Fluid Intake in Critically Ill Patients: The "Save Useless Fluids For Intensive Resuscitation" Multicenter Prospective Cohort Study.

OBJECTIVES: Patients at risk of adverse effects related to positive fluid balance could benefit from fluid intake optimization. Less attention is paid to nonresuscitation fluids. We aim to evaluate the heterogeneity of fluid intake at the initial phase of resuscitation. DESIGN: Prospective multicenter cohort study. SETTING: Thirty ICUs across France and one in Spain. PATIENTS: Patients requiring vasopressors and/or invasive mechanical ventilation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: All fluids administered by vascular or enteral lines were recorded over 24 hours following admission and were classified in four main groups according to their predefined indication: fluids having a well-documented homeostasis goal (resuscitation fluids, rehydration, blood products, and nutrition), drug carriers, maintenance fluids, and fluids for technical needs. Models of regression were constructed to determine fluid intake predicted by patient characteristics. Centers were classified according to tertiles of fluid intake. The cohort included 296 patients. The median total volume of fluids was 3546 mL (interquartile range, 2441-4955 mL), with fluids indisputably required for body fluid homeostasis representing 36% of this total. Saline, glucose-containing high chloride crystalloids, and balanced crystalloids represented 43%, 27%, and 16% of total volume, respectively. Whatever the class of fluids, center of inclusion was the strongest factor associated with volumes. Compared with the first tertile, the difference between the volume predicted by patient characteristics and the volume given was +1.2 ± 2.0 L in tertile 2 and +3.0 ± 2.8 L in tertile 3. CONCLUSIONS: Fluids indisputably required for body fluid homeostasis represent the minority of fluid intake during the 24 hours after ICU admission. Center effect is the strongest factor associated with the volume of fluids. Heterogeneity in practices suggests that optimal strategies for volume and goals of common fluids administration need to be developed.

Are bedside colonoscopies performed in intensive care unit really useful?

PURPOSE: Effectiveness of bedside Colonoscopies in Intensive Care Unit (CICU) might be limited by the poor quality of colonic preparation, and their feasibility. We sought to describe the indications and the profitability of CICU. METHODS: Retrospective, bicenter observational study (2004-2015) in unselected critically ill patients. We questioned the clinical profitability of CICU, according to its indications and preparation. RESULTS: One hundred and eleven CICU were performed in 84 patients (sex ratio 1.4, 49 M/35F; age 72.9 years [61.7-84.7]), for lower gastro-intestinal bleeding in 67 patients (LGIB, 60.3%) and for other causes in 44 (39.6%). The profitability was more frequent when CICU was performed for another reason than LGIB (75% vs 28.3%; p < 0.0001). Preparation was good in 47 procedures (42.3%) and allowed 33 complete CICU (29.7%). Fifty-six CICU (50.4%) were performed as a 2nd investigation after a contrast enhanced computed tomography. Three CICU were complicated by 3 hemodynamic and 2 respiratory failures, but none of them were fatal. CONCLUSIONS: CICU is clinically useful in half of cases, in the diagnostic and the therapeutic management of critically ill patients. Its profitability is close to scheduled colonoscopies and superior in non-lower gastro-intestinal bleeding indications.

[Inadequate involvement of general practitioners in end-of-life's decisions in an intensive care unit]. / Implication insuffisante des médecins généralistes lors des décisions de limitation et/ou d'arrêt des traitements au sein d'un service de réanimation.

INTERESTS AND OBJECTIVES: Patients' general practitioners (GPs) could be relevant consultants for collegial decisions of withholding or withdrawing treatment (WWT) defined by the Leonetti law. We therefore studied their implication by intensivists in end-of-life decisions and collected their feelings. Their wishes for the coming law revision were also investigated. METHODS: Retrospective descriptive study conducted in the polyvalent intensive care unit (ICU) of Longjumeau's hospital (France) using a distributed questionnaire to GPs of patients who benefited from collegial decisions of WWT in 2012. RESULTS: The response rate was 60.4% (32/53) and only 18.8% of the respondents participated as a consultant in WWT's decision for their patient. Two GPs out of three reported that they never participate in such decisions for their others patients. All uninvolved GPs did not contribute because intensivists did not consult them. Only 43.7% of GPs were contacted by intensivists during the stay and 21.9% at the discharge or death of their patient. GPs took news about their patient during ICU hospitalization in 37.5% of cases. Regarding uninvolved GPs, their participation could have changed WWT's decisions made for two patients (7.7%). Most respondents felt available (78.1%) and skilled (81.2 %) to participate in this kind of decision. A third was also questioned by the patient's family about it. Only 21.7% of GPs report to be familiar with the French end-of-life legislation. In case of a next revision, two thirds considered important to make the use of GPs obligatory in such decisions. CONCLUSION: Despite an undeniable interest, GPs are rarely involved in collegial processes of WWT in ICUs, partially related to an insufficient knowledge of the law by the healthcare providers. At the dawn of end-of-life law's revision, their share could however improve our practices in this field.