Early tracheotomy versus prolonged endotracheal intubation in unselected severely ill ICU patients.

OBJECTIVE: Although several advantages are attributed to tracheotomy in ICU patients requiring mechanical ventilation (MV), true benefits and the optimal timing of tracheotomy remain controversial. In this study, we compared early tracheotomy (ET) with prolonged intubation (PI) in severely ill patients requiring prolonged MV. DESIGN: Prospective, randomized study. SETTING: Twenty-five medical and surgical ICUs in France. PATIENTS: Patients expected to require MV > 7 days. MEASUREMENTS AND RESULTS: Patients were randomised to either (open or percutaneous) ET within 4 days or PI. The primary end-point was 28-day mortality. Secondary end-points were: the incidence of ICU-acquired pneumonia, number of d1-d28 ventilator-free days, time spent in the ICU, 60-day mortality, number of septic episodes, amount of sedation, comfort and laryngeal and tracheal complications. A sample size of 470 patients was considered necessary to obtain a reduction from 45 to 32% in 28-day mortality. After 30 months, 123 patients had been included (ET = 61, PI = 62) in 25 centres and the study was prematurely closed. All group characteristics were similar upon admission to ICU. No difference was found between the two groups for any of the primary or secondary end-points. Greater comfort was the sole benefit afforded by tracheotomy after subjective self-assessment by patients. CONCLUSIONS: The trial did not demonstrate any major benefit of tracheotomy in a general population of ICU patients, as suggested in a previous meta-analysis, but was underpowered to draw any firm conclusions. The potential advantage of ET may be restricted to selected groups of patients.

[Organ procurement and transplantation from non-heart-beating donors]. / Le prélèvement sur donneurs à coeur arrêté dans le cadre de la greffe rénale.

Despite a significant increase in procurement and transplantation activities observed in France in the last eight years, the shortage in grafts is on the rise and demand keeps being much higher than supply. Since 1968 and until now, procurement was limited to heart beating brain donors. The results of kidneys transplanted from non-heart-beating donors have significantly improved and are nowadays comparable to those of kidney transplantations from brain death donors, thanks to a more accurate selection of donors and recipients, to better respect of preventing cold and warm ischemia times and to several major therapeutic innovations. Procurement on non-heart-beating donors are therefore being reconsidered under considerations of feasibility, results and ethical and legal consequences, under a specific medical protocol issued by the agency of biomedicine with the pilot hospital center agreement to comply with the protocol. Referring to foreign experiences, this program is likely to decrease the organ shortage, which is jeopardizing the treatment of a large number of patients awaiting transplantation.

Reliability of HemoCue in patients with gastrointestinal bleeding.

OBJECTIVE: HemoCue is routinely used to manage bleeding patients, but few studies have evaluated its accuracy in this population. We compared HemoCue with laboratory determination of blood hemoglobin in patients with gastrointestinal bleeding. DESIGN AND SETTING: A prospective observational study in a 14-bed medicosurgical ICU and an emergency department in an urban general hospital. PATIENTS: 94 patients admitted to the emergency department or to the ICU for gastrointestinal bleeding. INTERVENTIONS: Blood was drawn at admission to measure laboratory hemoglobin and capillary hemoglobin was measured simultaneously by HemoCue. The unit of hospitalization and the presence or absence of impaired vital signs (tachycardia and/or hypotension and/or shock) were recorded. MEASUREMENTS AND RESULTS: The mean difference between HemoCue and hemoglobin (bias) was -0.06 g/dl and standard deviation (precision) 0.87 g/dl. (95% CI -1.8 to 1.68). Discrepancies between HemoCue and hemoglobin were greater than 1 g/dl in 21% of cases. Bias was comparable between patients admitted to the ICU and those in the emergency department. The accuracy of HemoCue was not affected by the presence of impaired vital signs or by a hemoglobin level below 9 g/dl or 7 g/dl. CONCLUSIONS: Although we demonstrated a low bias between HemoCue and blood hemoglobin determination, large HemoCue vs. hemoglobin differences may still occur, and therefore therapeutic decisions based upon capillary HemoCue alone should be very cautious.

[Organ donation: scarce and fragile resources]. / Le don d'organe: une ressource fragile et limitée.

Organ transplantation, the gold standard therapy for end-stage organ failures, has become a victim of its success. Indeed, the number of patients listed for transplantation has been increasing faster than that of available grafts. The number of brain-dead donors, the primary source of organ donation in France, is limited, but this figure is becoming more and more comprehensive, thanks to the work carried out by hospital transplant coordination units. The room for manoeuvre is limited: to increase the transplantation rate in this respect, the only possibility would be to reduce the rate of donation refusals, which still accounts for more than 30 percent of all identified brain deaths. It is thus more and more critical to resort to other donor sources: living donors and non-heart-beating donors. Each donor source is associated with different constraints and limitations in terms of available resources, removal organization and ethics. For cadaver donors, the key ethical issues are the acceptance of presumed consent, the difficulty in diagnosing the exact time of death and the notion of body integrity. For living donors, the ethical issues are related to the quality of the consent and the assessment of the risk undertaken by the donor, when no personal benefit is expected.

[When are we dead? Still debates!] / « Quand est-on mort ? ¼ : toujours des débats !

When are we dead? Still debates ! Set the time of death has always raised many debates. They oppose vitalists and pragmatics. The first accept death when it was full, having reached the last cell and were not in hurry to declare the death, before the beginning of body rot. The latter considered that death was real since the process that induces death was irreversible, without waiting for body damage; they have therefore been constantly seeking for "the" sign that would mark that irreversibility. This sign, namely the extended shutdown of the heart beat, was not finally accepted until the late nineteenth century. He was supplanted some sixty years later, because of advances in resuscitation by the signs of brain death. The heart has been replaced by the brain as the seat of life, or at least of the person, being recognized that in current conditions, the disappearance of the person defines death. The debate is not over because if the time of the diagnosis of death is not always easy in case of heart beating brain death, it becomes impossible, at least in the short term, in case of death after irreversible cardiac arrest. This therefore requires, in this instance, to define in advance the time indispensable to the irreversible deterioration of the brain. This can, we imagine, sow doubt. But if the risk was previously that of premature burial, it is currently a loss of opportunity and or possible premature organ retrieval.

« Quand est-on mort ? ¼ : Toujours des débats ! Définir le moment de la mort a de tout temps soulevé de nombreux débats qui opposaient les vitalistes et les pragmatiques. Les premiers n'acceptaient la mort que lorsqu'elle est totale, ayant atteint la dernière cellule, et se donnaient, avant de l'affirmer, le temps de voir apparaître éventuellement un début de putréfaction du corps. Les seconds considéraient que la mort était réelle dès lors que le processus qui l'induit était irréversible, sans attendre l'aboutissement de la dégradation du corps ; ils n'ont donc eu de cesse de trouver « le ¼ signe qui puisse marquer cette irréversibilité. Ce signe, à savoir l'arrêt prolongé des battements du cœur, ne fut enfin admis qu'à la fin du XIXe siècle. Il fut supplanté quelque 60 ans plus tard, du fait des progrès de la réanimation par les signes de la mort de l'encéphale. Le cœur a donc été remplacé par l'encéphale comme siège de la vie, ou du moins de la personne, étant admis que, dans les conditions actuelles, la disparition de la personne en définit le décès. Le débat n'est pas clos pour autant, car si le moment de ce diagnostic n'est pas toujours aisé en cas de mort encéphalique à cœur battant sous ventilation mécanique, il devient impossible, du moins à très court terme, en cas de décès après arrêt cardiaque irréversible. Cela impose donc, dans cette circonstance, de définir au préalable le délai indispensable à la détérioration irréversible de l'encéphale, ce qui, peut-on l'imaginer, sème le doute. Or si le risque était antérieurement celui d'une inhumation prématurée, il est actuellement celui d'une perte de chance et ou d'un éventuel prélèvement d'organe prématuré.

Culture, organization, and management in intensive care: construction and validation of a multidimensional questionnaire.

OBJECTIVE: The objective of this study is to develop and validate a questionnaire designed to assess the culture, organization, and management of intensive care units. DESIGN: This is a prospective multicenter study. SETTING: The study was conducted in 26 intensive care units located in Paris. PARTICIPANTS: All personnel were asked to complete the questionnaire. INTERVENTION: The questionnaire was developed in 2 steps: (1) development of a theoretical framework based on organizational theory and (2) testing of the reliability and validity of a comprehensive set of measures. METHOD: The internal consistency of the items composing each scale was tested by using the Cronbach alpha. Convergent, and discriminant validity was assessed by factor analysis with varimax rotation. RESULTS: The overall completion rate was 74% with 1000 respondents (750 nurses, 26 head nurses, 168 physicians, and 56 medical secretaries). Starting with a 220-item questionnaire, we constructed a short version-conserving metrological characteristics with good reliability and validity. The short questionnaire, entitled Culture, Organization, and Management in Intensive Care, consists of 106 items distributed in 9 dimensions and 22 scales: culture (n = 3), coordination and adaptation to uncertainty (n = 3), communication (n = 3), problem solving and conflict management (n = 2), organizational learning and organizational change (n = 2), skills developed in a patient-caregiver relationship (n = 1), subjective unit performance (n = 3), burnout (n = 3), and job satisfaction and intention to quit (n = 2). All the scales showed good-to-high reliability, with Cronbach alpha scores higher than .7 (with the exception of coordination [.6]). Team satisfaction-oriented culture is positively correlated with good managerial practices and individual well-being. CONCLUSIONS: The Culture, Organization, and Management in Intensive Care questionnaire enables staff and managers to assess the organizational performance of their intensive care unit.

Esophageal perforation associated with noninvasive ventilation: a case report.

Noninvasive positive-pressure ventilation (NIPPV) is widely used to treat acute respiratory failure, the goal being to avoid exposing patients to the morbidity associated with tracheal intubation. NIPPV may reduce the rates of intubation, morbidity, and mortality in selected patient subgroups. Although time-consuming for physicians and nurses, NIPPV is fairly easy to use, and few severe complications have been reported. Esophageal perforation is a well-recognized complication of tracheal intubation but has not been described in association with NIPPV. We report a case of fatal esophageal perforation associated with NIPPV after a surgical procedure.

Increased endogenous carbon monoxide production in severe sepsis.

OBJECTIVE: A comparison was made between the endogenous carbon monoxide (CO) production in mechanically ventilated critically ill adult patients with, and those without, severe sepsis. DESIGN: Prospective comparative study. SETTING: Medical ICU in a community hospital. PATIENTS: Twenty-four patients with severe sepsis of various etiologies and five control patients with varying diagnoses. INTERVENTION: CO concentration was determined with an infrared CO analyzer on exhaled breath collected at the outlet of the ventilator. Endogenous CO production was estimated by the lung CO excretion rate measured at steady state. MEASUREMENTS AND MAIN RESULTS: : Endogenous CO production was higher in the sepsis group during the first 3 days of treatment in comparison to the control group (10.9+/-5 (SD) microl/kg per h on day 1, 7.8+/-4.9 microl/kg per h on day 2 and 6.9+/-4.7 microl/kg per h on day 3 versus 2.1+/-0.5 microl/kg per h; p<0.01 for each comparison). Survivors of sepsis had a significantly higher endogenous CO production on day 1 compared to non-survivors (14.7+/-5.3 versus 8.5+/-3.3 microl/kg per h; p=0.02). CONCLUSION: Endogenous CO production was significantly higher in mechanically ventilated patients suffering from severe sepsis. Further studies are required in order to determine the mechanism(s) and the functional significance of this increase.

Family participation in care to the critically ill: opinions of families and staff.

BACKGROUND: Allowing family members to participate in the care of patients in intensive care units (ICUs) may improve the quality of their experience. No previous study has investigated opinions about family participation in ICUs. METHODS: Prospective multicenter survey in 78 ICUs (1,184 beds) in France involving 2,754 ICU caregivers and 544 family members of 357 consecutive patients. We determined opinions and experience about family participation in care; comprehension (of diagnosis, prognosis, and treatment) and satisfaction (Critical Care Family Needs Inventory) scores to assess the effectiveness of information to families and the Hospital Anxiety and Depression score for family members. RESULTS: Among caregivers 88.2% felt that participation in care should be offered to families. Only 33.4% of family members wanted to participate in care. Independent predictors of this desire fell into three groups: patient-related (SAPS II at ICU admission, OR 0.984); ICU stay length, OR 1.021), family-related (family member age, OR 0.97/year); family not of European descent, OR 0.294); previous ICU experience in the family, OR 1.59), and those related to emotional burden and effectiveness of information provided to family members (symptoms of depression in family members, OR 1.58); more time wanted for information, OR 1.06). CONCLUSIONS: Most ICU caregivers are willing to invite family members to participate in patient care, but most family members would decline.