Guerin C.,University of Lyon |
Reignier J.,Roche Holding AG |
Richard J.-C.,University of Lyon |
Beuret P.,Reanimation Polyvalente |
And 21 more authors.
New England Journal of Medicine | Year: 2013
BACKGROUND: Previous trials involving patients with the acute respiratory distress syndrome (ARDS) have failed to show a beneficial effect of prone positioning during mechanical ventilatory support on outcomes. We evaluated the effect of early application of prone positioning on outcomes in patients with severe ARDS. METHODS: In this multicenter, prospective, randomized, controlled trial, we randomly assigned 466 patients with severe ARDS to undergo prone-positioning sessions of at least 16 hours or to be left in the supine position. Severe ARDS was defined as a ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen (FIO2) of less than 150 mm Hg, with an FIO2 of at least 0.6, a positive end-expiratory pressure of at least 5 cm of water, and a tidal volume close to 6 ml per kilogram of predicted body weight. The primary outcome was the proportion of patients who died from any cause within 28 days after inclusion. RESULTS: A total of 237 patients were assigned to the prone group, and 229 patients were assigned to the supine group. The 28-day mortality was 16.0% in the prone group and 32.8% in the supine group (P<0.001). The hazard ratio for death with prone positioning was 0.39 (95% confidence interval [CI], 0.25 to 0.63). Unadjusted 90-day mortality was 23.6% in the prone group versus 41.0% in the supine group (P<0.001), with a hazard ratio of 0.44 (95% CI, 0.29 to 0.67). The incidence of complications did not differ significantly between the groups, except for the incidence of cardiac arrests, which was higher in the supine group. CONCLUSIONS: In patients with severe ARDS, early application of prolonged prone-positioning sessions significantly decreased 28-day and 90-day mortality. (Funded by the Programme Hospitalier de Recherche Clinique National 2006 and 2010 of the French Ministry of Health; PROSEVA ClinicalTrials.gov number, NCT00527813.) Copyright © 2013 Massachusetts Medical Society.
Sztrymf B.,Reanimation Medicale |
Jacobs F.,Reanimation Medicale |
Richard C.,Reanimation Medicale |
Millasseau S.C.,Pulse Wave Consulting
Journal of Clinical Monitoring and Computing | Year: 2013
The Complior device (Alam Medical, France) has contributed to the rise of arterial stiffness as a measure of cardiovascular risk. In its latest version (Complior Analyse) the sensor records pressure instead of distension waveforms thus allowing the measurement of central pressure and pulse wave analysis. The aim of our study was to verify that the new sensor measures pressure waveforms accurately in both time and frequency domain. Invasive and non-invasive signals were recorded simultaneously at the radial artery and compared in the frequency and time domain in haemodynamically stable intensive care unit patients. Twelve patients entered the study (8 men, 4 women, mean age 69 ± 17 years). Heart rate was 90 ± 15 bpm, systolic blood pressure 133 ± 19 mmHg and diastolic blood pressure 68 ± 15 mmHg. There was no statistical difference in the amplitude of harmonics between the invasive signal and Complior signal. When superimposing waveforms in the time domain, there was a small difference in the form factor (4.2 ± 2.8 %) and in the absolute area between the 2 waveforms (3.3 ± 1.7 mmHg·s-1). These differences were of the same magnitude as the beat-to-beat variation of the form factor (3.3 %) and of the absolute area (3.1 mmHg·s -1), respectively. The second systolic peak was detectable in 4 subjects, with no statistical difference between invasive and non-invasive values. The new pressure sensor of the Complior Analyse device recorded pressure waveforms accurately and could be used to perform pressure wave analysis. © 2013 Springer Science+Business Media New York.
Fowler R.A.,University of Toronto |
Fischer W.A.,University of North Carolina at Chapel Hill |
Lamontagne F.,Université de Sherbrooke |
Jacob S.,University of Washington |
And 19 more authors.
American Journal of Respiratory and Critical Care Medicine | Year: 2014
The largest ever Ebola virus disease outbreak is ravaging West Africa. The constellation of little public health infrastructure, low levels of health literacy, limited acute care and infection prevention and control resources, densely populated areas, and a highly transmissible and lethal viral infection have led to thousands of confirmed, probable, or suspected cases thus far. Ebola virus disease is characterized by a febrile severe illness with profound gastrointestinal manifestations and is complicated by intravascular volume depletion, shock, profound electrolyte abnormalities, and organ dysfunction. Despite no proven Ebola virus-specific medical therapies, the potential effect of supportive care is great for a condition with high baseline mortality and one usually occurring in resource-constrained settings.Withmore personnel, basic monitoring, and supportive treatment, many of the sickest patientswith Ebola virus disease do not need to die. Ebola virus disease represents an illness ready for a paradigmshift in care delivery and outcomes, and the profession of critical care medicine can and should be instrumental in helping this happen. Copyright © 2014 by the American Thoracic Society.
Thille A.W.,Reanimation Medicale |
Thille A.W.,University of Poitiers |
Thille A.W.,CARMAS Research Group |
Boissier F.,CARMAS Research Group |
And 4 more authors.
Critical Care Medicine | Year: 2015
Objective: The influence of delirium, ICU-acquired paresis, and cardiac performance on extubation outcome has never been evaluated together. We aimed to assess the respective role of these factors on the risk of extubation failure and to assess the predictive accuracy of caregivers. Design and Setting: Prospective observational study of all planned extubations in a 13-bed medical ICU of a teaching hospital. Interventions: On the day of extubation, muscle strength of the four limbs, criteria for delirium, cardiac performance, cough strength, and the risk of extubation failure predicted by caregivers were prospectively assessed. Extubation failure was defined as the need for reintubation within the following 7 days. Measurements and Main Results: Over the 18-month study period, 533 patients required intubation. Among the 225 patients intubated for more than 24 hours who experienced a planned extubation attempt, 31 patients (14%) required reintubation within the 7 days following extubation. In multivariate analysis, duration of mechanical ventilation more than 7 days prior to extubation, ineffective cough, and severe systolic left ventricular dysfunction were the three independent factors associated with extubation failure. Although patients considered at high risk for extubation failure had higher reintubation rate, prediction of extubation failure by caregivers at time of extubation had high specificity but low sensitivity. Conclusions: An ineffective cough, a prior duration of mechanical ventilation more than 7 days, and severe systolic left ventricular dysfunction were stronger predictors of extubation failure than delirium or ICU-acquired weakness. Only one-third patients who required reintubation were considered at high risk for extubation failure by caregivers. Copyright © 2015 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Wong H.R.,Foundation Medicine |
Wong H.R.,University of Cincinnati |
Lindsell C.J.,University of Cincinnati |
Lahni P.,Foundation Medicine |
And 3 more authors.
Shock | Year: 2013
Purpose: We previously identified interleukin 27 (IL-27) as a sepsis diagnostic biomarker in critically ill children. The current study tested the performance of IL-27 alone and in combination with procalcitonin (PCT) for diagnosing sepsis in critically ill adults. Methods: Serum samples were made available from a prior prospective study of sepsis biomarkers in critically ill adults. The primary analysis used receiver operating characteristic curves to evaluate the performance of IL-27 and PCT. Secondary analysis explored IL-27 performance in subgroups of patients with sepsis secondary to lung and nonlung sources of infection. The net reclassification improvement was used to estimate the incremental predictive ability of IL-27 compared with PCT alone. Classification and regression tree analysis was used to generate an IL-27-and PCT-based decision tree. Results: There were 145 patients with sepsis and 125 without sepsis. The receiver operating characteristic curve for IL-27 was inferior (area under the curve [AUC], 0.68; 95% confidence interval [CI], 0.62-0.75) to that of PCT (AUC, 0.84; 95% CI, 0.79-0.89). Similar findings were observed when comparing patients with a lung source of infection and those without sepsis. For sepsis patients with a nonlung source of infection, adding IL-27 to PCT improved discrimination (net reclassification improvement = 0.685; P < 0.001). The AUC for the classification and regression tree-derived decision tree was 0.92 (95% CI, 0.88-0.96) and was significantly greater than that of PCT alone. Conclusions: When used in combination with PCT, IL-27 may improve classification of critically ill adults with sepsis secondary to a nonlung source of infection. Copyright © 2013 by the Shock Society.
Schortgen F.,Reanimation Medicale
Reanimation | Year: 2014
Shortly after obtaining their market authorization, hydroxyethyl starches (HES) have emerged as the preferred fluid for resuscitation in many countries including France. Its natural origin and a lesser cost than that of albumin have promoted their large use. However, the benefit of colloids over crystalloids has never been demonstrated in the intensive care unit (ICU), and severe side-effects of HES have been rapidly described in humans. By reducing their molecular weight and substitution, the changing characteristics of the different HES generations shorted their intravascular half-life but did not improve the safety of the solutions. Several large randomized trials and meta-analyzes conclude on the renal toxicity of HES and even on a higher mortality in critically ill patients, independently of HES characteristics. These recent data have justified the reevaluation of the benefit-risk ratio of HES by the Food and Drug Administration and the European Medecines Agency. Their conclusions indicate that HES should not be used in critically ill patients. Since the first description of HES-related kidney damages, 20 years have been elapsed before prohibiting their use in the ICU. This literature review discusses the recently published evidences on the benefit-risk ratio of HES and the reasons that led to such a delay before health alert was triggered. We must learn from this experience. © 2014 Société de réanimation de langue française (SRLF) and Springer-Verlag.
Guerin C.,Reanimation Medicale |
Guerin C.,CNRS Research Center for Image Acquisition and Processing for Health
Current Opinion in Critical Care | Year: 2014
PURPOSE OF REVIEW: Prone position can prevent ventilator-induced lung injury in acute respiratory distress syndrome (ARDS) patients receiving conventional mechanical ventilation and, hence, may have the potential to improve survival from this basis. Even though no single randomized controlled trial has proven benefit on patient outcome until recently, two meta-Analyses, one on grouped data and the other on individual data, have shown that patients with PaO2/FIO2 ratio less than 100 mmHg at the time of inclusion did benefit from prone position. As a fifth trial completed recently has shown a significant reduction in mortality in patients with severe and confirmed ARDS from using prone position, the purpose of this review is to revisit prone positioning in ARDS in the light of these new findings. RECENT FINDINGS: In this trial done in patients with severe ARDS severity criteria (PaO2/FIO2 ratio less than 150â€ŠmmHg with positive end expiratory pressure of 5â€ŠcmH2O or more, FIO2 of 60% or more and tidal volume around 6â€Šml/kg predicted body weight) confirmed 12-24â€Šh after the onset of ARDS, the day 28 mortality in the supine group (229 patients) was 32.8 versus 16% in the prone group (237 patients) (Pâ€Š<â€Š0.001). Significant reduction in mortality was confirmed at day 90. SUMMARY: From the combined results of the two meta-Analyses and the last randomized controlled trial, there is a very strong signal to use prone position in patients with severe ARDS, as early as possible and for long sessions. © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins.
Rouze A.,Reanimation Medicale |
Nseir S.,Reanimation Medicale |
Nseir S.,University of Lille Nord de France
Current Opinion in Critical Care | Year: 2013
PURPOSE OF REVIEW: Ventilator-Associated pneumonia (VAP) is a major cause of death, morbidity and costs in ICUs. Several evidence-based clinical interventions have been increasingly described for its prevention. However, continuous control of tracheal cuff pressure (Pcuff) is rarely mentioned in the latest clinical guidelines. This review focuses on the available data about the management of Pcuff in the ICU, including discontinuous and continuous control, and its impact on the prevention of VAP. RECENT FINDINGS: Current discontinuous monitoring and adjustment of Pcuff, even well performed, is inaccurate in maintaining Pcuff in the target range. Underinflation (Pcuff <20â€ŠcmH2O) of tracheal cuff is an independent risk factor for VAP through microaspiration of contaminated subglottic secretions into the lower respiratory tract. Two main types of devices, electronic and pneumatic, have been developed for the continuous control of Pcuff. Both have shown effectiveness in maintaining Pcuff in recommended range in ICU patients, but only the pneumatic device has provided a reduction in microaspiration and VAP incidence. SUMMARY: Continuous controllers of Pcuff represent effective, easy to use and timesaving devices in todayÊs busy ICU environment. However, further studies are required to determine the impact of continuous control of Pcuff on VAP incidence, patient outcomes, antimicrobial consumption and to compare pneumatic and electronic devices, before generalizing their use in routine practice. © 2013 Wolters Kluwer Health Lippincott Williams & Wilkins.
Gibot S.,Reanimation Medicale |
Gibot S.,University of Lorraine |
Bene M.C.,University of Lorraine |
Noel R.,Reanimation Medicale |
And 9 more authors.
American Journal of Respiratory and Critical Care Medicine | Year: 2012
Rationale: Although the outcome of sepsis benefits from the prompt administration of appropriate antibiotics on correct diagnosis, the assessment of infection in critically ill patients is often a challenge for clinicians. In this setting, simple biomarkers, especially when used in combination, could prove useful. Objectives: To determine the usefulness of combination biomarkers to diagnose sepsis. Methods: Three hundred consecutive patients were enrolled to construct a biologic score that was next validated in an independent prospective cohort of 79 critically ill patients from another center. Measurement and Main Results: Plasma concentrations of soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) and procalcitonin (PCT) were assayed, and the expression of the high-affinity immunoglobulin-Fc fragment receptor I (FcgRI) CD64 on neutrophils (polymorphonuclear [PMN] CD64 index) in flow cytometry was measured. A "bioscore" combining these biomarkers was constructed. Serum concentrations of PCT and sTREM-1 and the PMN CD64 index were higher in patients with sepsis compared with all others (P < 0.001 for the three markers). These biomarkers were all independent predictors of infection, the best receiver-operating characteristic curve being obtained for the PMN CD64 index. The performance of the bioscore, better than that of each individual biomarker, was externally confirmed in the validation cohort. Conclusions: This prospective study, including inceptive and validation cohorts of unselected intensive care unit patients, demonstrates the high performance of a bioscore combining the PMNCD64 index together with PCT and sTREM-1 serum levels in diagnosing sepsis in the critically ill patient. Copyright © 2012 by the American Thoracic Society.
Leon K.,European University of Brittany |
Moisan C.,European University of Brittany |
Amerand A.,European University of Brittany |
Poupon G.,European University of Brittany |
L'Her E.,Reanimation medicale
Redox Report | Year: 2013
This study aimed to determine the effect of induced mild hypothermia (34°C) on the production of two cytokines (interleukin (IL-6) and tumor necrosis factor (TNF)alpha) and reactive nitrogen and oxygen species in plasma and the heart of acutely septic rats. After anesthesia and in conditions of normothermia (38°C) or mild hypothermia (34°C), acute sepsis was induced by cecal ligation and perforation. For each temperature three groups were formed: (1) baseline (blood sample collected at T0 hour), (2) sham (blood sample at T4 hours) and (3) septic (blood sample at T4 hours). At either temperature sepsis induced a significant increase in plasma IL-6, TNF-alpha and HO• concentration, compared with the sham groups (P ≤ 0.016). Compared with the normothermic septic group, septic rats exposed to mild hypothermia showed a mild decrease in TNF-alpha concentration (104 ± 50 pg/ml vs. 215± 114 pg/ml; P > 0.05) and a significant decrease in IL-6 (1131 ± 402 pg/ml vs. 2494 ± 691 pg/ml, P = 0.038). At either temperature sepsis induced no enhancement within the heart of lipoperoxidation (malondialdehyde content) or antioxidant activities (superoxide dismutase and catalase). In conclusion, during acute sepsis, induced mild hypothermia appears to reduce some pro-inflammatory and oxidative responses. This may, in part, explain the beneficial effect of hypothermia on survival duration of septic rats. © W. S. Maney & Son Ltd 2013.