A data-driven approach to identify risk profiles and protective drugs in COVID-19.

As the COVID-19 pandemic is spreading around the world, increasing evidence highlights the role of cardiometabolic risk factors in determining the susceptibility to the disease. The fragmented data collected during the initial emergency limited the possibility of investigating the effect of highly correlated covariates and of modeling the interplay between risk factors and medication. The present study is based on comprehensive monitoring of 576 COVID-19 patients. Different statistical approaches were applied to gain a comprehensive insight in terms of both the identification of risk factors and the analysis of dependency structure among clinical and demographic characteristics. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus enters host cells by binding to the angiotensin-converting enzyme 2 (ACE2), but whether or not renin-angiotensin-aldosterone system inhibitors (RAASi) would be beneficial to COVID-19 cases remains controversial. The survival tree approach was applied to define a multilayer risk stratification and better profile patient survival with respect to drug regimens, showing a significant protective effect of RAASi with a reduced risk of in-hospital death. Bayesian networks were estimated, to uncover complex interrelationships and confounding effects. The results confirmed the role of RAASi in reducing the risk of death in COVID-19 patients. De novo treatment with RAASi in patients hospitalized with COVID-19 should be prospectively investigated in a randomized controlled trial to ascertain the extent of risk reduction for in-hospital death in COVID-19.

Stellate ganglion block combined with intra-arterial treatment: a "one-stop shop" for cerebral vasospasm after aneurysmal subarachnoid hemorrhage-a pilot study.

PURPOSE: Delayed cerebral ischemia (DCI) is a frequent cause of morbidity and mortality in patients with cerebral vasospasm (CV) following aneurysmal subarachnoid hemorrhage (aSAH). Refractory CV remains challenging to treat and often leads to permanent deficits and death despite aggressive therapy. We hereby report the feasibility and safety of stellate ganglion block (SGB) performed with a vascular roadmap-guided technique to minimize the risk of accidental vascular puncture and may be coupled to a diagnostic or therapeutic cerebral angiography. METHODS: In addition to a detailed description of the technique, we performed a retrospective analysis of a series of consecutive patients with refractory CV after aSAH that were treated with adjuvant roadmap-guided SGB. Clinical outcomes at discharge are reported. RESULTS: Nineteen SGB procedures were performed in 10 patients, after failure of traditional hemodynamic and endovascular treatments. Each patient received 1 to 3 SGB, usually interspaced by 24 h. In 4 patients, an indwelling microcatheter for continuous infusion was inserted. First SGB occurred on average 7.3 days after aSAH. SGB was coupled to intra-arterial nimodipine infusion or balloon angioplasty in 9 patients. SGB was technically successful in all patients. There were no technical or clinical complications. CONCLUSION: Adjuvant SGB may be coupled to endovascular therapy to treat refractory cerebral vasopasm within the same session. To guide needle placement, using a roadmap of the supra-aortic arteries may decrease the risk of complications. More prospective data is needed to evaluate the therapeutic efficacy, durability, and safety of SGB compared with the established standard of care.

Initiative for Burnout of ICU Caregivers: Feasibility and Preliminary Results of a Psychological Support.

BACKGROUND: Intensive care unit (ICU) caregivers are at high risk of burnout and the shortage of this highly specialized personal is a problem. The feasibility and impact of a psychological intervention were never assessed in this special context. METHODS: A randomized controlled single-blind study in an ICU. The first intervention consisted in weekly problem-based sessions led by psychologists with small groups of caregivers using a systemic approach over 3 months. The modified intervention was lead for 9 months. The scores of Maslach Burnout Inventory and Hospital Anxiety and Depression Scale were compared between the intervention and control groups, before and after the intervention. RESULTS: One-hundred and sixty six caregivers were randomized in intervention and control groups. The major finding was the way the psychologists could modify the original methodology in order to enable caregivers to attend the sessions. Burnout scores tended to decrease across the whole ICU team after the intervention period, more in the intervention group. Participation in the study was poor at 6 months after intervention. CONCLUSIONS: This is the first study attempting to evaluate a psychological intervention on the mental health of ICU caregivers. It shows a modified method of a psychological support with a systemic approach in the special environment of ICU. Notwithstanding the modest results related to the short length of the process and the turnover of the personal, we demonstrated that such an approach is feasible. Further studies on larger scale and of longer duration are needed to investigate the effect of such interventions on the mental health of ICU caregivers.

Determinants of the calibration of SAPS II and SAPS 3 mortality scores in intensive care: a European multicenter study.

BACKGROUND: The aim of the Simplified Acute Physiology Score (SAPS) II and SAPS 3 is to predict the mortality of patients admitted to intensive care units (ICUs). Previous studies have suggested that the calibration of these scores may vary across countries, centers, and/or characteristics of patients. In the present study, we aimed to assess determinants of the calibration of these scores. METHODS: We assessed the calibration of the SAPS II and SAPS 3 scores among 5266 patients admitted to ICUs during a 4-week period at 120 centers in 17 European countries. We obtained calibration curves, Brier scores, and standardized mortality ratios. Points attributed to SAPS items were reevaluated and compared with those of the original scores. Finally, we tested associations between the calibration and center characteristics. RESULTS: The mortality was overestimated by both scores: The standardized mortality ratios were 0.75 (95% CI 0.71-0.79) for the SAPS II score and 0.91 (95% CI 0.86-0.96) for the SAPS 3 score. This overestimation was partially explained by changes in associations between some items of the scores and mortality, especially the heart rate, Glasgow Coma Scale score, and diagnosis of AIDS for SAPS II. The calibration of both scores was better in countries with low health expenditures. The between-center variability in calibration curves was much greater than expected by chance. CONCLUSIONS: Both scores overestimate current mortality among European ICU patients. The magnitude of the miscalibration of SAPS II and SAPS 3 scores depends not only on patient characteristics but also on center characteristics. Furthermore, much between-center variability in calibration remains unexplained by these factors. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01422070 . Registered 19 August 2011.

Reproducibility of transpulmonary thermodilution cardiac output measurements in clinical practice: a systematic review.

Measuring cardiac output (CO) is an integral part of the diagnostic and therapeutic strategy in critically ill patients. During the last decade, the single transpulmonary thermodilution (TPTD) technique was implemented in clinical practice. The purpose of this paper was to systematically review and critically assess the existing data concerning the reproducibility of CO measured using TPTD (COTPTD). A total of 16 studies were identified to potentially be included in our study because these studies had the required information that allowed for calculating the reproducibility of COTPTD measurements. 14 adult studies and 2 pediatric studies were analyzed. In total, 3432 averaged CO values in the adult population and 78 averaged CO values in the pediatric population were analyzed. The overall reproducibility of COTPTD measurements was 6.1 ± 2.0 % in the adult studies and 3.9 ± 2.9 % in the pediatric studies. An average of 3 boluses was necessary for obtaining a mean CO value. Achieving more than 3 boluses did not improve reproducibility; however, achieving less than 3 boluses significantly affects the reproducibility of this technique. The present results emphasize that TPTD is a highly reproducible technique for monitoring CO in critically ill patients, especially in the pediatric population. Our findings suggest that obtaining a mean of 3 measurements for determining CO values is recommended.

Impact of a communication strategy on family satisfaction in the intensive care unit.

BACKGROUND: Family satisfaction of critically ill patients has gained increased interest as important indicator to evaluate the quality of care in the intensive care unit (ICU). The family satisfaction in the ICU questionnaire (FS-ICU 24) is a well-established tool to assess satisfaction in such settings. We tested the hypothesis that an intervention, aiming at improved communication between health professionals and patients' next of kin in the ICU improves family satisfaction, as assessed by FS-ICU 24. METHODS: Using a multicenter before-and-after study design, we evaluated medium-term effectiveness of VALUE, a recently proposed strategy aiming at improved communication. Satisfaction was assessed using the FS-ICU 24 questionnaire. Performance-importance plots were generated in order to identify items highly correlated with overall satisfaction but with low individual score. RESULTS: A total of 163 completed family questionnaires in the pre-intervention and 118 in the post-intervention period were analyzed. Following the intervention, we observed: (1) a non-significant increase in family satisfaction summary score and sub-scores; (2) no decline in any individual family satisfaction item, and (3) improvement in items with high overall impact on satisfaction but quoted with low degree of satisfaction. CONCLUSION: No significant improvement in family satisfaction of critically ill adult patients could be found after implementing the VALUE strategy. Whether these results are due to insufficient training of the new strategy or a missing effect of the strategy in our socio-economic environment remains to be shown.

Clinical symptoms, signs and tests for identification of impending and current water-loss dehydration in older people.

BACKGROUND: There is evidence that water-loss dehydration is common in older people and associated with many causes of morbidity and mortality. However, it is unclear what clinical symptoms, signs and tests may be used to identify early dehydration in older people, so that support can be mobilised to improve hydration before health and well-being are compromised. OBJECTIVES: To determine the diagnostic accuracy of state (one time), minimally invasive clinical symptoms, signs and tests to be used as screening tests for detecting water-loss dehydration in older people by systematically reviewing studies that have measured a reference standard and at least one index test in people aged 65 years and over. Water-loss dehydration was defined primarily as including everyone with either impending or current water-loss dehydration (including all those with serum osmolality ≥ 295 mOsm/kg as being dehydrated). SEARCH METHODS: Structured search strategies were developed for MEDLINE (OvidSP), EMBASE (OvidSP), CINAHL, LILACS, DARE and HTA databases (The Cochrane Library), and the International Clinical Trials Registry Platform (ICTRP). Reference lists of included studies and identified relevant reviews were checked. Authors of included studies were contacted for details of further studies. SELECTION CRITERIA: Titles and abstracts were scanned and all potentially relevant studies obtained in full text. Inclusion of full text studies was assessed independently in duplicate, and disagreements resolved by a third author. We wrote to authors of all studies that appeared to have collected data on at least one reference standard and at least one index test, and in at least 10 people aged ≥ 65 years, even where no comparative analysis has been published, requesting original dataset so we could create 2 x 2 tables. DATA COLLECTION AND ANALYSIS: Diagnostic accuracy of each test was assessed against the best available reference standard for water-loss dehydration (serum or plasma osmolality cut-off ≥ 295 mOsm/kg, serum osmolarity or weight change) within each study. For each index test study data were presented in forest plots of sensitivity and specificity. The primary target condition was water-loss dehydration (including either impending or current water-loss dehydration). Secondary target conditions were intended as current (> 300 mOsm/kg) and impending (295 to 300 mOsm/kg) water-loss dehydration, but restricted to current dehydration in the final review.We conducted bivariate random-effects meta-analyses (Stata/IC, StataCorp) for index tests where there were at least four studies and study datasets could be pooled to construct sensitivity and specificity summary estimates. We assigned the same approach for index tests with continuous outcome data for each of three pre-specified cut-off points investigated.Pre-set minimum sensitivity of a useful test was 60%, minimum specificity 75%. As pre-specifying three cut-offs for each continuous test may have led to missing a cut-off with useful sensitivity and specificity, we conducted post-hoc exploratory analyses to create receiver operating characteristic (ROC) curves where there appeared some possibility of a useful cut-off missed by the original three. These analyses enabled assessment of which tests may be worth assessing in further research. A further exploratory analysis assessed the value of combining the best two index tests where each had some individual predictive ability. MAIN RESULTS: There were few published studies of the diagnostic accuracy of state (one time), minimally invasive clinical symptoms, signs or tests to be used as screening tests for detecting water-loss dehydration in older people. Therefore, to complete this review we sought, analysed and included raw datasets that included a reference standard and an index test in people aged ≥ 65 years.We included three studies with published diagnostic accuracy data and a further 21 studies provided datasets that we analysed. We assessed 67 tests (at three cut-offs for each continuous outcome) for diagnostic accuracy of water-loss dehydration (primary target condition) and of current dehydration (secondary target condition).Only three tests showed any ability to diagnose water-loss dehydration (including both impending and current water-loss dehydration) as stand-alone tests: expressing fatigue (sensitivity 0.71 (95% CI 0.29 to 0.96), specificity 0.75 (95% CI 0.63 to 0.85), in one study with 71 participants, but two additional studies had lower sensitivity); missing drinks between meals (sensitivity 1.00 (95% CI 0.59 to 1.00), specificity 0.77 (95% CI 0.64 to 0.86), in one study with 71 participants) and BIA resistance at 50 kHz (sensitivities 1.00 (95% CI 0.48 to 1.00) and 0.71 (95% CI 0.44 to 0.90) and specificities of 1.00 (95% CI 0.69 to 1.00) and 0.80 (95% CI 0.28 to 0.99) in 15 and 22 people respectively for two studies, but with sensitivities of 0.54 (95% CI 0.25 to 0.81) and 0.69 (95% CI 0.56 to 0.79) and specificities of 0.50 (95% CI 0.16 to 0.84) and 0.19 (95% CI 0.17 to 0.21) in 21 and 1947 people respectively in two other studies). In post-hoc ROC plots drinks intake, urine osmolality and axillial moisture also showed limited diagnostic accuracy. No test was consistently useful in more than one study.Combining two tests so that an individual both missed some drinks between meals and expressed fatigue was sensitive at 0.71 (95% CI 0.29 to 0.96) and specific at 0.92 (95% CI 0.83 to 0.97).There was sufficient evidence to suggest that several stand-alone tests often used to assess dehydration in older people (including fluid intake, urine specific gravity, urine colour, urine volume, heart rate, dry mouth, feeling thirsty and BIA assessment of intracellular water or extracellular water) are not useful, and should not be relied on individually as ways of assessing presence or absence of dehydration in older people.No tests were found consistently useful in diagnosing current water-loss dehydration. AUTHORS' CONCLUSIONS: There is limited evidence of the diagnostic utility of any individual clinical symptom, sign or test or combination of tests to indicate water-loss dehydration in older people. Individual tests should not be used in this population to indicate dehydration; they miss a high proportion of people with dehydration, and wrongly label those who are adequately hydrated.Promising tests identified by this review need to be further assessed, as do new methods in development. Combining several tests may improve diagnostic accuracy.

[Between the poles of life and death]. / Questions de vie ou de mort.

Sometimes, conditions of critically ill patients unable to communicate, force us to decide whether or not to continue treatment. The most frequent elements we have to consider in individual patients, are survival at any cost and reduced future physical functioning and quality of life. In this article, we highlight existing literature's inability to precisely determine a given patient's preferences or to guess what they might be. Confronted with this crucial decision, the intensivist must therefore avoid the misstep of imposing their own values and expectations upon the patients. Patients even when unable to communicate must remain the master of their own destiny through their health care surrogate. If the question of their values and expectations, their advanced directives or their health care surrogate have been addressed or evoked beforehand by the family doctor, the chosen treatment modalities taken by the parties involved at a critical moment will thus allow the patient to remain the main actor of his care and destiny.

Feasibility of a multiple-choice mini mental state examination for chronically critically ill patients.

OBJECTIVES: Following treatment in an ICU, up to 70% of chronically critically ill patients present neurocognitive impairment that can have negative effects on their quality of life, daily activities, and return to work. The Mini Mental State Examination is a simple, widely used tool for neurocognitive assessment. Although of interest when evaluating ICU patients, the current version is restricted to patients who are able to speak. This study aimed to evaluate the feasibility of a visual, multiple-choice Mini Mental State Examination for ICU patients who are unable to speak. DESIGN: The multiple-choice Mini Mental State Examination and the standard Mini Mental State Examination were compared across three different speaking populations. The interrater and intrarater reliabilities of the multiple-choice Mini Mental State Examination were tested on both intubated and tracheostomized ICU patients. SETTING: Mixed 36-bed ICU and neuropsychology department in a university hospital. SUBJECTS: Twenty-six healthy volunteers, 20 neurological patients, 46 ICU patients able to speak, and 30 intubated or tracheostomized ICU patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Multiple-choice Mini Mental State Examination results correlated satisfactorily with standard Mini Mental State Examination results in all three speaking groups: healthy volunteers: intraclass correlation coefficient = 0.43 (95% CI, -0.18 to 0.62); neurology patients: 0.90 (95% CI, 0.82-0.95); and ICU patients able to speak: 0.86 (95% CI, 0.70-0.92). The interrater and intrarater reliabilities were good (0.95 [0.87-0.98] and 0.94 [0.31-0.99], respectively). In all populations, a Bland-Altman analysis showed systematically higher scores using the multiple-choice Mini Mental State Examination. CONCLUSIONS: Administration of the multiple-choice Mini Mental State Examination to ICU patients was straightforward and produced exploitable results comparable to those of the standard Mini Mental State Examination. It should be of interest for the assessment and monitoring of the neurocognitive performance of chronically critically ill patients during and after their ICU stay. The multiple-choice Mini Mental State Examination tool's role in neurorehabilitation and its utility in monitoring neurocognitive functions in ICU should be assessed in future studies.

The short-term prognosis of cardiogenic shock can be determined using hemodynamic variables: a retrospective cohort study*.

OBJECTIVES: Few reports address the relationship between hemodynamic variables and the cardiogenic shock outcome in critically ill patients. The present study aimed to investigate the association between hemodynamic variables and early cardiogenic shock mortality in critically ill patients. DESIGN: Retrospective, single-center cohort study. SETTING: Tertiary academic hospital's 36-bed multidisciplinary intensive care. PATIENTS: Initial presentation with cardiogenic shock. MEASUREMENTS AND MAIN RESULTS: The authors retrospectively analyzed medical information and the hemodynamic variables (recorded during the first 24 hr following admission to the ICU) of patients with cardiogenic shock. For all the patients, the Simplified Acute Physiology Score II, cardiac index, cardiac power index, and continuous hemodynamic values following the first 24 hours of admission were reviewed. Mortality within 28 days was the primary endpoint. All the variables were then compared with survival and nonsurvival status and those variables with a significant association in the univariate analysis were entered into a multivariate logistic regression model. Seventy-one patients were included. Among them, 26 (37%) died within 28 days after ICU admission and were classified as "nonsurvivors." The minimum value for diastolic arterial blood pressure during the first 24 hours was independently associated with the 28-day mortality in the univariate and multivariate analyses model. This model performed better than the model using the Simplified Acute Physiology Score II, even when assessing the effect of inotrope and vasoactive treatments at 24, 48, and 72 hours. CONCLUSIONS: In the first 24 hours of an ICU admission, the minimum diastolic arterial blood pressure was a hemodynamic variable that was independently associated with 28-day mortality in cardiogenic shock patients.

Obstacles to patient inclusion in CPR/DNAR decisions and challenging conversations: A qualitative study with internal medicine physicians in Southern Switzerland.

Despite cardiopulmonary resuscitation (CPR) and do-not-attempt-resuscitation (DNAR) decisions are increasingly considered an essential component of hospital practice and patient inclusion in these conversations an ethical imperative in most cases, there is evidence that such discussions between physicians and patients/surrogate decision-makers (the person or people providing direction in decision making if a person is unable to make decisions about personal health care, e.g., family members or friends) are often inadequate, excessively delayed, or absent. We conducted a study to qualitatively explore physician-reported CPR/DNAR decision-making approaches and CPR/DNAR conversations with patients hospitalized in the internal medicine wards of the four main hospitals in Ticino, Southern Switzerland. We conducted four focus groups with 19 resident and staff physicians employed in the internal medicine unit of the four public hospitals in Ticino. Questions aimed to elicit participants' specific experiences in deciding on and discussing CPR/DNAR with patients and their families, the stakeholders (ideally) involved in the discussion, and their responsibilities. We found that participants experienced two main tensions. On the one side, CPR/DNAR decisions were dominated by the belief that patient involvement is often pointless, even though participants favored a shared decision-making approach. On the other, despite aiming at a non-manipulative conversation, participants were aware that most CPR/DNAR conversations are characterized by a nudging communicative approach where the physician gently pushes patients towards his/her recommendation. Participants identified structural cause to the previous two tensions that go beyond the patient-physician relationship. CPR/DNAR decisions are examples of best interests assessments at the end of life. Such assessments represent value judgments that cannot be validly ascertained without patient input. CPR/DNAR conversations should be regarded as complex interventions that need to be thoroughly and regularly taught, in a manner similar to technical interventions.

Efficacy of endotracheal tube clamping to prevent positive airways pressure loss and pressure behavior after reconnection: a bench study.

BACKGROUND: Endotracheal tube (ETT) clamping before disconnecting the patient from the mechanical ventilator is routinely performed in patients with acute respiratory distress syndrome (ARDS) to minimize alveolar de-recruitment. Clinical data on the effects of ETT clamping are lacking, and bench data are sparse. We aimed to evaluate the effects of three different types of clamps applied to ETTs of different sizes at different clamping moments during the respiratory cycle and in addition to assess pressure behavior following reconnection to the ventilator after a clamping maneuver. METHODS: A mechanical ventilator was connected to an ASL 5000 lung simulator using an ARDS simulated condition. Airway pressures and lung volumes were measured at three time points (5 s, 15 s and 30 s) after disconnection from the ventilator with different clamps (Klemmer, Chest-Tube and ECMO) on different ETT sizes (internal diameter of 6, 7 and 8 mm) at different clamping moments (end-expiration, end-inspiration and end-inspiration with tidal volume halved). In addition, we recorded airway pressures after reconnection to the ventilator. Pressures and volumes were compared among different clamps, different ETT-sizes and the different moments of clamp during the respiratory cycle. RESULTS: The efficacy of clamping depended on the type of clamp, the duration of clamping, the size of the ETT and the clamping moment. With an ETT ID 6 mm all clamps showed similar pressure and volume results. With an ETT ID 7 and 8 mm only the ECMO clamp was effective in maintaining stable pressure and volume in the respiratory system during disconnection at all observation times. Clamping with Klemmer and Chest-Tube at end inspiration and at end inspiration with halved tidal volume was more efficient than clamping at end expiration (p < 0.03). After reconnection to the mechanical ventilator, end-inspiratory clamping generated higher alveolar pressures as compared with end-inspiratory clamping with halved tidal volume (p < 0.001). CONCLUSIONS: ECMO was the most effective in preventing significant airway pressure and volume loss independently from tube size and clamp duration. Our findings support the use of ECMO clamp and clamping at end-expiration. ETT clamping at end-inspiration with tidal volume halved could minimize the risk of generating high alveolar pressures following reconnection to the ventilator and loss of airway pressure under PEEP.

Burnout in ICU caregivers: a multicenter study of factors associated to centers.

RATIONALE: The stressful work environment of ICUs can lead to burnout. Burnout can impact on the welfare and performance of caregivers, and may lead them to resign their job. The shortage of ICU caregivers is becoming a real threat for health care leaders. OBJECTIVES: To investigate the factors associated with burnout on a national level in order to determine potential important factors. METHODS: Prospective, multicenter, observational survey of all caregivers from 74 of the 92 Swiss ICUs, measuring the prevalence of burnout among the caregivers and the pre-specified center-, patient- and caregiver-related factors influencing its prevalence. MEASUREMENTS AND MAIN RESULTS: Out of the 4322 questionnaires distributed from March 2006 to April 2007, 3052 (71%) were returned, with a response rate of 72% by center, 69% from nurse-assistants, 73% from nurses and 69% from physicians. A high proportion of female nurses among the team was associated with a decreased individual risk of high burnout (OR 0.98, 95% CI:0.97-0.99 for every %). The caregiver-related factors associated with a high risk of burnout were being a nurse-assistant, being a male, having no children and being under 40 years old. CONCLUSIONS: The findings of this study seem to open a new frontier concerning burnout in ICUs, highlighting the importance of team composition. Our results should be confirmed in a prospective multicenter, multinational study. Whether our results can be exported to other medical settings where team-working is pivotal remains to be investigated.

[Burnout in intensive care units]. / Burnout aux soins intensifs.

Intensive care units are highly stressful for the patients but for the caregivers as well, including nurse-assistants, nurses and physicians. The psychological syndrome of work exhaustion more commonly named burnout threatens these caregivers. The aims of the present paper are to describe: a) the incidence of burnout in intensive care units; b) the factors favoring burnout and c) the impacts of burnout at the individual, at the unit and institutional level. We suggest some possible ways to decrease the incidence of burnout. Finally, since the problematic of burnout is not specific to intensive care, we sought to underline some possible consequences of the burnout of caregivers on health systems.

"Heparinization" and hyperfibrinogenolysis by wasp sting.

We report on a patient with coagulation abnormalities induced by a wasp sting anaphylaxis. First, we observed an unclottable activated partial thromboplastin time and a significant anti-Xa activity (equivalent to a therapeutic heparin range), whereas the patient had received no heparin. This phenomenon is probably due to activated mast cells that release mediators such as heparin and tryptase. Heparin can then act as an anticoagulant by binding to antithrombin. This "heparinization" explains the anti-Xa activity contributing to the unclottable activated partial thromboplastin time detected in our patient. Second, we noted an extremely low fibrinogen level in the presence of normal platelet count and only a slight increase of D-dimers (absence of important disseminated intravascular coagulation). This is probably due to serum tryptase released during massive mast cell activation. Tryptase cleaves the alpha and beta chains of fibrinogen. This results in the removal of the thrombin cleavage site and of the critical polymerization site from the fibrinogen beta chain. Thrombin- initiated clot formation is therefore inhibited. Tryptase also acts directly on the fibrinolytic pathway by activating the single-chain urinary-type plasminogen activator, resulting in conversion of plasminogen into plasmin and therefore degradation of fibrinogen and other coagulation factors. This hyperfibrinogenolysis explains both the prolonged clotting times and the low fibrinogen level observed. Although our patient did not bleed, in other settings (trauma, during surgery) patients with anaphylaxis may present bleeding disorders. Although the mechanisms underlying these abnormalities have been described in vitro and in vivo animal trials, this is the first time they are described in a human clinical setting.

[Elderly patients in the intensive care unit]. / Patient agé aux soins intensifs.

Occidental countries are affected by a demographic ageing. The growing number of elderlies in the intensive care units (ICU) reflects this phenomenon. The physicians must deal with many medical, ethical and economical questions about the care policy provided to these patients. Despite the various definitions or thresholds used to characterize elderly patients, studies analyzing the long-term survival and quality of life do not allow us from applying care restrictions on an age basis only. Tools to improve the ability to estimate prognosis during the triage process or during an ICU stay are necessary. Currently no prediction model can decide about the ICU admission or about the treatment to provide to elderly patients without the opinion of an ICU specialist.

Burnout in a surgical ICU team.

OBJECTIVE: Psychologically stressful situations, a physically demanding workload and a high requirement for technological skills can lead ICU caregivers to burnout. The aim of our study was to evaluate their level of burnout as well as the related factors. DESIGN: A self-administered anonymous questionnaire. SETTING: A 20-bed surgical ICU in a university hospital. PATIENTS AND PARTICIPANTS: Nurse assistants, nurses. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Ninety-seven of 107 questionnaires (91%) were returned. Of the members of ICU nursing team, 28% showed a high level of burnout. They reported a number of concerns, and that they felt discomfort and suffering. There was a discrepancy between the factors felt to be important by them and those statistically related to the burnout. Among the reported concerns, only the lack of patients' co-operation, the organization of the service and the rapid patient turnover were independently associated with a high level of burnout. As many as 49% of the nursing team felt stressed. CONCLUSIONS: Almost a third of the ICU nursing team showed a high level of burnout. The factors felt to be important may not be those related to burnout. Since the well-being of the nursing team is important for the quality of care, corrective actions against the related factors should be sought in order to alleviate the suffering.

From the ICU to the ward: cross-checking of the physician's transfer report by intensive care nurses.

OBJECTIVE: To assess whether cross-checking of the physician ICU transfer report by ICU nurses may reduce transfer report errors. DESIGN: Prospective, observational study with random selection (according to patient registration code) of ICU transfer reports. SETTING: Eight-bed multidisciplinary intensive care unit of a teaching hospital. PATIENTS AND PARTICIPANTS: ICU transfer reports of 123 patients were randomly selected at discharge from the ICU between November 2006 and February 2007. INTERVENTIONS: Physician ICU transfer reports were cross-checked by nurses using defined review criteria. Inter-rater agreement (between nurses and the head of ICU) was assessed by kappa-values, and was excellent overall (0.9). All intercepted errors (100%) were consequently corrected by the interns. MEASUREMENTS AND RESULTS: Out of 123 transfer reports, 76 (62%) were affected by at least one error. Among 305 intercepted errors, 247 were prescription errors (26% of all prescriptions), 45 involved proposed procedures, and 13 were deficient in updating diagnoses. Most of the errors (248/305, 81%) were classified as simple, 43 (14%) as serious, or 14 (5%) as critical. Thirty-five (28%) transfer reports were considered potentially harmful (i.e., affected by at least one critical/serious error). In a multivariate model, only the number of medications included in the transfer report was associated with the occurrence of at least one critical/serious error. CONCLUSIONS: Errors in ICU transfer reports are frequent and may be potentially harmful. ICU nurses may help to effectively and accurately intercept those inaccuracies, and therefore reduce the exportation of errors from the ICU to the ward.

What limits for acute care in the elderly?

PURPOSE OF REVIEW: This review aims to address the important question of the increasing life expectancy and the aging population in the healthcare system today. We try to give some elements that will help the reflection about the ethical stakes balancing the necessity of care in the increasing number of elderly patients and the limited resources available, in the special context of acute care. RECENT FINDINGS: There is growing evidence that the chronological age itself is not a reliable marker of bad prognosis or of mortality. The new concept of frailty may better correlate with the aging process of the elderly. The frailty index is an integrative approach considering the multiple factors impacting on the aging individual. Applied in the practical arena, it might become a useful tool for clinicians. SUMMARY: Aging implies many biological modifications at molecular, cellular, organic levels as well as of the behavior. Some aspects of these processes and their consequences on health are described. The frailty concept is detailed, and its potential interest explained. We conclude that the measurement of aging phenomenon, including the frailty index, may help us to better assess the true health and the required therapeutics of elderly patients.