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Le Touquet – Paris-Plage, France

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.

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 150 mmHg with positive end expiratory pressure of 5 cmH2O or more, FIO2 of 60% or more and tidal volume around 6 ml/kg predicted body weight) confirmed 12-24 h 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) (P < 0.001). 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.

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.

Abroug F.,ICU CHU F. Bourguiba | Abroug F.,University of Monastir | Ouanes-Besbes L.,ICU CHU F. Bourguiba | Dachraoui F.,ICU CHU F. Bourguiba | And 4 more authors.
Critical Care | Year: 2011

Introduction: In patients with acute lung injury (ALI) and/or acute respiratory distress syndrome (ARDS), recent randomised controlled trials (RCTs) showed a consistent trend of mortality reduction with prone ventilation. We updated a meta-analysis on this topic.Methods: RCTs that compared ventilation of adult patients with ALI/ARDS in prone versus supine position were included in this study-level meta-analysis. Analysis was made by a random-effects model. The effect size on intensive care unit (ICU) mortality was computed in the overall included studies and in two subgroups of studies: those that included all ALI or hypoxemic patients, and those that restricted inclusion to only ARDS patients. A relationship between studies' effect size and daily prone duration was sought with meta-regression. We also computed the effects of prone positioning on major adverse airway complications.Results: Seven RCTs (including 1,675 adult patients, of whom 862 were ventilated in the prone position) were included. The four most recent trials included only ARDS patients, and also applied the longest proning durations and used lung-protective ventilation. The effects of prone positioning differed according to the type of study. Overall, prone ventilation did not reduce ICU mortality (odds ratio = 0.91, 95% confidence interval = 0.75 to 1.2; P = 0.39), but it significantly reduced the ICU mortality in the four recent studies that enrolled only patients with ARDS (odds ratio = 0.71; 95% confidence interval = 0.5 to 0.99; P = 0.048; number needed to treat = 11). Meta-regression on all studies disclosed only a trend to explain effect variation by prone duration (P = 0.06). Prone positioning was not associated with a statistical increase in major airway complications.Conclusions: Long duration of ventilation in prone position significantly reduces ICU mortality when only ARDS patients are considered. © 2011 Abroug et al.; licensee BioMed Central Ltd.

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.

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