[Intensive care and Covid]. / Réanimation et Covid.

The health crisis linked to COVID-19 has put the whole hospital under stress. Intensive care units (ICU) have been on the front line to manage the most serious cases. The number of new admissions together with cumulative number of occupied intensive care beds have been and still are a key element in measuring the intensity of the crisis. Intensive care is a specialty largely unknown to the general public which is problematic when dealing with such difficult questions as should we give priority to health or to the economy; is there a loss of chance for non-COVID patients due to deprogramming? The increase in the demand for critical care has necessitated an extension of hospitalization capacities by transforming intermediate care beds into ICU beds, by creating neo-ICU, or in some regions by carrying out critical care, usually performed in ICU, in regular wards. Among the several limiting factors, human resources with qualified personnel was a key element together with the relative shortage of drugs. The mismatch between demand and supply has led to the establishment of rules for prioritizing access to ICU. This review deals with all these issues and can contribute to a reflection on the adaptation of the critical care department to cope with major sanitary crisis.

Attitudes of physicians towards the care of critically ill elderly patients - a European survey.

BACKGROUND: Very elderly patients are one of the fastest growing population in ICUs worldwide. There are lots of controversies regarding admission, discharge of critically ill elderly patients, and also on treatment intensity during the ICU stay. As a consequence, practices vary considerably from one ICU to another. In that perspective, we collected opinions of experienced ICU physicians across Europe on statements focusing on patients older than 80. METHODS: We sent an online questionnaire to the coordinator ICU physician of all participating ICUs of an recent European, observational study of Very old critically Ill Patients (VIP1 study). This questionnaire contained 12 statements about admission, triage, treatment and discharge of patients older than 80. RESULTS: We received answers from 162 ICUs (52% of VIP1-study) spanning 20 different European countries. There were major disagreements between ICUs. Responders disagree that: there is clear evidence that ICU admission is beneficial (37%); seeking relatives' opinion is mandatory (17%); written triage guidelines must be available either at the hospital or ICU level (20%); level of care should be reduced (25%); a consultation of a geriatrician should be sought (34%) and a geriatrician should be part of the post-ICU trail (11%). The percentage of disagreement varies between statements and European regions. CONCLUSION: There are major differences in the attitude of European ICU physicians on the admission, triage and treatment policies of patients older than 80 emphasizing the lack of consensus and poor level of evidence for most of the statements and outlining the need for future interventional studies.

Frailty assessment in critically ill older adults: a narrative review.

Frailty, a condition that was first defined 20 years ago, is now assessed via multiple different tools. The Frailty Phenotype was initially used to identify a population of "pre-frail" and "frail" older adults, so as to prevent falls, loss of mobility, and hospitalizations. A different definition of frailty, via the Clinical Frailty Scale, is now actively used in critical care situations to evaluate over 65 year-old patients, whether it be for Intensive Care Unit (ICU) admissions, limitation of life-sustaining treatments or prognostication. Confusion remains when mentioning "frailty" in older adults, as to which tools are used, and what the impact or the bias of using these tools might be. In addition, it is essential to clarify which tools are appropriate in medical emergencies. In this review, we clarify various concepts and differences between frailty, functional autonomy and comorbidities; then focus on the current use of frailty scales in critically ill older adults. Finally, we discuss the benefits and risks of using standardized scales to describe patients, and suggest ways to maintain a complex, three-dimensional, patient evaluation, despite time constraints. Frailty in the ICU is common, involving around 40% of patients over 75. The most commonly used scale is the Clinical Frailty Scale (CFS), a rapid substitute for Comprehensive Geriatric Assessment (CGA). Significant associations exist between the CFS-scale and both short and long-term mortality, as well as long-term outcomes, such as loss of functional ability and being discharged home. The CFS became a mainstream tool newly used for triage during the Covid-19 pandemic, in response to the pressure on healthcare systems. It was found to be significantly associated with in-hospital mortality. The improper use of scales may lead to hastened decision-making, especially when there are strains on healthcare resources or time-constraints. Being aware of theses biases is essential to facilitate older adults' access to equitable decision-making regarding critical care. The aim is to help counteract assessments which may be abridged by time and organisational constraints.

Outcome of spontaneous and iatrogenic pneumothoraces managed with small-bore chest tubes.

BACKGROUND: Little is known about the efficacy of management of iatrogenic pneumothoraces with small-bore chest tubes. The aim of this study was to assess the outcome of iatrogenic pneumothoraces requiring drainage managed with a small-bore chest tube and to compare the results to spontaneous pneumothoraces treated in the same unit with the same device. The primary outcome was requirement of video-assisted thoracoscopic surgery for drainage failure; secondary outcomes were length of drainage and number of inserted chest tubes. METHODS: Patients with pneumothorax admitted between 1997 and 2007 were retrospectively identified. Traumatic pneumothoraces and those occurring under mechanical ventilation were excluded. All pneumothoraces were drained using the same small-bore chest tube (8 French) according to our local protocol. RESULTS: Five hundred sixty-one pneumothoraces were analysed, 431 (76.8%) were spontaneous pneumothoraces and 130 (23.2%) were iatrogenic. Iatrogenic pneumothoraces were associated with less requirement of video-assisted thoracoscopic surgery for drainage failure [adjusted odds ratio= 0.24 (0.04, 0.86)]. Length of drainage of iatrogenic pneumothoraces was longer than for primary spontaneous pneumothoraces (3.8 ± 3.1 vs. 2.7 ± 1.8 days, P < 0.001) and shorter than for secondary spontaneous pneumothoraces (4.6 ± 2.3 days, P = 0.004). Number of inserted chest tubes per patient was not significantly different according to pneumothoraces' aetiology. CONCLUSION: Small-bore chest tubes are feasible for treatment of iatrogenic pneumothoraces and have a better rate of success and slightly longer drainage duration than when used for spontaneous pneumothoraces.

Adult intensive-care patients with 2009 pandemic influenza A(H1N1) infection.

In France, the surveillance of hospitalized cases of pandemic influenza was implemented in July 2009 and restricted to intensive-care unit (ICU) patients in November. We described the characteristics of the 1065 adult patients admitted to ICUs and analysed risk factors for severe outcome (mechanical ventilation or death). Eighty-seven percent of cases were aged 15-64 years. The case-fatality ratio was 20%. The risk for severe outcome increased with age and obesity while this association was negative for chronic respiratory disease. Late antiviral therapy was associated with a severe outcome in ICU patients with risk factors (adjusted OR 2·0, 95% CI 1·4-3·0). This study confirms the considerable contribution of young adults to A(H1N1) 2009 mortality. It shows the role of obesity as an independent risk factor for severe disease, and of early antiviral therapy as a protective factor, at least in patients with risk factors.

A systematic review of models for forecasting the number of emergency department visits.

The ability to predict patient visits to emergency departments (ED) is crucial for designing strategies aimed at avoiding overcrowding. A good working knowledge of the mathematical models used to predict patient volume and of their results is therefore essential. Articles retrieved by a Medline search were reviewed for studies designed to predict patient attendance at ED or walk-in clinics. Nine studies were identified. Most of the models used to predict patient volume were either linear regression models including calendar variables or time series models. These models explained 31-75% of patient-volume variability. Although the day of the week had the strongest effect, this variable explained only part of the variability. Other causes of this variability are to be defined. However, the performance of the models was good, with errors ranging from 4.2% to 14.4%. Adding meteorological data failed to improve model performance. The mathematical methods developed to predict ED visits have a low rate of error, but the prediction of daily patient visits should be used carefully and therefore does not allow day-to-day adjustments of staff. ED directors or managers should be aware of the model limitations. These models should certainly be used on a larger scale to assess future needs.

Case volume and mortality in haematological patients with acute respiratory failure.

High case volume is associated with improved survival in medical and surgical conditions. The present study sought to determine whether intensive care unit (ICU) case volume was associated with survival of critically ill patients with haematological malignancies and acute respiratory failure (ARF). A regional database containing data from 1,753 haematological patients with ARF admitted to 28 medical ICUs from 1997 to 2004 was used. Multivariate analysis using mixed models was performed to adjust for severity of illness and other confounding factors, including a propensity score that incorporates differences between ICUs with different case volumes. The three case volume tertiles were: low volume (<12 admissions per year), intermediate volume (12-30 admissions per year), and high volume (>30 admissions per year). In univariate analyses, ICU case volume was not associated with ICU mortality. After adjusting for prognostic factors for ICU mortality and the propensity score, patients in high-volume ICUs had lower mortality than other patients. A case volume increase of one admission per year led to a significant mortality reduction with an odds ratio of 0.98 (95% confidence limits 0.97-0.99). Mortality was independently associated with severity of organ dysfunction. In intensive care units admitting larger numbers of critically ill haematological patients with acute respiratory failure, mortality was lower than in other intensive care units. The mechanisms of the relationship between volume and outcome among haematological patients with acute respiratory deserve additional studies.

Haemodilution induced by hydroxyethyl starches 130/0.4 is similar in septic and non-septic patients.

BACKGROUND: Fluid therapy induces haemodilution related to plasma volume expansion. The aim of our study was to compare haemodilution after a single hydroxyethyl starches (HES) 130/0.4 infusion in two groups of patients, one with and one without sepsis. We hypothesized that a single HES challenge would induce similar sustained haemodilution in both groups. METHODS: In this prospective preliminary study, patients predicted to require a single further volume-expander infusion were included immediately before receiving 500 ml of 6% HES 130/0.4 over a 15-min period. No additional fluid was administered over the next 8 h. Haematocrit, and serum albumin and protein were determined immediately before HES infusion then after 1, 2, 3, 4, and 8 h. RESULTS: Twelve patients were included in each group. In both groups, all three haemodilution markers had significantly lower values after 1 h than at baseline. None of the values after 1 and 3 h differed significantly between the two groups. Neither did any of the other study variables show significant differences between the groups with and without sepsis. CONCLUSION: We found that a starch-based compound was as effective in inducing haemodilution in patients with sepsis as in controls without sepsis, suggesting that HES may remain within the intravascular space even in patients with sepsis. Haemodilution parameters such as haematocrit, serum albumin and serum protein are useful for assessing the duration of plasma volume expansion induced by fluid therapy in critically ill patients.

[Organization of intensive care in situation of avian flu pandemic]. / Organisation de la réanimation en situation de pandémie de grippe aviaire.

The influenza pandemic will create a major increase in demand for hospital admissions, particularly for critical care services. The recommendations detailed herein have been elaborated by experts from medical societies potentially involved in this situation and focus on general hospital organization. Intensive care units will initially face high demand for admission; the Healthcare Authorities must therefore study how ICU capacity can be expanded. Pediatric intensive care units will be particularly affected by this situation of relative bed shortage, since young children, particularly infants, are expected to be affected by severe clinical forms of avian flu. Therefore, the weight threshold for admission to the adult ICU was lowered to 20 kg. Neonatal intensive care units (NICU) should remain, if possible, low viral density areas. Mixed (neonatal and pediatric) intensive care units could be dedicated to infants and children only. NICU admission of extreme premature babies should be limited in this difficult situation. Pediatric intensive care units (PICU) admission capacity could be doubled by using intermediate care and postoperative care units. The staff could be increased by doctors and nurses involved in canceled programmed activities. Healthcare workers transferred to PICU should be given special training.

[The organisation of intensive care in a situation of pandemic avian influenza]. / Organisation de la réanimation en situation de pandémie de grippe aviaire.

The development of an epidemic of avian influenza will have a major impact on the organisation and structure of the facilities for treatment. This paper, the product of collaboration between the six learned societies concerned, analyses the impact of a possible pandemic on the various aspects of management of patients requiring intensive care. It describes the organisation of hospital pathways for flu and non-flu patients with, in particular, the necessary actions in terms of separation of care facilities, the triage of patients and the cancellation of non-urgent activities. It analyses the preconditions necessary for the efficient functioning of intensive care and the predictable limiting factors. It underlines the importance of training of medical and paramedical personnel. Finally, it tackles the specific problems of paediatric intensive care: organisation, capacity for admissions and training.

The status of intensive care medicine research and a future agenda for very old patients in the ICU.

The "very old intensive care patients" (abbreviated to VOPs; greater than 80 years old) are probably the fastest expanding subgroup of all intensive care unit (ICU) patients. Up until recently most ICU physicians have been reluctant to admit these VOPs. The general consensus was that there was little survival to gain and the incremental life expectancy of ICU admission was considered too small. Several publications have questioned this belief, but others have confirmed the poor long-term mortality rates in VOPs. More appropriate triage (resource limitation enforced decisions), admission decisions based on shared decision-making and improved prediction models are also needed for this particular patient group. Here, an expert panel proposes a research agenda for VOPs for the coming years.

[The evaluation of health care outcomes and hospital performance indicators]. / De l'évaluation de la qualité des soins à la performance des soins.

INTRODUCTION: The assessment of the performance of health care establishments has undergone a considerable development over the past 15 years in the United States and to a lesser extent in other developed countries. BACKGROUND: The aim of measurement of performance indicators is to improve the quality of care (outcomes), patient information and the contractual arrangements with purchasers. However, this approach poses numerous methodological problems in the choice of performance indicators as well as the collection and interpretation of data. Specific structural patterns such as social and geographic environment, research and educational assignments, are often inadequately considered. In terms of public health the impact of the publication of these measurements has not been well studied. Based on the data in the literature this revue defines the measures of hospital performance and describes the main studies, their impacts and limitations. VIEWPOINT: It seems likely that the French public authorities will, in the short term, ask health care establishments to undertake this approach. CONCLUSIONS: Complimentary studies are needed to clarify the links between performance indicators and health care outcomes.

[Diagnostic ultrasound in pneumothorax]. / Diagnostic échographique du pneumothorax.

For a long time the lung has been regarded as inaccessible to ultrasound. However, recent clinical studies have shown that this organ can be examined by this technique, which appears, in some situations, to be superior to thoracic radiography. The examination does not require special equipment and is possible using a combination of simple qualitative signs: lung sliding, the presence of B lines and the demonstration of the lung point. The lung sliding corresponds to the artefact produced by the movement of the two pleural layers, one against the other. The B lines indicate the presence of an interstitial syndrome. The presence of lung sliding and/or B lines has a negative predictive value of 100% and formally excludes a pneumothorax in the area where the probe has been applied. The presence of the lung point is pathognomonic of pneumothorax but the sensitivity is no more than 60%. Ultrasound is therefore a rapid and simple means of excluding a pneumothorax (lung sliding or B lines) and of confirming a pneumothorax when the lung point is visible. The question that remains is whether ultrasound can totally replace radiography in the management of this disorder.

Plasma antiproteinase screen and neutrophil-mediated platelet activation. A major role played by alpha 1 antitrypsin.

Upon activation, human polymorphonuclear neutrophils (PMN) release two serine proteinases, cathepsin G (Cat.G) and elastase (HLE), which in turn synergize to activate nearby platelets. We looked for the inhibitory effect of plasma and the involvement of alpha 1 antichymotrypsin (alpha 1 ACT) and alpha 1 antitrypsin (alpha 1 AT), on this cell-to-cell cooperation. It was observed that inhibition by plasma of PMN-mediated platelet activation was rather correlated with an effect on HLE (r = 0.95) than on Cat.G (r = 0.65) enzymatic activity. Purified alpha 1 AT suppressed in a concentration-dependent manner HLE activity present in the supernatant of activated PMN. When HLE was fully blocked, alpha 1 AT started to inhibit Cat.G activity. By contrast and as expected, purified alpha 1 ACT inhibited only Cat.G activity. Using specific blocking polyclonal antibodies against alpha 1 AT and alpha 1 ACT, it was demonstrated that the inhibitory effect of plasma vs. HLE was entirely mediated by alpha 1 AT. By contrast, blockade of Cat.G activity was only partly due to plasma alpha 1 ACT and around 50% was attributable to alpha 1 AT. When plasma from patients with an acute inflammatory state was used in place of plasma from normal subjects, the inhibitory effect was more pronounced, while plasma depleted in alpha 1 AT and alpha 1 ACT was less effective. These data indicate a predominant role of alpha 1 AT in the inhibition by plasma of the PMN-mediated platelet activation.

Nordihydroguaiaretic acid inhibits urokinase synthesis by phorbol myristate acetate-stimulated LLC-PK1 cells.

Protein kinase C (PKC) activation is regulated by Ca2+, phospholipids, diacylglycerol (DAG) and fatty acids. Phorbol myristate acetate (PMA) which mimics the effect of DAG on PKC induces transcriptional activation of the urokinase-type plasminogen activator (u-PA) gene in LLC-PK1 cells. We examined in the present work the relationships between PKC activity, fatty acids, and u-PA synthesis in this cell line. We showed that H7, an inhibitor of PKC, inhibited the PMA-induced u-PA synthesis by LLC-PK1 cells. PMA-induced u-PA synthesis was enhanced by eicosatetraynoic acid (ETYA), a competitive inhibitor of both the lipoxygenase and cyclooxygenase pathways and inhibited by nordihydroguaiaretic acid (NDGA), an inhibitor of the lipoxygenase pathway. Three other unrelated lipoxygenase inhibitors (phenidone 100 microM, BW755 50 microM and diethylcarbamazine 50 microM) had no effect on u-PA biosynthesis. Two polyunsaturated fatty acids other than ETYA, arachidonic acid and linoleic acid, also potentiated the PMA effect and a lipoxygenase derivative, 12 hydroxyeicosatetraenoic acid (12 HETE), did not modify the basal and PMA-stimulated u-PA syntheses. PKC activity purified from cytosol of LLC-PK1 cells was stimulated by addition of 16 nM PMA in vitro and this effect was blunted by simultaneous addition of 5 microM NDGA. By Northern blot analysis using a pig u-PA cDNA probe we found that PMA increased the steady state level of u-PA mRNA after 2 h of incubation and that NDGA inhibited this effect. These data suggest that NDGA inhibits PMA-stimulated PKC activity in intact cells leading to a decrease of u-PA mRNA level and u-PA biosynthesis in PMA-stimulated LLC-PK1 cells. Polyunsaturated fatty acids have opposite effects.

Severe Extra-Cerebral Anticoagulant-Related Bleeding in Intensive Care Unit: A Retrospective Study From 2000 to 2013.

Bleeding is the most frequent complication of anticoagulant therapy, responsible for a number of hospitalizations or deaths. However, studies describing the management and prognosis factors of extra-cerebral anticoagulant-related bleedings in intensive care unit (ICU) are lacking.Retrospective observational study in an 18-bed ICU in a tertiary teaching hospital. From January 2000 to December 2013, all consecutive patients, older than 18 years, admitted for severe anticoagulant-related bleeding (SAB) except intracerebral site were included.A total of 100 patients were included, the mean age was 77 ± 11 years and 62% were women. SAB incidence in ICU doubled over 10 years (P = 0.03). In ICU, the average length of stay was 5 ± 6 days and mortality was 30%. Nonsurviving patients had a higher SAPS II (78 ± 24 vs 53 ± 24, P < 0.0001), a higher SOFA (9.0 ± 3.6 vs 4.7 ± 3.4, P < 0.0001) and received more frequently support therapy such as mechanical ventilation (87% vs 16%, P < 0.0001) and vasopressors (90% vs 27%, P < 0.0001). The volume of blood-derived products transfused was more important in nonsurvivors mainly during the first 24 hours of resuscitation. Rapid anticoagulant reversal therapy was associated with better prognosis (ICU survivors 66% vs 39%, Fisher test P = 0.04). Anterior abdominal wall was identified as a frequent site of bleeding (22%) due to epigastric artery injury during subcutaneous injection of heparin and was associated with a large mortality (55%).Extra-cerebral SAB is a life-threatening complication that requires rapid resuscitation and anticoagulant reversal therapy. Injection of heparin should be done carefully in the subcutaneous tissue thereby avoiding artery injury.