ICU physicians' and nurses' perceptions of terminal extubation and terminal weaning: a self-questionnaire study.

PURPOSE: Terminal extubation (TE) and terminal weaning (TW) are the methods available for withdrawing mechanical ventilation. Perceptions of TE and TW by intensive care unit (ICU) staff may influence bedside practices and the feasibility of studies comparing these methods. METHODS: From January to June 2013, 5 nurses and 5 physicians in each of 46 (out of 70, 65.7 %) French ICUs completed an anonymous self-questionnaire. Clusters of staff members defined by perceptions of TE and TW were identified by exploratory analysis. Denominators for computing percentages were total numbers of responses to each item; cases with missing data were excluded for the relevant item. RESULTS: Of the 451 (98 %) participants (225 nurses and 226 physicians), 37 (8.4 %) had never or almost never performed TW and 138 (31.3 %) had never or almost never performed TE. A moral difference between TW and TE was perceived by 205 (45.8 %) participants. The exploratory analysis identified three clusters defined by personal beliefs about TW and TE: 21.2 % of participants preferred TW, 18.1 % preferred TE, and 60.7 % had no preference. A preference for TW seemed chiefly related to unfavorable perceptions or insufficient knowledge of TE. Staff members who preferred TE and those with no preference perceived TE as providing a more natural dying process with less ambiguity. CONCLUSION: Nearly two-fifths of ICU nurses and physicians in participating ICUs preferred TW or TE. This finding suggests both a need for shared decision-making and training before performing TE or TW and a high risk of poor compliance with randomly allocated TW or TE.

Symptoms of depression in ICU physicians.

BACKGROUND: Work and family are the two domains from which most adults develop satisfaction in life. They also are responsible for stressful experiences. There is a perception in the community that work is increasingly the source of much of our stress and distress. Depressive symptoms may be related to repeated stressful experiences. Intensive care unit (ICU) physicians are exposed to major stressors. However, the existence of depressive symptoms in these doctors has been poorly studied. This study was designed to evaluate the prevalence and associated risk factors of depressive symptoms in junior and senior ICU physicians. METHOD: A one-day national survey was conducted in adult intensive care units (ICU) in French public hospitals. Symptoms of depression were assessed using the Centers of Epidemiologic Studies Depression Scale (CES-D). RESULTS: A total of 189 ICUs participated, and 901 surveys were returned (75.8% response rate). Symptoms of depression were found in 23.8% of the respondents using the CES-D scale. Fifty-eight percent of these intensivists presenting symptoms of depression wished to leave their job compared with only 33% of those who did not exhibit signs of depression as assessed by the CES-D scale (p < 0.0001). Multiple logistic regression showed that organizational factors were associated with the presence of depressive symptoms. Workload (long interval since the last nonworking weekend, absence of relief of service until the next working day after a night shift) and impaired relationships with other intensivists were independently associated with the presence of depressive symptoms. A high level of burnout also was related to the presence of depressive symptoms. In contrast, no demographic factors regarding ICU physicians and no factor related to the severity of illness of patients were retained by the model. The quality of relationships with other physicians (from other departments) was associated with the absence of depressive symptoms (protective effect). CONCLUSIONS: Approximately one of four intensivists presented symptoms of depression. The next step could be to test whether organization modification is associated with less depressive symptoms and less desire to leave the job.

[Burn out syndrome among critical care workers]. / Epuisement professionnel en réanimation.

Burnout syndrome (BOS) is a psychological state resulting from prolonged exposure to job stressors. Because intensive care units (ICUs) are characterized by a high level of work-related stress, we reviewed the available literature on BOS among ICU-healthcare workers. Recent studies suggest that severe BOS (measured with the Maslach Burnout Inventory) is present in about half of all critical care physicians and one-third of critical care nurses. Interestingly, the determinants of BOS difer between the two groups of caregivers. Intensivists with severe BOS tend to be those with a large number of working hours (number of night shifts, and time since last vacation), whereas severe BOS among ICU nurses is mainly related to ICU organization and end-of-life care policy. ICU conflicts were independent predictors of severe BOS in both groups. Recent studies also identify potential preventive measures, such as ICU working groups, better communication during end-of-life care, and prevention and management of ICU conflicts.

Microbiogical data, but not procalcitonin improve the accuracy of the clinical pulmonary infection score.

OBJECTIVE: Early and adequate treatment of ventilator-associated pneumonia (VAP) is mandatory to improve the outcome. The aim of this study was to evaluate, in medical ICU patients, the respective and combined impact of the Clinical Pulmonary Infection Score (CPIS), broncho-alveolar lavage (BAL) gram staining, endotracheal aspirate and a biomarker (procalcitonin) for the early diagnosis of VAP. DESIGN: Prospective, observational study SETTING: A medical intensive care unit in a teaching hospital. PATIENTS: Over an 8-month period, we prospectively included 57 patients suspected of having 86 episodes of VAP. INTERVENTION: The day of suspicion, a BAL as well as alveolar and serum procalcitonin determinations and evaluation of CPIS were performed. MEASUREMENTS AND MAIN RESULTS: Of 86 BAL performed, 48 were considered positive (cutoff of 10(4) cfu ml(-1)). We found no differences in alveolar or serum procalcitonin between VAP and non-VAP patients. Including procalcitonin in the CPIS score did not increase its accuracy (55%) for the diagnosis of VAP. The best tests to predict VAP were modified CPIS (threshold at 6) combined with microbiological data. Indeed, both routinely twice weekly performed endotracheal aspiration at a threshold of 10(5) cfu ml(-1) and BAL gram staining improved pre-test diagnostic accuracy of VAP (77 and 66%, respectively). CONCLUSION: This study showed that alveolar procalcitonin performed by BAL does not help the clinician to identify VAP. It confirmed that serum procalcitonin is not an accurate marker of VAP. In contrast, microbiological resources available at the time of VAP suspicion (BAL gram staining, last available endotracheal aspirate) combined or not with CPIS are helpful in distinguishing VAP diagnosed by BAL from patients with a negative BAL.

Bacterial ventilator-associated pneumonia: bronchoalveolar lavage results are not influenced by dilution.

OBJECTIVE: This study was designed to determine if bronchoalveolar lavage (BAL) quantitative culture results can be used confidently for the diagnosis of bacterial ventilator-associated pneumonia (VAP) without taking dilution into account. DESIGN: Prospective observational cohort study. SETTING: A 12-bed medical ICU in a teaching hospital. PATIENTS: A total of 241 BAL (three 50-mL aliquots) were performed in 127 patients presenting a suspicion of VAP. INTERVENTIONS: All consecutive adults who were ventilated more than 48 h were included if VAP was clinically suspected. A dilution factor, k, was developed according to the formula: dilution factor k = concentration of urea in plasma/concentration of urea in lavage fluid recovered. Using this dilution factor, the quantitative bacterial counts were interpreted accordingly with a corrected positive threshold at 10(5) colony forming unit (CFU) mL(-1). MEASUREMENTS AND RESULTS: Eighty-nine BAL with at least one micro-organism > or = 10(4) CFU mL(-1) were identified (37%). In 176 BAL (73%), k ranged from 10 to 100. Median k was 24.4 (9.7-40.2) in VAP group and 24.6 (13.1-57.8) in patients without pneumonia (NS). Among the 25 BAL with micro-organism counts of 10(4) CFU mL(-1), 3 had a dilution factor lower than 10, resulting in corrected counts below the threshold of 10(5) CFU mL(-1). Two out of 15 patients with micro-organism counts of 10(3) CFU mL(-1) had corrected micro-organism counts of 10(5) CFU mL(-1). Finally, only five BAL (2.1%) were misclassified when the dilution correction factor was applied. CONCLUSIONS: Using urea as dilution factor, we showed that BAL dilution variations did not alter the interpretation of BAL quantitative bacterial culture when administrating three aliquots of 50 mL of saline.

FIO2 and acute respiratory distress syndrome definition during lung protective ventilation.

OBJECTIVE: PaO2/FIO2 ratio (P/F) is the marker of hypoxemia used in the American-European Consensus Conference on lung injury. A high FIO2 level has been reported to variably alter PaO2/FIO2. We investigated the effect of high FIO2 levels on the course of P/F in lung protective mechanically ventilated patients with acute respiratory distress syndrome. DESIGN: Prospective, controlled, interventional study. SETTING: University teaching French medical intensive care unit. PATIENTS: Twenty-four patients with acute respiratory distress syndrome having P/F between 100 and 200 mm Hg at FIO2 0.5 received low-volume controlled ventilation (V(T) = 6 mL/kg predicted body weight) with a positive end-expiratory pressure at 2 cm H2O above the lower inflection point if present, or 10 cm H2O. INTERVENTION: The following FIO2 levels were applied randomly for 20 mins: 0.5, 0.6, 0.7, 0.8, 0.9, and 1. MEASUREMENTS AND RESULTS: Increasing FIO2 above 0.7 was associated with a significant increase in P/F (p < 0.001). The mean P/F change between FIO2 0.5 and 1 (Delta P/F) was 47% +/- 35%. Sixteen patients (67%) had a P/F >200 at FIO2 1 whereas P/F was <200 at FIO2 0.5. Venous admixture (Q(VA)/Q(T)) decreased linearly for each FIO2 step (p < 0.001). The Q(VA)/Q(T) change between FIO2 0.5 and 1 was strongly correlated with Delta P/F (r = 0.84). Delta P/F was higher in patients with true shunt <30% (64% [54-93]) than in those with shunt >30% (20% [10-36]; p = 0.003). CONCLUSION: The P/F ratio increased significantly with a FIO2 >0.7. P/F variation, induced by a switch from FIO2 0.5 to 1, was responsible for two thirds of patients changing from the acute respiratory distress syndrome to the acute lung injury stage of the American-European Consensus Conference definition. FIO2 should be carefully defined for the screening of lung-injured patients.

Burnout syndrome among critical care healthcare workers.

PURPOSE OF REVIEW: Burnout syndrome is a psychological state resulting from prolonged exposure to job stressors. Because ICUs are characterized by a high level of work-related stress, a factor known to increase the risk of burnout syndrome, we sought to review the available literature on burnout syndrome in ICU healthcare workers. RECENT FINDINGS: Based on most recent studies, severe burnout syndrome (as measured using the Maslach Burnout Inventory) is present in about 50% of critical care physicians and in one third of critical care nurses. Strikingly, determinants of burnout syndrome are different in the two groups of caregivers. Namely, intensivists who have severe burnout syndrome are those with a high number of working hours (number of night shifts and time from last vacation) but determinants of severe burnout syndrome in ICU-nurses are related to ICU organization and end-of-life-related characteristics. ICU conflicts, however, were independent predictors of severe burnout syndrome in both groups. SUMMARY: Recent studies reported high levels of severe burnout syndrome in ICU healthcare workers and identified potential targets for preventive strategies such as ICU working groups, communication strategies during end-of-life care and prevention and management of ICU conflicts.

High level of burnout in intensivists: prevalence and associated factors.

RATIONALE: Professional burnout is a psychological syndrome arising in response to chronic interpersonal stressors on the job. There is the perception that intensivists are particularly exposed to stress because lives are literally in their hands. OBJECTIVE: To evaluate the prevalence and associated factors (patients or organization) of burnout among physicians working in intensive care units (ICUs) (including interns, residents, fellows, and attending physicians). METHODS: A 1-day national survey was conducted in adult ICUs in French public hospitals. MEASUREMENTS: The level of burnout was evaluated on the basis of the Maslach Burnout Inventory (MBI). MAIN RESULTS: A total of 189 ICUs participated and 978 surveys were returned (82.3% response rate). A high level of burnout was identified in 46.5% of the respondents. Ordinal logistic regression showed that female sex (odds ratio, 1.58; 95% confidence interval, 1.09 to 2.30) was independently associated with a higher MBI score. Whereas no factor related to the severity of illness of patients was retained by the model, organizational factors were strongly associated with a higher MBI score. Workload (the number of night shifts per month, a long period of time from the last nonworking week, night shift the day before the survey) and impaired relationships (such as conflict with another colleague intensivist, and/or with a nurse) were the variables independently associated with a higher MBI score. In contrast, the quality of the relationships with chief nurses and nurses was associated with a lower MBI score. CONCLUSIONS: Approximately one-half of the intensivists presented a high level of burnout. Organizational factors, but not factors related to the patients, appeared to be associated with burnout.