Improved 30-Day Survival Estimation in ICU Patients: A Comparative Analysis of Different Approaches With Real-World Data.

OBJECTIVES: The objective of this study was to compare three different approaches for estimating 30-day survival in ICU studies, considering the issue of informative censoring that occurs when patients are lost to follow-up after discharge. DESIGN: A comparative analysis was conducted to evaluate the effect of different approaches on the estimation of 30-day survival. Three methods were compared: the classical approach using the Kaplan-Meier (KM) estimator and Cox regression modeling, the competing risk approach using the Fine and gray model, considering censoring as a competing event, and the logistic regression approach. SETTING: The study was conducted in a university ICU and data from patients admitted between 2010 and 2020 were included. Patient characteristics were collected from electronic records. PATIENTS: A total of 10,581 patients were included in the study. The true date of death for each patient, obtained from a national registry, allowed for an absence of censoring. INTERVENTIONS: All patients were censored at the time of discharge from the ICU, and the three different approaches were applied to estimate the mortality rate and the effects of covariates on mortality. Regression analyses were performed using five variables known to be associated with ICU mortality. MEASUREMENTS AND MAIN RESULTS: The 30-day survival rate for the included patients was found to be 80.5% (95% CI, 79.7-81.2%). The KM estimator severely underestimated the 30-day survival (50.6%; 95% CI, 48.0-53.4%), while the competing risk and logistic regression approaches provided similar results, only slightly overestimating the survival rate (84.5%; 95% CI, 83.8-85.2%). Regression analyses showed that the estimates were not systematically biased, with the Cox and logistic regression models exhibiting greater bias compared with the competing risk regression method. CONCLUSIONS: The competing risk approach provides more accurate estimates of 30-day survival and is less biased compared with the other methods evaluated.

Nurse-to-Nurse Familiarity and Mortality in the Critically Ill: A Multicenter Observational Study.

Rationale: Nurse-to-nurse familiarity at work should strengthen the components of teamwork and enhance its efficiency. However, its impact on patient outcomes in critical care remains poorly investigated. Objectives: To explore the role of nurse-to-nurse familiarity on inpatient deaths during ICU stay. Methods: This was a retrospective observational study in eight adult academic ICUs between January 1, 2011 and December 31, 2016. Measurements and Main Results: Nurse-to-nurse familiarity was measured across day and night 12-hour daily shifts as the mean number of previous collaborations between each nursing team member during previous shifts within the given ICU (suboptimal if <50). Primary outcome was a shift with at least one inpatient death, excluding death of patients with a decision to forego life-sustaining therapy. A multiple modified Poisson regression was computed to identify the determinants of mortality per shift, taking into account ICU, patient characteristics, patient-to-nurse and patient-to-assistant nurse ratios, nurse experience length, and workload. A total of 43,479 patients were admitted, of whom 3,311 (8%) died. The adjusted model showed a lower risk of a shift with mortality when nurse-to-nurse familiarity increased in the shift (relative risk, 0.90; 95% confidence interval per 10 shifts, 0.82-0.98; P = 0.012). Low nurse-to-nurse familiarity during the shift combined with suboptimal patient-to-nurse and patient-to-assistant nurse ratios (suboptimal if >2.5 and >4, respectively) were associated with increased risk of shift with mortality (relative risk, 1.84; 95% confidence interval, 1.15-2.96; P < 0.001). Conclusions: Shifts with low nurse-to-nurse familiarity were associated with an increased risk of patient deaths.

Weak Correlation Between Perceived and Measured Intensive Care Unit Nursing Workload: An Observational Study.

BACKGROUND: Efficient management of nursing workload in the intensive care unit (ICU) is essential for patient safety, care quality, and nurse well-being. Current ICU-specific workload assessment scores lack comprehensive coverage of nursing activities and perceived workload. PURPOSE: The purpose of this study was to assess the correlation between ICU nurses' perceived workload and the Nine Equivalents of Nursing Manpower Use Score (NEMS). METHODS: In a 45-bed adult ICU at a tertiary academic hospital, nurses' perceived shift workload (measured with an 11-point Likert scale) was correlated with the NEMS, calculated manually and electronically. RESULTS: The study included 1734 observations. The perceived workload was recorded for 77.6% of observations. A weak positive correlation was found between perceived and objectively measured workload. CONCLUSION: Findings indicate a need to consider the multifaceted nature of nursing activities and individual workload perceptions in the ICU.

Strategy to secure the neuraxial route in anaesthesia: Risk mapping and feedback from the application of the ISO 80369-6 standard NRFit® connectors.

INTRODUCTION: In anesthesia, a medication error would occur every 20 to 133 anesthesia procedures, and 14% is related to a route administration error. To secure neuraxial route, ISO group published a norm in 2016 to develop specific connectors, the "NRFit® connector". The main objective of this work, is to develop a risk mapping related to neuraxial medication errors therefore prepare the NRFit® implementation in anesthesia units in a French Universitary Hospital. METHODS: Failure modes, effects and criticality analysis (FMECA) methodology was used for our risk mapping which was divided in 3 anesthesia specialities. For each, the analysis was performed for accidental neuraxial administration of intravenous drugs, and its opposite error. Secondly, NRFit® devices were tested for 1 month by 3 experimented anesthetists. RESULTS: The majority of reported errors concerns epidural and intrathecal anesthesia, and more frequently in the field of obstetrics. Opioids and tranexamic acid, administered in neuraxial route, are drugs with the highest criticality. The tests were rather conclusive and made it possible to highlight the additional needs in medical devices. DISCUSSION: Obstetrics is the riskiest area due to the frequency of epidural anesthesia, the administration of critical drugs in intravenous and neuraxial route. This work increased the awareness of our group, improved the measure of this risk and harmonized practices. CONCLUSION: This work is the first step of the project to prevent administration route error in anesthesia during patient's drug management. The next step will be the NRFit® implementation for epidural and combined spinal-epidural anesthesia in our hospital.

Ethical issues encountered by French intensive care unit caregivers during the first COVID-19 outbreak.

PURPOSE: We aimed to describe the ethical issues encountered by health care workers during the first COVID-19 outbreak in French intensive care units (ICUs), and the factors associated with their emergence. METHODS: This descriptive multicentre survey study was conducted by distributing a questionnaire to 26 French ICUs, from 1 June to 1 October 2020. Physicians, residents, nurses, and orderlies who worked in an ICU during the first COVID-19 outbreak were included. Multiple logistic regression models were performed to identify the factors associated with ethical issues. RESULTS: Among the 4,670 questionnaires sent out, 1,188 responses were received, giving a participation rate of 25.4%. Overall, 953 participants (80.2%) reported experiencing issue(s) while caring for patients during the first COVID-19 outbreak. The most common issues encountered concerned the restriction of family visits in the ICU (91.7%) and the risk of contamination for health care workers (72.3%). Nurses and orderlies faced this latter issue more than physicians (adjusted odds ratio [ORa], 2.98; 95% confidence interval [CI], 1.87 to 4.76; P < 0.001 and ORa, 4.35; 95% CI, 2.08 to 9.12; P < 0.001, respectively). They also faced more the issue "act contrary to the patient's advance directives" (ORa, 4.59; 95% CI, 1.74 to 12.08; P < 0.01 and ORa, 10.65; 95% CI, 3.71 to 30.60; P < 0.001, respectively). A total of 1,132 (86.9%) respondents thought that ethics training should be better integrated into the initial training of health care workers. CONCLUSION: Eight out of ten responding French ICU health care workers experienced ethical issues during the first COVID-19 outbreak. Identifying these issues is a first step towards anticipating and managing such issues, particularly in the context of potential future health crises.

RéSUMé: OBJECTIF: Notre objectif était de décrire les enjeux éthiques rencontrés par les personnels de santé lors de la première éclosion de COVID-19 dans les unités de soins intensifs (USI) françaises, ainsi que les facteurs associés à leur apparition. MéTHODE: Cette enquête multicentrique descriptive a été réalisée en distribuant un questionnaire à 26 unités de soins intensifs françaises, du 1er juin au 1er octobre 2020. Les médecins, les internes, le personnel infirmier et les aides-soignant·es qui travaillaient dans une unité de soins intensifs pendant la première éclosion de COVID-19 ont été inclus·es. Des modèles de régression logistique multiple ont été réalisés pour identifier les facteurs associés aux questions éthiques. RéSULTATS: Parmi les 4670 questionnaires envoyés, 1188 réponses ont été reçues, soit un taux de participation de 25,4 %. Dans l'ensemble, 953 personnes participantes (80,2 %) ont déclaré avoir éprouvé un ou des problèmes alors qu'elles s'occupaient de patient·es lors de la première éclosion de COVID-19. Les problèmatiques les plus fréquemment rencontrées concernaient la restriction des visites des familles dans les USI (91,7 %) et le risque de contamination pour les personnels de la santé (72,3 %). Le personnel infirmier et les aides-soignant·es étaient davantage confronté·es à ce dernier problème que les médecins (rapport de cotes ajusté [RCa], 2,98; intervalle de confiance [IC] à 95 %, 1,87 à 4,76; P < 0,001 et RCa, 4.35; IC 95 %, 2,08 à 9,12; P < 0,001, respectivement), tout comme ils étaient davantage confrontées à la question d'« agir contrairement aux directives médicales anticipées du/de la patient·e ¼ (RCa, 4,59; IC 95 %, 1,74 à 12,08; P < 0,01 et RCa, 10,65; IC 95 %, 3,71 à 30,60; P < 0,001, respectivement). Au total, 1132 répondant·es (86,9 %) estimaient que la formation en éthique devrait être mieux intégrée à la formation initiale des personnels de santé. CONCLUSION: Huit travailleuses et travailleurs de santé français·es des soins intensifs sur dix ont été confronté·es à des problèmes éthiques lors de la première éclosion de COVID-19. L'identification de ces enjeux est une première étape vers leur anticipation et leur gestion, en particulier dans le contexte d'éventuelles crises sanitaires futures.

Prone Position in COVID-19 and -COVID-19 Acute Respiratory Distress Syndrome: An International Multicenter Observational Comparative Study.

OBJECTIVES: Prone position is used in acute respiratory distress syndrome and in coronavirus disease 2019 acute respiratory distress syndrome. However, it is unclear how responders may be identified and whether an oxygenation response improves outcome. The objective of this study was to quantify the response to prone position, describe the differences between coronavirus disease 2019 acute respiratory distress syndrome and acute respiratory distress syndrome, and explore variables associated with survival. DESIGN: Retrospective, observational, multicenter, international cohort study. SETTING: Seven ICUs in Italy, United Kingdom, and France. PATIENTS: Three hundred seventy-six adults (220 coronavirus disease 2019 acute respiratory distress syndrome and 156 acute respiratory distress syndrome). INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Preproning, a greater proportion of coronavirus disease 2019 acute respiratory distress syndrome patients had severe disease (53% vs 40%), worse Pao2/Fio2 (13.0 kPa [interquartile range, 10.5-15.5 kPa] vs 14.1 kPa [interquartile range, 10.5-18.6 kPa]; p = 0.017) but greater compliance (38 mL/cm H2O [interquartile range, 27-53 mL/cm H2O] vs 31 mL/cm H2O [interquartile range, 21-37 mL/cm H2O]; p < 0.001). Patients with coronavirus disease 2019 acute respiratory distress syndrome had a longer median time from intubation to prone position (2.0 d [interquartile range, 0.7-5.0 d] vs 1.0 d [interquartile range, 0.5-2.9 d]; p = 0.03). The proportion of responders, defined by an increase in Pao2/Fio2 greater than or equal to 2.67 kPa (20 mm Hg), upon proning, was similar between acute respiratory distress syndrome and coronavirus disease 2019 acute respiratory distress syndrome (79% vs 76%; p = 0.5). Responders had earlier prone position (1.4 d [interquartile range, 0.7-4.2 d] vs 2.5 d [interquartile range, 0.8-6.2 d]; p = 0.06)]. Prone position less than 24 hours from intubation achieved greater improvement in oxygenation (11 kPa [interquartile range, 4-21 kPa] vs 7 kPa [interquartile range, 2-13 kPa]; p = 0.002). The variables independently associated with the "responder" category were Pao2/Fio2 preproning (odds ratio, 0.89 kPa-1 [95% CI, 0.85-0.93 kPa-1]; p < 0.001) and interval between intubation and proning (odds ratio, 0.94 d-1 [95% CI, 0.89-0.99 d-1]; p = 0.019). The overall mortality was 45%, with no significant difference observed between acute respiratory distress syndrome and coronavirus disease 2019 acute respiratory distress syndrome. Variables independently associated with mortality included age (odds ratio, 1.03 yr-1 [95% CI, 1.01-1.05 yr-1]; p < 0.001); interval between hospital admission and proning (odds ratio, 1.04 d-1 [95% CI, 1.002-1.084 d-1]; p = 0.047); and change in Pao2/Fio2 on proning (odds ratio, 0.97 kPa-1 [95% CI, 0.95-0.99 kPa-1]; p = 0.002). CONCLUSIONS: Prone position, particularly when delivered early, achieved a significant oxygenation response in ~80% of coronavirus disease 2019 acute respiratory distress syndrome, similar to acute respiratory distress syndrome. This response was independently associated with improved survival.

Impact of COVID-19 pandemic on antifungal consumption: a multicenter retrospective analysis.

BACKGROUND: In the context of COVID-19 pandemic, antifungal overuse may have occurred in our hospitals as it has been previously reported for antibacterials. METHODS: To investigate the impact of COVID-19 on antifungal consumption, a multicenter retrospective study including four medical sites and 14 intensive care units (ICU) was performed. Antifungal consumption and incidences of invasive fungal diseases before and during COVID-19 pandemic, for non-COVID-19 patients and COVID-19 patients, were described. RESULTS: An increase in voriconazole consumption was observed in 2020 compared with 2019 for both the whole hospital and the ICU (+ 40.3% and + 63.7%, respectively), whereas the incidence of invasive aspergillosis significantly increased in slightly lower proportions in the ICU (+ 46%). Caspofungin consumption also increased in 2020 compared to 2019 for both the whole hospital and the ICU (+ 34.9% and + 17.0%, respectively) with an increased incidence of invasive candidiasis in the whole hospital and the ICU but in lower proportions (+ 20.0% and + 10.9%, respectively). CONCLUSIONS: We observed an increased consumption of antifungals including voriconazole and caspofungin in our hospital during the COVID-19 pandemic and explained in part by an increased incidence of invasive fungal diseases in COVID-19 patients. These results are of utmost importance as it raises concern about the urgent need for appropriate antifungal stewardship activities to control antifungal consumption.

A retrospective comparison of COVID-19 and seasonal influenza mortality and outcomes in the ICUs of a French university hospital.

BACKGROUND: SARS-Cov-2 (COVID-19) has become a major worldwide health concern since its appearance in China at the end of 2019. OBJECTIVE: To evaluate the intrinsic mortality and burden of COVID-19 and seasonal influenza pneumonia in ICUs in the city of Lyon, France. DESIGN: A retrospective study. SETTING: Six ICUs in a single institution in Lyon, France. PATIENTS: Consecutive patients admitted to an ICU with SARS-CoV-2 pneumonia from 27 February to 4 April 2020 (COVID-19 group) and seasonal influenza pneumonia from 1 November 2015 to 30 April 2019 (influenza group). A total of 350 patients were included in the COVID-19 group (18 refused to consent) and 325 in the influenza group (one refused to consent). Diagnosis was confirmed by RT-PCR. Follow-up was completed on 1 April 2021. MAIN OUTCOMES AND MEASURES: Differences in 90-day adjusted-mortality between the COVID-19 and influenza groups were evaluated using a multivariable Cox proportional hazards model. RESULTS: COVID-19 patients were younger, mostly men and had a higher median BMI, and comorbidities, including immunosuppressive condition or respiratory history were less frequent. In univariate analysis, no significant differences were observed between the two groups regarding in-ICU mortality, 30, 60 and 90-day mortality. After Cox modelling adjusted on age, sex, BMI, cancer, sepsis-related organ failure assessment (SOFA) score, simplified acute physiology score SAPS II score, chronic obstructive pulmonary disease and myocardial infarction, the probability of death associated with COVID-19 was significantly higher in comparison to seasonal influenza [hazard ratio 1.57, 95% CI (1.14 to 2.17); P = 0.006]. The clinical course and morbidity profile of both groups was markedly different; COVID-19 patients had less severe illness at admission (SAPS II score, 37 [28 to 48] vs. 48 [39 to 61], P < 0.001 and SOFA score, 4 [2 to 8] vs. 8 [5 to 11], P < 0.001), but the disease was more severe considering ICU length of stay, duration of mechanical ventilation, PEEP level and prone positioning requirement. CONCLUSION: After ICU admission, COVID-19 was associated with an increased risk of death compared with seasonal influenza. Patient characteristics, clinical course and morbidity profile of these diseases is markedly different.

Association Between Short-, Intermediate-, and Long-term Mortality and Myocardial Injury After Noncardiac Surgery After Hip Fracture Surgery: A Retrospective Cohort.

BACKGROUND: For more than 20 years, hip fracture 1-year mortality has remained around 20%. An elevation of the postoperative troponin peak within 72 hours (myocardial injury after noncardiac surgery [MINS]) is associated with a greater risk of short-term mortality in the general population. However, there seem to be conflicting results in the specific population who undergo hip fracture surgery, with some studies finding an association between troponin and mortality and some not. The objective of the present study was to investigate the association of MINS and the short- (before 28th day), intermediate- (before 180th day), and long-term (before 365th day) mortality after hip fracture surgery. METHODS: We conducted a single-center retrospective cohort of patients undergoing hip fracture surgery from November 2013 to December 2015. MINS was defined as postoperative troponin peak within the 72 hours >5 ng/L. Four MINS subgroups were defined according to the value of troponin peak (ie, ≥5-<20, ≥20-<65, ≥65-<1000, and ≥1000 ng/L). To document the association between the different mortality terms and the troponin peak, odds ratio (OR) and adjusted OR (aOR) associated with their 95% confidence interval (CI) with the log of the scaled troponin peak within 72 hours were estimated, with and without patients presenting a postoperative acute coronary syndrome (ACS). Cox proportional hazards modeling was used to estimate hazard ratio (HR) and adjusted HR (aHR) of death between the no MINS and MINS subgroups. The adjustment was performed on the main confounding factors (ie, sex, American Society of Anesthesiologists [ASA] physical status, dementia status, age, and time from admission to surgery). RESULTS: Among 729 participants, the mean age was 83.1 (standard deviation [SD] = 10.8) years, and 77.4% were women; 30 patients presented an ACS (4%). Short-, intermediate-, and long-term mortality were at 5%, 16%, and 23%, respectively. The troponin peak was significantly associated with all terms of mortality before and after adjustment and before and after exclusion of patients presenting an ACS. HR and aHR for each subgroup of troponin level were significantly associated with an increased probability of survival, except for the 5 to 20 ng/L group for which aHR was not significant (1.75, 95% CI, 0.82-3.74). In the landmark analysis, there was still an association between survival at the 365th day and troponin peak after the short- and intermediate-term truncated mortality. CONCLUSIONS: MINS is associated with short-, intermediate-, and long-term mortality after hip fracture surgery. This could be a valuable indicator to determine the population at high risk of mortality that could benefit from targeted prevention and possible intervention.

Associations between peripheral perfusion disorders, mean arterial pressure and dose of norepinephrine administrated in the early phase of septic shock.

The aim of the study was to explore the correlations between peripheral perfusion, mean arterial pressure and the dose-rate of norepinephrine (NE) infused for the treatment of septic shock. The study is retrospective analysis of data acquired prospectively on 57 patients during the first 24 hours after the occurrence of the shock. Clinical and haemodynamic characteristics, skin perfusion parameters (capillary refill time [CRT], mottling score and temperature gradients) and the dose rate of NE infusion were collected. Negative correlations between mean arterial pressure (MAP) and temperature gradients (core-to-toe: P = .03, core-to-index: P = .04) were found and abnormal CRT was associated with lower MAP (P = .02). The dose rate of NE was negatively correlated with temperature gradients (core-to-toe: P = .02, core-to-index: P = .01, forearm-to-index: P = .008) in the overall population. In patients receiving NE for at least 12 hours, the NE dose rate positively was correlated with the mottling score (P = .006), temperature gradients (core-to-toe: P = .04, forearm-to-index: P = .02, core-to-index: P = .005) and CRT (P = .001). The dose of NE administrated was associated with 14-days mortality (odds ration [OR] = 1.21 [1.06-1.38], P = .006) and with 28-days mortality (OR = 1.17 [1.01-1.36], P = 0.04). In conclusion, the study described the presence of correlations between peripheral perfusion and MAP and between peripheral perfusion and the dose rate of NE infusion.

The state of vascular access teams: Results of a European survey.

BACKGROUND: Many European health institutions have appointed multidisciplinary teams for the general management of vascular access to help improve efficiency, patient safety and reduce costs. Vascular access teams (VATs), or infusion teams, are specifically trained groups of healthcare professionals who assess, place, manage and monitor various outcomes and aspects of vascular access care. OBJECTIVE: To assess the current landscape of vascular access management as a discipline across Europe. METHODS: A Faculty of European VAT leads and experts developed a survey of 20 questions which was disseminated across several European countries. Questions focused on respondent and institution profile, vascular access device selection and placement, monitoring and reporting of complications, and access to training and education. The 1449 respondents included physicians, nurses, anaesthetists, radiologists and surgeons from public and private institutions ranging in size. RESULTS: Availability of dedicated VATs vary by country, institution size, and institution type. Institutions with a VAT are more likely to utilise a tool (eg, algorithm or guideline) to determine the appropriate vascular access device (55% vs 38%, P < .0002) and to have feedback on systematic monitoring of complications (40% vs 28%, P = .015). Respondents from institutions with a VAT are more likely to have received training on vascular access management (79% vs 53%, P < .0001) and indicated that the VAT was a source of support when difficulties arise. CONCLUSION: The survey results highlight some of the potential benefits of implementing a dedicated VAT including the use of a broader range of vascular access devices, increased awareness of the presence of vascular access policies, increased the likelihood of recent vascular access training, and increased rates of systematic monitoring of associated complications. The study reveals potential areas for further focus in the field of vascular access care, specifically examining the direct impact of vascular access teams.

Safety and efficacy of a strategy of vitamin K antagonist reversal with prothrombin complex concentrates compared to vitamin K in patients with hip fracture.

Background: Increased preoperative delay in patients with hip fractures may be responsible for increased morbidity and mortality. We hypothesized that a strategy of reversal of vitamin K antagonist (VKA) by prothrombin complexes concentrates (PCCs), as compared to vitamin K, is safe and reduces preoperative delay and hospital length of stay (LOS). Methods: In this pilot study, we reviewed the records of patients admitted to a university-affiliated hospital for hip fracture between Jan. 1, 2012, and Dec. 31, 2016, who were taking VKA. Patients were stratified according to reversal strategy (vitamin K v. PCC). Adverse effects, time to surgery, LOS and mortality were collected from the electronic medical record and were compared between the 2 study groups and a control group not treated with VKA. Results: A total of 141 patients were included in the study: 65 in the vitamin K group, 26 in the PCC group and 50 in the control group. The median preoperative delay in the PCC group (20 h [interquartile range (IQR)] 13-25 h]) and the control group (20 h [IQR 15-33 h]) was lower than that in the vitamin K group (45 h [IQR 31-52 h]) (p < 0.001). Patients in the PCC group had a shorter median hospital LOS than those in the vitamin K group (6 d [IQR 4-9 d] v. 8 d [IQR 6-11 d], p < 0.05). No difference was observed in the proportion of patients who received a red blood cell transfusion, or had thrombotic or hemorrhagic complications. No difference in mortality at 12 months was observed between the groups. Conclusion: In patients with hip fracture, the use of PCCs as compared to vitamin K to reverse the effect of VKA significantly reduced preoperative delay and hospital LOS, and was not associated with an increase in the rates of thrombotic or hemorrhagic complications. Prospective studies involving a greater number of patients are required to confirm these promising results.

Contexte: L'allongement du délai préopératoire chez les patients atteints d'une fracture de la hanche pourrait expliquer l'augmentation de la morbidité et de la mortalité. Selon notre hypothèse, une stratégie d'inversion des antagonistes de la vitamine K (AVK) au moyen de concentrés de complexes prothrombiques (CCP), plutôt que de vitamine K, est sécuritaire et réduit le délai préopératoire et la durée du séjour hospitalier. Méthodes: Pendant cette étude pilote, nous avons passé en revue les dossiers de patients sous AVK admis dans un centre universitaire pour fracture de la hanche entre le 1er janvier 2012 et le 31 décembre 2016. Les patients ont été stratifiés selon la stratégie d'inversion choisie (vitamine K c. CCP). Les effets indésirables, le délai préopératoire, la durée du séjour hospitalier et la mortalité ont été recueillis à partir des dossiers médicaux électroniques et ont été comparés entre les 2 groupes de l'étude et un groupe témoin non sous AVK. Résultats: En tout, 141 patients ont été inclus dans l'étude, 65 dans le groupe sous vitamine K, 26 dans le groupe sous CCP et 50 dans le groupe témoin. Le délai préopératoire médian pour le groupe sous CCP (20 h [éventail interquartile (ÉIQ)] 13­25 h]) et le groupe témoin (20 h [ÉIQ 15­33 h]) a été plus bref que pour le groupe sous vitamine K (45 h [ÉIQ 31­52 h]) (p < 0,001). Les patients du groupe sous CCP ont eu un séjour hospitalier médian plus bref que les patients du groupe sous vitamine K (6 j [ÉIQ 4­9 j] c. 8 j [ÉIQ 6­11 j]) (p < 0,05). Aucune différence n'a été observée quant à la proportion de patients ayant reçu une transfusion de culot globulaire ou ayant manifesté des complications thrombotiques ou hémorragiques. Aucune différence quant à la mortalité à 12 mois n'a été observée entre les groupes. Conclusion: Chez les patients atteints d'une fracture de la hanche, l'utilisation des CCP plutôt que de la vitamine K pour inverser l'effet des AVK a significativement abrégé le délai préopératoire et la durée du séjour hospitalier, et n'a pas été associée à une augmentation des taux de complications thrombotiques ou hémorragiques. Des études prospectives sur un plus grand nombre de patients sont nécessaires pour confirmer ces résultats prometteurs.

Hospital Length of Stay Reduction Over Time and Patient Readmission for Severe Adverse Events Following Surgery.

OBJECTIVE: The aim of the study was to investigate whether patients who undergo surgery in hospitals experiencing significant length of stay (LOS) reductions over time are exposed to a higher risk of severe adverse events in the postoperative period. SUMMARY BACKGROUND DATA: Surgical care innovation has encouraged hospitals to shorten LOS under financial pressures with uncertain impact on patient outcomes. METHODS: We selected all patients who underwent elective colectomy or urgent hip fracture repair in French hospitals between 2013 and 2016. For each procedure, hospitals were categorized into 3 groups according to variations in their median LOS as follows: major decrease, moderate decrease, and no decrease. These groups were matched using propensity scores based on patients' and hospitals' potential confounders. Potentially avoidable readmission for severe adverse events and death at 6 months were compared between groups using Cox regressions. RESULTS: We considered 98,713 patients in 540 hospitals for colectomy and 206,812 patients in 414 hospitals for hip fracture repair before matching. After colectomy, patient outcomes were not negatively impacted when hospitals reduced their LOS [hazard ratio (95% confidence interval): 0.93 (0.78-1.10)]. After hip fracture repair, patients in hospitals with major decreases in LOS had a higher risk of severe adverse events [1.22 (1.11-1.34)] and death [1.17 (1.04-1.32)]. CONCLUSIONS: Patients who underwent surgical procedures in hospitals experiencing major decreases in LOS were demonstrated worse postoperative outcomes after urgent hip fracture repair and not after elective colectomy. Development of care bundles to enhance recovery after emergency surgeries may allow better control of LOS reduction and patient outcomes.

Compliance with sedation analgesia protocols: Do clinical pharmacists have an impact?

WHAT IS KNOWN AND OBJECTIVES: The agreement between prescribed sedation objectives and sedation pump syringe rate adaptation is not optimal. Delays in adjustment of sedation doses are associated with an increased patient length of stay in the intensive care unit. Our objectives were to assess compliance with the approved sedation protocol and to evaluate the impact of a clinical pharmacist daily controlling sedation and analgesia scores and pump syringe rates on patients' outcomes in a critical care unit. METHODS: Prospective before/after study involving 60 adult patients divided into two groups (non-intervention and intervention groups) who received mechanical ventilation and continuous infusions of sedative and analgesic drugs in an intensive care unit. In both groups, data were collected daily in 30 mechanically ventilated patients receiving a sedation/analgesia regimen during a 3-month period according to a standardized protocol. A pharmacist was in charge of intervening with physicians when the local sedation analgesia protocol was not followed. RESULTS AND DISCUSSION: There were no significant differences between the groups in terms of demographic characteristics except a higher proportion of men in the intervention group (70% vs 40%, P = .019). In the control group, sedation and analgesia objectives were not prescribed in more than half the cases. Pharmacist intervention reduced sedation duration (5 [2-11] vs 2 [1-5.5] days, P = .019). The cumulative delay in adaptation of the sedation analgesia electric syringe pump was significantly decreased in the intervention group (8 [0-29.5] vs 28.5 hours [11.1-68.4], P = .034). Total doses of sedatives (midazolam, propofol) and analgesics (sufentanil, remifentanil) per patient were decreased in the intervention group compared to the control group (respectively, P = .24, P = .0009, P = .0013 and P = .0007). CONCLUSIONS: Pharmacist intervention can decrease the sedation duration and the total dose of sedation medications and reinforce adherence to sedation/analgesia guidelines.

Effect of Hydroxyethyl Starch vs Saline for Volume Replacement Therapy on Death or Postoperative Complications Among High-Risk Patients Undergoing Major Abdominal Surgery: The FLASH Randomized Clinical Trial.

Importance: It is not known if use of colloid solutions containing hydroxyethyl starch (HES) to correct for intravascular deficits in high-risk surgical patients is either effective or safe. Objective: To evaluate the effect of HES 130/0.4 compared with 0.9% saline for intravascular volume expansion on mortality and postoperative complications after major abdominal surgery. Design, Setting, and Participants: Multicenter, double-blind, parallel-group, randomized clinical trial of 775 adult patients at increased risk of postoperative kidney injury undergoing major abdominal surgery at 20 university hospitals in France from February 2016 to July 2018; final follow-up was in October 2018. Interventions: Patients were randomized to receive fluid containing either 6% HES 130/0.4 diluted in 0.9% saline (n = 389) or 0.9% saline alone (n = 386) in 250-mL boluses using an individualized hemodynamic algorithm during surgery and for up to 24 hours on the first postoperative day, defined as ending at 7:59 am the following day. Main Outcomes and Measures: The primary outcome was a composite of death or major postoperative complications at 14 days after surgery. Secondary outcomes included predefined postoperative complications within 14 days after surgery, durations of intensive care unit and hospital stays, and all-cause mortality at postoperative days 28 and 90. Results: Among 826 patients enrolled (mean age, 68 [SD, 7] years; 91 women [12%]), 775 (94%) completed the trial. The primary outcome occurred in 139 of 389 patients (36%) in the HES group and 125 of 386 patients (32%) in the saline group (difference, 3.3% [95% CI, -3.3% to 10.0%]; relative risk, 1.10 [95% CI, 0.91-1.34]; P = .33). Among 12 prespecified secondary outcomes reported, 11 showed no significant difference, but a statistically significant difference was found in median volume of study fluid administered on day 1: 1250 mL (interquartile range, 750-2000 mL) in the HES group and 1500 mL (interquartile range, 750-2150 mL) in the saline group (median difference, 250 mL [95% CI, 83-417 mL]; P = .006). At 28 days after surgery, 4.1% and 2.3% of patients had died in the HES and saline groups, respectively (difference, 1.8% [95% CI, -0.7% to 4.3%]; relative risk, 1.76 [95% CI, 0.79-3.94]; P = .17). Conclusions and Relevance: Among patients at risk of postoperative kidney injury undergoing major abdominal surgery, use of HES for volume replacement therapy compared with 0.9% saline resulted in no significant difference in a composite outcome of death or major postoperative complications within 14 days after surgery. These findings do not support the use of HES for volume replacement therapy in such patients. Trial Registration: ClinicalTrials.gov Identifier: NCT02502773.

Mottling Incidence and Mottling Score According to Arterial Lactate Level in Septic Shock Patients.

OBJECTIVES: Mottling score is estimated from 0-5 according to mottling over the knee and described as clinical evaluation of tissue perfusion. This score was developed with ancient definitions of sepsis without lactate level, a major prognostic parameter when superior to 2 mmol/L. This study describes mottling incidence and mottling score in septic shock patients according to lactate level. MATERIALS AND METHODS: We reanalyzed our prospective study in a French tertiary hospital in the intensive care unit (ICU) which studied mottling score and thermography correlation. Patients admitted to septic shock diagnosis and requiring vasoactive drugs were included. We recorded hemodynamic variables, mottling score, and lactate. Data collection was realized at ICU admission (H0) and after six hours (H6). RESULTS: Forty-three patients were included. Mean age was 67 (±4), mean sequential organ failure assessment (SOFA) score was 11 (8-12), and SAPS II 58 ±20. Mortality rate at day 28 was 30%. Among patients with lactate ≥2 mmol/L, mottling was more prevalent in 82.6% vs 47.4% (p value = 0.016), and at H6 mottling score was higher (p value = 0.009). Although, mottling incidence was not different between dead (85%) and survivors (81%; p value = 0.795). CONCLUSION: A new sepsis definition implies a new epidemiology in mottling according to lactate threshold. Patients with lactate ≥2 mmol/L presented a higher incidence and score of mottling. However, mortality was not influenced by mottling in this study. CLINICAL SIGNIFICANCE: Arterial lactate is a major prognostic parameter when superior to 2 mmol/L.A new definition of sepsis was published in 2016 with a new paradigm and epidemiology of septic shockPatients with lactate ≥2 mmol/L presented a higher incidence and score of mottling.Mottling score is a clinical sign of microcirculatory alteration, related to lactate level in septic shock. HOW TO CITE THIS ARTICLE: Ferraris A, Bouisse C, Thiollière F, Piriou V, Allaouchiche B. Mottling Incidence and Mottling Score According to Arterial Lactate Level in Septic Shock Patients. Indian J Crit Care Med 2020;24(8):672-676.

Drug incompatibilities in intravenous therapy: evaluation and proposition of preventive tools in intensive care and hematology units.

PURPOSE: Physicochemical incompatibility (PCI) between drugs infused together is frequent, but under-recognized. PCI can lead to drug inactivity, catheter occlusion, embolism or inflammatory reactions. The aims of this work were to identify most frequent and relevant drug incompatibilities and to review and develop strategies for their prevention. METHOD: This was an observational prospective survey conducted between January and March 2015 in an intensive care unit (ICU) and in September 2014 in a hematology sterile unit (HSU). Drugs administered to patients were recorded and their compatibility assessed based on published compatibility data. RESULTS: Drug incompatibilities accounted for 12% (23/189) and 17% (116/686) of drug pairs infused in the ICU and the HSU, respectively. Pantoprazole was the most frequent drug implied in PCI. Regarding drug classes, anti-infective agents and gastrointestinal drugs were the most frequently implied. Among the incompatible pairs, 78% and 61% implicated a drug with extreme pH in the ICU and HSU, respectively. The tools proposed to reduce the frequency of PCI included: compatibility cross-tables, labeling of drugs with extreme pH and optimized administration schedules. CONCLUSIONS: Given the frequency and the potential for severe consequences of PCI, pharmacists have a role to play in raising awareness of nurses and practitioners, and proposing adequate tools and solutions to reduce their incidence.

Estimation of Extra Length of Stay Attributable to Hospital-Acquired Infections in Adult ICUs Using a Time-Dependent Multistate Model.

OBJECTIVES: The objective of the study was to estimate the length of stay of patients with hospital-acquired infections hospitalized in ICUs using a multistate model. DESIGN: Active prospective surveillance of hospital-acquired infection from January 1, 1995, to December 31, 2012. SETTING: Twelve ICUs at the University of Lyon hospital (France). PATIENTS: Adult patients age greater than or equal to 18 years old and hospitalized greater than or equal to 2 days were included in the surveillance. All hospital-acquired infections (pneumonia, bacteremia, and urinary tract infection) occurring during ICU stay were collected. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The competitive risks of in-hospital death, transfer, or discharge were considered in estimating the change in length of stay due to infection(s), using a multistate model, time of infection onset. Thirty-three thousand four-hundred forty-nine patients were involved, with an overall hospital-acquired infection attack rate of 15.5% (n = 5,176). Mean length of stay was 27.4 (± 18.3) days in patients with hospital-acquired infection and 7.3 (± 7.6) days in patients without hospital-acquired infection. A multistate model-estimated mean found an increase in length of stay by 5.0 days (95% CI, 4.6-5.4 d). The extra length of stay increased with the number of infected site and was higher for patients discharged alive from ICU. No increased length of stay was found for patients presenting late-onset hospital-acquired infection, more than the 25th day after admission. CONCLUSIONS: An increase length of stay of 5 days attributable to hospital-acquired infection in the ICU was estimated using a multistate model in a prospective surveillance study in France. The dose-response relationship between the number of hospitalacquired infection and length of stay and the impact of early-stage hospital-acquired infection may strengthen attention for clinicians to focus interventions on early preventions of hospital-acquired infection in ICU.

Immune hemolysis secondary to injection of contrast medium.

BACKGROUND: Drug-induced immune hemolytic anemia (DIIHA) is a rare but sometimes severe side effect. CASE REPORT: We describe the case of a 32-year-old patient who presented a cardiovascular collapse and a severe hemolysis secondary to the injection of iomeprol, a contrast medium, after a carcinologic surgery. RESULTS: The evolution was favorable after blood transfusion and short catecholamine support. The biology showed drug-dependent antibodies after incubation with iomeprol. CONCLUSION: This case is the second report of DIIHA with iomeprol.

Protective ventilation during anaesthesia reduces major postoperative complications after lung cancer surgery: A double-blind randomised controlled trial.

BACKGROUND: Thoracic surgery for lung resection is associated with a high incidence of postoperative pulmonary complications. Controlled ventilation with a large tidal volume has been documented to be a risk factor for postoperative respiratory complications after major abdominal surgery, whereas the use of low tidal volumes and positive end-expiratory pressure (PEEP) has a protective effect. OBJECTIVE: To evaluate the effects of ventilation with low tidal volume and PEEP on major complications after thoracic surgery. DESIGN: A double-blind, randomised controlled study. SETTING: A multicentre trial from December 2008 to October 2011. PATIENTS: A total of 346 patients undergoing lobectomy or pneumonectomy for lung cancer. MAIN OUTCOME MEASURES: The primary outcome was the occurrence of major postoperative complications (pneumonia, acute lung injury, acute respiratory distress syndrome, pulmonary embolism, shock, myocardial infarction or death) within 30 days after surgery. INTERVENTIONS: Patients were randomly assigned to receive either lung-protective ventilation (LPV group) [tidal volume 5 ml kg ideal body weight + PEEP between 5 and 8 cmH2O] or nonprotective ventilation (control group) (tidal volume 10 ml kg ideal body weight without PEEP) during anaesthesia. RESULTS: The trial was stopped prematurely because of an insufficient inclusion rate. Major postoperative complications occurred in 23/172 patients in the LPV group (13.4%) vs. 38/171 (22.2%) in the control group (odds ratio 0.54, 95% confidence interval, 0.31 to 0.95, P = 0.03). The incidence of other complications (supraventricular cardiac arrhythmia, bronchial obstruction, pulmonary atelectasis, hypercapnia, bronchial fistula and persistent air leak) was also lower in the LPV group (37.2 vs. 49.4%, odds ratio 0.60, 95% confidence interval, 0.39 to 0.92, P = 0.02).The duration of hospital stay was shorter in the LPV group, 11 [interquartile range, 9 to 15] days vs. 12 [9 to 16] days, P = 0.048. CONCLUSION: Compared with high tidal volume and no PEEP, LPV combining low tidal volume and PEEP during anaesthesia for lung cancer surgery seems to improve postoperative outcomes. TRIALS REGISTRATION: ClinicalTrials.gov number: NCT00805077.