Comparison of mortality and outcomes of four respiratory viruses in the intensive care unit: a multicenter retrospective study.

This retrospective study aimed to compare the mortality and burden of respiratory syncytial virus (RSV group), SARS-CoV-2 (COVID-19 group), non-H1N1 (Seasonal influenza group) and H1N1 influenza (H1N1 group) in adult patients admitted to intensive care unit (ICU) with respiratory failure. A total of 807 patients were included. Mortality was compared between the four following groups: RSV, COVID-19, seasonal influenza, and H1N1 groups. Patients in the RSV group had significantly more comorbidities than the other patients. At admission, patients in the COVID-19 group were significantly less severe than the others according to the simplified acute physiology score-2 (SAPS-II) and sepsis-related organ failure assessment (SOFA) scores. Using competing risk regression, COVID-19 (sHR = 1.61; 95% CI 1.10; 2.36) and H1N1 (sHR = 1.87; 95% CI 1.20; 2.93) were associated with a statistically significant higher mortality while seasonal influenza was not (sHR = 0.93; 95% CI 0.65; 1.31), when compared to RSV. Despite occurring in more severe patients, RSV and seasonal influenza group appear to be associated with a more favorable outcome than COVID-19 and H1N1 groups.

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.

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.

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.

Pre-anaesthesia Telephone Consultation: A Safe Alternative for Anaesthesia Assessment in Case of Repeated Low or Intermediate Risk Surgeries: A Prospective Cohort Study.

Objective: Telemedicine has widely expanded during the coronavirus disease-2019 pandemic. Our objective was to evaluate the feasibility, safety, effectiveness, and satisfaction of pre-anaesthesia telephone consultation (PATC). Methods: From December 2015 to October 2016, a prospective survey was administered to anaesthesiologists, nurse anaesthetists, and patients of the ambulatory and maxillofacial departments. Patients having a pre-anaesthesia consultation (PAC) within the previous year in the department, whose health state was considered stable, and for whom the surgical procedure was related to the previous one, were eligible for PATC. Three questionnaires concerning the pre- (Q1), per- (Q2), and postoperative (Q3) periods were answered by the patient, the anaesthesiologist, and the anaesthesiologist nurse to evaluate the feasibility and satisfaction of the PATC. We collected the cancelation rate and any incident occurring during the surgery. Results: Over the study period, 210 patients were included. The response rate was 200/210 (95.2%) for Q1, 108/208 (51.9%) for Q2 and 146/208 (70.2%) for Q3. PATC was performed in a median (IQR) of 13 (7-20) days before the procedure. Patients answered directly in 73% of cases without the need for recall. During surgery, 4 incidents occurred and none were attributable to PATC. Patient satisfaction was 93.3% and 85.8% of them preferred PATC to conventional PAC. The kilometric saving was 74 (30-196) km per PATC. Conclusion: Both patients and professionals were satisfied with PATC, which did not impact safety. On the selected patients, PATC brings many practical benefits and increases organizational flexibility.

Multitasking in postanesthesia care unit following nurse interruptions, an analysis of the causes and consequences using classification tree: an observational prospective study

Abstract Background: Postanesthesia Care Unit (PACU) is an environment associated with an important workload which is susceptible to lead to task interruption (TI), leading to task-switching or concurrent multitasking. The objective of the study was to determine the predictors of the reaction of the nurses facing TI and assess those who lead to an alteration of the initial task. Methods: We conducted a prospective observational study into the PACU of a university hospital during February 2017. Among 18 nurses, a selected one was observed each day, documenting for each TI the reaction of the nurse (task switching or concurrent multitasking), and the characteristics associated with the TI. We performed classification tree analyses using C5.0 algorithm in order to select the main predictors of the type of multitasking performed and the alteration of the initial task. Results: We observed 1119 TI during 132 hours (8.5 TI/hour). The main reaction was concurrent multitasking (805 TI, 72%). The short duration of the task interruption (one minute or less) was the most important predictor leading to concurrent multitasking. Other predictors of response to TI were the identity of the task interrupter and the number of nurses present. Regarding the consequences of the task switching, long interruption (more than five minutes) was the most important predictor of the alteration of the initial task. Conclusions: By analysing the predictors of the type of multitasking in front of TI, we propose a novel approach to understanding TI, offering new perspective for prevention strategies.

Description and evaluation of cocaine body-packers management in French Guiana (2016-2019).

INTRODUCTION: French Guiana is a hub for drugs trafficking between South America and Europe. In Corpore transport, or Body-packing, is one of the options favored. In 2018, 577 people were arrested for smuggling cocaine from French Guiana to mainland France. The objective of this study was to update the epidemiological data and to evaluate the overall management of body-packers. METHODS: A monocentric retrospective and observational study included patients admitted to the emergency department of the Cayenne General Hospital from January 1st, 2016 to December 31st, 2019 after ingestion of cocaine pellets. RESULTS: During the period, 668 people were referred to Cayenne hospital's emergency department by for suspected body-packing. Two hundred nineteen were excluded due to the absence of cocaine pellets in the initial X-ray or because they were carrying cannabis pellets. The mean age was 25.2 years with a sex ratio of 2.21 males per female. Among them, 13.7% of cases were complicated without endangering the vital prognosis. The mean number of pellets was similar between the population with and without complications (respectively 54.1 [50.9-57.4] and 57.8 [48.9-66.6], p = 0.22). The presence of cocaine in the urine was not significantly associated with the risk of complications (OR = 0.5, [95%CI = 0.1-1.8], p = 0.23). Compared to the CT-scanner which has the highest diagnostic accuracy (Se 100%, Sp 94%), the sensitivity of the Abdominal X-ray was 44%. CONCLUSION: This study showed that complications were rare, most of which were digestive stagnation requiring endoscopy. Given the low rate of complications and their low severity the average duration of hospitalization was relatively short. The type 3, micro-industrial quality packaging, almost exclusively used in body-packing in French Guiana, seems to be the main factor in this reduction of complications. This observation suggests possible adaptations of the current protocol for body-packers monitoring.

Insurance Claims for Wrong-Side, Wrong-Organ, Wrong-Procedure, or Wrong-Person Surgical Errors: A Retrospective Study for 10 Years.

OBJECTIVE: Serious adverse events, such as wrong-side, wrong-organ, wrong-procedure, or wrong-person errors, still occur despite the implementation of preventative measures. In France, we describe the claims related to such errors based on the database from one of the main insurance companies. METHODS: A retrospective analysis of claims declared between January 2007 and December 2017 to Relyens, a medical liability insurance company (Sham), was performed. Their database was queried using the following keywords: "wrong side," "wrong organ," and "wrong person." RESULTS: We collected 219 claims (0.4% of the total claims). The main specialties involved were orthopedics (34% of cases), neurosurgery (14%), and dentistry (14%). The claims were related to wrong organ (44%), side (39%), identity (13%), or procedure (4%). Juridical entity involved were mainly public facility (69%), followed by private facility (19%) or private physician (10%). The mean number of annual claims made has decreased of 20% since the mandatory implementation of the checklist in 2010 (22 versus 17.5 events per year). The main risk factors identified according to the ALARM protocol were factor related to the team (87%) or to the task to accomplish (78%). A direct causal factor was involved in 20% of the files, the main one being the organization (43%) closely related to the medical file (36%). The settlement was performed by conciliation in 69% of the claim and in court in 30%. The compensation was higher during a court settlement. CONCLUSIONS: Wrong-side, wrong-organ, wrong-procedure, or wrong-person surgical errors are rare but fully preventable by the implementation of a safety culture.

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.

Vascular access unit: Six-years experience report in France.

BACKGROUND: The role of nurses in peripherally inserted central catheters (PICC) placement has been limited in France. Having a fully trained nurse-led PICC team can positively impact nursing profession and make better use of valuable human and economic healthcare resources. It can also improve the standards of patient's care, procedural experience, and safety. AIM: The aim of this article is to report the successful outcomes of nurse-led PICC team performed over a 6-year period from a single central hospital in France. METHODS: The authors reviewed all PICCs insertions performed by their trained nurse led team between 2014 and 2019. All quantitative and qualitative variables were considered: the patients admitted, the type of PICC inserted, overall procedural time, the mentor's help, the insert failures, the number of punctures required, the procedural pain utilizing Visual Analog Scale (VAS), any procedural complications, chest X-rays needed, the follow up to the eighth day (D8). RESULTS: From 2014 to 2019, 12,687 PICC were inserted with 128 failed procedures (1%). In 2019, 73% of procedural insertion time was less than 10 min. The request of support rapidly decreased to 2 calls/month. More than 90% of procedures were associated with mild pain (VAS ⩽ 3). After the first month of training, 81% of all procedures were performed with a single insertion puncture. Accidental artery puncture during procedure was 0.5%. The authors found room for improvement, progressing from 97% in the first year to 99% in 2019. Furthermore, the authors found that only 1.85% of all catheters developed local infection within D8, and only 0.83% evolved in vein thrombosis. Total bloodstream infection was at 0.1%. CONCLUSION: The authors report successful outcomes from data collected during the 6-year period demonstrating clear benefits of a nurse-led vascular access team with regard to system wide efficiencies and patient satisfaction.

Multitasking in postanesthesia care unit following nurse interruptions, an analysis of the causes and consequences using classification tree: an observational prospective study.

BACKGROUND: Postanesthesia Care Unit (PACU) is an environment associated with an important workload which is susceptible to lead to task interruption (TI), leading to task-switching or concurrent multitasking. The objective of the study was to determine the predictors of the reaction of the nurses facing TI and assess those who lead to an alteration of the initial task. METHODS: We conducted a prospective observational study into the PACU of a university hospital during February 2017. Among 18 nurses, a selected one was observed each day, documenting for each TI the reaction of the nurse (task switching or concurrent multitasking), and the characteristics associated with the TI. We performed classification tree analyses using C5.0 algorithm in order to select the main predictors of the type of multitasking performed and the alteration of the initial task. RESULTS: We observed 1119 TI during 132 hours (8.5 TI/hour). The main reaction was concurrent multitasking (805 TI, 72%). The short duration of the task interruption (one minute or less) was the most important predictor leading to concurrent multitasking. Other predictors of response to TI were the identity of the task interrupter and the number of nurses present. Regarding the consequences of the task switching, long interruption (more than five minutes) was the most important predictor of the alteration of the initial task. CONCLUSIONS: By analysing the predictors of the type of multitasking in front of TI, we propose a novel approach to understanding TI, offering new perspective for prevention strategies.

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.

Safety Attitude of Operating Room Personnel Associated With Accurate Completion of a Surgical Checklist: A Cross-sectional Observational Study.

OBJECTIVE: How the checklist is executed in routine practice may reflect the teamwork and safety climate in the operating room (OR). This cross-sectional study aimed to identify whether the presence of a fully completed checklist in medical records was associated with teams' safety attitudes. METHODS: Data from 29 French hospitals, including 5677 operated patients and 834 OR professionals, were prospectively collected. The degree of checklist compliance was categorized for each patient in 1 of 4 ways: full, incomplete, inaccurate, and no checklist completed. The members of OR teams were invited to complete a questionnaire including teamwork climate measurement (Safety Attitudes Questionnaire) and their opinion regarding checklist use, checklist audibly reading, and communication change with checklist. Multilevel modeling was performed to investigate the effect of variables related to hospitals and professionals on checklist compliance, after adjustment for patient characteristics. RESULTS: A checklist was present for 83% of patients, but only 35% demonstrated full completion. Compared with no checklist, full completion was associated with higher safety attitude (high teamwork climate [adjusted odds ratio for full completion, 4.14; 95% confidence interval, 1.75-9.76]; communication change [1.31, 1.04-1.66]; checklist aloud reading [1.16, 1.02-1.32]) and was reinforced by the designation of a checklist coordinator (2.43, 1.06-5.55). Incomplete completion was also associated with enhanced safety attitude contrary to inaccurate completion. CONCLUSIONS: Compliance with checklists is associated with safer OR team practice and can be considered as an indicator of the extent of safety in OR practice.

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.

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.

Association between voriconazole exposure and Sequential Organ Failure Assessment (SOFA) score in critically ill patients.

Therapeutic drug monitoring (TDM) is essential for voriconazole to ensure optimal drug exposure, mainly in critically ill patients for whom voriconazole demonstrated a large variability. The study aimed at describing factors associated with trough voriconazole concentrations in critically ill patients and evaluating the impact of voriconazole concentrations on adverse effects. A 2-year retrospective multicenter cohort study (NCT04502771) was conducted in six intensive care units. Adult patients who had at least one voriconazole TDM were included. Univariable and multivariable linear regression analyses were performed to identify predictors of voriconazole concentrations, and univariable logistic regression analysis, to study the relationship between voriconazole concentrations and adverse effects. During the 2-year study period, 70 patients were included. Optimal trough voriconazole concentrations were reported in 37 patients (52.8%), subtherapeutic in 20 (28.6%), and supratherapeutic in 13 (18.6%). Adverse effects were reported in six (8.6%) patients. SOFA score was identified as a factor associated with an increase in voriconazole concentration (p = 0.025), mainly in the group of patients who had SOFA score ≥ 10. Moreover, an increase in voriconazole concentration was shown to be a risk factor for occurrence of adverse effects (p = 0.011). In that respect, critically ill patients who received voriconazole treatment must benefit from a TDM, particularly if they have a SOFA score ≥ 10. Indeed, identifying patients who are overdosed will help to prevent voriconazole related adverse effects. This result is of utmost importance given the recognized COVID-19-associated pulmonary aspergillosis in ICU patients for whom voriconazole is among the recommended first-line treatment.

The Effect of Foot Reflexology on Chemotherapy-Induced Nausea and Vomiting in Patients With Digestive or Lung Cancer: Randomized Controlled Trial.

BACKGROUND: Cancer is a chronic disease with an incidence of 24.5 million and 9.6 million deaths worldwide in 2017. Lung and colorectal cancer are the most common cancers for both sexes and, according to national and international recommendations, platinum-based chemotherapy is the reference adjuvant treatment. This chemotherapy can be moderately to highly emetogenic. Despite antiemetic therapy, chemotherapy-induced nausea and vomiting (CINV) may persist. Moreover, cancer patients are increasingly interested in alternative and complementary medicines and have expressed the desire that nonpharmacological treatments be used in hospitals. Among alternative and complementary medicines, foot reflexology significantly decreases the severity of CINV in patients with breast cancer. OBJECTIVE: The primary aim of this study was to assess the benefits of foot reflexology as a complement therapy to conventional treatments regarding the severity of acute CINV in patients with digestive or lung cancer. The secondary objectives assessed were the frequency and severity of delayed CINV, quality of life, anxiety, and self-esteem. METHODS: This study was conducted between April 2018 and April 2020 in the Hospices Civils de Lyon, France. This was an open-label randomized controlled trial. Participants were randomized into two groups: the intervention group (ie, conventional care with foot reflexology; n=40) and the control group (ie, conventional care without foot reflexology; n=40). Foot reflexology sessions (30 minutes each) were performed on outpatients or inpatients. Eligible participants were patients with lung or digestive cancer with an indication for platinum-based chemotherapy. RESULTS: The severity of acute nausea and vomiting was assessed with a visual analog scale during the second cycle of chemotherapy. A significant increase of at least 2 points was observed for the control group (7/34, 21%; P=.001). Across all cycles, the foot reflexology group showed a trend toward less frequent delayed nausea (P=.28), a significantly less frequent consumption of antiemetic drugs (P=.04), and no significant difference for vomiting (P=.99); there was a trend toward a perception of stronger severity for delayed nausea in the control group (P=.39). Regarding quality of life and anxiety, there was no significant difference between the intervention group and the control group (P=.32 and P=.53, respectively). CONCLUSIONS: This study's results indicate that foot reflexology provides significantly better management of acute nausea severity and decreased consumption of antiemetic drugs in patients with lung or digestive cancer. In order to fulfill patients' desires to use nonpharmacological treatments and complementary and alternative medicines in hospitals, foot reflexology could be provided as a complementary intervention to conventional antiemetic drugs. Foot reflexology did not result in adverse effects. To assess the benefits of foot reflexology in routine practice, a larger study with several health care centers would be needed with a cluster randomized controlled trial. TRIAL REGISTRATION: ClinicalTrials.gov NCT03508180; https://clinicaltrials.gov/ct2/show/NCT03508180. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/17232.

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.

Short- and long-term prognosis of acute critically ill patients with systemic rheumatic diseases: A retrospective multicentre study.

ABSTRACT: Patients with systemic rheumatic disease (SRD) share the risks of multi-organ flare-up, cardiovascular diseases, and immunosuppression. Such situations can lead to an acute critical illness. The present study describes the clinical features of SRD patients admitted to the intensive care unit (ICU) and their short- and long- term mortality.We performed a multicentre retrospective study in 10 French ICU in Lyon, France. Inclusion criteria were SRD diagnosis and admission for an acute organ failure. The primary endpoint was ICU mortality.A total of 271 patients were included. SRD included systemic lupus erythematosus (23.2% of included patients), vasculitis (10.7%), systemic sclerosis (10.7%), idiopathic inflammatory myopathy (6.3%), and other connective tissue disorders (rheumatoid arthritis, Sjögren and Sharp syndromes; 50.9%). Initial organ failure(s) were shock (43.5% of included patients), acute kidney injury (30.5%), and acute respiratory failure (23.2%). The cause(s) of ICU admission included sepsis (61.6%), cardiovascular events (33.9%), SRD-flare up (32.8%), and decompensations related to comorbidities (28%). The ICU mortality reached 14.3%. The factors associated with ICU mortality were chronic cardiac failure, invasive ventilation and admission in ICU for another reason than sepsis or SRD flare-up. The median follow-up after ICU discharge was 33.6 months. During follow-up, 109 patients died. The factors associated with long-term mortality included age, Charlson comorbidity index, and ICU admission for sepsis or SRD flare-up.The ICU mortality of patients with SRD was low. Sepsis was the first cause of admission. Cardiovascular events and comorbidities negatively impacted ICU mortality. Admission for sepsis or SRD flare-up exerted a negative effect on the long-term outcome.

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.