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1.
Clin Infect Dis ; 2020 Mar 09.
Artigo em Inglês | MEDLINE | ID: mdl-32150603

RESUMO

BACKGROUND: The optimal dosing of antibiotics in critically ill patients receiving renal replacement therapy (RRT) remains unclear. In this study, we describe the variability in RRT techniques and antibiotic dosing in critically ill patients receiving RRT and to relate observed trough antibiotic concentrations to optimal targets. METHODS: We performed a prospective, observational, multi-national, pharmacokinetic study in 29 intensive care units from 14 countries. We collected demographic, clinical and RRT data. We measured trough antibiotic concentrations of meropenem, piperacillin-tazobactam and vancomycin and related them to high and low target trough concentrations. RESULTS: We studied 381 patients and obtained 508 trough antibiotic concentrations. There was wide variability (4-8 fold) in antibiotic dosing regimens; RRT prescription, and estimated endogenous renal function. The overall median estimated total renal clearance (eTRCL) was 50 mL/min (interquartile range [IQR] 35-65) and higher eTRCL was associated with lower trough concentrations for all antibiotics (p<0.05). The median (IQR) trough concentration for meropenem was 12.1 mg/L (7.9-18.8), piperacillin 78.6 mg/L (49.5-127.3), tazobactam 9.5 mg/L (6.3-14.2) and vancomycin 14.3 mg/L (11.6-21.8). Trough concentrations failed to meet optimal higher limits in 26%, 36%, 72%, and optimal lower limits in 4%, 4%, and 55% of patients for meropenem, piperacillin and vancomycin respectively. CONCLUSIONS: In critically ill patients treated with RRT, antibiotic dosing regimens, RRT prescription and eTRCL varied markedly and resulted in highly variable antibiotic concentrations that failed to meet therapeutic targets in many patients.

2.
Crit Care ; 23(1): 393, 2019 Dec 05.
Artigo em Inglês | MEDLINE | ID: mdl-31805988

RESUMO

BACKGROUND: Recent international guidelines for acute pancreatitis (AP) recommend limiting anti-infective therapy (AIT) to cases of suspected necrotizing AP or nosocomial extrapancreatic infection. Limited data are available concerning empirical and documented AIT prescribing practices in patients admitted to the intensive care unit (ICU) for the management of AP. METHODS: Using a multicentre, retrospective (2009-2014), observational database of ICU patients admitted for AP, our primary objective was to assess the incidence of AIT prescribing practices during the first 30 days following admission. Secondary objectives were to assess the independent impact of centre characteristics on the incidence of AIT and to identify factors associated with crude hospital mortality in a logistic regression model. RESULTS: In this cohort of 860 patients, 359 (42%) received AIT on admission. Before day 30, 340/359 (95%) AIT patients and 226/501 (45%) AIT-free patients on admission received additional AIT, mainly for intra-abdominal and lung infections. A large heterogeneity was observed between centres in terms of the incidence of infections, therapeutic management including AIT and prognosis. Administration of AIT on admission or until day 30 was not associated with an increased mortality rate. Patients receiving AIT on admission had increased rates of complications (septic shock, intra-abdominal and pulmonary infections), therapeutic (surgical, percutaneous, endoscopic) interventions and increased length of ICU stay compared to AIT-free patients. Patients receiving delayed AIT after admission and until day 30 had increased rates of complications (respiratory distress syndrome, intra-abdominal and pulmonary infections), therapeutic interventions and increased length of ICU stay compared to those receiving AIT on admission. Risk factors for hospital mortality assessed on admission were age (adjusted odds ratio [95% confidence interval] 1.03 [1.02-1.05]; p < 0.0001), Balthazar score E (2.26 [1.43-3.56]; p < 0.0001), oliguria/anuria (2.18 [1.82-4.33]; p < 0.0001), vasoactive support (2.83 [1.73-4.62]; p < 0.0001) and mechanical ventilation (1.90 [1.15-3.14]; p = 0.011), but not AIT (0.63 [0.40-1.01]; p = 0.057). CONCLUSIONS: High proportions of ICU patients admitted for AP receive AIT, both on admission and during their ICU stay. A large heterogeneity was observed between centres in terms of incidence of infections, AIT prescribing practices, therapeutic management and outcome. AIT reflects the initial severity and complications of AP, but is not a risk factor for death.

3.
Can J Kidney Health Dis ; 6: 2054358119892174, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31839974

RESUMO

Background: KDIGO (Kidney Disease: Improving Global Outcomes) defines acute kidney injury (AKI) solely by serum creatinine (SCr) and urine output variation. Severe AKI is a syndrome covering various clinical situations. Objective: To describe severe AKI heterogeneity by department of hospitalization. Design: This is a prospective observational single-center study. Setting: Adult patients hospitalized in a French tertiary hospital from August 2016 to December 2017. Patients: All adults with severe AKI, defined by dialysis for AKI or an increase in SCr above 354 µmol/L. Measurements: Patient characteristics, clinical and laboratory presentation, AKI cause, medical indication for renal replacement therapy (RRT), planned palliative care, and vital status 30 days after severe AKI. Methods: A global description of patient characteristics, care, and prognosis and comparison by department of hospitalization: intensive care unit (ICU), nephrology, and others. Results: The study included 480 patients (73% men, median age: 72 years, range: 64-83), with medical histories including cardiovascular disease, diabetes, cancer, and chronic kidney disease. Principal causes were sepsis (104; 22%), hypovolemia (98; 20%), obstructive AKI (84; 18%), acute tubular necrosis (ATN; 74; 15%), and cardiorenal syndrome (51; 11%). Severe AKI was diagnosed in the ICU for 188 (39%) patients, the nephrology department for 130 (27%), and in other wards for 162 (34%). Patient characteristics differed by department for age, comorbidity, cause, and RRT use and indications. Palliative care was planned for 72 (15%) patients, most frequently in other wards. Limitations: We studied a subgroup of stage 3 KDIGO AKI patients in a single center without cardiac surgery. Conclusion: Patients hospitalized for severe AKI have frequent and various comorbidities, different clinical presentations, care, hospitalization in various departments, and different prognosis. The heterogeneity of this severe AKI implies the need for personalized care, which requires prognostic tools that include information besides SCr and diuresis.

4.
JAMA Intern Med ; 2019 Dec 16.
Artigo em Inglês | MEDLINE | ID: mdl-31841577

RESUMO

Importance: The role of herpes simplex virus (HSV) reactivation on morbidity and mortality in patients in the intensive care unit requiring mechanical ventilation remains unknown. Objective: To determine whether preemptive treatment with intravenous acyclovir reduces the duration of mechanical ventilation in patients with HSV oropharyngeal reactivation. Design, Setting, and Participants: A double-blind, placebo-controlled randomized clinical trial was conducted in 16 intensive care units in France. Participants included 239 adults (age, >18 years) who received mechanical ventilation for at least 96 hours and continued to receive mechanical ventilation for 48 hours or more, with HSV oropharyngeal reactivation. Patients were enrolled between February 2, 2014, and February 22, 2018. Interventions: Participants were randomized to receive intravenous acyclovir, 5 mg/kg, 3 times daily for 14 days or a matching placebo. Main Outcomes and Measures: The primary end point was ventilator-free days from randomization to day 60. Prespecified secondary outcomes included mortality at 60 days. Main analyses were conducted on an intention-to-treat basis. Results: Of 239 patients enrolled and randomized, 1 patient withdrew consent, leaving 238 patients, with 119 patients in both the acyclovir and placebo (control) groups (median [IQR] age, 61 [50-70] years; 76 [32%] women) available for primary outcome measurement. On day 60, the median (IQR) numbers of ventilator-free days were 35 (0-53) for acyclovir recipients and 36 (0-50]) for controls (P = .17 for between-group comparison). Among secondary outcomes, 26 patients (22%) and 39 patients (33%) had died at day 60 (risk difference, 0.11, 95% CI, -0.004 to 0.22, P = .06). The adverse event frequency was similar for both groups (28% in the acyclovir group and 23% in the placebo group, P = .40), particularly acute renal failure post randomization affecting 3 acyclovir recipients (3%) and 2 controls (2%). Four patients (3%) in the acyclovir group vs none in the placebo group stopped the study drug for treatment-related adverse events. Conclusions and Relevance: In patients receiving mechanical ventilation for 96 hours or more with HSV reactivation in the throat, use of acyclovir, 5 mg/kg, 3 times daily for 14 days, did not increase the number of ventilator-free days at day 60, compared with placebo. These findings do not appear to support routine preemptive use of acyclovir in this setting. Trial Registration: ClinicalTrials.gov identifier: NCT02152358.

5.
Crit Care Med ; 47(12): e953-e961, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31567524

RESUMO

OBJECTIVES: The association between outcome and kidney injury detected at discharge from the ICU using different biomarkers remains unknown. The objective was to evaluate the association between 1-year survival and kidney injury at ICU discharge. DESIGN: Ancillary investigation of a prospective observational study. SETTING: Twenty-one ICUs with 1-year follow-up. PATIENTS: Critically ill patients receiving mechanical ventilation and/or hemodynamic support for at least 24 hours were included. INTERVENTIONS: Serum creatinine, plasma Cystatin C, plasma neutrophil gelatinase-associated lipocalin, urinary neutrophil gelatinase-associated lipocalin, plasma Proenkephalin A 119-159, and estimated glomerular filtration rate (on serum creatinine and plasma Cystatin C) were measured at ICU discharge among ICU survivors. MEASUREMENTS AND MAIN RESULTS: The association between kidney biomarkers at discharge and mortality was estimated using logistic model with and without adjustment for prognostic factors previously identified in this cohort. Subgroup analyses were performed in patients with discharge serum creatinine less than 1.5-fold baseline at ICU discharge. Among 1,207 ICU survivors included, 231 died during the year following ICU discharge (19.2%). Estimated glomerular filtration rate was significantly lower and kidney injury biomarkers higher at discharge in nonsurvivors. The association between biomarker levels or estimated glomerular filtration rate and mortality remained after adjustment to potential cofounding factors influencing outcome. In patients with low serum creatinine at ICU discharge, 25-47% of patients were classified as subclinical kidney injury depending on the biomarker. The association between kidney biomarkers and mortality remained and mortality was higher than patients without subclinical kidney injury. The majority of patients who developed acute kidney injury during ICU stay had elevated biomarkers of kidney injury at discharge even with apparent recovery based on serum creatinine (i.e., subclinical acute kidney disease). CONCLUSIONS: Elevated kidney biomarkers measured at ICU discharge are associated with poor 1-year outcome, including in patients with low serum creatinine at ICU discharge.

6.
JAMA ; 2019 Oct 02.
Artigo em Inglês | MEDLINE | ID: mdl-31577035

RESUMO

Importance: Norepinephrine, the first-line vasopressor for septic shock, is not always effective and has important catecholaminergic adverse effects. Selepressin, a selective vasopressin V1a receptor agonist, is a noncatecholaminergic vasopressor that may mitigate sepsis-induced vasodilatation, vascular leakage, and edema, with fewer adverse effects. Objective: To test whether selepressin improves outcome in septic shock. Design, Setting, and Participants: An adaptive phase 2b/3 randomized clinical trial comprising 2 parts that included adult patients (n = 868) with septic shock requiring more than 5 µg/min of norepinephrine. Part 1 used a Bayesian algorithm to adjust randomization probabilities to alternative selepressin dosing regimens and to trigger transition to part 2, which would compare the best-performing regimen with placebo. The trial was conducted between July 2015 and August 2017 in 63 hospitals in Belgium, Denmark, France, the Netherlands, and the United States, and follow-up was completed by May 2018. Interventions: Random assignment to 1 of 3 dosing regimens of selepressin (starting infusion rates of 1.7, 2.5, and 3.5 ng/kg/min; n = 585) or to placebo (n = 283), all administered as continuous infusions titrated according to hemodynamic parameters. Main Outcomes and Measures: Primary end point was ventilator- and vasopressor-free days within 30 days (deaths assigned zero days) of commencing study drug. Key secondary end points were 90-day mortality, kidney replacement therapy-free days, and ICU-free days. Results: Among 868 randomized patients, 828 received study drug (mean age, 66.3 years; 341 [41.2%] women) and comprised the primary analysis cohort, of whom 562 received 1 of 3 selepressin regimens, 266 received placebo, and 817 (98.7%) completed the trial. The trial was stopped for futility at the end of part 1. Median study drug duration was 37.8 hours (IQR, 17.8-72.4). There were no significant differences in the primary end point (ventilator- and vasopressor-free days: 15.0 vs 14.5 in the selepressin and placebo groups; difference, 0.6 [95% CI, -1.3 to 2.4]; P = .30) or key secondary end points (90-day mortality, 40.6% vs 39.4%; difference, 1.1% [95% CI, -6.5% to 8.8%]; P = .77; kidney replacement therapy-free days: 18.5 vs 18.2; difference, 0.3 [95% CI, -2.1 to 2.6]; P = .85; ICU-free days: 12.6 vs 12.2; difference, 0.5 [95% CI, -1.2 to 2.2]; P = .41). Adverse event rates included cardiac arrhythmias (27.9% vs 25.2% of patients), cardiac ischemia (6.6% vs 5.6%), mesenteric ischemia (3.2% vs 2.6%), and peripheral ischemia (2.3% vs 2.3%). Conclusions and Relevance: Among patients with septic shock receiving norepinephrine, administration of selepressin, compared with placebo, did not result in improvement in vasopressor- and ventilator-free days within 30 days. Further research would be needed to evaluate the potential role of selepressin for other patient-centered outcomes in septic shock. Trial Registration: ClinicalTrials.gov Identifier: NCT02508649.

7.
Artigo em Inglês | MEDLINE | ID: mdl-31614244

RESUMO

BACKGROUND: Rapid sequence induction (RSI) is recommended in patients at risk of aspiration, but induced haemodynamic adverse events, including tachycardia. In elderly patients, this trial aimed to assess the impact of the addition of remifentanil during RSI on the occurrence of: tachycardia (primary outcome), hypertension (due to intubation) nor hypotension (remifentanil). METHODS: In this three-arm parallel, double blind, multicentre controlled study, elderly patients (65 to 90 years old) hospitalised in three centres and requiring RSI were randomly allocated to three groups, where anaesthesia was induced with etomidate (0.3mg/kg) followed within 15seconds by either placebo, or low (0.5µg/kg), or high (1.0µg/kg) doses of remifentanil, followed by succinylcholine 1.0mg/kg. Heart rate (HR) and mean arterial pressure (MAP) were recorded before induction and after intubation. RESULTS: In total, eighty patients were randomised and analysed. Baseline HR and MAP were similar between groups. For primary endpoint, the absolute change in HR between induction and intubation was greater in the control group (15 bpm; 95% CI [8-21]) than that in the remifentanil 0.5µg/kg group (4 bpm; 95% CI [-1-+8]; P=0.005) and the remifentanil 1.0µg/kg group (-3 bpm; 95% CI [-9-+3]; P<0.0001). The increase in MAP was greater in the placebo group than in both remifentanil groups (P<0.0001). Twice as many hypertension episodes were recorded in the placebo group compared to the remifentanil 0.5µg/kg and 1.0µg/kg groups (60%, 30%, and 28% patients respectively; P=0.032), but no placebo patients experienced hypotension episodes versus 11% and 24% in the remifentanil 0.5µg/kg and 1.0µg/kg groups respectively (P=0.016). CONCLUSION: Remifentanil (0.5-1.0µg/kg) prevents the occurrence of tachycardia and hypertension in elderly patients requiring RSI.

8.
Artigo em Inglês | MEDLINE | ID: mdl-31481443

RESUMO

Amikacin is commonly used for probabilistic antimicrobial therapy in critically ill patients with sepsis. Its narrow therapeutic margin makes it challenging to determine the right individual dose that ensures the highest efficacy target attainment rate (TAR) in this setting. This study aims to develop a new initial dosing approach for amikacin by optimizing the a priori TAR in this population. A population pharmacokinetic model was built with a learning data set from critically ill patients who received amikacin. It was then used to design an initial dosing approach maximizing a priori TAR for a target ratio of ≥8 for the peak concentration to the MIC (C max/MIC) or of ≥75 for the ratio of the area under the concentration-time curve from 0 to 24 h to the MIC (AUC0-24/MIC). In the 166 patients included, 53% had amikacin C max of ≥64 mg/liter with a median dose of 23.4 mg/kg. A two-compartment model with creatinine clearance and body surface area as covariates best described the data and showed good predictive performance. Our dosing approach was successful in optimizing TAR for C max/MIC, with a rate of 92.9% versus 67.9% using a 30-mg/kg regimen, based on an external subset of data and assuming a MIC of 8 mg/liter. Mean optimal doses were higher (3.5 ± 0.5 g) than with the 30-mg/kg regimen (2.1 ± 0.3 g). Suggested doses varied with the MIC, the target index, and desired TAR threshold. A dosing algorithm based on the method is proposed for a large range of patient covariates. Clinical studies are necessary to confirm efficacy and safety of this optimized dosing approach.

9.
Lancet Respir Med ; 7(10): 870-880, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31399381

RESUMO

BACKGROUND: The effect of personalised mechanical ventilation on clinical outcomes in patients with acute respiratory distress syndrome (ARDS) remains uncertain and needs to be evaluated. We aimed to test whether a mechanical ventilation strategy that was personalised to individual patients' lung morphology would improve the survival of patients with ARDS when compared with standard of care. METHODS: We designed a multicentre, single-blind, stratified, parallel-group, randomised controlled trial enrolling patients with moderate-to-severe ARDS in 20 university or non-university intensive care units in France. Patients older than 18 years with early ARDS for less than 12 h were randomly assigned (1:1) to either the control group or the personalised group using a minimisation algorithm and stratified according to the study site, lung morphology, and duration of mechanical ventilation. Only the patients were masked to allocation. In the control group, patients received a tidal volume of 6 mL/kg per predicted bodyweight and positive end-expiratory pressure (PEEP) was selected according to a low PEEP and fraction of inspired oxygen table, and early prone position was encouraged. In the personalised group, the treatment approach was based on lung morphology; patients with focal ARDS received a tidal volume of 8 mL/kg, low PEEP, and prone position. Patients with non-focal ARDS received a tidal volume of 6 mL/kg, along with recruitment manoeuvres and high PEEP. The primary outcome was 90-day mortality as established by intention-to-treat analysis. This study is registered online with ClinicalTrials.gov, NCT02149589. FINDINGS: From June 12, 2014, to Feb 2, 2017, 420 patients were randomly assigned to treatment. 11 patients were excluded in the personalised group and nine patients were excluded in the control group; 196 patients in the personalised group and 204 in the control group were included in the analysis. In a multivariate analysis, there was no difference in 90-day mortality between the group treated with personalised ventilation and the control group in the intention-to-treat analysis (hazard ratio [HR] 1·01; 95% CI 0·61-1·66; p=0·98). However, misclassification of patients as having focal or non-focal ARDS by the investigators was observed in 85 (21%) of 400 patients. We found a significant interaction between misclassification and randomised group allocation with respect to the primary outcome (p<0·001). In the subgroup analysis, the 90-day mortality of the misclassified patients was higher in the personalised group (26 [65%] of 40 patients) than in the control group (18 [32%] of 57 patients; HR 2·8; 95% CI 1·5-5·1; p=0·012. INTERPRETATION: Personalisation of mechanical ventilation did not decrease mortality in patients with ARDS, possibly because of the misclassification of 21% of patients. A ventilator strategy misaligned with lung morphology substantially increases mortality. Whether improvement in ARDS phenotyping can decrease mortality should be assessed in a future clinical trial. FUNDING: French Ministry of Health (Programme Hospitalier de Recherche Clinique InterRégional 2013).

10.
BMC Infect Dis ; 19(1): 636, 2019 Jul 17.
Artigo em Inglês | MEDLINE | ID: mdl-31315560

RESUMO

BACKGROUND: We describe a case of severe Guillain-Barre syndrome (GBS) associated with chronic active hepatitis C and mixed cryoglobulinemia (MC). To our knowledge, this association between GBS and hepatitis C virus (HCV) infection has been rarely reported. CASE PRESENTATION: A 56-year-old man developed symmetrical muscle weakness in all extremities, areflexia and sensorial disorder followed by acute respiratory failure associated with chronic active hepatitis C, which was confirmed by the presence of anti-HCV antibodies in the serum and persistence of HCV RNA viral load for more than 6 months. Chronic hepatitis C was further complicated by type 3 MC. Electromyography showed peripheral nerve injury (mainly in axon). A severe acute motor sensory axonal neuropathy (AMSAN) was diagnosed. After treatment with intravenous immunoglobulin and plasma exchange followed by antiviral therapy by direct-acting antiviral agent, patient showed progressive recovery and was transferred 3 months after his first admission to a rehabilitation center. CONCLUSIONS: Our case reported a severe GBS associated with HCV infection and MC. EMG classified for the first time the subtype of GBS (severe AMSAN) correlated with severe clinical form. HCV infection should be screened in high-risk patients to prevent silent progression of the chronic hepatitis C and its potentially severe extra-hepatic manifestations.


Assuntos
Crioglobulinemia/etiologia , Síndrome de Guillain-Barré/etiologia , Hepatite C Crônica/etiologia , Antivirais/uso terapêutico , Crioglobulinemia/tratamento farmacológico , Hepatite C Crônica/complicações , Hepatite C Crônica/tratamento farmacológico , Humanos , Imunoglobulinas Intravenosas/uso terapêutico , Masculino , Pessoa de Meia-Idade , Síndrome do Desconforto Respiratório do Adulto/tratamento farmacológico , Síndrome do Desconforto Respiratório do Adulto/etiologia
11.
Crit Care ; 23(1): 179, 2019 05 16.
Artigo em Inglês | MEDLINE | ID: mdl-31097012

RESUMO

BACKGROUND: Fluid challenge (FC) is one of the most common practices in Intensive Care Unit (ICU). The present study aimed to evaluate whether echocardiographic assessment of the response to FC at the end of the infusion or 20 min later could affect the results of the FC. METHODS: This is a prospective, observational, multicenter study including all ICU patients in septic shock requiring a FC of 500 mL crystalloids over 10 min. Fluid responsiveness was defined as a > 15% increase in stroke volume (SV) assessed by velocity-time integral (VTI) measurements at baseline (T0), at the end of FC (T10), then 10 (T20) and 20 min (T30) after the end of FC. RESULTS: From May 20, 2014, to January 7, 2016, a total of 143 patients were enrolled in 11 French ICUs (mean age 64 ± 14 years, median IGS II 53 [43-63], median SOFA score 10 [8-12]). Among the 76/143 (53%) patient responders to FC at T10, 37 patients were transient responders (TR), i.e., became non-responders (NR) at T30 (49%, 95%CI = [37-60]), and 39 (51%, 95%CI = [38-62]) patients were persistent responders (PR), i.e., remained responders at T30. Among the 67 NR at T10, 4 became responders at T30, (6%, 95%CI = [1.9-15.3]). In the subgroup analysis, no statistical difference in hemodynamic and echocardiographic parameters was found between groups. CONCLUSIONS: This study shows that 51.3% of initial responders have a persistent response to fluid 30 min after the beginning of fluid infusion and only 41.3% have a transient response highlighting that fluid responsiveness is time dependent. TRIAL REGISTRATION: ClinicalTrials.gov , NCT02116413 . Registered on April 16, 2014.


Assuntos
Hidratação/métodos , Sepse/terapia , Fatores de Tempo , Idoso , Pressão Arterial/efeitos dos fármacos , Pressão Arterial/fisiologia , Débito Cardíaco/efeitos dos fármacos , Débito Cardíaco/fisiologia , Soluções Cristaloides/uso terapêutico , Ecocardiografia/métodos , Feminino , França , Humanos , Unidades de Terapia Intensiva/organização & administração , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Sepse/fisiopatologia
12.
Ann Intensive Care ; 9(1): 43, 2019 Mar 29.
Artigo em Inglês | MEDLINE | ID: mdl-30927096

RESUMO

PURPOSE: Few studies analyzed gender-related outcome differences of critically ill patients and found inconsistent results. This study aimed to test the independent association of gender and long-term survival of ICU patients. MATERIALS AND METHODS: FROG-ICU was a prospective, observational, multi-center cohort designed to investigate the long-term mortality of critically ill adult patients. The primary endpoint of this study was 1-year mortality after ICU admission of women compared to men. RESULTS: The study included 2087 patients, 726 women and 1361 men. Women and men had similar baseline characteristics, clinical presentation, and disease severity. No significant difference in 1-year mortality was found between women and men (34.9% vs. 37.9%, P = 0.18). After multivariable adjustment, no difference in the hazard of death was observed [HR 0.99 (95% CI 0.77-1.28)]. Similar 1-year survival between women and men was found in a propensity score-matched patient cohort of 506 patients [HR 0.79 (95% CI 0.54-1.14)]. CONCLUSION: Women constituted one-third of the population of critically ill patients and were unexpectedly similar to men regarding demographic characteristics, clinical presentation, and disease severity and had similar risk of death at 1 year after ICU admission. Trial registration ClinicalTrials.gov NCT01367093; registered on June 6, 2011.

13.
Air Med J ; 38(2): 100-105, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30898280

RESUMO

OBJECTIVE: Minimizing out-of-hospital time reduces morbidity and mortality in patients with severe trauma, acute coronary syndrome, or acute stroke. Our objective was to compare out-of-hospital times by helicopter versus ground services when the estimated time of arrival on the scene was over 20 minutes. METHODS: We proposed a retrospective observational monocentric study following 2 cohorts. The helicopter group and the ground group included patients with severe trauma, acute coronary syndrome, or acute stroke transported by helicopter or ground services. RESULTS: Two hundred thirty-nine patients were included; 118 were in the ground group, and 121 were in the helicopter group. Distances for the helicopter group were higher (62.1 ± 22.5 km vs. 27.6 ± 10.4 km, P < .001). When distances were over 35 km, the helicopter group was faster. We identified distance, need for surgery, and intensive care hospitalization as 3 predicting factors for choosing helicopters over ground modes of transport. CONCLUSION: In cases of severe trauma, acute coronary syndrome, or acute stroke, emergency medical helicopter transport can be chosen over ground transport when patients are in a severe state and when the distance is further than 35 km from the hospital.

14.
PLoS One ; 14(3): e0213683, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30893349

RESUMO

BACKGROUND: Ultrasound (US) guidance has yet to prove its applicability in radial arterial blood gas analysis (ABGA) punctures. The main objective of our study was to compare the number of first-attempt successes (NFAS) for radial arterial puncture in difficult patients with or without US guidance. The Secondary aims were to compare the number of punctures (NOP), puncture time, and patient pain. METHODS: In this single-center, randomized controlled trial, patients who required a radial ABGA and in whom the arterial puncture was assessed as difficult (because of non-palpable radial arteries or two previous puncture failures by a nurse) were assigned to the US group or no-US (NUS) group (procedure performed by a trained physician). RESULTS: Thirty-six patients were included in the US group and 37 in the NUS groups. The NFAS was 7 (19%) in the NUS group and 19 (53%) in the US group. The relative risk of success in the US group was 2.79 (95% CI,1.34 to 5.82), p = 0.01. In the NUS and US groups, respectively, the median NOP was 3 [2; 6] vs. 1 [1; 2], estimated difference -2.0 (95%CI, -3.4 to -0.6), p < 0.01; the respective puncture time was 3.1 [1.6; 5.4] vs. 1.4 [0.6; 3.1] min, estimated difference -1.45 (95%CI, -2.57 to -0.39), p = 0.01; the respective median patient pain was 6 [4; 8] vs. 2 [1; 4], estimated difference -4.0 (95%CI, -5.8 to -2.3); p < 0.01. CONCLUSION: US guidance by a trained physician significantly improves the rate of success in difficult radial ABGA patients.


Assuntos
Gasometria , Coleta de Amostras Sanguíneas/métodos , Punções/métodos , Artéria Radial/diagnóstico por imagem , Idoso , Artérias , Coleta de Amostras Sanguíneas/efeitos adversos , Cateterismo Periférico/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Dor/etiologia , Medição da Dor , Satisfação do Paciente , Estudos Prospectivos , Punções/efeitos adversos , Risco , Resultado do Tratamento , Ultrassonografia de Intervenção
15.
PLoS One ; 14(1): e0210140, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30620747

RESUMO

BACKGROUND: Standard operating rooms (SOR) are assumed to be the best place to prevent microbial contamination when performing tissue procurement. However, mobilizing an operating room is time and cost consuming if no organ retrieval is performed. In such case, non-operating dedicated rooms (NODR) are usually recommended by European guidelines for tissue harvesting. Performing the tissue retrieval in the Intensive care unit (ICU) when possible might be considered as it allows a faster and simpler procedure. OBJECTIVE: Our primary objective was to study the relationship between the risk of microbial contamination and the location (ICU, SOR or NODR) of the tissue retrieval in heart-beating and non-heart-beating deceased donors. MATERIALS AND METHOD: We retrospectively reviewed all deceased donors' files of the local tissue banks of Montpellier and Marseille from January 2007 to December 2014. The primary endpoint was the microbial contamination of the grafts. We built a multivariate regression model and used a GEE (generalized estimating equations) allowing us to take into account the clustered structure of our data. RESULTS: 2535 cases were analyzed involving 1027 donors. The retrieval took place for 1189 in a SOR, for 996 in a hospital mortuary (NODR) and for 350 in an ICU. 285 (11%) microbial contaminations were revealed. The multivariate analysis found that the location in a hospital mortuary was associated with a lower risk of contamination (OR 0.43, 95% CI [0.2-0.91], p = 0.03). A procurement performed in the ICU was not associated with a significant increased risk (OR 0.62, 95% CI [0.26-1.48], p = 0.4). CONCLUSION: According to our results, performing tissue procurement in dedicated non-sterile rooms could decrease the rate of allograft tissue contamination. This study also suggests that in daily clinical practice, transferring patients from ICU to SOR for tissue procurement could be avoided as it does not lead to less microbial contamination.


Assuntos
Microbiologia do Ar/normas , Aloenxertos/microbiologia , Coleta de Tecidos e Órgãos/normas , Obtenção de Tecidos e Órgãos/normas , Adulto , Idoso , Feminino , França , Humanos , Unidades de Terapia Intensiva/normas , Masculino , Pessoa de Meia-Idade , Necrotério/normas , Salas Cirúrgicas/normas , Transferência de Pacientes/normas , Guias de Prática Clínica como Assunto , Estudos Retrospectivos , Bancos de Tecidos/estatística & dados numéricos , Coleta de Tecidos e Órgãos/efeitos adversos , Coleta de Tecidos e Órgãos/métodos
16.
Shock ; 52(4): 449-455, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-30300317

RESUMO

BACKGROUND: The correlation between cardiac output (CO) evaluated by echocardiography and CO measured by thermodilution (COth) varies according to different studies. A new transthoracic echocardiography (TTE) tool allows automatic calculation of the subaortic velocity time index (VTIauto) and CO (COauto). The main objective was to evaluate the correlation between COth and COauto in an anesthetized, ventilated piglet hemorrhagic shock (HS) model. The secondary objectives were to evaluate the correlation between COth and CO evaluated by manual measurements of VTI, and the preload-dependency of VTIvaresp. METHODS: Eighteen piglets were bled until mean arterial pressure reached 40 mm Hg. Controlled hemorrhage was maintained for 30 min before a resuscitation phase. CO was measured by Pulse index Contour Cardiac Output thermodilution methods. At each time of the experiment, three VTI values were measured (min, med, max) and the average value was calculated. COs were calculated by TTE (COmax, COmed, COmin, COave). RESULTS: For the 204 measures attempted, the success rate was 197 (97%) manually and 122 (60%) automatically (P < 0.01). The correlation coefficients (r) between COth and, respectively, COauto, COave, COmax, COmed, and COmin were: 0.83 (95% CI [0.76; 0.88]; P < 0.01), 0.54 (95% CI [0.43; 0.63]; P < 0.01), 0.43 (95% CI [0.31; 0.54]; P < 0.01), 0.58 (95% CI [0.48; 0.67]; P < 0.01), and 0.52 (95% CI [0.41; 0.62]; P < 0.01). CONCLUSION: In an experimental model of HS, a new ultrasound tool, COauto, seems better correlated with COth than manual echocardiographic measurements.

17.
Transfusion ; 59(1): 191-195, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30456761

RESUMO

BACKGROUND: Transfusion-associated circulatory overload (TACO) is a growing concern in clinical practice. STUDY DESIGN AND METHODS: A case control study was performed at the Nîmes University Hospital, France. TACO cases occurring after RBC transfusion reported from January 1, 2014, to May 31, 2017, were included as cases. Four controls by case were randomly selected among the other RBC recipients on the same day. RESULTS: During the study period, 60 TACO diagnoses were reported for 37,029 transfused RBCs to a total of 8787 patients; 240 controls were included. The average rate of TACO was one case every 616 RBCs transfused. One in 146 transfused patients experienced TACO. TACO was associated with a higher 28-day mortality (22% vs. 11%; p = 0.003), and a longer hospital stay compared with controls (23.5 ± 19.6 days vs. 15.9 ± 20.1 days; p < 0.001). Four risk factors were independently associated with TACO in multivariable analysis: chronic use of loop diuretics (odds ratio [OR], 6.5, 95% confidence interval [CI], 3.3-12.9), hemorrhagic shock (OR, 12; 95% CI, 2.9-50), body weight <46 kg (OR, 7.9; 95% CI, 2.3-26.8) and chronic hypertension (OR, 4.1; 95% CI, 2-8.5). CONCLUSION: TACO was frequent and associated with poor outcome. Four independent risk factors were identified: hemorrhagic shock, low body weight, chronic use of diuretics, and chronic hypertension.


Assuntos
Transfusão de Sangue/métodos , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Feminino , Humanos , Modelos Logísticos , Masculino , Análise Multivariada , Fatores de Risco , Choque Hemorrágico
18.
J Vasc Access ; 20(4): 404-408, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30457029

RESUMO

INTRODUCTION: The aims of our study were to compare the performance of experienced emergency physicians for internal jugular vein puncture using a conventional ultrasound device versus a pocket-sized ultrasound in a training model. METHODS: In this single-center, prospective, randomized study, emergency physicians performed one puncture with each device in a randomized order. No emergency physicians used a pocket-sized ultrasound for central vascular catheter insertion in clinical practice. A medium-fidelity training model was used. Each image was judged based on an image quality scale from 0 to 5. RESULTS: Twenty emergency physicians were included: nine females (45%), median experience 2.5 years [2.0;4.3]. The median time to achieve a puncture with the conventional ultrasound device was 22 s [17;26] versus 28 s [13;43] with the pocket-sized ultrasound (p = 0.43). Eighteen (90%) emergency physician punctures were successful with the conventional ultrasound device versus 18 (90%) with the pocket-sized ultrasound (p = 1). The image quality was 4 [3;5] in the conventional ultrasound device group versus 4 [3;5] in the pocket-sized ultrasound group (p = 0.32). CONCLUSION: Pocket-sized ultrasound and conventional ultrasound device performances are not statistically different for internal jugular vein-guided ultrasonography in a training model. These results must be confirmed in a clinical study.


Assuntos
Cateterismo Venoso Central/instrumentação , Veias Jugulares/diagnóstico por imagem , Médicos , Sistemas Automatizados de Assistência Junto ao Leito , Treinamento por Simulação/métodos , Ultrassonografia de Intervenção/instrumentação , Cateterismo Venoso Central/efeitos adversos , Cateterismo Venoso Central/métodos , Cateteres Venosos Centrais , Serviços Médicos de Emergência , Desenho de Equipamento , França , Humanos , Manequins , Estudos Prospectivos , Punções , Análise e Desempenho de Tarefas , Fatores de Tempo
19.
Anaesth Crit Care Pain Med ; 38(1): 15-23, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-29902538

RESUMO

INTRODUCTION: In elderly patients, goal-directed haemodynamic therapy (GDHT), depth of anaesthesia monitoring and lung-protective ventilation have been shown to improve postoperative outcomes. The aim of this study was to evaluate current practices concerning strategies of anaesthesia optimisation in patients aged≥75 years. PATIENTS AND METHODS: A multicentre observational study was performed from February to May 2015 in 23 French academic centres. On 30 consecutive days in each centre, patients≥75 years with at least one major comorbidity undergoing elective or emergency procedures (femoral-neck fractures surgery, intraperitoneal abdominal surgery or vascular surgery) were included. Patient characteristics and data related to GHDT, management of hypotension, monitoring of temperature and depth of anaesthesia, lung ventilation, point of care haemoglobin testing were collected. RESULTS: In total, 807 patients were included. Only 2% of patients [95% CI: 1-3] received GHDT in full accordance with guidelines. Depth of anaesthesia monitoring was largely performed (53% [95% CI: 50-56]). The multifaceted strategy of lung-protective ventilation combining low tidal volumes (6-8mL/kg), PEEP of 5-8cm cmH2O, and repeated recruitment manoeuvres, was performed in only 4% [95% CI: 3-5] of patients. A centre effect was a major determinant of variation concerning implementation of these strategies. DISCUSSION: In patients'≥75 years, strategies of anaesthesia optimisation are not in accordance with eligible guidelines. Implementation of these techniques varies independently of factors related to the patient or the type of surgery and may be dependent on the generated constraints.

20.
Br J Haematol ; 183(4): 636-647, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30203833

RESUMO

An ancillary analysis to the SepsiCoag multicentric prospective observational study on patients entering an intensive care unit with septic shock evaluated the prognostic potential of fibrin generation markers (FGMs) tested at inclusion in the study, on survival at day 30. After centralization of samples, three automated FGMs were compared: D-dimers (DDi), fibrin/fibrinogen degradation products (FDP) and fibrin monomers (FM). FM was the single FGM that was significantly higher in non-surviving patients, area under the receiver-operator characteristic curve (AUCROC ): 0·617, P < 0·0001. Significantly higher International Society on Thrombosis and Haemostasis Disseminated Intravascular Coagulation (ISTH DIC) scores were calculated in non-survivors using each of the three FGMs. A dose-effect relationship was observed between ISTH DIC scores and non-survival, with highest significance obtained using FM as the FGM. An overt DIC diagnosis using the ISTH DIC score calculated using FM was a predictor of non-survival at day 30, independently from overt DIC diagnosis based on scores calculated using FDP or DDi. The AUCROC values testing the ability of the ISTH DIC score to predict non-survival were 0·650, 0·624 and 0·602 using FM, DDi and FDP, respectively, as the FGM. In patients with septic shock, among the commercially-available automated assays, automated FM is the FGM best related with late prognosis.


Assuntos
Coagulação Intravascular Disseminada , Produtos de Degradação da Fibrina e do Fibrinogênio/metabolismo , Choque Séptico , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Intervalo Livre de Doença , Coagulação Intravascular Disseminada/sangue , Coagulação Intravascular Disseminada/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Choque Séptico/sangue , Choque Séptico/mortalidade , Taxa de Sobrevida
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