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In relatives of patients dying in intensive care units (ICUs), inadequate team support can increase the prevalence of prolonged grief and other psychological harm. We aimed to evaluate whether a proactive communication and support intervention would improve relatives' outcomes.We undertook a prospective, multicentre, cluster randomised controlled trial in 34 ICUs in France, to compare standard care with a physician-driven, nurse-aided, three-step support strategy for families throughout the dying process, following a decision to withdraw or withhold life support. Inclusion criteria were relatives of patients older than 18 years with an ICU length of stay 2 days or longer. Participating ICUs were randomly assigned (1:1 ratio) into an intervention cluster and a control cluster. The randomisation scheme was generated centrally by a statistician not otherwise involved in the study, using permutation blocks of non-released size. In the intervention group, three meetings were held with relatives: a family conference to prepare the relatives for the imminent death, an ICU-room visit to provide active support, and a meeting after the patient's death to offer condolences and closure. ICUs randomly assigned to the control group applied their best standard of care in terms of support and communication with relatives of dying patients. The primary endpoint was the proportion of relatives with prolonged grief (measured with PG-13, score ≥30) 6 months after the death. Analysis was by intention to treat, with the bereaved relatives as the unit of observation. The study is registered with ClinicalTrials.gov, NCT02955992.Between Feb 23, 2017, and Oct 8, 2019, we enrolled 484 relatives of ICU patients to the intervention group and 391 to the control group. 379 (78%) relatives in the intervention group and 309 (79%) in the control group completed the 6-month interview to measure the primary endpoint. The intervention significantly reduced the number of relatives with prolonged grief symptoms (66 [21%] vs 57 [15%]; p=0·035) and the median PG-13 score was significantly lower in the intervention group than in the control group (19 [IQR 14-26] vs 21 [15-29], mean difference 2·5, 95% CI 1·04-3·95).Among relatives of patients dying in the ICU, a physician-driven, nurse-aided, three-step support strategy significantly reduced prolonged grief symptoms.French Ministry of Health.

Purpose To compare the effects of two therapeutic bundles of management in SARS-CoV2 ICU patients. Materials and methods Our retrospective, observational study was performed in a university ICU from March to June 2020 (first wave) and from September 2020 to January 2021 (second wave). In first wave, patients received bundle 1 including early invasive ventilation, hydroxychloroquine, cefotaxime and azithromycin. In second wave, bundle 2 included non-invasive oxygenation support and dexamethasone. The main outcome was in-hospital mortality. Secondary outcomes included ICU and hospital length of stay, ICU supportive therapies, viral clearance and antimicrobial resistance emergence. Results 129 patients with SARS-CoV-2 pneumonia were admitted to our ICU. Thirty-five were treated according to bundle 1 and 76 to bundle 2. In-hospital mortality was similar in the two groups (23%, p = 1). The hospital (p = 0.003) and ICU (p = 0.01) length of stay and ventilator-free days at 28 days (p = 0.03) were significantly reduced in bundle 2. Increasing age, vasopressor use and PaO2/FiO2 ratio < 125 were associated with in-hospital mortality. Conclusion Within the limitations of our study, changes in therapeutic bundles for SARS-Cov-2 ICU patients might have no effect on in-hospital mortality but were associated with less exposure to mechanical ventilation and reduced hospital length of stay.

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

International audience

Fungi are responsible for around 20% of microbiologically documented infections in intensive care units (ICU). In the last decade, the incidence of invasive fungal infections (IFI), including candidemia, has increased steadily because of increased numbers of both immunocompromised and ICU patients. To improve the outcomes of patients with IFI, intensivists need to be aware of the inherent challenges. This narrative review summarizes the features of routinely used treatments directed against IFI in non-neutropenic ICU patients, which include three classes of antifungals: polyenes, azoles, and echinocandins. ICU patients' pathophysiological changes are responsible for deep changes in the pharmacokinetics of antifungals. Moreover, drug interactions affect the response to antifungal treatments. Consequently, appropriate antifungal dosage is a challenge under these special conditions. Dosages should be based on renal and liver function, and serum concentrations should be monitored. This review summarizes recent guidelines, focusing on bedside management.

Background The Radiographic Assessment of Lung Edema (RALE) score is associated with the severity of ARDS, and treatments targeted at reducing pulmonary edema such as conservative fluid management cause a reduction in RALE score over time. Research Question Are early changes in RALE score over time associated with survival in patients with ARDS? Study Design and Methods Data from patients enrolled in three centers in the Lung Imaging for Ventilation sEtting in ARDS (LIVE) trial with available chest radiographs at baseline (day 0) and days 2 or 3 were used. The RALE was scored by two independent reviewers. The primary end point was death by day 90, considering RALE score both at baseline and as a time-varying covariate in a marginal Cox survival model. Results RALE was scored from 135, 64, and 88 radiographs on days 0, 2, and 3, respectively. Both baseline RALE (hazard ratio [HR] for each one-point increment, 1.04; 95% CI, 1.01-1.08; P = .006) and the change in RALE over time (HR for each one-point decrease per unit of time, 0.99; 95% CI, 0.99-0.99; P = .03) were associated with death by day 90, even after adjustment for age, sex, BMI, Simplified Acute Physiology Score II, vasopressor use, and total volume of fluids received since study entry. Interpretation The change in RALE during the first days after ARDS onset is independently associated with survival and may be useful as a surrogate end point in future clinical trials of new therapeutics in ARDS.

Blunt traumatic aortic injury (BTAI) in severe trauma patients is rare but potentially lethal. The aim of this work was to perform a current epidemiological analysis of the clinical and surgical management of these patients in a European country.This was a multicentre, retrospective study using prospectively collected data from the French National Trauma Registry and the National Uniform Hospital Discharge Database from 10 trauma centres in France. The primary endpoint was the prevalence of BTAI. The secondary endpoints focused chronologically on injury characteristics, management, and patient outcomes.209 patients were included with a mean age of 43 ± 19 years and 168 (80%) were men. The calculated prevalence of BTAI at hospital admission was 1% (162/15 094) (BTAI admissions/all trauma). The time to diagnosis increased with the severity of aortic injury and the clinical severity of the patients (grade 1: 94 [74, 143] minutes to grade 4: 154 [112, 202] minutes, p = .020). This delay seemed to be associated with the intensity of the required resuscitation. Sixty seven patients (32%) received no surgical treatment. Among those treated, 130 (92%) received endovascular treatment, 14 (10%) open surgery (two were combined), and 123 (85%) were treated within the first 24 hours. Overall mortality was 20% and the attributed cause of death was haemorrhagic shock (69%). Mortality was increased according to aortic injury severity, from 6% for grade 1 to 65% for grade 4 (p.001). Twenty-six (18.3%) patients treated by endovascular aortic repair had complications.BTAI prevalence at hospital admission was low but occurred in severe high velocity trauma patients and in those with a high clinical suspicion of severe haemorrhage. The association of shock with high grade aortic injury and increasing time to diagnosis suggests a need to optimise early resuscitation to minimise the time to treatment. Endovascular treatment has been established as the reference treatment, accounting for more than 90% of interventional treatment options for BTAI.

International audience; Background: Before total body computed tomography scan, an initial rapid imaging assessment should be conducted in the trauma bay. It generally includes a chest x-ray, pelvic x-ray, and an extended focused ultrasonography assessment for trauma. This initial imaging assessment has been poorly described since the increase in the use of ultrasound. Therefore, our study aimed to evaluate the diagnostic accuracy and therapeutic impact of this initial imaging work-up in severe trauma patients. A secondary aim was to assess the therapeutic impact of a chest x-ray according to the lung ultrasonography findings.Methods: Patients with severe trauma who were admitted directly to our level 1 trauma center were consecutively included in this retrospective single center study. The diagnostic accuracy, therapeutic impact, and appropriate decision rate were calculated according to the initial assessment results of the whole body computed tomography scan and surgery reports.Results: Among the 1315 trauma patients admitted, 756 were included in this research. Lung ultrasound showed a higher diagnostic accuracy for haemothorax and pneumothorax cases than the chest x-ray. Sensitivity and specificity of the abdominal ultrasound to detect intraperitoneal effusion were 70% and 96%, respectively. The initial assessment had a therapeutic impact in 76 (10%) of the patients, including 16 (2%) immediate laparotomies and 58 (7%) chest tube insertions. The pelvic x-ray had no therapeutic impact, and when the lung ultrasound was normal, the chest x-ray had a therapeutic impact of only 0.13%. Combining the chest x-ray and lung ultrasound allowed adequate management of all the pneumothorax and haemothorax cases. Only one of the 756 patients had initial management that was judged as inappropriate. This patient had a missed pelvic disjunction with active retroperitoneal bleeding, and Abbreviations: underwent an inappropriate immediate laparotomy.Conclusions: In our cohort, the initial imaging assessment allowed appropriate decisions in 755 of 756 patients, with a global therapeutic impact of 10%. The pelvic x-ray had a minimal therapeutic impact, and in the patients with normal lung ultrasounds, the chest x-ray marginally affected the management of our patients. The potential consequences of abandoning systematic chest and pelvic x-rays should be investigated in future randomized prospective studies. (C) 2018 Elsevier Ltd. All rights reserved.

Context and objective Among the different products and protective gear used by riders of two-wheeled motorized vehicles, back protectors that are designed to prevent damage to the spinal column are widely used today compared other protections. However, few studies measure their effectiveness. Can their effectiveness be measured? How do they help decrease or change the nature of thoracolumbar traumas that occur? To address these questions and remedy the lack of objective data regarding these products, an epidemiological, clinical, and biomechanical analysis of motorcycle riders who were admitted to a French trauma center after an accident was performed. So, this study investigates the effectiveness of back protectors, including their ability to prevent specific mechanisms of thoracic and lumbar spinal injuries related to TWMV accidents. Method A questionnaire was administered to victims of accidents involving two-wheeled motorized vehicles who were admitted to the trauma room at the Marseille trauma center over the course of 2016. Collect data are related to the victim, the accident scenario, and a detailed description of the observed injuries using AIS (Abbreviated Injury Scale) coding and Magerl classification. Univariate analyses and Fisher tests were performed for victims who were or were not wearing back protectors. Results This study collected data from 124 victims. Almost half of the victims were wearing a back protector at the time of the accident (53 victims, thus 43% of riders). Collectively, twenty-nine victims who were wearing back protectors had 57 thoracolumbar injuries, and twenty eight victims who were not wearing back protectors had 75 thoracolumbar lesions. The results from this study show that there is no significant difference in the nature and mechanism of thoracolumbar injuries as a function of back protection. The majority of the thoracolumbar injuries were not severe. They were primarily bone injuries, essentially compression fractures, regardless of whether a back protector was worn. Conclusion This study shows that the use of back protection does not decrease the number, type, or mechanism of thoracolumbar injuries associated with accidents involving two-wheeled motorized vehicles. However, it suggests that lumbar vertebral injuries are deflected towards the thoracic vertebrae when back protectors are worn. Finally, it suggests that the design of back protectors should be reconsidered to better protect riders from what are referred to as compression fractures (craniocaudal force), which remain the primary form of fracture regardless of the rider’s characteristics, based on the data analyzed.

Purpose: This study aimed to describe by mathematical modeling an accurate course of core body temperature (CBT) in severe trauma patients and its relation to sepsis. Methods: In a cohort of severe trauma, the CBT measurements were collected for 24 h on day 2 after admission and rhythmicity assessed by Fourier transform and Cosinor analysis to describe circadian features (frequency and amplitude). CBT was compared between patients who developed sepsis or not during the early ICU stay. Results: 33 patients were included in this analysis. 24 patients (73%) had a predominant rhythm of 24 h (period). The main period was lower in the 9 remaining patients (6 of 12 h, 1 of 8 h, and 2 of 6 h). Other significant frequencies of oscillation (second and third frequencies) were found, which showed an association of several well marked rhythms. Patients with sepsis (n = 12) had a significantly higher level of CBT, but also more intense rhythms and higher amplitudes of CBT. Conclusion: Trauma patients exhibit complex temperature circadian rhythms. Early exacerbation of the temperature rhythmicity (in frequency and amplitude) is associated with the development of sepsis. This observation accentuates the concept of circadian disruption and sepsis in ICU patients. (C) 2020 Elsevier Inc. All rights reserved.

International audience; Ventilator-associated pneumonia (VAP) due to methicillin-resistant Staphylococcus aureus (MRSA) is associated with excess mortality and costs. Molecular biology test allows rapid identification of MRSA in sputum with high negative predictive value. We hypothesized that use of a rapid diagnostic test in patients with suspected VAP was associated with reduced use of antibiotics directed against MRSA. This retrospective, observational study was conducted in a polyvalent intensive care unit (ICU) of a university hospital. We compared two periods: before (2007-2010) and after (2010-2015) the implementation of a rapid diagnostic test, which uses RT-PCR to detect pathogens in 60 minutes. The primary endpoint was the effect on the empirical use of anti-MRSA antibiotics. The second endpoint was the effect of this strategy on the cost regarding antibiotic treatment. The first group included 120 suspected VAP (88 patients) and the second group 121 suspected VAP (89 patients). Empirical use of vancomycin and linezolid decreased by 50 % between the two periods. Twenty-seven VAP (22 %) were treated with an anti-MRSA treatment between 2007 and 2010, and 13 (11 %) between 2010 and 2015 (p = 0.04). The mean cost of anti-MRSA treatment by patients in the first group was 63 +/- 223 a,notsign, and 13 +/- 52 a,notsign in the second group (p < 0.001). This study shows that a rapid diagnostic test was associated with reduced use and cost of anti-MRSA antibiotics in patients with suspected VAP. These results should be confirmed by further multicenter prospective studies.

IF 16.834 (2017); International audience; BACKGROUND Vasopressor agents could have certain specific effects in patients with cardiogenic shock (CS) after myocardial infarction, which may influence outcome. Although norepinephrine and epinephrine are currently the most commonly used agents, no randomized trial has compared their effects, and intervention data are lacking. OBJECTIVES The goal of this paper was to compare in a prospective, double-blind, multicenter, randomized study, the efficacy and safety of epinephrine and norepinephrine in patients with CS after acute myocardial infarction. METHODS The primary efficacy outcome was cardiac index evolution, and the primary safety outcome was the occurrence of refractory CS. Refractory CS was defined as CS with sustained hypotension, end-organ hypoperfusion and hyperlactatemia, and high inotrope and vasopressor doses. RESULTS Fifty-seven patients were randomized into 2 study arms, epinephrine and norepinephrine. For the primary efficacy endpoint, cardiac index evolution was similar between the 2 groups (p = 0.43) from baseline (H0) to H72. For the main safety endpoint, the observed higher incidence of refractory shock in the epinephrine group (10 of 27 [37%] vs. norepinephrine 2 of 30 [7%]; p = 0.008) led to early termination of the study. Heart rate increased significantly with epinephrine from H2 to H24 while remaining unchanged with norepinephrine (p < 0.0001). Several metabolic changes were unfavorable to epinephrine compared with norepinephrine, including an increase in cardiac double product (p = 0.0002) and lactic acidosis from H2 to H24 (p < 0.0001). CONCLUSIONS In patients with CS secondary to acute myocardial infarction, the use of epinephrine compared with norepinephrine was associated with similar effects on arterial pressure and cardiac index and a higher incidence of refractory shock. (Study Comparing the Efficacy and Tolerability of Epinephrine and Norepinephrine in Cardiogenic Shock [OptimaCC]; NCT01367743) (J AmColl Cardiol 2018; 72: 173-82) (C) 2018 by the American College of Cardiology Foundation.

International audience; Objective: To assess the impact of an electronic checklist during the morning rounds on ventilatorassociated pneumonia (VAP) in the intensive care unit (ICU). Patients and methods: We conducted a retrospective, before/after study in a single ICU of a university hospital. A systematic electronic checklist focusing on guidelines adherence was introduced in January 2012. From January 2008 to June 2014, we screened patients with ICU stay durations of at least 48 hours. Propensity score-matched analysis with conditional logistic regression was used to compare the rate of VAP and number of days free of invasive devices before and after implementation of the electronic checklist. Results: We analysed 1711 patients (before group, n = 761; after group, n = 950). The rates of VAP were 21% and 11% in the before and after groups, respectively (p < 0.001). In propensity-score matched analysis (n = 742 in each group), VAP occurred in 151 patients (21%) during the before period compared with 72 patients (10%) during the after period (odds ratio [OR] = 0.38; 95% confidence interval [CI] = 0.27-0.53). The after group showed increases in ICU-free days (OR = 1.05; 95% CI = 1.04-1.07) and mechanical ventilation-free days (OR = 1.03; 95% CI = 1.01-1.04). Conclusion: In this matched before/after study, implementation of an electronic checklist was associated with positive effects on patient outcomes, especially on VAP. Further prospective studies are needed to confirm these observations. (C) 2017 Societefrancaise d'anesthesie et de reanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.

International audience; The aim of this study was to compare septic shock directly associated-mortality between severe trauma patients and nontrauma patients to assess the role of comorbidities and age. We conducted a retrospective study in an intensive care unit (ICU) (15 beds) of a university hospital (928 beds). From January 2009 to May 2015, we reviewed 2 anonymized databases including severe trauma patients and nontrauma patients. We selected the patients with a septic shock episode. Among 385 patients (318 nontrauma patients and 67 severe trauma patients), the ICU death rate was 43%. Septic shock was directly responsible for death among 35% of our cohort, representing 123 (39%) nontrauma patients and 10 (15%) trauma patients (P

We assessed outcomes in brain-injured patients after implementation of a multi-faceted approach to reduce respiratory complications in intensive care units. Prospective nationwide before–after trial. Consecutive adults with acute brain injury requiring mechanical ventilation for ≥24 h in 20 French intensive care units (ICUs) were included. The management of invasive ventilation in brain-injured patients admitted between 1 July 2013 and 31 October 2013 (4 months) was monitored and analysed. After the baseline period (1 November 2013–31 December 2013), ventilator settings and decision to extubate were selected as targets to hasten weaning from invasive ventilation. During the intervention period, low tidal volume (≤7 ml/kg), moderate positive end-expiratory pressure (PEEP, 6–8 cm H2O) and an early extubation protocol were recommended. The primary endpoint was the number of days free of invasive ventilation at day 90. Comparisons were performed between the two periods and between the compliant and non-compliant groups. A total of 744 patients from 20 ICUs were included (391 pre-intervention; 353 intervention). No difference in the number of invasive ventilation-free days at day 90 was observed between the two periods [71 (0–80) vs. 67 (0–80) days; P = 0.746]. Compliance with the complete set of recommendations increased from 8 (2%) to 52 (15%) patients after the intervention (P

IF 12.015; International audience; Prone position (PP) improves oxygenation and outcome of acute respiratory distress syndrome (ARDS) patients with a PaO2/FiO(2) ratio < 150 mmHg. Regional changes in lung aeration can be assessed by lung ultrasound (LUS). Our aim was to predict the magnitude of oxygenation response after PP using bedside LUS. We conducted a prospective multicenter study that included adult patients with severe and moderate ARDS. LUS data were collected at four time points: 1 h before (baseline) and 1 h after turning the patient to PP, 1 h before and 1 h after turning the patient back to the supine position. Regional lung aeration changes and ultrasound reaeration scores were assessed at each time. Overdistension was not assessed. Fifty-one patients were included. Oxygenation response after PP was not correlated with a specific LUS pattern. The patients with focal and non-focal ARDS showed no difference in global reaeration score. With regard to the entire PP session, the patients with non-focal ARDS had an improved aeration gain in the anterior areas. Oxygenation response was not associated with aeration changes. No difference in PaCO2 change was found according to oxygenation response or lung morphology. In ARDS patients with a PaO2/FiO(2) ratio aecurrency sign150 mmHg, bedside LUS cannot predict oxygenation response after the first PP session. At the bedside, LUS enables monitoring of aeration changes during PP.

Resume Objectif Decrire les applications cliniques et les perspectives offertes par l’echographie pulmonaire en reanimation. Methodologie Rappel de la semiologie echographique pulmonaire et synthese des donnees publiees durant les cinq dernieres annees sur l’utilisation de l’echographie pleuropulmonaire en reanimation. La base de donnees Pubmed™ a ete utilisee. Les etudes cliniques publiees en langue francaise ou anglaise ont ete analysees. Synthese des donnees L’echographie permet le diagnostic et la quantification des epanchements pleuraux. En cas d’admission d’un patient en detresse respiratoire aigue d’origine medicale ou traumatique, elle participe au diagnostic etiologique, a la mise en route des traitements et a la surveillance de leur efficacite. Elle represente une aide a la prise en charge des pneumonies et des patients ayant un syndrome de detresse respiratoire aigue. L’etude de l’œdeme interstitiel apporte des informations hemodynamiques dont le role merite d’etre evalue. Conclusion L’echographie pulmonaire est une technique d’imagerie simple, non invasive, non irradiante et rapidement disponible. Elle apporte des informations au lit du patient hospitalise en reanimation. L’impact de cette technique sur le pronostic merite d’etre evalue dans de futures etudes.

To describe current use and diagnostic and therapeutic impacts of point-of-care ultrasound (POCUS) in the intensive care unit (ICU). POCUS is of growing importance in the ICU. Several guidelines recommend its use for procedural guidance and diagnostic assessment. Nevertheless, its current use and clinical impact remain unknown. Prospective multicentric study in 142 ICUs in France, Belgium, and Switzerland. All the POCUS procedures performed during a 24-h period were prospectively analyzed. Data regarding patient condition and the POCUS procedures were collected. Factors associated with diagnostic and therapeutic impacts were identified. Among 1954 patients hospitalized during the study period, 1073 (55 %) POCUS/day were performed in 709 (36 %) patients. POCUS served for diagnostic assessment in 932 (87 %) cases and procedural guidance in 141 (13 %) cases. Transthoracic echocardiography, lung ultrasound, and transcranial Doppler accounted for 51, 17, and 16 % of procedures, respectively. Diagnostic and therapeutic impacts of diagnostic POCUS examinations were 84 and 69 %, respectively. Ultrasound guidance was used in 54 and 15 % of cases for central venous line and arterial catheter placement, respectively. Hemodynamic instability, emergency conditions, transthoracic echocardiography, and ultrasounds performed by certified intensivists themselves were independent factors affecting diagnostic or therapeutic impacts. With regard to guidelines, POCUS utilization for procedural guidance remains insufficient. In contrast, POCUS for diagnostic assessment is of extensive use. Its impact on both diagnosis and treatment of ICU patients seems critical. This study identified factors associated with an improved clinical value of POCUS.

The study was designed to assess whether high dosages of norepinephrine are associated with increased death rate and to determine the dosage of norepinephrine associated with an intensive care unit (ICU) death rate greater than 90%. We conducted a retrospective, noninterventional, observational study in a single ICU (15 beds) of an academic hospital. From January 2009 to May 2013, data of all patients with a diagnosis of septic shock were extracted from our database. Data were collected at the time of the admission in ICU, at the onset of septic shock, and when the maximal posology of norepinephrine was reached. Mortality was assessed in ICU, in hospital, and at day 90. Among the 324 patients with septic shock, the death rate was 48%. The death rate reached 90% for the quantile of patients receiving more than 1 μg/kg per minute of norepinephrine. In our cohort, four independent factors associated with mortality were identified: age (odds ratio, 1.02 [95% confidence interval, 1.00-1.04]; P = 0.02), thrombocytopenia (odds ratio, 3.8 [95% confidence interval, 1.8-8.5]; P < 0.001), urine output less than 500 mL (odds ratio, 8.7 [95% confidence interval, 3.6-25]; P < 0.001), and dosage of norepinephrine greater than 1 μg/kg per minute (odds ratio, 9.7 [95% confidence interval, 4.5-23]; P < 0.001). However, because of the study's design, unmeasured confounding factors should be taken into account in our findings.

To determine the effect of implementing a daily lung ultrasound round on the number of chest radiographs and chest computed tomography (CT) scans in a polyvalent intensive care unit (ICU).Retrospective study comparing two consecutive periods.All patients hospitalized for longer than 48 hours in a polyvalent ICU.Implementation of a daily lung ultrasound round after a short educational program. The number of chest radiographs and chest CT scans and the patient outcome were measured before (group PRE) and after (group POST) the implementation of a daily lung ultrasound round.No demographic difference was found between the two groups, with the exception of a higher severity score in the group POST. For each ICU stay, the number of chest radiographs was 10.3 ± 12.4 in the group PRE and 7.7 ± 10.3 in the group POST, respectively (P0.005) The number of chest CT scans was not reduced in the group POST, as compared with the group PRE (0.5 ± 0.7 CT scan/patient/ICU stay versus 0.4 ± 0.6 CT scan/patient/ICU stay, P=0.01). The ICU mortality was similar in both groups (21% versus 22%, P=0.75) CONCLUSION: The implementation of a daily lung ultrasound round was associated with a reduction in radiation exposure and medical cost without altering patient outcome.

Introduction Premiere cause de mortalite chez les sujets de moins de 40 ans, la traumatologie reste un enjeu de sante publique avec une morbidite majeure. L’agression facilite les infections nosocomiales, avec pour risque le choc septique. Notre etude a pour objectif principal l’identification des facteurs de risques de choc septique et pour objectif secondaire l’estimation de l’incidence et de la mortalite des chocs septiques chez des patients traumatises graves hospitalises en reanimation. Nous avons egalement cherche les facteurs de risque de mortalite du choc septique. Materiel et methodes Nous avons inclus retrospectivement 581 patients admission en reanimation, pour traumatisme grave defini par un Injury Severity Score (ISS) superieur a 15 dans un centre de traumatologie de niveau 1 au CHU de l’hopital Nord Marseille entre aout 2010 et decembre 2013. Le jour du choc septique a ete defini par l’introduction de vasopresseur dans un contexte de sepsis grave. Le groupe choc septique est compare au groupe temoin qui representait les patients n’ayant pas fait de choc septique. Resultats Notre etude a mis en evidence les facteurs de risque de choc septique suivants en analyse univariee : l’âge, l’IGS2 a l’admission, l’utilisation de catecholamines dans les premieres 24 heures, la duree de sejour en reanimation, le nombre de jours d’exposition a un catheter arteriel, le nombre de jours d’exposition a une voie veineuse centrale, le nombre de jours d’exposition a une sonde urinaire. L’analyse multivariee par regression logistique « pas a pas » a identifie deux facteurs de risque independants de choc septique : l’âge et le monitorage de la PIC. Les objectifs secondaires etaient de determiner l’incidence du choc septique et d’evaluer sa mortalite. Dans notre cohorte de patients traumatises graves, 52 (9 %) patients ont developpe un choc septique. La mortalite en reanimation etait de 25 % dans le groupe choc septique et 19 % dans le groupe temoin ( p = 0,38). La mortalite hospitaliere etait de 31 % dans le groupe choc septique et 21 % dans le groupe temoin ( p = 0,13). On a obtenu une difference significative de mortalite hospitaliere a j90 entre le groupe choc septique et le groupe temoin ( p = 0,0009). La mortalite a j90 est de 29 % dans le groupe choc septique et de 20 % dans le groupe temoin ( p = 0,21). L’analyse multivariee par regression logistique « pas a pas » a identifie six facteurs de risque independants de mortalite hospitaliere : l’âge, l’ISS > 30, le support par catecholamines, la presence d’une HTIC, le taux de lactate > 4 mmol/L. Discussion Pour la premiere fois, notre etude a mis en evidence deux facteurs de risque independants de developper un choc septique apres un traumatisme grave : l’âge et le monitorage de la pression intracrânienne. L’incidence du choc septique etait de 9 % avec une mortalite en reanimation a 25 %, comparee a 19 % chez les temoins. Ces resultats suggerent, d’une part, que la survenue d’un choc septique chez les traumatises est peu previsible et, d’autre part, que les traumatises graves ne sont pas une population specialement a risque de faire un choc septique et que la mortalite du choc septique est en grande partie liee aux co-morbidites.

Introduction En reanimation, la ventilation mecanique peut etre prolongee avec une morbi-mortalite elevee notamment en cas de pneumonies acquises sous ventilation mecanique. La tracheotomie peut alors etre proposee bien que ces avantages sur la morbi-mortalite ne soient pas demontres [1] . Or la litterature actuelle ne permet pas de predire la duree de ventilation et le moment ideal de la tracheotomie [2] . L’objectif de cette etude etait de rechercher des criteres predictifs de ventilation mecanique prolongee chez les patients en postoperatoire de chirurgie thoracique. Patients et methodes Nous avons realise une etude retrospective sur 3 ans dans une reanimation polyvalente : 221 patients analyses repartis en 2 populations. Population A patients ventiles plus et moins de 48 h et population B : patients ventiles plus et moins de 14 jours. L’objectif etait de determiner si des criteres cliniques, biologiques ou des scores de gravite, a l’admission et pendant le sejour pouvaient predire une ventilation superieure a 48 heures et a 14 jours. Resultats L’analyse statistique unie variee a montre pour la population A, que l’index de masse corporelle (IMC), l’albuminemie preoperatoire, les scores SOFA et IGS2 sont correles de facon significative avec une duree de ventilation longue. Ces resultats sont confirmes dans la population B pour le SOFA et l’IGS2. Pour les populations A et B, les patients ventiles plus longtemps ont presente significativement plus de complications a type de pneumonies, syndrome de detresse respiratoire (SDRA), fistules, pleuresie, fibrillation auriculaire (FA), et echec d’extubation. Les analyses multivariees ont montre pour la population A que les facteurs predictifs de ventilation superieure a 48 h sont le score SOFA et la survenue d’une FA avec des odds ratio respectifs de 1,6 [1,3–2] et 7 [2,7–19], p p Tableau 1 . Discussion L’impact de l’ALR sur la prise en charge postoperatoire permet une rehabilitation precoce et est retrouve dans notre etude comme un facteur protecteur de ventilation prolongee. A l’inverse : le score IGS2, la survenue d’une complication a type de FA, de pneumonie ou de SDRA sont des facteurs de risque. Isolement ces facteurs ne peuvent predire une duree de ventilation superieure a 14 jours mais ensemble ils peuvent aider a definir un groupe a risque chez qui la tracheotomie peut etre discutee precocement.

Background At the bedside, the reference method for creatinine clearance determination is based on the measurement of creatinine concentrations in urine and serum (mCrCl). Several models are available to calculate the creatinine clearance from the serum creatinine concentration. This observational survey aimed at testing the hypothesis that the proposed equations are unreliable to determine accurate creatinine clearance in patients admitted to intensive care unit (ICU). Method Creatinine clearance was determined by the use of mCrCl. Then, we compared three equations: Cockcroft-Gault (CG), Simplified Modification of Diet in Renal Disease (MDRDs), and Chronic Kidney Disease Epidemiology (CKD-EPI) in 156 consecutive patients within the first 24 hours after ICU admission. We tested the hypothesis that the three equations were equivalent. The agreement between the three equations was evaluated by linear regression and Bland and Altman analysis. Results Bland and Altman analysis showed similar agreement between the three equations. The biases and precisions were –4.8 ± 51, –1.3 ± 50, and 8.2 ± 44 for CG, MDRDs, and CKD-EPI equations, respectively ( P > 0.05). The precisions were similar for the three equations ( P > 0.05). The percentages of outliers at ± 30% were 44%, 45%, and 49% for CG, MDRDs, and CKD-EPI, respectively ( P > 0.05). Conclusion Regarding the high percentage of outliers, the use of these equations cannot be recommended in ICU patients.

Objective To determine the incidence of occult pulmonary embolism (PE) and the associated morbidity in an intensive care unit (ICU). Design Retrospective study. Setting Fifteen-bed ICU of a university hospital. Participants Two hundred patients who underwent chest computed tomography (CT) scans with administration of contrast. Interventions The patients were classified into 3 groups: (1) Occult PE if the chest CT scan was not taken, specifically for elucidating the diagnosis of PE, but it confirmed this diagnosis; (2) non-occult PE if the chest CT scan was taken to elucidate a suspected diagnosis of PE and confirmed this diagnosis; and (3) the chest CT scan did not confirm this diagnosis. The analysis was conducted to identify the effect of a diagnosis of occult PE on the outcomes of patients. Measurements and Main Results Among the 200 patients who underwent chest CT scan, 27 (13%) patients had PE, in whom 18 (9%) were classified as occult PE and 9 (4.5%) as non-occult PE. The duration of ICU stay was increased in patients with PE, as compared with the controls (23 [18-48] days v 17 [10-20] days v 14 [7-29] days; p = 0.02 for occult PE, non-occult PE, and controls, respectively). No difference was observed in mortality rate among the 3 groups. Conclusion Occult PE was found in 9% of the cohort. This emphasized the need for developing diagnostic strategies in high-risk patients. Future studies should aim at assessing interventions for preventing this event.

Introduction La prise en charge des patients apres un traumatisme grave represente un enjeu sanitaire et economique. Le temps est un element important du pronostic et l’imagerie est indispensable pour decider de l’orientation de ces patients [1] . L’objectif de cette etude etait l’analyse du parcours intrahospitalier et des delais de prise en charge de ces patients au cours des 24 heures suivant le traumatisme. Materiel et methodes Etude observationnelle retrospective monocentrique conduite dans un service de reanimation traumatologique et polyvalente au CHU Nord de Marseille entre juillet 2011 et juillet 2013. Nous avons analyses les dossiers des 343 patients traumatises graves admis directement en reanimation (Les 191 patients admis via le service des urgences ou un autre centre hospitalier ont ete exclus). L’analyse a porte sur : profil demographique, mecanisme et bilan lesionnel, lieu d’admission, transfert au scanner et/ou bloc operatoire ou arterioembolisation), et sur les delais de prise en charge : obtention du bilan radiologique initial (radiographie thorax + bassin + FAST echographie), du scanner corps entier et delai avant chirurgie urgente. Resultats L’âge moyen des patients etait de 39 ans (± 18 ans), l’IGS median etait a 33 [24–36]. Le mecanisme lesionnel etait dans 61 % des cas un accident de la voie publique, 14 % des patients presentaient un traumatisme penetrant, parmi eux 5 patients (1,5 %) ont ete admis directement au bloc operatoire devant une instabilite hemodynamique majeure. Apres une admission en reanimation et la realisation du bilan radiologique initial (delai median : 14 min [10–22]), 300 patients (87 %) ont ete conduits au scanner (IGS median 35 [6–102], mortalite 16 %) pour un bilan lesionnel exhaustif (delai median : 41 min [24–59]). Seuls 20 patients (6 %) etaient transferes directement au bloc operatoire (IGS median 54 [28–80], mortalite 30 %, p Fig. 1 ). Discussion L’analyse du parcours de soins, dans le cadre de l’evaluation des pratiques professionnelles, met en evidence la place cruciale de l’imagerie dans la strategie diagnostique et decisionnelle des l’admission du patient traumatise. La chirurgie urgente des l’admission concerne tres peu de patients et est associee a une mortalite elevee. La tres grande majorite des patients (87 %) est concernee par la realisation en premiere intention d’une tomodensitometrie pour bilan lesionnel exhaustif. L’optimisation de la prise en charge doit permettre l’obtention de ce bilan dans le delai le plus court possible.

Introduction L’echographie pleuro-pulmonaire (EP) et la radiographie pulmonaire (RP) sont recommandees dans la prise en charge du traumatise grave. La puissance diagnostique de l’echographie est superieure a celle de la radiographie pour les epanchements pleuraux. L’impact therapeutique des deux techniques en association est peu etudie. L’objectif principal etait de comparer la puissance diagnostique de l’EP et de la RP pour le diagnostic du pneumothorax (PNO) et de l’hemothorax. L’objectif secondaire etait d’evaluer l’impact therapeutique respectif de ces procedures. Materiel et methodes Etude retrospective monocentrique (CHU Nord, Marseille) avec collecte prospective des donnees. Pour chaque patient traumatise primaire, une RP, une EP et une TDM corps entier etaient realisees. Selon les protocoles de service, une fiche de recueil des resultats des imageries et des traitements etait remplie avec une analyse retrospective. Les dossiers des patients etaient ensuite relus (un seul relecteur) pour determiner si les decisions etaient appropriees. La puissance diagnostique de la RP et de l’EP etaient definies par rapport a la TDM. L’impact therapeutique etait defini par le nombre de modifications induites par les examens d’imagerie (RP, EP ou RP + EP) avant TDM rapportes au nombre d’examens realises. Resultats En 30 mois, 146 patients traumatises primaires ont ete inclus dans l’etude. Les puissances diagnostiques et impacts therapeutiques des deux examens sont resumes dans le Tableau 1 . En cas d’EP anormale, l’impact therapeutique de la RP etait de 28 %. En cas d’EP normale, il etait nul. Les PNO n’etaient draines que sur une positivite des deux examens (EP + RP). Trois hemothorax non detectes a la RP ont ete draines sur les donnees de l’EP. Aucun drainage inapproprie n’etait detecte a la relecture des dossiers. Trois abstentions de drainage ont ete analyses comme inappropriees (PNO draines secondairement non detectes a l’EP et a la RP). Discussion L’EP a une puissance diagnostique et un impact therapeutique superieurs a la RP sans toutefois etre parfaite dans le contexte de l’urgence. L’association des deux techniques evite de drainer a tort des PNO minimes detectes par l’EP. Cependant, si l’EP est normale, la RP n’apportait aucune modification therapeutique. Les consequences d’une prescription de RP basee sur les resultats de l’EP en termes de qualite de prise en charge initiale restent a evaluer par de futures etudes.

Introduction Dans le choc septique, l’utilisation de la noradrenaline est recommandee en premiere intention. L’impact des hautes doses de noradrenaline sur la survie des patients reste meconnu. L’objectif de cette etude etait de determiner la dose de noradrenaline pour laquelle le pourcentage de deces excede 90 % et de determiner si la dose maximale de noradrenaline administree est un facteur de risque independant de mortalite. Materiel et methodes Nous avons conduit une etude retrospective, observationnelle et monocentrique de janvier 2009 a mai 2013. Tous les patients ayant presente un choc septique ont ete inclus. Nous avons recueilli les donnees demographiques, le score SOFA et SAPS 2, le site infectieux, la presence d’une defaillance d’organe, la dose maximale en μg/kg/min de noradrenaline et sa duree d’administration. Nous avons recueilli au premier jour du choc septique et le jour ou la dose maximale de noradrenaline a ete atteinte les parametres hemodynamiques. A la sortie de reanimation nous avons egalement releve la duree de ventilation mecanique, la duree totale du sejour en reanimation, ainsi que le recours a l’adrenaline, la dobutamine, l’isoprenaline, la terlipressine et l’hemisuccinate d’hydrocortisone. Nous avons recherche la survenue du deces, en reanimation, en hospitalisation ou dans les 28 premiers jours. Resultats Sur les 324 patients inclus le taux de mortalite etait de 48 %. Le taux de mortalite atteint 90 % pour les patients qui depassent la dose de 1 μg/kg/min de noradrenaline. Nous avons identifie quatre facteurs de risque independants de mortalite : l’âge (1,02 [1,0–1,04], p = 0,019), la thrombopenie (3,8 [1,7–8,5], p Discussion Au cours du choc septique, une dose de noradrenaline superieure a 1 μg/kg/min constitue un facteur de risque independant de mortalite. Une dose maximale de noradrenaline superieure a 1ug/kg/min est associee a un risque de mortalite superieur a 90 %. Ce resultat peut aider a definir une dose dite « refractaire » dans de futures etudes.

Introduction L’acces a une imagerie pulmonaire performante est necessaire en reanimation, exposant aux radiations ionisantes et aux transferts dangereux [1] . L’echographie pulmonaire (EP) est une technique non irradiante et disponible aux performances diagnostiques superieures a la radiographie thoracique (RT) [2] . Elle represente une alternative aux examens ionisants [3] . L’objectif de notre etude etait de determiner l’impact de l’echographie pleuro-pulmonaire en reanimation sur le nombre de RT et de scanners thoraciques (ST) prescrits. Une analyse en sous-groupe excluant les patients ayant eu une chirurgie thoracique (prescription de radios et de scanner par les chirurgiens) etait realisee. Materiel et methodes Etude retrospective comparant deux periodes consecutives dans une reanimation de 15 lits d’un hopital universitaire. Inclusion des patients hospitalises plus de 48 h. Mise en place d’un examen d’EP a la demande quotidien apres courte periode de formation du personnel medical a la technique. Le nombre de RT, de ST ainsi que les caracteristiques des patients etaient mesures avant (groupe PRE) et apres (groupe POST) l’introduction de l’echographie, le personnel medical n’etait pas informe de la realisation d’une etude. Resultats Les donnees epidemiologiques des deux groupes etaient comparables, seul le score de gravite IGS II etait plus eleve dans le groupe POST 35 ± 16 vs. 39 ± 17 ( p = 0,005). Pour chaque sejour en reanimation, le nombre de RT et de ST etait significativement reduit dans le groupe POST (10,3 ± 12 RT dans le groupe PRE vs. 7,7 ± 10 dans le groupe POST ( p vs. 0,4 ± 1 dans le groupe POST ( p = 0,01)). Apres exclusion des patients ayant eu une chirurgie thoracique, la reduction de prescription etait plus importante (9,4 ± 11 vs. 6,4 ± 8 ( p = 0,0001)). La mortalite en reanimation etait similaire dans les deux groupes (21 % vs. 22 %, ( p = 0,75)) ( Tableau 1 ). Discussion L’introduction de l’echographie pleuro-pulmonaire etait associee a une reduction significative du nombre de RT et de ST reduisant l’exposition des patients aux radiations ionisantes et les depenses de sante sans consequence pronostique. L’economie realisee sur un an dans notre structure est evaluee a 1000 mGy et 30 000 euros. Ce resultat a ete obtenu sans protocole dictant les indications respectives des examens d’imagerie thoracique de reanimation. L’impact d’un tel protocole pourrait accentuer la tendance constatee et reste a evaluer dans de futurs travaux prospectifs.