Body composition and muscle strength at the end of ICU stay are associated with 1-year mortality, a prospective multicenter observational study.

BACKGROUND & AIMS: After a prolonged intensive care unit (ICU) stay patients experience increased mortality and morbidity. The primary aim of this study was to assess the prognostic value of nutritional status, body mass composition and muscle strength, as assessed by body mass index (BMI), bioelectrical impedance analysis (BIA), handgrip (HG) test, and that of the biological features to predict one-year survival at the end of a prolonged ICU stay. METHODS: This was a multicenter prospective observational study. Survivor patients older than 18 years with ICU length of stay >72 h were eligible for inclusion. BIA and HG were performed at the end of the ICU stay. Malnutrition was defined by BMI and fat-free mass index (FFMI). The primary endpoint was one-year mortality. Multivariable logistic regression was performed to determine parameters associated with mortality. RESULTS: 572 patients were included with a median age of 63 years [53.5; 71.1], BMI of 26.6 kg/m2 [22.8; 31.3], SAPS II score of 43 [31; 58], and ICU length of stay of 9 days [6; 15]. Malnutrition was observed in 142 (24.9%) patients. During the 1-year follow-up after discharge, 96 (18.5%) patients died. After adjustment, a low HG test score (aOR = 1.44 [1.11; 1.89], p = 0.01) was associated with 1-year mortality. Patients with low HG score, malnutrition, and Albuminemia <30 g/L had a one-year death rate of 41.4%. Conversely, patients with none of these parameters had a 1-year death rate of 4.1%. CONCLUSION: BIA to assess FFMI, HG and albuminemia at the end of ICU stay could be used to predict 1-year mortality. Their ability to identify patients eligible for a structured recovery program could be studied.

Cost assessment of a new oral care program in the intensive care unit to prevent ventilator-associated pneumonia.

OBJECTIVES: Ventilator-associated pneumonia (VAP) is the most frequent hospital-acquired infections in intensive care units (ICU). In the bundle of care to prevent the VAP, the oral care is very important strategies, to decrease the oropharyngeal bacterial colonization and presence of causative bacteria of VAP. In view of the paucity of medical economics studies, our objective was to determine the cost of implementing this oral care program for preventing VAP. MATERIALS AND METHODS: In five ICUs, during period 1, caregivers used a foam stick for oral care and, during period 2, a stick and tooth brushing with aspiration. Budgetary effect of the new program from the hospital's point of view was analyzed for both periods. The costs avoided were calculated from the incidence density of VAP (cases per 1000 days of intubation). The cost study included device cost, benefit lost, and ICU cost (medication, employer and employee contributions, blood sample analysis…). RESULTS: A total of 2030 intubated patients admitted to the ICUs benefited from oral care. The cost of implementing the study protocol was estimated to be €11,500 per year. VAP rates decreased significantly between the two periods (p1 = 12.8% and p2 = 8.5%, p = 0.002). The VAP revenue was ranged from €28,000 to €45,000 and the average cost from €39,906 to €42,332. The total cost assessment calculated was thus around €1.9 million in favor of the new oral care program. CONCLUSION AND CLINICAL RELEVANCE: Our study showed that the implementation of a simple strategy improved the quality of patient care is economically viable. TRIAL REGISTRATION: NCT02400294.

Comparative study of 2 oral care protocols in intensive care units.

BACKGROUND: The quality of oral care is important in limiting the emergence of ventilator-associated pneumonia (VAP) in intubated patients. Our main objective was to measure the quality improvement in oral care following the implementation of a new oral care protocol. We also monitored VAP rates. MATERIAL/METHODS: This was a cohort study of patients in 5 adult ICUs covering different specialties. During period 1, caregivers used a foam stick for oral care and during period 2 a stick and tooth brushing with aspiration. Oral chlorhexidine was used during both periods. The caregivers rated improvement in oral health on the basis of 4 criteria (tongue, mucous membranes, gingivae, and teeth). Caregiver satisfaction was also assessed. The incidence of VAP was monitored. RESULTS: A total of 2,030 intubated patients admitted to intensive care units benefited from oral care. The patient populations during the 2 periods were similar with regard to demographic data and VAP potential risk factors. Oral health was significantly better from the third day of oral care in period 2 onward (period 1, 6.4 ± 2.1; period 2, 5.6 ± 1.8; P = .043). Caregivers found the period 2 protocol easier to implement and more effective. VAP rates decreased significantly between the 2 periods (period 1, 12.8%; period 2, 8.5%; P = .002). CONCLUSIONS: Our study showed that the implementation of a simple strategy improved the quality of oral care of patients in intensive care units, and decreased VAP rates.

Ethanol lock and risk of hemodialysis catheter infection in critically ill patients. A randomized controlled trial.

RATIONALE: Ethanol rapidly eradicated experimental biofilm. Clinical studies of ethanol lock to prevent catheter-related infections (CRIs) suggest preventive efficacy. No such studies have been done in intensive care units (ICU). OBJECTIVES: To determine whether ethanol lock decreases the risk of major CRI in patients with short-term dialysis catheters (DCs). METHODS: A randomized, double-blind, placebo-controlled trial was performed in 16 ICUs in seven university hospitals and one general hospital in France between June 2009 and December 2011. Adults with insertion of a nontunneled, nonantimicrobial-impregnated double-lumen DC for an expected duration greater than 48 hours, to perform renal-replacement therapy or plasma exchange, were randomly allocated (1:1) to receive a 2-minute catheter lock with either 60% wt/wt ethanol solution (ethanol group) or 0.9% saline solution (control group) at the end of DC insertion and after each renal-replacement therapy or plasma exchange session. The main outcome was major CRI defined as either catheter-related clinical sepsis without bloodstream infection or catheter-related bloodstream infection during the ICU stay. MEASUREMENTS AND MAIN RESULTS: The intent-to-treat analysis included 1,460 patients (2,172 catheters, 12,944 catheter-days, and 8,442 study locks). Median DC duration was 4 days (interquartile range, 2-8) and was similar in both groups. Major CRI incidence did not differ between the ethanol and control groups (3.83 vs. 2.64 per 1,000 catheter-days, respectively; hazard ratio, 1.55; 95% confidence interval, 0.83-2.87; P = 0.17). No significant differences occurred for catheter colonization (P = 0.57) or catheter-related bloodstream infection (P = 0.99). CONCLUSIONS: A 2-minute ethanol lock does not decrease the frequency of infection of DCs in ICU patients. Clinical trial registered with www.clinicaltrials.gov (NCT 00875069).

Epidemiology and outcome of thrombocytopenic patients in the intensive care unit: results of a prospective multicenter study.

PURPOSE: To assess the epidemiology of intensive care unit (ICU) patients with thrombocytopenia (TP). METHODS: All consecutive ICU-admitted patients with TP either on admission or acquired during ICU stay were included. TP was defined as either absolute (platelet count <100 × 10(9)/L) or relative (decrease in the platelet count >30 %). Extensive diagnostic workup of TP including bone marrow aspiration was performed. RESULTS: Absolute TP was diagnosed in 208 patients and relative TP in 93. In six patients (2 %), no cause of TP was identified. The median number of TP etiologies per patient was two, with sepsis being the leading cause. Bone marrow aspirates were analyzed in 238 patients. They showed a normal megakaryocyte number in 221 (93 %) and provided novel information for diagnosis in 52 (22 %). Results were susceptible to having an impact on patient management in 22 cases (11 %). The frequency of bone marrow aspiration with results susceptible to having an impact on management did not differ between patients with and without disseminated intravascular coagulation (P = 0.22) and with and without sepsis/septic shock (P = 0.7) but was significantly lower in patients with relative TP than in those with absolute TP (P < 0.01). A serious bleeding event was observed in 30 patients (14.9 %) and a nadir platelet count below 50 × 10(9)/L was an independent risk factor (P < 0.05). CONCLUSIONS: In thrombocytopenic patients, sepsis is the leading cause of TP. Bone marrow aspirates may yield significant information on TP mechanisms and contribute to the subsequent management of patients, especially those with absolute TP.

[Jugular venous and arterial concentrations of serum S100B protein in patients with severe head injury]. / Concentrations sériques jugulaire et artérielle de la protéine S100B chez les patients victimes d'un traumatisme crânien grave.

It is important for physicians in intensive care units to be able to predict the presence and severity of central nervous system injury in patients with severe head injury (SHI). The extent of S100B elevation has been found to be useful in predicting clinical outcome after brain injury. However, only two studies were realized with jugular venous blood samples. The purpose of our study is to compare the interest between jugular venous and arterial concentrations evaluation of serum S100B protein in patients with SHI. We recruited 17 patients with a SHI, admitted to the intensive care unit. Paired arterial and jugular venous samples were taken at kinetically after injury. S100B median was 0.16 µg/L in arterial and 0.25 µg/L in jugular. This arterio-jugular difference is significant. However, there was any significant arterio-jugular difference in the patients group showing an unfavourable outcome or for the earlier samples (earlier than 24h). We observed there was no significant decrease of S100B in jugular, unlike in arterial, 24h after the head injury in the patients group showing an unfavourable outcome. Determination of S100B concentration in jugular samples appears to be better than in arterial to predict clinical outcome after brain injury.

A recruitment maneuver increases oxygenation after intubation of hypoxemic intensive care unit patients: a randomized controlled study.

INTRODUCTION: Tracheal intubation and anaesthesia promotes lung collapse and hypoxemia. In acute lung injury patients, recruitment maneuvers (RMs) increase lung volume and oxygenation, and decrease atelectasis. The aim of this study was to evaluate the efficacy and safety of RMs performed immediately after intubation. METHODS: This randomized controlled study was conducted in two 16-bed medical-surgical intensive care units within the same university hospital. Consecutive patients requiring intubation for acute hypoxemic respiratory failure were included. Patients were randomized to undergo a RM immediately (within 2 minutes) after intubation, consisting of a continuous positive airway pressure (CPAP) of 40 cmH2O over 30 seconds (RM group), or not (control group). Blood gases were sampled and blood samples taken for culture before, within 2 minutes, 5 minutes, and 30 minutes after intubation. Haemodynamic and respiratory parameters were continuously recorded throughout the study. Positive end expiratory pressure (PEEP) was set at 5 cmH2O throughout. RESULTS: The control (n = 20) and RM (n = 20) groups were similar in terms of age, disease severity, diagnosis at time of admission, and PaO2 obtained under 10-15 L/min oxygen flow immediately before (81 +/- 15 vs 83 +/- 35 mmHg, P = 0.9), and within 2 minutes after, intubation under 100% FiO2 (81 +/- 15 vs 83 +/- 35 mmHg, P = 0.9). Five minutes after intubation, PaO2 obtained under 100% FiO2 was significantly higher in the RM group compared with the control group (93 +/- 36 vs 236 +/- 117 mmHg, P = 0.008). The difference remained significant at 30 minutes with 110 +/- 39 and 180 +/- 79 mmHg, respectively, for the control and RM groups. No significant difference in haemodynamic conditions was observed between groups at any time. Following tracheal intubation, 15 patients had positive blood cultures, showing microorganisms shared with tracheal aspirates, with no significant difference in the incidence of culture positivity between groups. CONCLUSIONS: Recruitment maneuver following intubation in hypoxemic patients improved short-term oxygenation, and was not associated with increased adverse effects. TRIAL REGISTRATION: NCT01014299.

Comparison of acceptability, skin tolerance, and compliance between handwashing and alcohol-based handrub in ICUs: results of a multicentric study.

OBJECTIVE: We compared handwashing (HW) and alcohol-based handrub (ABH) for skin tolerance, acceptability, and hand hygiene compliance in health-care workers (HCWs) in a multicentric study. DESIGN AND SETTING: Before/after study over two periods (P1 and P2) in seven ICUs. Monitoring of methicillin-resistant Staphylococcus aureus (MRSA) acquisition in two ICUs (U4 and U6). SUBJECTS AND PATIENTS: All HCWs of the seven ICUs, and the patients of U4 and U6 without MRSA carriage on admission. INTERVENTIONS: Handwashing was available in P1 and P2. ABH was introduced after P1 and available throughout P2. HCWs completed questionnaires on skin tolerance in P1 and P2, and on acceptability in P2. Compliance with hand hygiene was assessed in P1 and P2 using a standardized method. ICU-acquired MRSA colonization/infection in U4 and U6 was recorded. MEASUREMENTS AND MAIN RESULTS: Hand erythema was reported during P1 and P2 by 21.7 and 11% of HCWs, respectively (P = 0.01), itching by 15.8 and 7.1% (P = 0.02), oozing by 0.8 and 1.1% (P = 0.82), and bleeding by 4.2 and 1.1% (P = 0.1). ABH was considered easier and quicker than HW (P < 0.01), but overall acceptability did not differ between the two. Compliance increased from 51% (334/647) in P1 to 60% (251/418) in P2, P < 0.01. No significant reduction in MRSA colonization/infection between P1 and P2 (P = 0.30) was observed, but the study was underpowered. CONCLUSIONS: Self-report questionnaires show that when ABH is available in ICUs, fewer unpleasant skin sensations are reported. ABH is considered to be easier and quicker to use than HW and compliance is improved after glove removal.

Oral probiotic and prevention of Pseudomonas aeruginosa infections: a randomized, double-blind, placebo-controlled pilot study in intensive care unit patients.

INTRODUCTION: Preventing carriage of potentially pathogenic micro-organisms from the aerodigestive tract is an infection control strategy used to reduce the occurrence of ventilator-associated pneumonia in intensive care units. However, antibiotic use in selective decontamination protocols is controversial. The purpose of this study was to investigate the effect of oral administration of a probiotic, namely Lactobacillus, on gastric and respiratory tract colonization/infection with Pseudomonas aeruginosa strains. Our hypothesis was that an indigenous flora should exhibit a protective effect against secondary colonization. METHODS: We conducted a prospective, randomized, double-blind, placebo-controlled pilot study between March 2003 and October 2004 in a 17-bed intensive care unit of a teaching hospital in Clermont-Ferrand, France. Consecutive patients with a unit stay of longer than 48 hours were included, 106 in the placebo group and 102 in the probiotic group. Through a nasogastric feeding tube, patients received either 109 colony-forming units unity forming colony of Lactobacillus casei rhamnosus or placebo twice daily, from the third day after admission to discharge. Digestive tract carriage of P. aeruginosa was monitored by cultures of gastric aspirates at admission, once a week thereafter and on discharge. In addition, bacteriological analyses of respiratory tract specimens were conducted to determine patient infectious status. RESULTS: The occurrence of P. aeruginosa respiratory colonization and/or infection was significantly delayed in the probiotic group, with a difference in median delay to acquisition of 11 days versus 50 days (P = 0.01), and a nonacquisition expectancy mean of 69 days versus 77 days (P = 0.01). The occurrence of ventilator-associated pneumonia due to P. aeruginosa in the patients receiving the probiotic was less frequent, although not significantly reduced, in patients in the probiotic group (2.9%) compared with those in the placebo group (7.5%). After multivariate Cox proportional hazards modelling, the absence of probiotic treatment increased the risk for P. aeruginosa colonization in respiratory tract (adjusted hazard ratio = 3.2, 95% confidence interval - 1.1 to 9.1). CONCLUSION: In this pilot study, oral administration of a probiotic delayed respiratory tract colonization/infection by P. aeruginosa. TRIAL REGISTRATION: The trial registration number for this study is NCT00604110.

Effects of systematic prone positioning in hypoxemic acute respiratory failure: a randomized controlled trial.

CONTEXT: A recent trial showed that placing patients with acute lung injury in the prone position did not increase survival; however, whether those results hold true for patients with hypoxemic acute respiratory failure (ARF) is unclear. OBJECTIVE: To determine whether prone positioning improves mortality in ARF patients. DESIGN, SETTING, AND PATIENTS: Prospective, unblinded, multicenter controlled trial of 791 ARF patients in 21 general intensive care units in France using concealed randomization conducted from December 14, 1998, through December 31, 2002. To be included, patients had to be at least 18 years, hemodynamically stable, receiving mechanical ventilation, and intubated and had to have a partial pressure of arterial oxygen (PaO2) to fraction of inspired oxygen (FIO2) ratio of 300 or less and no contraindications to lying prone. INTERVENTIONS: Patients were randomly assigned to prone position placement (n = 413), applied as early as possible for at least 8 hours per day on standard beds, or to supine position placement (n = 378). MAIN OUTCOME MEASURES: The primary end point was 28-day mortality; secondary end points were 90-day mortality, duration of mechanical ventilation, incidence of ventilator-associated pneumonia (VAP), and oxygenation. RESULTS: The 2 groups were comparable at randomization. The 28-day mortality rate was 32.4% for the prone group and 31.5% for the supine group (relative risk [RR], 0.97; 95% confidence interval [CI], 0.79-1.19; P = .77). Ninety-day mortality for the prone group was 43.3% vs 42.2% for the supine group (RR, 0.98; 95% CI, 0.84-1.13; P = .74). The mean (SD) duration of mechanical ventilation was 13.7 (7.8) days for the prone group vs 14.1 (8.6) days for the supine group (P = .93) and the VAP incidence was 1.66 vs 2.14 episodes per 100-patients days of intubation, respectively (P = .045). The PaO2/FIO2 ratio was significantly higher in the prone group during the 28-day follow-up. However, pressure sores, selective intubation, and endotracheal tube obstruction incidences were higher in the prone group. CONCLUSIONS: This trial demonstrated no beneficial outcomes and some safety concerns associated with prone positioning. For patients with hypoxemic ARF, prone position placement may lower the incidence of VAP.