The hip fracture surgery in elderly patients (HIPELD) study to evaluate xenon anaesthesia for the prevention of postoperative delirium: a multicentre, randomized clinical trial.

BACKGROUND: Postoperative delirium occurs frequently in elderly hip fracture surgery patients and is associated with poorer overall outcomes. Because xenon anaesthesia has neuroprotective properties, we evaluated its effect on the incidence of delirium and other outcomes after hip fracture surgery. METHODS: This was a phase II, multicentre, randomized, double-blind, parallel-group, controlled clinical trial conducted in hospitals in six European countries (September 2010 to October 2014). Elderly (≥75yr-old) and mentally functional hip fracture patients were randomly assigned 1:1 to receive either xenon- or sevoflurane-based general anaesthesia during surgery. The primary outcome was postoperative delirium diagnosed through postoperative day 4. Secondary outcomes were delirium diagnosed anytime after surgery, postoperative sequential organ failure assessment (SOFA) scores, and adverse events (AEs). RESULTS: Of 256 enrolled patients, 124 were treated with xenon and 132 with sevoflurane. The incidence of delirium with xenon (9.7% [95% CI: 4.5 -14.9]) or with sevoflurane (13.6% [95% CI: 7.8 -19.5]) were not significantly different (P=0.33). Overall SOFA scores were significantly lower with xenon (least-squares mean difference: -0.33 [95% CI: -0.60 to -0.06]; P=0.017). For xenon and sevoflurane, the incidence of serious AEs and fatal AEs was 8.0% vs 15.9% (P=0.05) and 0% vs 3.8% (P=0.06), respectively. CONCLUSIONS: Xenon anaesthesia did not significantly reduce the incidence of postoperative delirium after hip fracture surgery. Nevertheless, exploratory observations concerning postoperative SOFA-scores, serious AEs, and deaths warrant further study of the potential benefits of xenon anaesthesia in elderly hip fracture surgery patients. CLINICAL TRIAL REGISTRATION: EudraCT 2009-017153-35; ClinicalTrials.gov NCT01199276.

[Organization of mechanical ventilation in French Intensive care units]. / Organisation de la ventilation artificielle dans les unités de réanimation en France.

OBJECTIVES: To clarify the procedures related to mechanical ventilation in the intensive care unit setting: allocation of ventilators, team education, maintenance and reference documents. STUDY DESIGN: Declarative survey. METHODS: Between September and December 2010, we assessed the assignment and types of ventilators (ICU ventilators, temporary repair ventilators, non-invasive ventilators [NIV], and transportation ventilators), medical and nurse education, maintenance of the ventilators, presence of reference documents. Results are expressed in median/range and proportions. RESULTS: Among the 62 participating ICUs, a median of 15 ventilators/ICU (range 1-50) was reported with more than one trademark in 47 (76%) units. Specific ventilators were used for NIV in 22 (35%) units, temporary repair in 49 (79%) and transportation in all the units. Nurse education courses were given by ICU physicians in 54 (87%) units or by a company in 29 (47%) units. Medical education courses were made by ICU senior physicians in 55 (89%) units or by a company in 21 (34%) units. These courses were organized occasionally in 24 (39%) ICU and bi-annually in 16 (26%) units. Maintenance procedures were made by the ICU staff in 39 (63%) units, dedicated staff (17 [27%]) or bioengineering technicians (14 [23%] ICU). Reference documents were written for maintenance procedures in 48 (77%) units, ventilator setup in 22 (35%) units and ventilator dysfunction in 20 (32%) ICU. CONCLUSIONS: This first survey shows disparate distribution of ventilators and practices among French ICU. Education and understanding of the proper use of ventilators are key issues for security improvement.

Procedure volume is one determinant of centre effect in mechanically ventilated patients.

Survival rates vary significantly between intensive care units, most notably in patients requiring mechanical ventilation (MV). The present study sought to estimate the effect of hospital MV volume on hospital mortality. We included 179,197 consecutive patients who received mechanical ventilation in 294 hospitals. Multivariate logistic regression models with random intercepts were used to estimate the effect of annual MV volume in each hospital, adjusting for differences in severity of illness and case mix. Median annual MV volume was 162 patients (interquartile range 99-282). Hospital mortality in MV patients was 31.4% overall, 40.8% in the lowest annual volume quartile and 28.2% in the highest quartile. After adjustment for severity of illness, age, diagnosis and organ failure, higher MV volume was associated with significantly lower hospital mortality among MV patients (OR 0.9985 per 10 additional patients, 95% CI 0.9978-0.9992; p = 0.0001). A significant centre effect on hospital mortality persisted after adjustment for volume effect (p < 0.0001). Our study demonstrated higher hospital MV volume to be independently associated with increased survival among MV patients. Significant differences in outcomes persisted between centres after adjustment for hospital MV volume, supporting a role for other significant determinants of the centre effect.

[ICU performance: results of a French study involving 80,000 ICU stays]. / Performance en réanimation: résultats du PHRC Sfar-SRLF.

OBJECTIVE: The Standard Mortality Ratio (SMR), comparing the observed in-hospital mortality to the predicted, may measure the intensive care units (ICU) performance. STUDY DESIGN: Multicentric retrospective national study. METHODS: A probability model using a severity score such SAPS II calculated the predicted mortality rate. A national French study has been undertaken to compare the SMR of ICUs and looked for explanation. RESULTS: One hundred six units, 34 were medical (32%), 18 surgical (17%) and 57 medical/surgical (51%) participated to the study. Forty-six ICUs (43%) were located in teaching hospitals. The SMR of the 87,099 stays was 0.84 (0.82-0.85). The SMR of ICUs varied from 0.41 to 1.55. Ten units had a SMR>0.85, which suggested a low performance. They had more stays for cardiovascular failures, as compared with others. The best units (SMR<0.82) had more stays for drug overdose. The SMR increased with the number of organ failures, from 0.47 with zero failure to 1.11 with 4 or more organ failures. The stays with cardiovascular failure, either unique or associated, had a higher SMR. The 7935 stays with a drug overdose had a SMR of 0.12 (0.10-0.14), which suggested a bad calibration of the model in theses cases. CONCLUSION: The case mix must be taken in account when comparing the ICUs performance by the mean of SMR, particularly when the units admitted a lot of drug overdoses.

[Completeness of ICU activity reports sent to French healthcare authorities]. / Exhaustivité des résumés d'unité médicale adressés aux départements d'information médicale.

INTRODUCTION: Hospital units report on their inpatient care activity by writing yearly activity reports, which are used by their Medical Information Department (MID) to develop standardized summaries for communication to healthcare authorities. The data are categorized by uniform patient groups and used to describe inpatient care activity and to guide resource allocation. The objective of this study was to evaluate the completeness of activity reports from intensive care units (ICUs) in France. METHODS: Activity reports sent in 1998 and 1999 by French ICUs participating in the study were collected using dedicated abstracting software supplied to the relevant MIDs. Completeness of data in the activity reports was evaluated, with special attention to the SAPSII score, Omega rating of ICU procedures according to the Classification of Medical Procedures, and primary and secondary diagnoses. RESULTS: The 106 ICUs that volunteered for the study reported data on 107,652-hospital stays. Mean age and SAPSII were 55 +/- 21 years and 35 +/- 21 years, respectively. Mean ICU and hospital lengths of stay were 6.2 +/- 12.4 and 16.1 +/- 21.6 days, respectively. Mean ICU and hospital mortality rates were 15% and 19%. The SAPSII and Omega procedures were reported for 81% and 80% of stays, respectively. The SAPSII and Omega procedures were calculated or coded in 94% (100/106) and 96% (102/106) of ICUs, respectively. Mean number of Omega procedures was 4.3+/-3.9. However, only 5% (5/106) of ICUs entered the SAPSII for every stay, and 21% (22/106) of ICUs failed to enter the SAPSII for over 20% of stays. Similarly, 53% (56/106) of ICUs rated no more than five Omega procedures on average per stay. The primary diagnosis was reported for all stays, and the mean number of secondary diagnoses was 3.5 +/- 3.8. In 80% (86/106) of ICUs, no more than five secondary diagnoses were coded on average per stay. CONCLUSION: The analysis of this national database shows that data communicated to the MIDs and therefore to the healthcare authorities, are incomplete regarding SAPSII, ICU procedures, treatment intensity, and diagnoses. This may lead to the underestimation of ICU activity and resource needs, particularly if the SAPSII and selected procedures identified as markers for high-intensity critical care are used in the future.

[Synercid emergency prescription program. The French experience]. / Programme de prescription d'urgence de Synercid. L'expérience française.

OBJECTIVE: An emergency-use program forof Synercid (quinupristin/dalfopristin, Q/D) has been set up following the occurrence of Gram-positive infections with no therapeutic alternatives to the available antibiotic arsenal. METHODS: The experience in France is based on a collective of 88 infections analysed in 74 patients. The most frequent clinical indications were: central catheter-related bacteremia, bone and joint infection, endocarditis and, intraabdominal infection. The most frequently causative pathogens were: S. aureus (n = 26, including 24/26 meticillin-resistant), coagulase negative staphylococci (n = 28, including 24/28 meticillin-resistant), enterococci (n = 15), and others (n = 5). Q/D was administered most frequently by central venous infusion, 3 times a day (68/74 patients); the mean and median dose per infusion was 7.4 mg/kg and the mean duration of treatment was 15.6 days. A combined antibiotic therapy was used in 70/74 patients (a glycopeptide in 41/54 staphylococcal infections). RESULTS: A Clinical success at the end of treatment was obtained in 40/74 patients (54%; CI 42.1%-65.7%) [the analysis included 25 patients (34%) with an indeterminate clinical response, categorized as failures] et and 39/73 patients (53%) at the follow-up [including 22 deaths (30%), categorized as failure at the follow-up]. The end-of-treatment success rate in patients with staphylococcal and enterococcal infections was respectively 30/54 (56%) and 8/15 (53%). The safety analysis indicated that 24/74 patients presented at least one treatment-related intercurrent event (possible or probable relationship), the most frequent ones being digestive disordersturbances, signs of venous intolerance, or diffuse or muscular pain. CONCLUSION: Q/D has demonstrated a therapeutic potential in a variety of Gram-positive infections (staphylococcal and enterococcal) in patients with no therapeutic antibiotic alternative, and the type of the intercurrent events reported was consistent with those expected ones in this population of seriously ill patients.

[Are pharmacoeconomic studies pertinant?]. / Quelle est la pertinence des études pharmaco-économiques?

Pharmacoeconomic studies are more and more considered to be part of both medical practice and evaluation. Today they are essential to drug registration. The implementation of clinical studies includes many difficulties, as costs have to be precisely defined. Depending on the type of clinical study, the pharmacoeconomic study may be aimed at lowering the costs; it may also be either a cost-efficacy, a cost-benefit or a cost-utility analysis. Difficulties are maximal in intensive care. An analysis of two examples issuing from the nomenclature of homogeneous groups of patients shows the inadequacy of this classification actually in Intensive care and for the analyses of drug cost. In regard to intensive care, difficulties in evaluating properly the cost of nosocomial infections is illustrated through concrete examples.

A new simple method to perform pressure-volume curves obtained under quasi-static conditions during mechanical ventilation.

OBJECTIVE: To describe a fast, simple method to acquire pressure-volume curves of the respiratory system and to compare this with a classic method in terms of reliability of the data and speed. DESIGN: Acquisition of pressure-volume curves by low flow inflation technique (P-Vlf) versus the occlusion technique (P-Vst) using the standard equipment of a Cesar ventilator. SETTING: General ICU - Aix en Provence Hospital. PATIENTS: Ten sedated, curarized patients undergoing mechanical ventilation. INTERVENTIONS: P-Vlf curves were acquired by setting the ventilator parameters at f = 5 c./min, duty time Ti/Ttot = 80 %, VT = 1100 ml, pause time = 0. The pressure and volume data were collected directly on the ventilator screen. P-Vst curves were acquired using an airway occlusion technique. The pressures obtained for the same inflation volumes and times necessary for performance of the two techniques were compared. RESULTS: The time needed to acquire a P-Vlf curve was 3 min versus 38 min for P-Vst curve. Concordance analysis between the two methods showed a 95 % confidence interval of (-0.5 cm H2O, + 1.8 cm H2O) for pressure. CONCLUSIONS: P-Vlf curves are close to P-Vst curves, are much less time-consuming, easy to acquire with Cesar ventilator equipment, and may be used in clinical routine to assess the elastic properties of the respiratory system.

[Enterobacter aerogenes pneumopathy treated by a cefepime-sulbactam-gentamicin combination]. / Pneumopathie à Enterobacter aerogenes traitée par l'association céfépime-sulbactam-gentamicine.

BACKGROUND: Enterobacter aerogenes is the fifth most frequent pathogen causing nosocomial infections. Several strains have developed multiple resistance by over-production of a natural cephalosporinase and by the presence of wide-spectrum betalactamases. CASE REPORT: A patient with chronic respiratory failure developed Enterobacter aerogenes pneumonia while under mechanical ventilation. The infection was successfully treated with a cefepime, sulbactam, gentamycin combination. DISCUSSION: Choosing the optimum antibiotic therapy is a difficult task in many nosocomial infections. In certain cases, combining a betalactamase inhibitor with the appropriate antibiotic can improve bactericidal activity and provide successful cure.

[Embolism in the brain stem as a consequence of cervical spine dislocation complicated by thrombosis of the vertebral artery]. / Embolie du tronc cérébral consécutive à une luxation du rachis cervical compliquée d'une thrombose de l'artère vertébrale.

A case is reported of a 52-year-old man who sustained a cervical spine dislocation in a road traffic accident, which was complicated by an initially asymptomatic vertebral arterial thrombosis. Embolism from this thrombosis into the vertebrobasilar territory during the surgical manoeuvers to reduce the dislocation was the cause of a fatal postanaesthetic coma. Such unexpected but life-threatening neurological consequences may be found with trauma of the cervical spine of various intensities. The diagnosis may be made by angiography. However, the usefulness of atraumatic investigations, such as the cervical doppler, and the indications for angiography need to be assessed.