2017
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17. Debate: Intermittent Hemodialysis versus Continuous Kidney Replacement Therapy in the Critically Ill Patient: The Choice Should Be Evidence Based

Author: Khalil Chaïbi, Didier Dreyfuss, and Stéphane Gaudry
Subjects: Transplantation, Nephrology, Epidemiology, Critical Care and Intensive Care Medicine
Published: 2023

18. The Effect of an Accelerated Renal Replacement Therapy Initiation Is Not Modified by Baseline Risk

Author: Federico Angriman, Bruno L. Ferreyro, Natalia Angeloni, Bruno R. da Costa, Ron Wald, Sean M. Bagshaw, Neill K.J. Adhikari, Rinaldo Bellomo, Didier Dreyfuss, Bin Du, Martin P. Gallagher, Stéphane Gaudry, François Lamontagne, Michael Joannidis, Kathleen D. Liu, Daniel F. McAuley, Shay P. McGuinness, Alistair D. Nichol, Marlies Ostermann, Paul M. Palevsky, Haibo Qiu, Ville Pettilä, Antoine G. Schneider, Orla M. Smith, Suvi T. Vaara, Matthew Weir, Glenn M. Eastwood, Leah Peck, Helen Young, Peter Kruger, Gordon Laurie, Emma Saylor, Jason Meyer, Ellen Venz, Krista Wetzig, Craig French, Forbes McGain, John Mulder, Gerard Fennessy, Sathyajith Koottayi, Samantha Bates, Miriam Towns, Rebecca Morgan, Anna Tippett, Andrew Udy, Chris Mason, Elisa Licari, Dashiell Gantner, Jason McClure, Alistair Nichol, Phoebe McCracken, Jasmin Board, Emma Martin, Shirley Vallance, Meredith Young, Chelsey Vladic, Steve McGloughlin, David Gattas, Heidi Buhr, Jennifer Coles, Debra Hutch, James Wun, Louise Cole, Christina Whitehead, Julie Lowrey, Kristy Masters, Rebecca Gresham, Victoria Campbell, David Gutierrez, Jane Brailsford, Loretta Forbes, Lauren Murray, Teena Maguire, Martina NiChonghaile, Neil Orford, Allison Bone, Tania Elderkin, Tania Salerno, Tim Chimunda, Jason Fletcher, Emma Broadfield, Sanjay Porwal, Cameron Knott, Catherine Boschert, Julie Smith, Angus Richardson, Dianne Hill, Graeme Duke, Peter Oziemski, Santiago Cegarra, Peter Chan, Deborah Welsh, Stephanie Hunter, Owen Roodenburg, John Dyett, Nicos Kokotsis, Max Moser, Yang Yang, Laven Padayachee, Joseph Vetro, Himangsu Gangopadhyay, Melissa Kaufman, Angaj Ghosh, Simone Said, Alpesh Patel, Shailesh Bihari, Elisha Matheson, Xia Jin, Tapaswi Shrestha, Kate Schwartz, Rosalba Cross, Winston Cheung, Helen Wong, Mark Kol, Asim Shah, Amanda Y. Wang, Zoltan Endre, Celia Bradford, Pierre Janin, Simon Finfer, Naomi Diel, Jonathan Gatward, Naomi Hammond, Anthony Delaney, Frances Bass, Elizabeth Yarad, Hergen Buscher, Claire Reynolds, Nerilee Baker, Romuald Bellmann, Andreas Peer, Julia Hasslacher, Paul Koglberger, Sebastian Klein, Klemens Zotter, Anna Brandtner, Armin Finkenstedt, Adelheid Ditlbacher, Frank Hartig, Dietmar Fries, Mirjam Bachler, Bettina Schenk, Martin Wagner, Philipp Eller, Thomas Staudinger, Esther Tiller, Peter Schellongowski, Andja Bojic, Eric A. Hoste, Stephanie Bracke, Luc De Crop, Daisy Vermeiren, Fernando Thome, Bianca Chiella, Lucia Fendt, Veronica Antunes, Frédérick D'Aragon, Charles St-Arnaud, Michael Mayette, Élaine Carbonnaeu, Joannie Marchand, Marie-Hélène Masse, Marilène Ladouceur, Alexis F. Turgeon, François Lauzier, David Bellemare, Charles Langis Francoeur, Guillaume LeBlanc, Gabrielle Guilbault, Stéphanie Grenier, Eve Cloutier, Annick Boivin, Charles Delisle-Thibault, Panagiota Giannakouros, Olivier Costerousse, Jean-François Cailhier, François-Martin Carrier, Ali Ghamraoui, Martine Lebrasseur, Fatna Benettaib, Maya Salamé, Dounia Boumahni, Ying Tung Sia, Jean-François Naud, Isabelle Roy, Henry T. Stelfox, Stacey Ruddell, Braden J. Manns, Shelley Duggan, Dominic Carney, Jennifer Barchard, Richard P. Whitlock, Emilie Belley-Cote, Nevena Savija, Alexandra Sabev, Troy Campbell, Thais Creary, Kelson Devereaux, Shira Brodutch, Claudio Rigatto, Bojan Paunovic, Owen Mooney, Anna Glybina, Oksana Harasemiw, Michelle Di Nella, John Harmon, Navdeep Mehta, Louis Lakatos, Nicole Haslam, Francois Lellouche, Mathieu Simon, Ying Tung, Patricia Lizotte, Pierre-Alexandre Bourchard, Bram Rochwerg, Tim Karachi, Tina Millen, John Muscedere, David Maslove, J. Gordon Boyd, Stephanie Sibley, John Drover, Miranda Hunt, Ilinca Georgescu, Randy Wax, Ilan Lenga, Kavita Sridhar, Andrew Steele, Kelly Fusco, Taneera Ghate, Michael Tolibas, Holly Robinson, Matthew A. Weir, Ravi Taneja, Ian M. Ball, Amit Garg, Eileen Campbell, Athena Ovsenek, Sean van Diepen, Nadia Baig, Sheldon Magder, Han Yao, Ahsan Alam, Josie Campisi, Erika MacIntyre, Ella Rokosh, Kimberly Scherr, Stephen Lapinsky, Sangeeta Mehta, Sumesh Shah, Daniel J. Niven, Michael Russell, Kym Jim, Gillian Brown, Kerry Oxtoby, Adam Hall, Luc Benoit, Colleen Sokolowski, Bhanu Prasad, Jag Rao, Shelley Giebel, Demetrios J. Kutsogiannis, Patricia Thompson, Tayne Thompson, Robert Cirone, Kanthi Kavikondala, Mark Soth, France Clarke, Alyson Takaoka, David Mazer, Karen Burns, Jan Friedrich, David Klein, Gyan Sandhu, Marlene Santos, Imrana Khalid, Jennifer Hodder, Peter Dodek, Najib Ayas, Victoria Alcuaz, Gabriel Suen, Oleksa Rewa, Gurmeet Singh, Sean Norris, Neil Gibson, Castro Arias, Aysha Shami, Celine Pelletier, Alireza Zahirieh, Andre Amaral, Nicole Marinoff, Navjot Kaur, Adic Perez, Jane Wang, Gregory Haljan, Christopher Condin, Lauralyn McIntyre, Brigette Gomes, Rebecca Porteous, Irene Watpool, Swapnil Hiremath, Edward Clark, Margaret S. Herridge, Felicity Backhouse, M. Elizabeth Wilcox, Karolina Walczak, Vincent Ki, Asheer Sharman, Martin Romano, R.T. Noel Gibney, Adam S. Romanovsky, Lorena McCoshen, Gordon Wood, Daniel Ovakim, Fiona Auld, Gayle Carney, Meili Duan, Xiaojun Ji, Dongchen Guo, Zhili Qi, Jin Lin, Meng Zhang, Lei Dong, Jingfeng Liu, Pei Liu, Deyuan Zhi, Guoqiang Bai, Yu Qiu, Ziqi Yang, Jing Bai, Zhuang Liu, Haizhou Zhuang, Haiman Wang, Jian Li, Mengya Zhao, Xiao Zhou, Xianqing Shi, Baning Ye, Manli Liu, Jing Wu, Yongjian Fu, Dali Long, Yu Pan, Jinlong Wang, Huaxian Mei, Songsong Zhang, Mingxiang Wen, Enyu Yang, Sijie Mu, Jianquan Li, Tingting Hu, Bingyu Qin, Min Li, Cunzhen Wang, Xin Dong, Kaiwu Wang, Haibo Wang, Jianxu Yang, Chuanyao Wang, Dongxin Wang, Nan Li, Zhui Yu, Song Xu, Lan Yao, Guo Hou, Zhou Liu, Liping Lu, Yingtao Lian, Chunting Wang, Jichen Zhang, Ruiqi Ding, Guoqing Qi, Qizhi Wang, Peng Wang, Zhaoli Meng, Man Chen, Xiaobo Hu, Xiandi He, Shibing Zhao, Lele Hang, Rui Li, Suhui Qin, Kun Lu, Shijuan Dun, Cheng Liu, Qi Zhou, Zhenzhen Chen, Jing Mei, Minwei Zhang, Hao Xu, Jincan Lin, Qindong Shi, Lijuan Fu, Qinjing Zeng, Hongye Ma, Jinqi Yan, Lan Gao, Hongjuan Liu, Lei Zhang, Hao Li, Xiaona He, Jingqun Fan, Litao Guo, Yu Liu, Xue Wang, Jingjing Sun, Zhongmin Liu, Juan Yang, Lili Ding, Lulu Sheng, Xingang Liu, Jie Yan, Quihui Wang, Yifeng Wang, Dan Zhao, Shuangping Zhao, Chenghuan Hu, Jing Li, Fuxing Deng, Haibo Qui, Yi Yang, Min Mo, Chun Pan, Changde Wu, Yingzi Huang, Lili Huang, Airan Liu, Anna-Maija Korhonen, Sanna Törnblom, Sari Sutinen, Leena Pettilä, Jonna Heinonen, Eliria Lappi, Taria Suhonen, Sari Karlsson, Sanna Hoppu, Ville Jalkanen, Anne Kuitunen, Markus Levoranta, Jaakko Långsjö, Sanna Ristimäki, Kaisa Malila, Anna Wootten, Simo Varila, Mikko J Järvisalo, Outi Inkinen, Satu Kentala, Keijo Leivo, Paivi Haltia, Jean-Damien Ricard, Jonathan Messika, Abirami Tiagarajah, Malo Emery, Aline Dechanet, Coralie Gernez, Damien Roux, Laurent Martin-Lefevre, Maud Fiancette, Isabelle Vinatier, Jean Claude Lacherade, Gwenhaël Colin, Christine Lebert, Marie-Ange Azais, Aihem Yehia, Caroline Pouplet, Matthieu Henry- Lagarrigue, Amélie Seguin, Laura Crosby, Julien Maizel, Dimitri Titeca-Beauport, Alain Combes, Ania Nieszkowska, Paul Masi, Alexandre Demoule, Julien Mayaux, Martin Dres, Elise Morawiec, Maxens Decalvele, Suela Demiri, Morgane Faure, Clémence Marios, Maxime Mallet, Marie Amélie Ordon, Laura Morizot, Marie Cantien, François Pousset, Florent Poirson, Yves Cohen, Laurent Argaud, Martin Cour, Laurent Bitker, Marie Simon, Romain Hernu, Thomas Baudry, Sylvie De La Salle, Adrien Robine, Nicholas Sedillot, Xavier Tchenio, Camille Bouisse, Sylvie Roux, Fabienne Tamion, Steven Grangé, Dorothée Carpentier, Guillaume Chevrel, Luis Ensenyat-Martin, Sophie Marque, Jean-Pierre Quenot, Pascal Andreu, Auguste Dargent, Audrey Large, Nicolas Chudeau, Mickael Landais, Benoit Derrien, Jean Christophe Callahan, Christophe Guitton, Charlène Le Moal, Alain Robert, Karim Asehnoune, Raphaël Cinotti, Nicolas Grillot, Dominique Demeure, Christophe Vinsonneau, Imen Rahmani, Mehdi Marzouk, Thibault Dekeyser, Caroline Sejourne, Mélanie Verlay, Fabienne Thevenin, Lucie Delecolle, Didier Thevenin, Bertrand Souweine, Elisabeth Coupez, Mireille Adda, Jean-Pierre Eraldi, Antoine Marchalot, Nicolas De Prost, Armand Mekontso Dessap, Keyvan Razazi, Ferhat Meziani, Julie Boisrame-Helms, Raphael Clere-Jehl, Xavier Delabranche, Christine Kummerlen, Hamid Merdji, Alexandra Monnier, Yannick Rabouel, Hassene Rahmani, Hayat Allam, Samir Chenaf, Vincenta Franja, Bertrand Pons, Michel Carles, Frédéric Martino, Régine Richard, Benjamin Zuber, Guillaume Lacave, Karim Lakhal, Bertrand Rozec, Hoa Dang Van, Éric Boulet, Fouad Fadel, Cedric Cleophax, Nicolas Dufour, Caroline Grant, Marie Thuong, Jean Reignier, Emmanuel Canet, Laurent Nicolet, Thierry Boulain, Mai-Anh Nay, Dalila Benzekri, François Barbier, Anne Bretagnol, Toufik Kamel, Armelle Mathonnet, Grégoire Muller, Marie Skarzynski, Julie Rossi, Amandine Pradet, Sandra Dos Santos, Aurore Guery, Lucie Muller, Luis Felix, Julien Bohé, Guillaume Thiéry, Nadia Aissaoui, Damien Vimpere, Morgane Commeureuc, Jean-Luc Diehl, Emmanuel Guerot, Orfeas Liangos, Monika Wittig, Alexander Zarbock, Mira Küllmar, Thomas van Waegeningh, Nadine Rosenow, Kathy Brickell, Peter Doran, Patrick T. Murray, Giovanni Landoni, Rosalba Lembo, Alberto Zangrillo, Giacomo Monti, Margherita Tozzi, Matteo Marzaroli, Gaetano Lombardi, Gianluca Paternoster, Michelangelo Vitiello, Shay McGuinness, Rachael Parke, Magdalena Butler, Eileen Gilder, Keri-Anne Cowdrey, Samantha Wallace, Jane Hallion, Melissa Woolett, Philippa Neal, Karina Duffy, Stephanie Long, Colin McArthur, Catherine Simmonds, Yan Chen, Rachael McConnochie, Lynette Newby, David Knight, Seton Henderson, Jan Mehrtens, Stacey Morgan, Anna Morris, Kymbalee Vander Hayden, Tara Burke, Matthew Bailey, Ross Freebairn, Lesley Chadwick, Penelope Park, Christine Rolls, Liz Thomas, Ulrike Buehner, Erin Williams, Jonathan Albrett, Simon Kirkham, Carolyn Jackson, Troy Browne, Jennifer Goodson, David Jackson, James Houghton, Owen Callender, Vicki Higson, Owen Keet, Clive Dominy, Paul Young, Anna Hunt, Harriet Judd, Cassie Lawrence, Shaanti Olatunji, Yvonne Robertson, Charlotte Latimer-Bell, Deborah Hendry, Agnes Mckay-Vucago, Nina Beehre, Eden Lesona, Leanlove Navarra, Chelsea Robinson, Ryan Jang, Andrea Junge, Bridget Lambert, Michel Thibault, Philippe Eckert, Sébastien Kissling, Erietta Polychronopoulos, Elettra Poli, Marco Altarelli, Madeleine Schnorf, Samia Abed Mallaird, Claudia Heidegger, Aurelie Perret, Philippe Montillier, Frederic Sangla, Seigenthaller Neils, Aude De Watteville, Mandeep-Kaur Phull, Aparna George, Nauman Hussain, Tatiana Pogreban, Steve Lobaz, Alison Daniels, Mishell Cunningham, Deborah Kerr, Alice Nicholson, Pradeep Shanmugasundaram, Judith Abrams, Katarina Manso, Geraldine Hambrook, Elizabeth McKerrow, Juvy Salva, Stephen Foulkes, Matthew Wise, Matt Morgan, Jenny Brooks, Jade Cole, Tracy Michelle Davies, Helen Hill, Emma Thomas, Marcela Vizcaychipi, Behrad Baharlo, Jaime Carungcong, Patricia Costa, Laura Martins, Ritoo Kapoor, Tracy Hazelton, Angela Moon, Janine Musselwhite, Ben Shelley, Philip McCall, Gill Arbane, Aneta Bociek, Martina Marotti, Rosario Lim, Sara Campos, Neus Grau Novellas, Armando Cennamo, Andrew Slack, Duncan Wyncoll, Luigi Camporota, Simon Sparkes, Rosalinde Tilley, Austin Rattray, Gayle Moreland, Jane Duffy, Elizabeth McGonigal, Philip Hopkins, Clare Finney, John Smith, Harriet Noble, Hayley Watson, Claire-Louise Harris, Emma Clarey, Eleanor Corcoran, James Beck, Clare Howcroft, Nora Youngs, Elizabeth Wilby, Bethan Ogg, Adam Wolverson, Sandra Lee, Susie Butler, Maryanne Okubanjo, Julia Hindle, Ingeborg Welters, Karen Williams, Emily Johnson, Julie Patrick-Heselton, David Shaw, Victoria Waugh, Richard Stewart, Esther Mwaura, Lynn Wren, Louise Mew, Sara-Beth Sutherland, Jane Adderley, Jim Ruddy, Margaret Harkins, Callum Kaye, Teresa Scott, Wendy Mitchell, Felicity Anderson, Fiona Willox, Vijay Jagannathan, Michele Clark, Sarah Purv, Andrew Sharman, Megan Meredith, Lucy Ryan, Louise Conner, Cecilia Peters, Dan Harvey, Ashraf Roshdy, Amy Collins, Malcolm Sim, Steven Henderson, Nigel Chee, Sally Pitts, Katie Bowman, Maria Dilawershah, Luke Vamplew, Elizabeth Howe, Paula Rogers, Clara Hernandez, Clara Prendergast, Jane Benton, Alex Rosenberg, Lui G. Forni, Alice Grant, Paula Carvelli, Ajay Raithatha, Sarah Bird, Max Richardson, Matthew Needham, Claire Hirst, Jonathan Ball, Susannah Leaver, Luisa Howlett, Carlos Castro Delgado, Sarah Farnell-Ward, Helen Farrah, Geraldine Gray, Gipsy Joseph, Francesca Robinson, Ascanio Tridente, Clare Harrop, Karen Shuker, Derek McLaughlan, Judith Ramsey, Sharon Meehan, Bernd Oliver Rose, Rosie Reece-Anthony, Babita Gurung, Tony Whitehouse, Catherine Snelson, Tonny Veenith, Andy Johnston, Lauren Cooper, Ron Carrera, Karen Ellis, Emma Fellows, Samanth Harkett, Colin Bergin, Elaine Spruce, Liesl Despy, Stephanie Goundry, Natalie Dooley, Tracy Mason, Amy Clark, Gemma Dignam, Geraldine Ward, Ben Attwood, Penny Parsons, Sophie Mason, Michael Margarson, Jenny Lord, Philip McGlone, Luke E. Hodgson, Indra Chadbourn, Raquel Gomez, Jordi Margalef, Rinus Pretorius, Alexandra Hamshere, Joseph Carter, Hazel Cahill, Lia Grainger, Kate Howard, Greg Forshaw, Zoe Guy, Kianoush B. Kashani, Robert C. Albright, Amy Amsbaugh, Anita Stoltenberg, Alexander S. Niven, Matthew Lynch, AnnMarie O'Mara, Syed Naeem, Sairah Sharif, Joyce McKenney Goulart, Ashita Tolwani, Claretha Lyas, Laura Latta, Azra Bihorac, Haleh Hashemighouchani, Philip Efron, Matthew Ruppert, Julie Cupka, Sean Kiley, Joshua Carson, Peggy White, George Omalay, Sherry Brown, Laura Velez, Alina Marceron, Javier A. Neyra, Juan Carlos Aycinena, Madona Elias, Victor M. Ortiz-Soriano, Caroline Hauschild, and Robert Dorfman
Subjects: Renal Replacement Therapy, Pulmonary and Respiratory Medicine, Critical Illness, Medicine and Health Sciences, Humans, Acute Kidney Injury
Published: 2022

19. Randomized Clinical Study of Temporary Transvenous Phrenic Nerve Stimulation in Difficult-to-Wean Patients

Author: Martin Dres, Marcelo Gama de Abreu, Hamid Merdji, Holger Müller-Redetzky, Dominic Dellweg, Winfried J. Randerath, Satar Mortaza, Boris Jung, Christian Bruells, Onnen Moerer, Martin Scharffenberg, Samir Jaber, Sébastien Besset, Thomas Bitter, Arnim Geise, Alexander Heine, Maximilian V. Malfertheiner, Andreas Kortgen, Jonathan Benzaquen, Teresa Nelson, Alexander Uhrig, Olaf Moenig, Ferhat Meziani, Alexandre Demoule, Thomas Similowski, François Beloncle, Pierre-Yves Olivier, Marie Lemerle, Pierre Asfar, Alain Mercat, Katharina Böllinger, Marc Giesa, Carmen Garcia, Till Jacobi, Nikolas Lambiris, Felix Machleid, Panagiotis Pergantis, Bastian Grube, Damien Roux, Santiago Freita Ramos, Noemie Zucman, Louis Marie Dumont, Laura Federici, Marc Amouretti, Jean-Damien Ricard, Didier Dreyfuss, Jakob Wittenstein, Andreas Güldner, Max Ragaller, Peter Spieth, Christopher Uhlig, Lars-Olav Harnisch, Frank Bloos, Daniel O. Thomas-Rüddel, Gérald Chanques, Mathieu Capdevila, Yassir Aarab, Fanny Garnier, Vincent Brunot, Kada Klouche, Valérie Moulaire, Philippe Corne, Fernand Macone, François Durand, Charles Hugo Marquette, Julie Delemazure, Julien Mayaux, Elise Morawiec, Alexandra Monnier, Hassene Rahmani, Louise-Marie Jandeaux, Antoine Studer, Julie Helms, and Raphaël Clere-Jehl
Subjects: Pulmonary and Respiratory Medicine, Critical Care and Intensive Care Medicine
Published: 2022

20. Extracorporeal Kidney-Replacement Therapy for Acute Kidney Injury

Author: Stéphane Gaudry, Paul M. Palevsky, and Didier Dreyfuss
Subjects: General Medicine
Published: 2022

21. Heat and Moisture Exchangers (HMEs)

Author: Jean-Damien Ricard, Alexandre Boyer, and Didier Dreyfuss
Published: 2023

22. Integration of Equipoise into Eligibility Criteria in the STARRT-AKI Trial

Author: Ron Wald, Sean M. Bagshaw, Neill K. J. Adhikari, Rinaldo Bellomo, Didier Dreyfuss, Bin Du, Martin P. Gallagher, Stéphane Gaudry, Eric A. Hoste, François Lamontagne, Michael Joannidis, Kathleen D. Liu, Daniel F. McAuley, Shay P. McGuinness, Alistair D. Nichol, Marlies Ostermann, Paul M. Palevsky, Haibo Qiu, Ville Pettilä, Antoine G. Schneider, Orla M. Smith, Suvi Vaara, and Matthew Weir
Subjects: Pulmonary and Respiratory Medicine, medicine.medical_specialty, Randomized controlled trial, law, business.industry, medicine.medical_treatment, medicine, Generalizability theory, Renal replacement therapy, Critical Care and Intensive Care Medicine, Intensive care medicine, business, law.invention
Published: 2021

23. Are bedside colonoscopies performed in intensive care unit really useful?

Author: Didier Dreyfuss, Matthieu Le Meur, Tazime Issoufaly, Dominique Prat, Jonathan Messika, Benjamin Sztrymf, Mohammed Laissi, Benoit Coffin, Guillaume Berquier, Heithem Soliman, Jean-Damien Ricard, and Henri Duboc
Subjects: medicine.medical_specialty, medicine.diagnostic_test, business.industry, Critically ill, Critical Illness, Colonoscopy, 030208 emergency & critical care medicine, Critical Care and Intensive Care Medicine, Intensive care unit, Poor quality, law.invention, Intensive Care Units, 03 medical and health sciences, 0302 clinical medicine, 030228 respiratory system, law, Emergency medicine, Humans, Medicine, Observational study, Gastrointestinal Hemorrhage, business, Aged, Retrospective Studies
Abstract: Effectiveness of bedside Colonoscopies in Intensive Care Unit (CICU) might be limited by the poor quality of colonic preparation, and their feasibility. We sought to describe the indications and the profitability of CICU.Retrospective, bicenter observational study (2004-2015) in unselected critically ill patients. We questioned the clinical profitability of CICU, according to its indications and preparation.One hundred and eleven CICU were performed in 84 patients (sex ratio 1.4, 49 M/35F; age 72.9 years [61.7-84.7]), for lower gastro-intestinal bleeding in 67 patients (LGIB, 60.3%) and for other causes in 44 (39.6%). The profitability was more frequent when CICU was performed for another reason than LGIB (75% vs 28.3%; p 0.0001). Preparation was good in 47 procedures (42.3%) and allowed 33 complete CICU (29.7%). Fifty-six CICU (50.4%) were performed as a 2nd investigation after a contrast enhanced computed tomography. Three CICU were complicated by 3 hemodynamic and 2 respiratory failures, but none of them were fatal.CICU is clinically useful in half of cases, in the diagnostic and the therapeutic management of critically ill patients. Its profitability is close to scheduled colonoscopies and superior in non-lower gastro-intestinal bleeding indications.
Published: 2021

24. Comparison of two delayed strategies for renal replacement therapy initiation for severe acute kidney injury (AKIKI 2): a multicentre, open-label, randomised, controlled trial

Author: Nicolas de Prost, Saber Barbar, Stéphane Gaudry, Jean-Pierre Quenot, Christophe Vinsonneau, Laurent Argaud, Eric Boulet, Didier Thevenin, Didier Dreyfuss, Marion Beuzelin, Adrien Robine, Cyril Cadoz, Steven Grangé, Béatrice La Combe, Dimitri Titeca-Beauport, Julien Mayaux, Julio Badie, Saad Nseir, Guillaume Chevrel, Karim Asehnoune, Florent Poirson, Kada Klouche, Sébastien Moschietto, Guillaume Louis, Guillaume Thiery, Marc Leone, David Hajage, Pascal Andreu, Elisabeth Coupez, Bertrand Pons, Said Lebbah, Jean-Damien Ricard, Jean-Marie Forel, Laurent Martin-Lefevre, Julien Bohé, Guillaume Geri, Sébastien Besset, Karim Lakhal, Nicolas Chudeau, Alain Combes, Bertrand Rozec, Nadia Aissaoui, Guillaume Lacave, Jean Reignier, CarMeN, laboratoire, Hôpital Avicenne [AP-HP], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP), UFR Santé, Médecine et Biologie Humaine (UFR SMBH), Université Sorbonne Paris Nord, AP-HP - Hôpital Bichat - Claude Bernard [Paris], Centre de Pharmacoépidémiologie de l'AP-HP (Cephepi), CHU Pitié-Salpêtrière [AP-HP], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU)-Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU), Institut Pierre Louis d'Epidémiologie et de Santé Publique (iPLESP), Institut National de la Santé et de la Recherche Médicale (INSERM)-Sorbonne Université (SU), Centre Hospitalier Départemental - Hôpital de La Roche-sur-Yon (CHD Vendée), Laboratoire Informatique, Image et Interaction - EA 2118 (L3I), La Rochelle Université (ULR), Centre Hospitalier Henri Duffaut (Avignon), CHU Amiens-Picardie, Université de Bretagne Sud - Lorient (UBS Lorient), Université de Bretagne Sud (UBS), Centre d'Etudes Lasers Intenses et Applications (CELIA), Université de Bordeaux (UB)-Commissariat à l'énergie atomique et aux énergies alternatives (CEA)-Centre National de la Recherche Scientifique (CNRS), Hôpital Henri Mondor, Laboratoire Sciences Analytiques, Bioanalytiques, et Miniaturisation (LSABM), Chimie-Biologie-Innovation (UMR 8231) (CBI), Ecole Superieure de Physique et de Chimie Industrielles de la Ville de Paris (ESPCI Paris), Université Paris sciences et lettres (PSL)-Université Paris sciences et lettres (PSL)-Institut de Chimie du CNRS (INC)-Centre National de la Recherche Scientifique (CNRS)-Ecole Superieure de Physique et de Chimie Industrielles de la Ville de Paris (ESPCI Paris), Université Paris sciences et lettres (PSL)-Université Paris sciences et lettres (PSL)-Institut de Chimie du CNRS (INC)-Centre National de la Recherche Scientifique (CNRS), Centre hospitalier de Dieppe, CH Belfort-Montbéliard, Centre Hospitalier Sud Francilien, Centre Hospitalier Lyon Sud [CHU - HCL] (CHLS), Hospices Civils de Lyon (HCL), CHU Gabriel Montpied [Clermont-Ferrand], CHU Clermont-Ferrand, Centre Hospitalier Le Mans (CH Le Mans), Hôpital Universitaire Carémeau [Nîmes] (CHU Nîmes), Centre Hospitalier Universitaire de Nîmes (CHU Nîmes), Assistance Publique - Hôpitaux de Marseille (APHM), Centre Hospitalier de Lens, Centre Hospitalier Régional Universitaire [Montpellier] (CHRU Montpellier), Hôpital Européen Georges Pompidou [APHP] (HEGP), Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Hôpitaux Universitaires Paris Ouest - Hôpitaux Universitaires Île de France Ouest (HUPO), Géomécanique, Matériaux et Structures (GEOMAS), Institut National des Sciences Appliquées de Lyon (INSA Lyon), Université de Lyon-Institut National des Sciences Appliquées (INSA)-Université de Lyon-Institut National des Sciences Appliquées (INSA), Microbes évolution phylogénie et infections (MEPHI), Institut de Recherche pour le Développement (IRD)-Aix Marseille Université (AMU)-Centre National de la Recherche Scientifique (CNRS), Service Anesthésie et Réanimation [Hôpital Nord - APHM], Aix Marseille Université (AMU)-Assistance Publique - Hôpitaux de Marseille (APHM)- Hôpital Nord [CHU - APHM], Centre Hospitalier de Versailles André Mignot (CHV), Centre d'Investigation Clinique - Innovation Technologique de Lille - CIC 1403 - CIC 9301 (CIC Lille), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Lille-Centre Hospitalier Régional Universitaire [Lille] (CHRU Lille), Centre hospitalier universitaire de Nantes (CHU Nantes), Hôpital Ambroise Paré [AP-HP], Physiologie & médecine expérimentale du Cœur et des Muscles [U 1046] (PhyMedExp), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Montpellier (UM)-Centre National de la Recherche Scientifique (CNRS), Centre Hospitalier Universitaire de Saint-Etienne (CHU de Saint-Etienne), Cardiovasculaire, métabolisme, diabétologie et nutrition (CarMeN), Université Claude Bernard Lyon 1 (UCBL), Université de Lyon-Université de Lyon-Hospices Civils de Lyon (HCL)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Institut National de Recherche pour l’Agriculture, l’Alimentation et l’Environnement (INRAE), Centre hospitalier régional Metz-Thionville (CHR Metz-Thionville), Service de Réanimation Médicale (CHU de Dijon), Centre Hospitalier Universitaire de Dijon - Hôpital François Mitterrand (CHU Dijon), Hôpital Louis Mourier - AP-HP [Colombes], Infection, Anti-microbiens, Modélisation, Evolution (IAME (UMR_S_1137 / U1137)), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université Paris Cité (UPCité)-Université Sorbonne Paris Nord, Programme Hospitalier de Recherche Clinique., Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU), Centre Hospitalier Universitaire de Saint-Etienne [CHU Saint-Etienne] (CHU ST-E), Sorbonne Université (SU)-Institut National de la Santé et de la Recherche Médicale (INSERM), Centre Hospitalier Départemental - Hôpital de La Roche-sur-Yon, Université de La Rochelle (ULR), Département de Rhumatologie[Montpellier], Centre Hospitalier Régional Universitaire [Montpellier] (CHRU Montpellier)-Hôpital Lapeyronie, Centre National de la Recherche Scientifique (CNRS)-Commissariat à l'énergie atomique et aux énergies alternatives (CEA)-Université de Bordeaux (UB), Laboratoire de Tribologie et Dynamique des Systèmes (LTDS), École Centrale de Lyon (ECL), Université de Lyon-Université de Lyon-École Nationale des Travaux Publics de l'État (ENTPE)-Ecole Nationale d'Ingénieurs de Saint Etienne-Centre National de la Recherche Scientifique (CNRS), Institut de Chimie du CNRS (INC)-Centre National de la Recherche Scientifique (CNRS)-Ecole Superieure de Physique et de Chimie Industrielles de la Ville de Paris (ESPCI Paris), Université Paris sciences et lettres (PSL)-Université Paris sciences et lettres (PSL), Centre Hospitalier Fleyriat [Bourg en Bresse], Centre Hospitalier Sud Francilien [Corbeil-Essonnes] (CH Sud Francilien), Centre Hospitalier de Béthune Beuvry (CH Béthune Beuvry), Hôpital Nord [CHU - APHM], GH Carnelle Portes de l'Oise, Hôpital Lapeyronie [Montpellier] (CHU), and Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Paris (UP)-Université Sorbonne Paris Nord
Subjects: medicine.medical_specialty, MESH: Acute Kidney Injury, [SDV]Life Sciences [q-bio], medicine.medical_treatment, Population, 030204 cardiovascular system & hematology, urologic and male genital diseases, MESH: Severity of Illnes Index, 03 medical and health sciences, MESH: Aged, 80 and over, 0302 clinical medicine, Oliguria, Intensive care, Internal medicine, Medicine, MESH: Time-to-Treatment, 030212 general & internal medicine, Renal replacement therapy, education, Blood urea nitrogen, MESH: Aged, education.field_of_study, MESH: Humans, MESH: Middle Aged, business.industry, Hazard ratio, Acute kidney injury, General Medicine, medicine.disease, MESH: Male, MESH: Prospective Studies, 3. Good health, [SDV] Life Sciences [q-bio], MESH: France, MESH: Intensive Care Units, medicine.symptom, MESH: Renal Remplacement Therapy, business, MESH: Female, Kidney disease
Abstract: International audience; BACKGROUND: Delaying renal replacement therapy (RRT) for some time in critically ill patients with severe acute kidney injury and no severe complication is safe and allows optimisation of the use of medical devices. Major uncertainty remains concerning the duration for which RRT can be postponed without risk. Our aim was to test the hypothesis that a more-delayed initiation strategy would result in more RRT-free days, compared with a delayed strategy. METHODS: This was an unmasked, multicentre, prospective, open-label, randomised, controlled trial done in 39 intensive care units in France. We monitored critically ill patients with severe acute kidney injury (defined as Kidney Disease: Improving Global Outcomes stage 3) until they had oliguria for more than 72 h or a blood urea nitrogen concentration higher than 112 mg/dL. Patients were then randomly assigned (1:1) to either a strategy (delayed strategy) in which RRT was started just after randomisation or to a more-delayed strategy. With the more-delayed strategy, RRT initiation was postponed until mandatory indication (noticeable hyperkalaemia or metabolic acidosis or pulmonary oedema) or until blood urea nitrogen concentration reached 140 mg/dL. The primary outcome was the number of days alive and free of RRT between randomisation and day 28 and was done in the intention-to-treat population. The study is registered with ClinicalTrial.gov, NCT03396757 and is completed. FINDINGS: Between May 7, 2018, and Oct 11, 2019, of 5336 patients assessed, 278 patients underwent randomisation; 137 were assigned to the delayed strategy and 141 to the more-delayed strategy. The number of complications potentially related to acute kidney injury or to RRT were similar between groups. The median number of RRT-free days was 12 days (IQR 0-25) in the delayed strategy and 10 days (IQR 0-24) in the more-delayed strategy (p=0·93). In a multivariable analysis, the hazard ratio for death at 60 days was 1·65 (95% CI 1·09-2·50, p=0·018) with the more-delayed versus the delayed strategy. The number of complications potentially related to acute kidney injury or renal replacement therapy did not differ between groups. INTERPRETATION: In severe acute kidney injury patients with oliguria for more than 72 h or blood urea nitrogen concentration higher than 112 mg/dL and no severe complication that would mandate immediate RRT, longer postponing of RRT initiation did not confer additional benefit and was associated with potential harm. FUNDING: Programme Hospitalier de Recherche Clinique.
Published: 2021

25. What's wrong with the ten myths about albumin: three layers for an indisputable dispute

Author: Khalil, Chaïbi, Stephane, Gaudry, Didier, Dreyfuss, and Thomas Edward, Woodcock
Subjects: Albumins, Humans, Dissent and Disputes
Published: 2022

26. Computer clinical decision support that automates personalized clinical care: a challenging but needed healthcare delivery strategy

Author: Alan H Morris, Christopher Horvat, Brian Stagg, David W Grainger, Michael Lanspa, James Orme, Terry P Clemmer, Lindell K Weaver, Frank O Thomas, Colin K Grissom, Ellie Hirshberg, Thomas D East, Carrie Jane Wallace, Michael P Young, Dean F Sittig, Mary Suchyta, James E Pearl, Antinio Pesenti, Michela Bombino, Eduardo Beck, Katherine A Sward, Charlene Weir, Shobha Phansalkar, Gordon R Bernard, B Taylor Thompson, Roy Brower, Jonathon Truwit, Jay Steingrub, R Duncan Hiten, Douglas F Willson, Jerry J Zimmerman, Vinay Nadkarni, Adrienne G Randolph, Martha A Q Curley, Christopher J L Newth, Jacques Lacroix, Michael S D Agus, Kang Hoe Lee, Bennett P deBoisblanc, Frederick Alan Moore, R Scott Evans, Dean K Sorenson, Anthony Wong, Michael V Boland, Willard H Dere, Alan Crandall, Julio Facelli, Stanley M Huff, Peter J Haug, Ulrike Pielmeier, Stephen E Rees, Dan S Karbing, Steen Andreassen, Eddy Fan, Roberta M Goldring, Kenneth I Berger, Beno W Oppenheimer, E Wesley Ely, Brian W Pickering, David A Schoenfeld, Irena Tocino, Russell S Gonnering, Peter J Pronovost, Lucy A Savitz, Didier Dreyfuss, Arthur S Slutsky, James D Crapo, Michael R Pinsky, Brent James, and Donald M Berwick
Subjects: decision-support, closed-loop, Computers, clinicians, Health Informatics, Decision Support Systems, Clinical, automated clinical care, Delivery of Health Care, clinical
Abstract: How to deliver best care in various clinical settings remains a vexing problem. All pertinent healthcare-related questions have not, cannot, and will not be addressable with costly time- and resource-consuming controlled clinical trials. At present, evidence-based guidelines can address only a small fraction of the types of care that clinicians deliver. Furthermore, underserved areas rarely can access state-of-the-art evidence-based guidelines in real-time, and often lack the wherewithal to implement advanced guidelines. Care providers in such settings frequently do not have sufficient training to undertake advanced guideline implementation. Nevertheless, in advanced modern healthcare delivery environments, use of eActions (validated clinical decision support systems) could help overcome the cognitive limitations of overburdened clinicians. Widespread use of eActions will require surmounting current healthcare technical and cultural barriers and installing clinical evidence/data curation systems. The authors expect that increased numbers of evidence-based guidelines will result from future comparative effectiveness clinical research carried out during routine healthcare delivery within learning healthcare systems.
Published: 2022

27. Timing of Initiation of Renal-Replacement Therapy in Acute Kidney Injury

Author: Starrt-Aki Investigators, Jean-Pierre Quenot, Bin Du, Paul J Young, Bruno R. da Costa, Stéphane Gaudry, Sean M. Bagshaw, Michael Joannidis, Eric Hoste, Haibo Qiu, Bram Rochwerg, Daniel F. McAuley, Didier Dreyfuss, Ron Wald, Antoine G. Schneider, Matthew A. Weir, Rinaldo Bellomo, Neill K.J. Adhikari, Kathleen D. Liu, Fernando Thomé, Marlies Ostermann, Suvi T. Vaara, Kevin E. Thorpe, Martin Gallagher, Amanda Y. Wang, Alexander Zarbock, Javier A. Neyra, Shay McGuinness, Francois Lamontagne, Ville Pettilä, Paul M. Palevsky, Orla Smith, Alistair Nichol, Giovanni Landoni, Bagshaw, S. M., Wald, R., Adhikari, N. K. J., Bellomo, R., da Costa, B. R., Dreyfuss, D., Du, B., Gallagher, M. P., Gaudry, S., Hoste, E. A., Lamontagne, F., Joannidis, M., Landoni, G., Liu, K. D., Mcauley, D. F., Mcguinness, S. P., Neyra, J. A., Nichol, A. D., Ostermann, M., Palevsky, P. M., Pettila, V., Quenot, J. -P., Qiu, H., Rochwerg, B., Schneider, A. G., Smith, O. M., Thome, F., Thorpe, K. E., Vaara, S., Weir, M., Wang, A. Y., Young, P., Zarbock, A (STARRT-AKI Investigators), and Zangrillo, A
Subjects: medicine.medical_specialty, medicine.medical_treatment, 610 Medicine & health, 030204 cardiovascular system & hematology, Lower risk, law.invention, 03 medical and health sciences, 0302 clinical medicine, Randomized controlled trial, 360 Social problems & social services, law, Internal medicine, DIALYSIS, Medicine and Health Sciences, medicine, 030212 general & internal medicine, Renal replacement therapy, Adverse effect, Dialysis, Intention-to-treat analysis, business.industry, MORTALITY, Acute kidney injury, General Medicine, medicine.disease, TRIALS, Relative risk, business, CRITICALLY-ILL PATIENTS
Abstract: Background Acute kidney injury is common in critically ill patients, many of whom receive renal-replacement therapy. However, the most effective timing for the initiation of such therapy remains uncertain. Methods We conducted a multinational, randomized, controlled trial involving critically ill patients with severe acute kidney injury. Patients were randomly assigned to receive an accelerated strategy of renal-replacement therapy (in which therapy was initiated within 12 hours after the patient had met eligibility criteria) or a standard strategy (in which renal-replacement therapy was discouraged unless conventional indications developed or acute kidney injury persisted for >72 hours). The primary outcome was death from any cause at 90 days. Results Of the 3019 patients who had undergone randomization, 2927 (97.0%) were included in the modified intention-to-treat analysis (1465 in the accelerated-strategy group and 1462 in the standard-strategy group). Of these patients, renal-replacement therapy was performed in 1418 (96.8%) in the accelerated-strategy group and in 903 (61.8%) in the standard-strategy group. At 90 days, death had occurred in 643 patients (43.9%) in the accelerated-strategy group and in 639 (43.7%) in the standard-strategy group (relative risk, 1.00; 95% confidence interval [CI], 0.93 to 1.09; P=0.92). Among survivors at 90 days, continued dependence on renal-replacement therapy was confirmed in 85 of 814 patients (10.4%) in the accelerated-strategy group and in 49 of 815 patients (6.0%) in the standard-strategy group (relative risk, 1.74; 95% CI, 1.24 to 2.43). Adverse events occurred in 346 of 1503 patients (23.0%) in the accelerated-strategy group and in 245 of 1489 patients (16.5%) in the standard-strategy group (P
Published: 2020

28. Evolution du capacitaire et des ressources humaines en réanimation après la première vague de la pandémie COVID-19 : une enquête du Syndicat des Médecins Réanimateurs

Author: Syndicat des Médecins Réanimateurs SMR, Laura Federici, Olivier Lesieur, Arnaud Sement, Jean-Luc Chagnon, Jean-Philippe Rigaud, Jean-Luc Diehl, Didier Dreyfuss, Philippe Guiot, Nicolas Joram, Hervé Outin, Chantal Sevens, Didier Thévenin, Samia Touati, Djillali Annane, and Nicolas Terzi
Subjects: Emergency Medicine, Emergency Nursing
Abstract: La France a connu au printemps 2020 une crise sanitaire sans précédent sur les plans sanitaire et sociétal due à la pandémie de COVID-19. Lors de cette première vague les hôpitaux ont fait face à un afflux important de patients dans les secteurs de Réanimation. Des mesures exceptionnelles ont été mises en place, pour permettre au système de soins de tenir. Au sortir de cette première vague des propositions ont été faites afin d’optimiser l’organisation des Soins Critiques. Dans ce contexte, nous avons mené une enquête auprès des services de Réanimation français en Janvier 2021, destinée à produire un état des lieux. L’objectif principal de cette enquête était de déterminer si les mesures revendiquées par les soignants et affichées par l’exécutif étaient effectives. Nous avons mené une enquête déclarative visant à établir l’état des lieux des lits de Réanimation et des effectifs soignants avant et après la première vague de la pandémie à COVID-19 en France. Nous avons ainsi pu démontré qu’aucun des lits supplémentaires ouverts pendant la première vague épidémique n’a été pérennisé. Plus inquiétant, 13% des 114 services répondeurs soulignent que le ratio d’une infirmière pour 2,5 patients n’est pas respecté par manque de personnels formés et disponibles. Ces éléments confirment qu’à l’heure actuelle, aucune mesure n’a été prise pour améliorer un capacitaire historiquement et conjoncturellement déficitaire. Cette indispensable correction ne pourra s’opérer qu’avec le recrutement, la formation et la stabilisation d’équipes soignantes spécialisées, médicales et paramédicales.
Published: 2022

29. The AKIKI 2 trial: a case for strategy of initiation instead of timing - Authors' reply

Author: David Hajage, Jean-Pierre Quenot, Didier Dreyfuss, Stéphane Gaudry, and Guillaume Louis
Subjects: Renal Replacement Therapy, medicine.medical_specialty, business.industry, MEDLINE, Medicine, Humans, General Medicine, Acute Kidney Injury, business, Intensive care medicine
Published: 2021

30. Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions

Author: Jacques Lacroix, Roy G. Brower, Katherine A. Sward, Derek C. Angus, Jay S. Steingrub, Arthur S. Slutsky, Stanley M. Huff, Jonathon D. Truwit, Antonio Pesenti, Kenneth I. Berger, Ognjen Gajic, Adrienne G. Randolph, Beno W. Oppenheimer, E. Wesley Ely, Brent C. James, Bennett P. deBoisblanc, James F. Orme, Alan H. Morris, Thomas D. East, Steen Andreassen, Charlene R. Weir, Anthony Wong, Peter J. Pronovost, Michael V. Boland, Vinay M. Nadkarni, Lindell K. Weaver, Lucy Savitz, Dean F. Sittig, Julio C. Facelli, Alan S. Crandall, Colin K. Grissom, Ellie Hirshberg, David W. Grainger, R. Duncan Hite, Jerry J. Zimmerman, Michael S. D. Agus, Gordon R. Bernard, B. Taylor Thompson, Christopher J. L. Newth, Douglas F. Willson, Shobha Phansalkar, Didier Dreyfuss, Stephen Edward Rees, Willard H. Dere, Carrie Jane Wallace, Eduardo Beck, Roberta M. Goldring, R. Scott Evans, Brian C. Stagg, Martha A. Q. Curley, Dean K. Sorenson, Russell S. Gonnering, Brian W. Pickering, David A. Schoenfeld, Dan Stieper Karbing, Irena Tocino, Eddy Fan, Michael P. Young, Michela Bombino, Michael J. Lanspa, James D. Crapo, Michael R. Pinsky, Ulrike Pielmeier, Frank Thomas, Kang H. Lee, Terry P. Clemmer, Donald M. Berwick, and Peter J. Haug
Subjects: Medical education, Computers, business.industry, media_common.quotation_subject, Clinical Decision-Making, MEDLINE, Health Informatics, Cognition, Context (language use), Documentation, Burnout, Learning Health System, Action (philosophy), Perspective, Health care, Electronic Health Records, Humans, Quality (business), Psychology, business, media_common
Abstract: Clinical decision-making is based on knowledge, expertise, and authority, with clinicians approving almost every intervention—the starting point for delivery of “All the right care, but only the right care,” an unachieved healthcare quality improvement goal. Unaided clinicians suffer from human cognitive limitations and biases when decisions are based only on their training, expertise, and experience. Electronic health records (EHRs) could improve healthcare with robust decision-support tools that reduce unwarranted variation of clinician decisions and actions. Current EHRs, focused on results review, documentation, and accounting, are awkward, time-consuming, and contribute to clinician stress and burnout. Decision-support tools could reduce clinician burden and enable replicable clinician decisions and actions that personalize patient care. Most current clinical decision-support tools or aids lack detail and neither reduce burden nor enable replicable actions. Clinicians must provide subjective interpretation and missing logic, thus introducing personal biases and mindless, unwarranted, variation from evidence-based practice. Replicability occurs when different clinicians, with the same patient information and context, come to the same decision and action. We propose a feasible subset of therapeutic decision-support tools based on credible clinical outcome evidence: computer protocols leading to replicable clinician actions (eActions). eActions enable different clinicians to make consistent decisions and actions when faced with the same patient input data. eActions embrace good everyday decision-making informed by evidence, experience, EHR data, and individual patient status. eActions can reduce unwarranted variation, increase quality of clinical care and research, reduce EHR noise, and could enable a learning healthcare system.
Published: 2021

31. Severe Acute Kidney Injury in Patients with COVID-19 and Acute Respiratory Distress Syndrome

Author: Víctor Daniel Gumucio-Sanguino, Didier Dreyfuss, Stéphane Gaudry, Fabio A. Di Paolo, Khalil Chaïbi, Xose L. Perez-Fernandez, Myriam Dao, Arthur Pavot, Tài Pham, and Yves Cohen
Subjects: Pulmonary and Respiratory Medicine, medicine.medical_specialty, 2019-20 coronavirus outbreak, Coronavirus disease 2019 (COVID-19), biology, business.industry, Incidence (epidemiology), Acute kidney injury, Acute respiratory distress, Critical Care and Intensive Care Medicine, medicine.disease, biology.organism_classification, Internal medicine, Pandemic, Correspondence, medicine, In patient, business, Betacoronavirus
Published: 2020

32. Quel effectif médical dans les services de réanimation et surveillance continue en France ? Une position du syndicat des médecins réanimateurs des hôpitaux publics

Author: Jean-Philippe Rigaud, Nicolas Terzi, Jean-Luc Chagnon, Benoit Misset, Hervé Outin, Olivier Lesieur, Djillali Annane, Jean Luc Diehl, Jonathan Messika, Samia Touati, Laetitia Bodet-Contentin, Didier Dreyfuss, Didier Thevenin, and A. Sement
Subjects: Emergency Medicine, Emergency Nursing
Published: 2019

33. Timing of Renal Replacement Therapy for Severe Acute Kidney Injury in Critically Ill Patients

Author: Didier Dreyfuss, David Hajage, Jean-Pierre Quenot, Saber Barbar, Jean-Damien Ricard, Stéphane Gaudry, and Alexandre Hertig
Subjects: Pulmonary and Respiratory Medicine, medicine.medical_specialty, Hyperkalemia, medicine.medical_treatment, Renal function, urologic and male genital diseases, Critical Care and Intensive Care Medicine, law.invention, 03 medical and health sciences, 0302 clinical medicine, Randomized controlled trial, law, medicine, 030212 general & internal medicine, Renal replacement therapy, Intensive care medicine, business.industry, Acute kidney injury, medicine.disease, Pulmonary edema, female genital diseases and pregnancy complications, 030228 respiratory system, Observational study, medicine.symptom, business, Watchful waiting
Abstract: Acute kidney injury (AKI) affects many ICU patients and is responsible for increased morbidity and mortality. Although lifesaving in many situations, renal replacement therapy (RRT) may be associated with complications, and the appropriate timing of its initiation is still the subject of intense debate. An early initiation strategy can prevent some metabolic complications, whereas a delayed one may allow for renal function recovery in some patients without need for this costly and potentially dangerous technique. For years, most of the knowledge on this issue stemmed from observational studies or small randomized controlled trials. Recent randomized controlled trials have indicated that a watchful waiting strategy (in the absence of life-threatening conditions such as severe hyperkalemia or pulmonary edema) during severe AKI allowed many patients to escape RRT and did not seem to adversely affect survival compared with a strategy of immediate RRT. In addition, data suggest that a delayed strategy may reduce the rate of complications (such as catheter infection) and favor renal function recovery. Ongoing studies will have to both confirm these conclusions and clarify to what extent the delay in initiating RRT can be prolonged. Pending those results, the bulk of evidence suggests that, in the absence of potential severe complications of AKI, delaying RRT is a valid and safe strategy that may also allow for considerable cost savings.
Published: 2019

34. Retarder une épuration extrarénale dans l’insuffisance rénale aiguë : la nuit nous appartient

Author: Khalil Chaïbi, S.D. Barbar, Didier Dreyfuss, Jean-Pierre Quenot, and Stéphane Gaudry
Subjects: 03 medical and health sciences, 0302 clinical medicine, Emergency Medicine, 030208 emergency & critical care medicine, 030212 general & internal medicine, Emergency Nursing
Abstract: Les indications de l’épuration extrarénale (EER) dans le contexte d’insuffisance rénale aiguë en réanimation sont débattues avec une certaine passion. Il est évident que les situations qui peuvent menacer immédiatement le pronostic vital (hyperkaliémie ou acidose métabolique réfractaire et sévère ou oedème pulmonaire de surcharge chez le patient anurique) nécessitent un recours urgent à l’EER. Hormis ces situations extrêmes, des études de haut niveau de preuve ont récemment montré que retarder l’indication de l’EER n’affecte pas la survie des patients et pourrait même favoriser la récupération de la fonction rénale par comparaison à une EER trop précoce. Cette mise au point se propose de discuter les risques théoriques liés au fait de différer l’EER et s’attache à montrer qu’ils constituent plus des craintes que des réalités.
Published: 2019

35. Extracorporeal membrane oxygenation network organisation and clinical outcomes during the COVID-19 pandemic in Greater Paris, France: a multicentre cohort study

Author: Guillaume Lebreton, Matthieu Schmidt, Maharajah Ponnaiah, Thierry Folliguet, Marylou Para, Julien Guihaire, Emmanuel Lansac, Edouard Sage, Bernard Cholley, Bruno Mégarbane, Pierrick Cronier, Jonathan Zarka, Daniel Da Silva, Sebastien Besset, Tristan Morichau-Beauchant, Igor Lacombat, Nicolas Mongardon, Christian Richard, Jacques Duranteau, Charles Cerf, Gabriel Saiydoun, Romain Sonneville, Jean-Daniel Chiche, Patrick Nataf, Dan Longrois, Alain Combes, Pascal Leprince, Charles JUVIN, Thibault SCHOELL, Cosimo D'Alessandro, Sofica MARIN, Nathalie NARDONE, Pierre DEMONDION, Horacio MEYER, Karl BOUNADER, Alexander MOIROUX, Ali AKAMKAM, Guillaume FADEL, Erwan RANDRIANALISOA, Sébastien CUSQUEL, Patrice LE GLOAHEC, Elisabeth HIRSCHAUER, Fabrice MUSQUET, Pierre-Marie Jego, Hélène Guedes, Théophile Roy, Lina Mercereau, Emmanuel Corvol, Anne Laboure, Flore Vilanove, Marco Peperoni, Dariène Machado, Aly Sely, Marion Fortanier, Séverine Gantois, Emilie Tran, Elisabeth Bosq, Aurélie Fontanier, Alice Morin, Jocelyne Cousin, Stéphanie Bovagnet, Charles Edouard Luyt, Guillaume Hekimian, Nicolas Brechot, Marc Pineton de Chambrun, Cyrielle Desnos, Juliette Chomeloux, Jeremy Arzoine, Emmanuelle Guerin, Antoine Monsel, Guillaume Voiriot, David Levy, Elodie Baron, Alexandra Beurton, Juliette Chommeloux, Meng Paris, Safaa Nemlaghi, Pierre Bay, Alexandre Demoule, Bertrand Guidet, Jean Michel Constantin, Muriel Fartoukh, Martin Dres, Guillaume Franchineau, Lucie Le Fevre, Richard Raffoul, Soleiman Alkhoder, Walid Ghodbane, Angelo Pisani, Wael Braham, Ali Bessem Gara, Pierre MORDANT, Yves-Hervé CASTIER, Etienne de MONTMOLLIN, Lila BOUADMA, Jean-François TIMSIT, Olivier Langeron, Quentin de Roux, Claire Alessandri, Margot Arminot-Frémaux, Simon Clariot, Thomas Dessalle, Agathe Kudela, André Ly, Arnaud Meffert, Elena Skripkina, Antonio Fiore, Costin Radu, Eleonora Dupuy-Montbrun, Christian Latremouille, Olaf Mercier, Philippe Deleuze, François STEPHAN, Marie Werner, Jean-Louis Teboul, Xavier Monnet, Hassan Debbagh, Alain Chapelier, Julien De Wolf, Matthieu Glorion, Ciprian Pricopi, Francesco Cassiano, Sébastien Jacquemin, Guillaume Tachon, François Parquin, Benjamin Zuber, Alain Carriou, Jean-Paul Mira, Julien Charpentier, Frederic Pene, Lee Nguyen, Sébastian Voicu, Nicolas Deye, Isabelle Malissin, Laetitia Sutterlin, Giulia Naim, Adrien Pépin-Lehalleur, Aymen Mrad, Jean-Michel Ekhérian, Philippe Nguyen, Georgios Sidéris, Dominique Vodovar, Caroline Grant, Mattéo Arcelli, Alban Copie, Zaccaria Errabih, Antoine Gonde, Adèle Magalhaes, Edouard Meurisse, Kiyoko Nitenberg, Arthur Perault, Lucile Perrin, Maxime Renaux, Sophie Marqué, Luis Ensenyat-Martin, Eric Delpierre, Matthieu Duprey, Daniel da Silva, Bruno Verdière, Julien Amour, Marina Clément, Yves Ollivier, Fabrice Daviaud, Camille Le Breton, Santiago Freita-Ramos, Marc Amouretti, Pierre Antoine Billiet, Myriam Dao, Louis Marie Dumont, Laura Federici, Baptiste Gaborieau, Pierre Postel-Vinay, Constance Vuillard, Noémie Zucman, Didier Dreyfuss, Jean Damien Ricard, Damien Roux, Unité de Recherche sur les Maladies Cardiovasculaires, du Métabolisme et de la Nutrition = Research Unit on Cardiovascular and Metabolic Diseases [IHU ICAN], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Sorbonne Université (SU)-Institut de Cardiométabolisme et Nutrition = Institute of Cardiometabolism and Nutrition [CHU Pitié Salpêtrière] (IHU ICAN), CHU Pitié-Salpêtrière [AP-HP], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU)-Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU)-CHU Pitié-Salpêtrière [AP-HP], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU), Hôpital Henri Mondor, Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Hôpital Henri Mondor-Université Paris-Est Créteil Val-de-Marne - Paris 12 (UPEC UP12), Laboratoire de Recherche Vasculaire Translationnelle (LVTS (UMR_S_1148 / U1148)), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université Paris Cité (UPCité)-Université Sorbonne Paris Nord, AP-HP - Hôpital Bichat - Claude Bernard [Paris], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP), Hôpital Marie-Lannelongue, Institut Mutualiste de Montsouris (IMM), Hôpital Foch [Suresnes], Hôpital Européen Georges Pompidou [APHP] (HEGP), Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Hôpitaux Universitaires Paris Ouest - Hôpitaux Universitaires Île de France Ouest (HUPO), Service de Réanimation Médicale et Toxicologique [Hôpital Lariboisière], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Hôpital Lariboisière-Fernand-Widal [APHP], Optimisation thérapeutique en Neuropsychopharmacologie (OPTeN (UMR_S_1144 / U1144)), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université Paris Cité (UPCité), Centre Hospitalier Sud Francilien, Centre hospitalier est francilien, Hôpital Delafontaine, Centre Hospitalier de Saint-Denis [Ile-de-France], Hôpital Louis Mourier - AP-HP [Colombes], Centre cardiologique du Nord (CCN), Hôpital Privé Jacques Cartier [Massy], AP-HP Hôpital Bicêtre (Le Kremlin-Bicêtre), Hôpital Cochin [AP-HP], Paris ECMO-COVID-19 investigators, Mégarbane, Bruno, and Unité de Recherche sur les Maladies Cardiovasculaires, du Métabolisme et de la Nutrition = Research Unit on Cardiovascular and Metabolic Diseases (ICAN)
Subjects: Male, ARDS, medicine.medical_treatment, Corrections, [SDV.MHEP.PSR]Life Sciences [q-bio]/Human health and pathology/Pulmonology and respiratory tract, Cohort Studies, 0302 clinical medicine, [SDV.MHEP.MI]Life Sciences [q-bio]/Human health and pathology/Infectious diseases, Fraction of inspired oxygen, score, support: volume, Renal Insufficiency, 030212 general & internal medicine, [SDV.MHEP.ME] Life Sciences [q-bio]/Human health and pathology/Emerging diseases, Respiratory Distress Syndrome, [SDV.MHEP.ME]Life Sciences [q-bio]/Human health and pathology/Emerging diseases, ecmo covid-19, Articles, Middle Aged, [SDV.MHEP.CSC] Life Sciences [q-bio]/Human health and pathology/Cardiology and cardiovascular system, Pulmonary embolism, [SDV.TOX] Life Sciences [q-bio]/Toxicology, Intensive Care Units, Outcome and Process Assessment, Health Care, surgical procedures, operative, [SDV.TOX]Life Sciences [q-bio]/Toxicology, [SDV.MHEP.MI] Life Sciences [q-bio]/Human health and pathology/Infectious diseases, Female, France, Cohort study, Pulmonary and Respiratory Medicine, medicine.medical_specialty, 03 medical and health sciences, Extracorporeal Membrane Oxygenation, [SDV.MHEP.CSC]Life Sciences [q-bio]/Human health and pathology/Cardiology and cardiovascular system, Intensive care, medicine, Extracorporeal membrane oxygenation, Humans, Renal replacement therapy, SARS-CoV-2, Septic shock, business.industry, COVID-19, medicine.disease, Survival Analysis, 030228 respiratory system, Emergency medicine, [SDV.MHEP.PSR] Life Sciences [q-bio]/Human health and pathology/Pulmonology and respiratory tract, Pulmonary Embolism, business
Abstract: Erratum inCorrection to Lancet Respir Med 2021; published online April 19. https://doi.org/10.1016/S2213-2600(21)00096-5.; International audience; Background: In the Île-de-France region (henceforth termed Greater Paris), extracorporeal membrane oxygenation (ECMO) for severe acute respiratory distress syndrome (ARDS) was considered early in the COVID-19 pandemic. We report ECMO network organisation and outcomes during the first wave of the pandemic.Methods: In this multicentre cohort study, we present an analysis of all adult patients with laboratory-confirmed SARS-CoV-2 infection and severe ARDS requiring ECMO who were admitted to 17 Greater Paris intensive care units between March 8 and June 3, 2020. Central regulation for ECMO indications and pooling of resources were organised for the Greater Paris intensive care units, with six mobile ECMO teams available for the region. Details of complications (including ECMO-related complications, renal replacement therapy, and pulmonary embolism), clinical outcomes, survival status at 90 days after ECMO initiation, and causes of death are reported. Multivariable analysis was used to identify pre-ECMO variables independently associated with 90-day survival after ECMO.Findings: The 302 patients included who underwent ECMO had a median age of 52 years (IQR 45-58) and Simplified Acute Physiology Score-II of 40 (31-56), and 235 (78%) of whom were men. 165 (55%) were transferred after cannulation by a mobile ECMO team. Before ECMO, 285 (94%) patients were prone positioned, median driving pressure was 18 cm H2O (14-21), and median ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen was 61 mm Hg (IQR 54-70). During ECMO, 115 (43%) of 270 patients had a major bleeding event, 27 of whom had intracranial haemorrhage; 130 (43%) of 301 patients received renal replacement therapy; and 53 (18%) of 294 had a pulmonary embolism. 138 (46%) patients were alive 90 days after ECMO. The most common causes of death were multiorgan failure (53 [18%] patients) and septic shock (47 [16%] patients). Shorter time between intubation and ECMO (odds ratio 0·91 [95% CI 0·84-0·99] per day decrease), younger age (2·89 [1·41-5·93] for ≤48 years and 2·01 [1·01-3·99] for 49-56 years vs ≥57 years), lower pre-ECMO renal component of the Sequential Organ Failure Assessment score (0·67, 0·55-0·83 per point increase), and treatment in centres managing at least 30 venovenous ECMO cases annually (2·98 [1·46-6·04]) were independently associated with improved 90-day survival. There was no significant difference in survival between patients who had mobile and on-site ECMO initiation.Interpretation: Beyond associations with similar factors to those reported on ECMO for non-COVID-19 ARDS, 90-day survival among ECMO-assisted patients with COVID-19 was strongly associated with a centre's experience in venovenous ECMO during the previous year. Early ECMO management in centres with a high venovenous ECMO case volume should be advocated, by applying centralisation and regulation of ECMO indications, which should also help to prevent a shortage of resources.
Published: 2021

36. Vascular access for renal replacement therapy among 459 critically ill patients: a pragmatic analysis of the randomized AKIKI trial

Author: Alexandre Boyer, Nicolas Lerolle, Guillaume Thiery, Anne Bretagnol, Saad Nseir, Guillaume Chevrel, Julien Maizel, Jean-Damien Ricard, Jean-Marie Forel, Laurent Martin-Lefevre, Alexandre Lautrette, Hodane Yonis, Philippe Markowicz, Eric Boulet, David Hajage, Florence Tubach, Bertrand Pons, Bruno Mégarbane, Frédérique Schortgen, Said Lebbah, Nicolas de Prost, Didier Dreyfuss, Julien Mayaux, Stéphane Gaudry, Marina Thirion, Dorothée Carpentier, Nicolas Benichou, Hôpital Européen Georges Pompidou [APHP] (HEGP), Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Hôpitaux Universitaires Paris Ouest - Hôpitaux Universitaires Île de France Ouest (HUPO), Des Maladies Rénales Rares aux Maladies Fréquentes, Remodelage et Réparation, Institut National de la Santé et de la Recherche Médicale (INSERM)-Sorbonne Université (SU), CHU Tenon [AP-HP], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU), Département de Biostatistique, Santé Publique et Information Médicale [CHU Pitié-Salpêtrière] (BIOSPIM ), CHU Pitié-Salpêtrière [AP-HP], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU)-Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU), Epidémiologie Clinique et Evaluation Economique Appliquées aux Populations Vulnérables (ECEVE (U1123 / UMR_S_1123)), Institut National de la Santé et de la Recherche Médicale (INSERM)-AP-HP Hôpital universitaire Robert-Debré [Paris], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Université Paris Cité (UPCité), Centre d'investigation clinique Paris Est (CIC Paris-Est), Institut National de la Santé et de la Recherche Médicale (INSERM)-CHU Pitié-Salpêtrière [AP-HP], Centre Hospitalier Départemental - Hôpital de La Roche-sur-Yon (CHD Vendée), CHU Pointe-à-Pitre/Abymes [Guadeloupe], Centre Hospitalier René Dubos [Pontoise], Hôpital Pellegrin, CHU Bordeaux [Bordeaux]-Groupe hospitalier Pellegrin, Centre Hospitalier Sud Francilien, Centre Hospitalier Universitaire d'Angers (CHU Angers), PRES Université Nantes Angers Le Mans (UNAM), CHU Rouen, Normandie Université (NU), CHU Henri Mondor, Université Paris-Est Créteil Val-de-Marne - Paris 12 (UPEC UP12), CHU Gabriel Montpied [Clermont-Ferrand], CHU Clermont-Ferrand, Centre Hospitalier Régional d'Orléans (CHRO), Service de Pneumologie et Réanimation Médicale [CHU Pitié-Salpêtrière] (Département ' R3S '), CHU Lille, Optimisation thérapeutique en Neuropsychopharmacologie (OPTeN (UMR_S_1144 / U1144)), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université Paris Cité (UPCité), Service de Réanimation Médicale et Toxicologique [Hôpital Lariboisière], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Hôpital Lariboisière-Fernand-Widal [APHP], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP), Centre Hospitalier Victor Dupouy, Hôpital Nord [CHU - APHM], Mécanismes physiopathologiques et conséquences des calcifications vasculaires - UR UPJV 7517 (MP3CV), Université de Picardie Jules Verne (UPJV)-CHU Amiens-Picardie, Hôpital de la Croix-Rousse [CHU - HCL], Hospices Civils de Lyon (HCL), Centre Hospitalier Intercommunal de Cornouaille (CHIC), Infection, Anti-microbiens, Modélisation, Evolution (IAME (UMR_S_1137 / U1137)), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université Paris Cité (UPCité)-Université Sorbonne Paris Nord, Hôpital Louis Mourier - AP-HP [Colombes], Service de Réanimation Médico-Chirurgicale [Avicenne], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Hôpital Avicenne [AP-HP], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Université Sorbonne Paris Nord, Centre d'investigation clinique Paris Est [CHU Pitié Salpêtrière] (CIC Paris-Est), Centre d'investigation clinique pluridisciplinaire [CHU Pitié Salpêtrière] (CIC-P 1421), Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU)-Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU)-Institut National de la Santé et de la Recherche Médicale (INSERM)-CHU Pitié-Salpêtrière [AP-HP], Gestionnaire, Hal Sorbonne Université, Sorbonne Université (SU)-Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP), Sorbonne Université (SU)-Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU)-Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP), Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Université de Paris (UP), Centre Hospitalier Départemental - Hôpital de La Roche-sur-Yon, CH Evry-Corbeil, Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Paris (UP), Hôpital Lariboisière-Fernand-Widal [APHP], and Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Paris (UP)-Université Sorbonne Paris Nord
Subjects: medicine.medical_specialty, medicine.medical_treatment, [SDV]Life Sciences [q-bio], Critical Care and Intensive Care Medicine, law.invention, 03 medical and health sciences, 0302 clinical medicine, law, Intensive care, medicine, Cumulative incidence, 030212 general & internal medicine, Renal replacement therapy, Prospective cohort study, Mechanical ventilation, Catheter, business.industry, Research, lcsh:Medical emergencies. Critical care. Intensive care. First aid, Acute kidney injury, 030208 emergency & critical care medicine, lcsh:RC86-88.9, medicine.disease, Intensive care unit, 3. Good health, Surgery, [SDV] Life Sciences [q-bio], Critical care, Vascular access, business
Abstract: BackgroundVascular access for renal replacement therapy (RRT) is routine question in the intensive care unit. Randomized trials comparing jugular and femoral sites have shown similar rate of nosocomial events and catheter dysfunction. However, recent prospective observational data on RRT catheters use are scarce. We aimed to assess the site of RRT catheter, the reasons for catheter replacement, and the complications according to site in a large population of critically ill patients with acute kidney injury.Patients and methodsWe performed an ancillary study of the AKIKI study, a pragmatic randomized controlled trial, in which patients with severe acute kidney injury (KDIGO 3 classification) with invasive mechanical ventilation, catecholamine infusion or both were randomly assigned to either an early or a delayed RRT initiation strategy. The present study involved all patients who underwent at least one RRT session. Number of RRT catheters, insertion sites, factors potentially associated with the choice of insertion site, duration of catheter use, reason for catheter replacement, and complications were prospectively collected.ResultsAmong the 619 patients included in AKIKI, 462 received RRT and 459 were finally included, with 598 RRT catheters. Femoral site was chosen preferentially (n = 319, 53%), followed by jugular (n = 256, 43%) and subclavian (n = 23, 4%). In multivariate analysis, continuous RRT modality was significantly associated with femoral site (OR = 2.33 (95% CI (1.34–4.07),p = 0.003) and higher weight with jugular site [88.9 vs 83.2 kg, OR = 0.99 (95% CI 0.98–1.00),p = 0.03]. Investigator site was also significantly associated with the choice of insertion site (p = 0.03). Cumulative incidence of catheter replacement did not differ between jugular and femoral site [sHR 0.90 (95% CI 0.64—1.25),p = 0.67]. Catheter dysfunction was the main reason for replacement (n = 47), followed by suspected infection (n = 29) which was actually seldom proven (n = 4). No mechanical complication (pneumothorax or hemothorax) occurred.ConclusionFemoral site was preferentially used in this prospective study of RRT catheters in 31 French intensive care units. The choice of insertion site depended on investigating center habits, weight, RRT modality. A high incidence of catheter infection suspicion led to undue replacement.
Published: 2021

37. Intensive care units, the Achilles heel of France in the COVID-19 battle

Author: Etienne Javouhey, Djillali Annane, Jean-Luc Chagnon, Olivier Lesieur, Samia Touati, Laura Federici, Hervé Outin, Didier Thevenin, Nicolas Terzi, Philippe Guiot, Chantal Sevens, Nicolas Joram, Didier Dreyfuss, Jean Philippe Rigaud, Arnaud Sement, and Jean Luc Diehl
Subjects: 2019-20 coronavirus outbreak, Heel, Battle, Coronavirus disease 2019 (COVID-19), business.industry, Health Policy, Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), media_common.quotation_subject, lcsh:Public aspects of medicine, lcsh:RA1-1270, medicine.disease, medicine.anatomical_structure, Oncology, Intensive care, Internal Medicine, medicine, Commentary, Medical emergency, business, media_common
Published: 2021

38. Extracorporeal membrane oxygenation for refractory COVID-19 acute respiratory distress syndrome

Author: B. Gaborieau, Noémie Zucman, M. Amouretti, Alain Combes, Didier Dreyfuss, P.A. Billiet, L.M. Dumont, P. Postel-Vinay, Guillaume Lebreton, S. Freita-Ramos, Jean-Damien Ricard, D. Longrois, Damien Roux, C. Le Breton, M. Dao, S. Besset, L. Federici, C. Vuillard, Des Maladies Rénales Rares aux Maladies Fréquentes, Remodelage et Réparation, Institut National de la Santé et de la Recherche Médicale (INSERM)-Sorbonne Université (SU), Université de Paris (UP), Université de Paris - UFR Médecine Paris Nord [Santé] (UP Médecine Paris Nord), Infection, Anti-microbiens, Modélisation, Evolution (IAME (UMR_S_1137 / U1137)), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Paris (UP)-Université Sorbonne Paris Nord, Unité de Recherche sur les Maladies Cardiovasculaires, du Métabolisme et de la Nutrition = Institute of cardiometabolism and nutrition (ICAN), Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Institut National de la Santé et de la Recherche Médicale (INSERM)-CHU Pitié-Salpêtrière [AP-HP], and Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU)-Sorbonne Université (SU)
Subjects: 2019-20 coronavirus outbreak, Coronavirus disease 2019 (COVID-19), Extracorporeal membrane oxygenation, Acute respiratory distress syndrome, business.industry, medicine.medical_treatment, Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), [SDV]Life Sciences [q-bio], COVID-19, Acute respiratory distress, 030204 cardiovascular system & hematology, Critical Care and Intensive Care Medicine, Article, 03 medical and health sciences, 0302 clinical medicine, Refractory, Anesthesia, medicine, 030212 general & internal medicine, business
Published: 2020
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39. COVID-19 : les sociétés savantes doivent se réinventer dans le monde d’après

Author: Didier Dreyfuss, Michel Dubois, Hervé Maisonneuve, Groupe d'Etude des Méthodes de l'Analyse Sociologique de la Sorbonne (GEMASS), and Fondation Maison des sciences de l'homme (FMSH)-Sorbonne Université (SU)-Centre National de la Recherche Scientifique (CNRS)
Subjects: 03 medical and health sciences, [SHS.SOCIO]Humanities and Social Sciences/Sociology, 0302 clinical medicine, 030228 respiratory system, Emergency Medicine, 030208 emergency & critical care medicine, Emergency Nursing, ComputingMilieux_MISCELLANEOUS
Abstract: International audience
Published: 2020

40. Successful continuation of pregnancy in a patient with COVID-19-related ARDS

Author: Olivier Picone, Didier Dreyfuss, Laura Federici, and Jeanne Sibiude
Subjects: myalgia, ARDS, medicine.medical_treatment, 0302 clinical medicine, Pregnancy, Fetal distress, 030212 general & internal medicine, Pregnancy Complications, Infectious, Respiratory Distress Syndrome, 030219 obstetrics & reproductive medicine, General Medicine, Haemolysis, Reminder of Important Clinical Lesson, pneumonia (infectious disease), Female, Radiography, Thoracic, medicine.symptom, Coronavirus Infections, Live Birth, Adult, medicine.medical_specialty, HELLP syndrome, Pneumonia, Viral, adult intensive care, mechanical ventilation, 03 medical and health sciences, Betacoronavirus, Internal medicine, obstetrics and gynaecology, medicine, Humans, Caesarean section, Pandemics, Mechanical ventilation, business.industry, SARS-CoV-2, COVID-19, medicine.disease, Respiration, Artificial, 51 522, business
Abstract: A 33-year-old pregnant woman was hospitalised with fever, cough, myalgia and dyspnoea at 23.5 weeks of gestation (WG). Development of acute respiratory distress syndrome (ARDS) mandated invasive mechanical ventilation. A nasopharyngeal swab proved positive for severe acute respiratory syndrome coronavirus 2 by reverse transcription-PCR. The patient developed hypertension and biological disorders suggesting pre-eclampsia and HELLP (haemolysis, elevated liver enzyme levels and low platelet levels) syndrome. Pre-eclampsia was subsequently ruled out by a low ratio of serum soluble fms-like tyrosine kinase-1 to placental growth factor. Given the severity of ARDS, delivery by caesarean section was contemplated. Because the ratio was normal and the patient’s respiratory condition stabilised, delivery was postponed. She recovered after 10 days of mechanical ventilation. She spontaneously delivered a healthy boy at 33.4 WG. Clinical and laboratory manifestations of COVID-19 infection can mimic HELLP syndrome. Fetal extraction should not be systematic in the absence of fetal distress or intractable maternal disease. Successful evolution was the result of a multidisciplinary teamwork.
Published: 2020

41. Renal replacement therapy in acute kidney injury - Authors' reply

Author: Agnès Dechartres, Stéphane Gaudry, Jean-Pierre Quenot, Didier Dreyfuss, and David Hajage
Subjects: medicine.medical_specialty, 2019-20 coronavirus outbreak, Coronavirus disease 2019 (COVID-19), business.industry, Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), medicine.medical_treatment, Acute kidney injury, General Medicine, Acute Kidney Injury, medicine.disease, Renal Replacement Therapy, Internal medicine, Medicine, Humans, Renal replacement therapy, business
Published: 2020

42. Strengths of the French end-of-life Law as Well as its Shortcomings in Handling Intractable Disputes Between Physicians and Families

Author: Virginie Fouilloux, Anahita Rouzé, Claire-Marie Barbier, Noël Boussard, Jonathan Messika, Fabrice Michel, Henry Silverman, Saad Nseir, Claude Guérin, Didier Dreyfuss, Hodane Yonis, Jean-Damien Ricard, Stéphane Gaudry, Infection, Anti-microbiens, Modélisation, Evolution (IAME (UMR_S_1137 / U1137)), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Paris (UP)-Université Sorbonne Paris Nord, Hôpital Louis Mourier - AP-HP [Colombes], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP), Hôpital de la Timone [CHU - APHM] (TIMONE), Anthropologie bio-culturelle, Droit, Ethique et Santé (ADES), Aix Marseille Université (AMU)-EFS ALPES MEDITERRANEE-Centre National de la Recherche Scientifique (CNRS), and Institut National de la Santé et de la Recherche Médicale (INSERM)-Université Paris Cité (UPCité)-Université Sorbonne Paris Nord
Subjects: Adult, Male, Adolescent, media_common.quotation_subject, [SDV]Life Sciences [q-bio], Treatment withdrawal, 030204 cardiovascular system & hematology, law.invention, 03 medical and health sciences, 0302 clinical medicine, law, Reading (process), Intensive care, Stress (linguistics), Humans, 030212 general & internal medicine, health care economics and organizations, ComputingMilieux_MISCELLANEOUS, Aged, media_common, Aged, 80 and over, Terminal Care, Jurisdiction, Infant, 16. Peace & justice, Dissent and Disputes, Intensive care unit, Intensive Care Units, Issues, ethics and legal aspects, Withholding Treatment, Female, France, Psychology
Abstract: French end-of-life law aims at protecting patients from unreasonable treatments, but has been used to force caregivers to prolong treatments deemed unreasonable. We describe six cases (five intensive care unit patients including two children) where families disagreed with a decision to withdraw treatments and sued medical teams. An emergent inquiry was instigated by the families. In two cases, the court rejected the families' inquiries. In two cases, the families appealed the decision, and in both the first jurisdiction decision was confirmed, compelling caregivers to pursue treatments, even though they deemed them unreasonable. We discuss how this law may be perverted. Legal procedures may result in the units' disorganisation and give rise to caregivers' stress. Families' requests may be subtended by religious beliefs. French end-of-life law has benefits in theoretically constraining physicians to withhold or withdraw disproportionate therapies. These cases underline some caveats and the perverse effects of its literal reading.
Published: 2020

43. Repenser l'innovation en santé : vers une approche éthique plurielle

Author: Catherine Bourgain, Grosset Marie, Pierre Lombrail, Ghislaine Filliatreau, Hervé Chneiweiss, Christine Dosquet, Isabelle Remy-Jouet, Mylène Botbol-Baum, Anne Buisson, Laurent Fleury, François Hirsch, Bernard Baertschi, Christine Lemaitre, Didier Dreyfuss, Duchange, Nathalie, Comité d'éthique de l'Inserm (CEI), Institut National de la Santé et de la Recherche Médicale (INSERM), CERMES3 - Centre de recherche Médecine, sciences, santé, santé mentale, société (CERMES3 - UMR 8211 / U988 / UM 7), École des hautes études en sciences sociales (EHESS)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Centre National de la Recherche Scientifique (CNRS)-Université Paris Cité (UPCité), Conseil d'Etat, Université Sorbonne Paris Nord, Inserm-Délégation à l'intégrité scientifique, AP -Comité d'évaluation éthique de l'Inserm, Inserm - Assurance qualité, technologies pour la santé, Université Catholique de Louvain = Catholic University of Louvain (UCL), CHU Trousseau [APHP], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU), Inserm-Pôle Expertise Collective, Inserm - Ethique des sciences de la vie, éthique de la recherche dans les pays du Sud, Université de Genève = University of Geneva (UNIGE), Hôpital Louis Mourier - AP-HP [Colombes], and Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)
Subjects: [SDV.ETH] Life Sciences [q-bio]/Ethics, [SDV.ETH]Life Sciences [q-bio]/Ethics
Abstract: Note du Comité. Groupe "Ethique de l'Innovation en Santé". Rédaction: Catherine Bourgain, Marie Grosset
Published: 2020

44. Delayed versus Early Renal Replacement Therapy for Severe Acute Kidney Injury: A Systematic Review and Individual Patient Data Meta-Analysis of Randomised Clinical Trials

Author: Nicolas Benichou, Alain Combes, Didier Dreyfuss, Nattachai Srisawat, David Hajage, Alexander Zarbock, Jean-Pierre Quenot, Tukaram Jamale, Guillaume Geri, Sean M. Bagshaw, Saber Barbar, Stéphane Gaudry, Khalil Chaïbi, Nuttha Lumlertgul, Ron Wald, and Agnès Dechartres
Subjects: Nephrology, medicine.medical_specialty, business.industry, medicine.medical_treatment, Acute kidney injury, urologic and male genital diseases, medicine.disease, Intensive care unit, law.invention, Transplantation, Clinical trial, law, Internal medicine, Meta-analysis, Relative risk, Emergency medicine, medicine, Renal replacement therapy, business
Abstract: Background: The timing of renal replacement therapy (RRT) for severe acute kidney injury (AKI) is highly debated when no life-threatening complication is present. We assessed whether a strategy of delayed versus early RRT initiation affects 28-day survival in critically-ill adults with severe AKI. Methods: In this systematic review and individual-patient data (IPD) meta-analysis, we searched MEDLINE via PubMed, EMBASE and the Cochrane Central Register of Controlled Trials for randomised trials published from April 2008 to December 2019 comparing delayed and early RRT initiation strategies in critically-ill patients with severe AKI. We contacted the principal investigator of each eligible trial to request IPD. The primary outcome was 28-day all-cause mortality. Findings: Of 1031 studies identified, 10 were eligible. We obtained IPD for 9/10 trials (2083/2143 patients). Among patients with severe AKI (n=1879), there were 946 [50·3%] in the delayed strategy and 933 [49·6%] in the early strategy. Mortality at 28-days did not significantly differ (366/837 [43·7%] in the delayed strategy vs 355/827[42·9%] in the early strategy;risk ratio 1·01 [95%CI, 0·91-1·13], p=0·798) with no heterogeneity across studies (phet=0.80, I2=0%; τ2=0). Mortality did not significantly differ at day-60, day-90 or at hospital discharge. Among patients allocated to the delayed strategy 390/929 (42%) did not receive RRT. Other secondary outcomes including RRT free-days and complication rates did not significantly differ between groups. Interpretation: RRT initiation strategy did not affect survival in critically ill patients with severe AKI who had no urgent indications for RRT. Delaying RRT initiation with close patient monitoring led to a reduced use of RRT which may allow for resource saving. Funding Statement: The authors stated there was no funding source. Declaration of Interests: NB is the recipient of a grant from the Societe Francophone de Nephrologie, Dialyse et Transplantation for the submitted work. SMB is supported by a Canada Research Chair in Critical Care Nephrology. SMB reports receiving grant support from Baxter Healthcare Corp and speaker fees from Baxter Healthcare Corp and CAN Diagnostic Inc. RW reports receiving grant support from Baxter Healthcare Corp and speaker fees from Baxter Healthcare Corp. SG, DH, KC, SB, AC, NL, NS, TJ, GG, AD, JPQ, DD declare no competing interests. Ethics Approval Statement: This study was approved by Assistance Publique Hopitaux de Paris.
Published: 2020

45. Underreporting of End-of-Life Decisions in Critical Care Trials: A Call to Modify the Consolidated Standards of Reporting Trials Statement

Author: Florence Tubach, Jean-Damien Ricard, Stéphane Gaudry, Jonathan Messika, S Guillo, Didier Dreyfuss, and David Hajage
Subjects: Male, Research Report, Pulmonary and Respiratory Medicine, medicine.medical_specialty, Critical Care, Statement (logic), Clinical Decision-Making, Alternative medicine, MEDLINE, Critical Care and Intensive Care Medicine, 03 medical and health sciences, 0302 clinical medicine, Clinical decision making, medicine, Humans, 030212 general & internal medicine, Mortality, Mortality trends, Randomized Controlled Trials as Topic, Publishing, Terminal Care, Medical education, business.industry, Consolidated Standards of Reporting Trials, 030208 emergency & critical care medicine, United States, Intensive Care Units, Withholding Treatment, Female, Periodicals as Topic, business
Published: 2018

46. Disclosure of conflicts of interest should appear in clinical guidelines

Author: Damien Roux, Didier Dreyfuss, and Nicolas Terzi
Subjects: Anesthesiology and Pain Medicine, Text mining, business.industry, Internet privacy, Medicine, General Medicine, Critical Care and Intensive Care Medicine, business
Published: 2021

47. Comparaison de stratégies d’initiation de l’épuration extra-rénale en réanimation : apport des modèles multi-états

Author: Stéphane Gaudry, David Hajage, Didier Dreyfuss, M. von Cube, and L. Jérome
Subjects: Epidemiology, Public Health, Environmental and Occupational Health
Abstract: Introduction Chez les patients hospitalises en reanimation et presentant une insuffisance renale aigue, l’epuration extra-renale (EER) peut etre debutee soit precocement, soit selon une strategie d’attente, c’est-a-dire seulement en cas d’apparition de complications metaboliques ou respiratoires mettant en jeu le pronostic vital. Plusieurs essais randomises et une meta-analyse recente n’ont pas montre de difference de mortalite entre les deux strategies. En l’absence de difference de mortalite, la meilleure strategie est celle qui permet de reduire le nombre de patients chez qui une EER est debutee ainsi que le temps passe sous EER. Mais quantifier ces elements en presence de donnees censurees, quand l’EER est debutee a des delais variables selon les individus (voir non debutee), et en tenant compte des risques competitifs de sortie vivant de reanimation et de deces, n’est pas immediat. Methodes Nous proposons de reanalyser les donnees de l’essai controle randomise AKIKI, comparant une strategie d’initiation precoce et a une strategie d’attente, a l’aide d’un modele multi-etat. Cinq etats sont definis au cours du suivi : « en reanimation et EER non debutee », « en reanimation sous EER », « en reanimation et sevre de l’EER », « sorti vivant de reanimation », « decede ». Sous l’hypothese markovienne, les probabilites d’occupation de chaque etat au cours du temps, ainsi que les durees moyennes tronquees d’occupation sont estimees et comparees entre les deux bras. Resultats La representation des probabilites d’occupation de chaque etat au cours du temps met en evidence les differents evenements d’interet sur un seul graphique ( Fig. 1 ). Pendant les 28 premiers jours, cette reanalyse suggere que les patients randomises dans la strategie d’attente sont epures significativement moins longtemps (difference moyenne = −2,0 jours [IC95 % : −3,7 ; −0,1]) par rapport a la strategie precoce, pour un pronostic similaire (difference moyenne de temps passe en vie hors de la reanimation = 0,1 jours [IC95 % : −2,2 ; 2,4]). Conclusion La strategie d’attente semble permettre de reduire le nombre de jours passes sous EER en reanimation, sans impact significatif sur le pronostic des patients. Il s’agit d’un resultat important, tant du point de vue du patient que dans une perspective hospitaliere. Les modeles multi-etats permettent de comparer de maniere simple mais complete differentes strategies d’initiation de l’EER en reanimation.
Published: 2021

48. Épuration extrarénale et insuffisance rénale aiguë en soins intensifs

Author: Charles Verney, Didier Dreyfuss, Nicolas Benichou, Stéphane Gaudry, Khalil Chaïbi, and David Hajage
Subjects: medicine.medical_specialty, business.industry, medicine.medical_treatment, Acute kidney injury, Renal function, 030208 emergency & critical care medicine, Heparin, urologic and male genital diseases, medicine.disease, Intensive care unit, law.invention, Discontinuation, Patient recruitment, 03 medical and health sciences, 0302 clinical medicine, Nephrology, law, Multicenter trial, Medicine, 030212 general & internal medicine, Renal replacement therapy, business, Intensive care medicine, medicine.drug
Abstract: Renal replacement therapy for acute kidney injury has been used for more than 60 years. Except when life-threatening metabolic complications such as severe hyperkalaemia are present, renal replacement therapy initiation criteria are the subject of intense debate. Significant progress has been made with the publication of the AKIKI multicenter trial, which showed that a delayed renal replacement therapy initiation strategy (in the absence of life-threatening metabolic complications) was not associated with a difference in mortality compared to an early renal replacement therapy initiation strategy. In addition, this delayed strategy obviated the need for renal replacement therapy in almost 50% of cases was associated with a more rapid renal function recovery and with a lower incidence of catheter-bloodstream related infections. Research on renal replacement therapy modalities (continuous vs. intermittent renal replacement therapy, citrate vs. heparin anticoagulation, jugular vs. femoral catheterization) did not show any obvious superiority of one modality over another. Thus, the choice depends mainly on local considerations (patient recruitment, availability of modalities, staff experience). The criteria for renal replacement therapy discontinuation are still unclear due to difficulties in assessing renal function recovery. Urine output remains the main criteria in the decision to wean from renal replacement therapy. Pending the confirmation of AKIKI trial by similar studies in progress, it seems reasonable to choose a delayed renal replacement therapy initiation strategy under watchful surveillance in case of severe acute kidney injury in the absence of life-threatening metabolic complications.
Published: 2017

49. Hyperoxia and hypertonic saline in patients with septic shock (HYPERS2S): a two-by-two factorial, multicentre, randomised, clinical trial

Author: Christophe Guitton, Matthieu Henry-Lagarrigue, Jérôme Devaquet, Ferhat Meziani, François Legay, Jean Marc Doise, Fabien Grelon, Alain Mercat, Maleka Schenck, Delphine Chatellier, Thierry Van Der Linden, Jean Dellamonica, Bruno Mégarbane, Peter Radermacher, Frédérique Schortgen, Nadia Anguel, Valérie Seegers, Frédéric Gonzalez, Didier Dreyfuss, Pierre Asfar, Sigismond Lasocki, Fabienne Tamion, Julien Charpentier, Julie Boisramé-Helms, Jean Philippe Rigaud, Emmanuel Guerot, and David Grimaldi
Subjects: Male, Pulmonary and Respiratory Medicine, Resuscitation, medicine.medical_treatment, Population, Hyperoxia, 03 medical and health sciences, 0302 clinical medicine, Intensive care, medicine, Humans, education, Saline, Aged, Saline Solution, Hypertonic, Mechanical ventilation, education.field_of_study, Septic shock, business.industry, 030208 emergency & critical care medicine, Middle Aged, medicine.disease, Respiration, Artificial, Shock, Septic, Intention to Treat Analysis, Hypertonic saline, Intensive Care Units, Treatment Outcome, 030228 respiratory system, Anesthesia, Fluid Therapy, Female, France, medicine.symptom, business
Abstract: Summary Background There is insufficient research into the use of mechanical ventilation with increased inspiratory oxygen concentration (FiO 2 ) and fluid resuscitation with hypertonic saline solution in patients with septic shock. We tested whether these interventions are associated with reduced mortality. Methods This two-by-two factorial, multicentre, randomised, clinical trial (HYPERS2S) recruited patients aged 18 years and older with septic shock who were on mechanical ventilation from 22 centres in France. Patients were randomly assigned 1:1:1:1 to four groups by a computer generated randomisation list stratified by site and presence or absence of acute respiratory distress syndrome by use of permuted blocks of random sizes. Patients received, in an open-labelled manner, mechanical ventilation either with FiO 2 at 1·0 (hyperoxia) or FiO 2 set to target an arterial haemoglobin oxygen saturation of 88–95% (normoxia) during the first 24 h; patients also received, in a double-blind manner, either 280 mL boluses of 3·0% (hypertonic) saline or 0·9% (isotonic) saline for fluid resuscitation during the first 72 h. The primary endpoint was mortality at day 28 after randomisation in the intention-to-treat population. This study was registered with ClinicalTrials.gov, number NCT01722422. Findings Between Nov 3, 2012, and June 13, 2014, 442 patients were recruited and assigned to a treatment group (normoxia [n=223] or hyperoxia [n=219]; isotonic [n=224] or hypertonic [n=218]). The trial was stopped prematurely for safety reasons. 28 day mortality was recorded for 434 patients; 93 (43%) of 217 patients had died in the hyperoxia group versus 77 (35%) of 217 patients in the normoxia group (hazard ratio [HR] 1·27, 95% CI 0·94–1·72; p=0·12). 89 (42%) of 214 patients had died in the hypertonic group versus 81 (37%) of 220 patients in the isotonic group (HR 1·19, 0·88–1·61; p=0·25). We found a significant difference in the overall incidence of serious adverse events between the hyperoxia (185 [85%]) and normoxia groups (165 [76%]; p=0·02), with a clinically relevant doubling in the hyperoxia group of the number of patients with intensive care unit-acquired weakness (24 [11%] vs 13 [6%]; p=0·06) and atelectasis (26 [12%] vs 13 [6%]; p=0·04) compared with the normoxia group. We found no statistical difference for serious adverse events between the two saline groups (p=0·23). Interpretation In patients with septic shock, setting FiO 2 to 1·0 to induce arterial hyperoxia might increase the risk of mortality. Hypertonic (3%) saline did not improve survival. Funding The French Ministry of Health.
Published: 2017

50. Longer symptom onset to aspiration time predicts success of needle aspiration in primary spontaneous pneumothorax

Author: Jean-Damien Ricard, Nicolas Javaud, Fadia Dib, Didier Dreyfuss, Myriam Chemouny, Jonathan Messika, Constance Vuillard, Jallal Achamlal, Damien Roux, and Stéphane Gaudry
Subjects: Pulmonary and Respiratory Medicine, Adult, Male, Time Factors, Thoracentesis, Chest tube insertion, law.invention, Time-to-Treatment, Primary outcome, law, Medicine, Humans, Symptom onset, Prospective Studies, Trial registration, Prospective cohort study, Retrospective Studies, business.industry, Pneumothorax, Primary spontaneous pneumothorax, medicine.disease, Intensive care unit, Treatment Outcome, Anesthesia, Chest Tubes, Female, business
Abstract: BackgroundNeedle aspiration (NA) is recommended as first-line treatment of primary spontaneous pneumothorax (PSP). We aimed to assess NA success and the effect of a longer symptom onset to NA time.MethodsA discovery phase was retrospectively conducted in the intensive care unit of Louis Mourier Hospital (January 2000 to December 2011) followed by a prospective validation cohort (January 2012 to August 2015). The primary outcome was immediate NA success defined by the absence of need for chest tube insertion within 24 hours of the procedure.ResultsIn the discovery phase, 130 patients were admitted for PSP and 98 had NA as first-line treatment (75%). The immediate success rate of NA was 34.7% and was higher when it was performed ≥48 hours after symptom onset (57.7% vs 25%; p=0.004). In the prospective cohort, 87 patients were admitted for PSP; 71 (82%) had NA as first-step treatment. The immediate success rate was 40.8%. NA was more successful when it was performed after 48 hours of symptoms’ onset (34.5% vs 7.1%; p=0.005). A delay between the first symptom and NA procedure ≥48 hours was associated with a higher success of NA (OR=13.54; 95% CI 1.37 to 133). A smaller pneumothorax estimated by Light’s index was associated with NA success (OR=0.95; 95% CI 0.92 to 0.98). To what extent some of these pneumothoraces would have had a spontaneous resolution remains unknown.ConclusionWhen managing PSP with NA, a longer symptom onset to NA time was associated with NA success.Trial registration numberNCT02528734.
Published: 2019

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