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.
Deye N.,French Institute of Health and Medical Research |
Cariou A.,Reanimation Medicale |
Girardie P.,Lille University Hospital Center |
Pichon N.,Limoges University Hospital Center |
And 22 more authors.
Circulation | Year: 2015
Background - Targeted temperature management is recommended after out-of-hospital cardiac arrest. Whether advanced internal cooling is superior to basic external cooling remains unknown. The aim of this multicenter, controlled trial was to evaluate the benefit of endovascular versus basic surface cooling. Methods and Results - Inclusion criteria were the following: age of 18 to 79 years, out-of-hospital cardiac arrest related to a presumed cardiac cause, time to return of spontaneous circulation <60 minutes, delay between return of spontaneous circulation and inclusion <240 minutes, and unconscious patient after return of spontaneous circulation and before the start of cooling. Exclusion criteria were terminal disease, pregnancy, known coagulopathy, uncontrolled bleeding, temperature on admission <30°C, in-hospital cardiac arrest, immediate need for extracorporeal life support or hemodialysis. Patients were randomized between 2 cooling strategies: endovascular femoral devices (Icy catheter, Coolgard, Zoll, formerly Alsius; n=203) or basic external cooling using fans, a homemade tent, and ice packs (n=197). The primary end point, that is, favorable outcome evaluated by survival without major neurological damage (Cerebral Performance Categories 1-2) at day 28, was not significantly different between groups (odds ratio, 1.41; 95% confidence interval, 0.93-2.16; P=0.107). Improvement in favorable outcome at day 90 in favor of the endovascular group did not reach significance (odds ratio, 1.51; 95% confidence interval, 0.96-2.35; P=0.07). Time to target temperature (33°C) was significantly shorter and target hypothermia was more strictly maintained in the endovascular than in the surface group (P<0.001). Minor side effects directly related to the cooling method were observed more frequently in the endovascular group (P=0.009). Conclusion - Despite better hypothermia induction and maintenance, endovascular cooling was not significantly superior to basic external cooling in terms of favorable outcome. © 2015 American Heart Association, Inc.
Gaudry S.,Intensive Care Unit |
Hajage D.,University Paris Diderot |
Schortgen F.,French Institute of Health and Medical Research |
Martin-Lefevre L.,APHP |
And 22 more authors.
New England Journal of Medicine | Year: 2016
Background The timing of renal-replacement therapy in critically ill patients who have acute kidney injury but no potentially life-threatening complication directly related to renal failure is a subject of debate. METHODS In this multicenter randomized trial, we assigned patients with severe acute kidney injury (Kidney Disease: Improving Global Outcomes [KDIGO] classification, stage 3 [stages range from 1 to 3, with higher stages indicating more severe kidney injury]) who required mechanical ventilation, catecholamine infusion, or both and did not have a potentially life-threatening complication directly related to renal failure to either an early or a delayed strategy of renal-replacement therapy. With the early strategy, renalreplacement therapy was started immediately after randomization. With the delayed strategy, renal-replacement therapy was initiated if at least one of the following criteria was met: severe hyperkalemia, metabolic acidosis, pulmonary edema, blood urea nitrogen level higher than 112 mg per deciliter, or oliguria for more than 72 hours after randomization. The primary outcome was overall survival at day 60. RESULTS A total of 620 patients underwent randomization. The Kaplan-Meier estimates of mortality at day 60 did not differ significantly between the early and delayed strategies; 150 deaths occurred among 311 patients in the early-strategy group (48.5%; 95% confidence interval [CI], 42.6 to 53.8), and 153 deaths occurred among 308 patients in the delayed-strategy group (49.7%, 95% CI, 43.8 to 55.0; P=0.79). A total of 151 patients (49%) in the delayed-strategy group did not receive renal-replacement therapy. The rate of catheter-related bloodstream infections was higher in the early-strategy group than in the delayed-strategy group (10% vs. 5%, P=0.03). Diuresis, a marker of improved kidney function, occurred earlier in the delayed-strategy group (P<0.001). CONCLUSIONS In a trial involving critically ill patients with severe acute kidney injury, we found no significant difference with regard to mortality between an early and a delayed strategy for the initiation of renal-replacement therapy. A delayed strategy averted the need for renal-replacement therapy in an appreciable number of patients. © 2016 Massachusetts Medical Society.
PubMed | University Claude Bernard Lyon 1, Lille University Hospital Center, Aix - Marseille University, University of Burgundy and 4 more.
Type: | Journal: Anaesthesia, critical care & pain medicine | Year: 2017
Chest Trauma remains an issue for health services for both severe and apparently mild trauma management. Severe chest trauma is associated with high mortality and is considered liable for 25% of mortality in multiple traumas. Moreover, mild trauma is also associated with significant morbidity especially in patients with preexisting conditions. Thus, whatever the severity, a fast-acting strategy must be organized. At this time there are no guidelines available from scientific societies. These expert recommendations aim to establish guidelines for chest trauma management in both pre hospital an in hospital settings, for the first 48hours. The Socit Franaise dAnesthsie Ranimation and the Socit Franaise de Mdecine dUrgence worked together on the 7 following questions: For each question, prespecified crucial (and sometimes also important) outcomes were identified by the panel of experts because it mattered for patients. We rated evidence across studies for these specific clinical outcomes. After a systematic GRADE approach, we defined 60 recommendations. Each recommendation has been evaluated by all the experts according to the DELPHI method.
Mimoz O.,University of Poitiers |
Auquier P.,University of Monastir |
Loundou A.,Unite dAide Methodologique A la Recherche Clinique et Epidemiologique |
Gauzit R.,Unite de Reanimation Chirurgicale |
And 5 more authors.
Intensive Care Medicine | Year: 2010
Purpose: To develop and validate the IPREA (Inconforts des Patients de REAnimation) questionnaire for the assessment of discomfort perceived by patients related to their intensive care unit (ICU) stay. Methods: This was a two step-study comprising a phase of item generation conducted in one ICU and a phase of psychometric evaluation during a multicenter prospective cohort study in 14 ICUs. Patients were unselected consecutive adult surviving ICU patients. On the day of ICU discharge, a nurse asked patients to rate the severity of 16 discomfort sources, from 0 to 100. Ten percent of patients were randomly chosen to be questioned again to assess the reproducibility. Results: Of 1,380 eligible patients, 1,113 survived and 868 patients could be questioned. The highest scores were for sleep deprivation (35 ± 33), being restrained by tubing, wires, and cables (33 ± 30), pain (32 ± 30), and thirst (32 ± 34). No multidimensional structure was identified. The mean overall score of discomfort was 22 ± 14. Internal consistency was satisfactory using Cronbach's alpha coefficient (0.78). The test-retest reliability study found average measure intraclass correlations ranging from 0.70 to 0.92. The mean duration of the questionnaire administration was 10 ± 7 min. Conclusion: The psychometric properties and acceptability of the IPREA questionnaire make it a potential instrument for measuring discomfort perceived by unselected ICU patients. © 2010 jointly held by Springer and ESICM.
PubMed | Pneumologie and Reanimation polyvalente
Type: Journal Article | Journal: Revue de pneumologie clinique | Year: 2016
High-risk pulmonary embolism (PE) is associated with high mortality rate (>50%). In some cases, diagnosis of PE remains a challenge with atypical presentations like in this case report with a PE revealed by status epilepticus.We report the case of a 40-year-old man without prior disease, hospitalized in ICU for status epilepticus. All paraclinical examinations at admission did not show any significant abnormalities (laboratory tests, cardiologic and neurological investigations). On day 1, he presented a sudden circulatory collapse and echocardiography showed right intra-auricular thrombus. He was treated by thrombolysis and arteriovenous extracorporeal membrane oxygenation. After stabilization, computed tomography showed severe bilateral PE. He developed multi-organ failure and died 4days after admission.Pulmonary embolism revealed by status epilepticus has rarely been reported and is associated with poor prognosis. Physicians should be aware and think of the possibility of PE in patients with status epilepticus without any history or risk factors of seizure and normal neurological investigations.
Schortgen F.,Groupe Hospitalier Henri Mondor |
Schortgen F.,French Institute of Health and Medical Research |
Clabault K.,University of Rouen |
Katsahian S.,Groupe Hospitalier Henri Mondor |
And 12 more authors.
American Journal of Respiratory and Critical Care Medicine | Year: 2012
Rationale: Fever control may improve vascular tone and decrease oxygen consumption, but fever may contribute to combat infection. Objectives: To determine whether fever control by external cooling diminishes vasopressor requirements in septic shock. Methods: In a multicenter randomized controlled trial, febrile patients with septic shock requiring vasopressors, mechanical ventilation, and sedation were allocated to external cooling (n = 101) to achieve normothermia (36.5-37°C) for 48 hours or no external cooling (n = 99). Vasopressors were tapered to maintain the same blood pressure target in the two groups. The primary endpoint was the numberof patients with a 50% decrease in baseline vasopressor dose after 48 hours. Measurements and Main Results: Body temperature was significantly lower in the cooling group after 2 hours of treatment (36.8 ± 0.7 vs. 38.4 ± 1.1°C; P < 0.01). A 50% vasopressor dose decrease was significantly more common with external cooling from 12 hours of treatment (54 vs. 20%; absolute difference, 34%; 95% confidence interval [95% CI], -46 to -21; P < 0.001) but not at 48 hours (72 vs. 61%; absolute difference,11%; 95% CI, -23 to 2). Shock reversal during the intensive care unit stay was significantly more common with cooling (86 vs. 73%; absolute difference,13%; 95% CI, 2 to 25; P=0.021). Day-14 mortality was significantly lower in the cooling group (19 vs. 34%; absolute difference, -16%; 95% CI, -28 to -4; P = 0.013). Conclusions: In this study, fever control using external cooling was safe and decreased vasopressor requirements and early mortality in septic shock. Copyright © 2012 by the American Thoracic Society.
Increased mortality in hematological malignancy patients with acute respiratory failure from undetermined etiology: a Groupe de Recherche en Réanimation Respiratoire en Onco-Hématologique (Grrr-OH) study
PubMed | Brest University Hospital Center, Informatics and biostatistics, Institute Paoli Calmettes, Angers University Hospital Center and 6 more.
Type: Journal Article | Journal: Annals of intensive care | Year: 2016
Acute respiratory failure (ARF) is the most frequent complication in patients with hematological malignancies and is associated with high morbidity and mortality. ARF etiologies are numerous, and despite extensive diagnostic workflow, some patients remain with undetermined ARF etiology.This is a post-hoc study of a prospective multicenter cohort performed on 1011 critically ill hematological patients. Relationship between ARF etiology and hospital mortality was assessed using a multivariable regression model adjusting for confounders.This study included 604 patients with ARF. All patients underwent noninvasive diagnostic tests, and a bronchoscopy and bronchoalveolar lavage (BAL) was performed in 155 (25.6%). Definite diagnoses were classified into four exclusive etiological categories: pneumonia (44.4%), non-infectious diagnoses (32.6%), opportunistic infection (10.1%) and undetermined (12.9%), with corresponding hospital mortality rates of 40, 35, 55 and 59%, respectively. Overall hospital mortality was 42%. By multivariable analysis, factors associated with hospital mortality were invasive pulmonary aspergillosis (OR 7.57 (95% CI 3.06-21.62); p<0.005), use of invasive mechanical ventilation (OR 1.65 (95% CI 1.07-2.55); p=0.02), a SOFA score >7 (OR 3.32 (95% CI 2.15-5.15); p<0.005) and an undetermined ARF etiology (OR 2.92 (95% CI 1.71-5.07); p<0.005).In patients with hematological malignancies and ARF, up to 13% remain with undetermined ARF etiology despite comprehensive diagnostic workup. Undetermined ARF etiology is independently associated with hospital mortality. Studies to guide second-line diagnostic strategies are warranted. ClinicalTrials.Gov NCT01172132.
Guidet B.,Reanimation medicale |
Guidet B.,University Pierre and Marie Curie |
Guidet B.,French Institute of Health and Medical Research |
Martinet O.,Reanimation Medicale |
And 10 more authors.
Critical Care | Year: 2012
Introduction: Inadequate initial treatment and delayed hemodynamic stabilization (HDS) may be associated with increased risk of death in severe sepsis patients.Methods: In order to compare the hemodynamic efficacy and safety of 6% HES 130/0.4 and NaCl 0.9% for HDS in patients with severe sepsis, we designed a prospective, multicenter, active-controlled, double-blind, randomized study in intensive care units.Results: 174 out of 196 patients reached HDS (88 and 86 patients for HES and NaCl, respectively). Significantly less HES was used to reach HDS vs. NaCl (1,379 ±886 ml in the HES group and 1,709 ±1,164 ml in the NaCl group (mean difference = -331± 1,033, 95% CI -640 to -21, P = 0.0185). Time to reach HDS was 11.8 10.1 hours vs. 14.3 ±11.1 hours for HES and NaCl, respectively. Total quantity of study drug infused over four consecutive days, ICU and hospital LOS, and area under the curve of SOFA score were comparable. Acute renal failure occurred in 24 (24.5%) and 19 (20%) patients for HES and NaCl, respectively (P = 0.454). There was no difference between AKIN and RIFLE criteria among groups and no difference in mortality, coagulation, or pruritus up to 90 days after treatment initiation.Conclusion: Significantly less volume was required to achieve HDS for HES vs. NaCl in the initial phase of fluid resuscitation in severe sepsis patients without any difference for adverse events in both groups.ClinicalTrials.gov: NCT00464204. © 2012 Guidet et al.; licensee BioMed Central Ltd.