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Perioperative ventilation is an important challenge of anaesthesia, especially in obese patients: body mass index is correlated with reduction of the pulmonary volume and they develop significantly more perioperative atelectasis and pulmonary complications. The alveolar recruitment manoeuvre is the most effective technique to reverse atelectasis. However, the clinical benefit on lung function in the perioperative period is not clear. The aim of the present study is to assess the perioperative clinical results of systematic alveolar recruitment manoeuvre associated with protective ventilation in patients undergoing laparoscopic bariatric surgery. It was a single-centre, randomised, double blind, superiority trial: control group with standard protective ventilation and recruitment group with protective ventilation and systematic recruitment manoeuvre. The primary outcome was a composite clinical criterion of pulmonary dysfunction including oxygen saturation, oxygen needs and dyspnoea in recovery room and at day 1. Secondary outcomes were recruitment manoeuvre tolerance, pulmonary and non-pulmonary complications, length of hospital stay and proportion of Intensive Care Unit admission. Two hundred and thirty patients were included: 115 in the recruitment manoeuvre group and 115 in the control group, 2 patients were excluded from the analysis in the control group. Patients in the recruitment manoeuvre group had significantly lower rate of pulmonary dysfunction in the recovery room (73% versus 84% (p = 0.043) and 77% versus 88% at postoperative day 1 (p = 0.043)). No significant differences were found for secondary outcomes. No patient was excluded from the recruitment manoeuvre group for intolerance to the manoeuvre. Recruitment manoeuvre is safe and effective in reducing early pulmonary dysfunction in obese patients undergoing bariatric surgery.

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.

International audience; Background: Different modes of death are described in selected populations, but few data report the characteristics of death in a general intensive care unit population. This study analyzed the causes and characteristics of death of critically ill patients and compared anticipated death patients to unexpected death counterparts.Methods: An observational multicenter cohort study was performed in 96 intensive care units. During 1 yr, each intensive care unit was randomized to participate during a 1-month period. Demographic data, characteristics of organ failures (Sequential Organ Failure Assessment subscore greater than or equal to 3), and organ supports were collected on all patients who died in the intensive care unit. Modes of death were defined as anticipated (after withdrawal or withholding of treatment or brain death) or unexpected (despite engagement of full-level care or sudden refractory cardiac arrest).Results: A total of 698 patients were included during the study period. At the time of death, 84% had one or more organ failures (mainly hemodynamic) and 89% required at least one organ support (mainly mechanical ventilation). Deaths were considered unexpected and anticipated in 225 and 473 cases, respectively. Compared to its anticipated counterpart, unexpected death occurred earlier (1 day vs. 5 days; P< 0.001) and had fewer organ failures (1 [1 to 2] vs. 1 [1 to 3]; P< 0.01) and more organ supports (2 [2 to 3] vs. 1 [1 to 2]; P< 0.01). Withdrawal or withholding of treatments accounted for half of the deaths.Conclusions: In a general intensive care unit population, the majority of patients present with at least one organ failure at the time of death. Anticipated and unexpected deaths represent two different modes of dying and exhibit profiles reflecting the different pathophysiologic underlying mechanisms.

Aims Lactate reflects hypoxic insult in many conditions and is considered as a prognosis factor. But, after cardiac arrest, its interest is still debated. Our study aimed to assess the prognosis value of lactate in out-of-hospital cardiac arrest patients treated with therapeutic hypothermia. Methods This retrospective observational study included out-of-hospital cardiac arrest patients treated with therapeutic hypothermia in four ICUs. Lactate levels were compared at different times during the first 24 hours according to outcome at ICU discharge and to the type of death (multiorgan or neurologic failure). Results Two hundred and seventy-two patients were included, 89 good outcome and 183 poor outcome. In the latter group, 171 patients died, from multiorgan failure in 30% and neurologic failure in 70%. Lactate levels were higher in the poor compared to the good outcome patients at admission (5.4 (3.3–9.4) vs. 2.2 (1.5–3.6) mmol/L; p

Background Termination of resuscitation rule permits to stop futile resuscitative efforts by paramedics. In a different setting, the decision to withhold resuscitation by emergency physician could be based on different factors. We aimed to identify the factors associated with the initiation of a medical ACLS in out-of-hospital cardiac arrest patients. Methods We prospectively collected the characteristics of all out-of hospital cardiac arrest patients occurring in a French district between March 2010 and December 2013 and managed by the emergency medical system. We analyzed the factors associated with the initiation of medical ACLS. Results Medical ACLS was initiated in 69 % of the 2690 patients included in the register. ACLS patients were younger (69 years [55–80] vs. 84 years [77–90]) and more frequently men. A higher percentage of witnessed cardiac arrest and BLS were observed. Duration of no-flow was shorter in the ACLS patients, whereas BLS duration was longer. A higher proportion of shockable rhythm and application of AED were found in this group. Mains factors associated with the initiation of medical ACLS were a suspected cardiac cause (1.73 [1.30–2.30]) and use of an automated external defibrillator (1.59 [1.18–2.16]), whereas factors associated with no medical ACLS were higher age (0.93 [0.92–0.94]), absence of BLS (0.62 [0.52–0.73]), asystole (0.31 [0.18–0.51]) and location in nursing home (0.23 [0.11–0.51]). Conclusions The medical decision to not initiate ACLS in out-of-hospital cardiac arrest patients seems to rely on a complex combination of validated criteria used for termination of resuscitation and factors resulting from an intuitive perception of the outcome.

International audience; Since the implementation of two French laws in 2002 and 2005 and the implementation of guidelines about End-of-Life (EoL) decisions, few studies concerning EoL practices in French intensive care units (ICUs) have been reported. This study was aimed at assessing compliance with recommendations and current legislation concerning EoL decisions. Prospective observational study based on 1-day audit conducted from January to May 2009 in 66 southern French ICUs. Six hundred and twenty-five patients were included (median age: 63 [52-76] years, median SAPS II: 46 [34-58]). The written designation of a surrogate decision-maker was reported for 87 (15%) patients. Advance directives were completed for only 4% of patients. The EoL decision-making process consisted in a multidisciplinary approach for 99 (47%) patients and was recorded in the medical chart for 63 (64%) cases. Families were informed about medical decisions in 58% of cases. This proportion was higher (87%) if a decision to forego life-sustaining therapy was made. EoL decisions consisted of withholding treatments for 72 (94%) patients and withdrawal of treatments for 5 (6%) patients. In the multivariate stepwise logistic regression, four variables were independently associated with a decision to forego life support: preexisting dependence on others (P

The present study assessed the opinion of general practitioners (GPs) concerning their relationships with intensivists. An anonymous questionnaire was mailed to 7,239 GPs. GPs were asked about their professional activities, postgraduate intensive care unit (ICU) training, the rate of patient admittance to ICUs, and their relationships with intensivists. Relationship assessment was performed by using a graduated visual analogue scale (VAS) ranging from 0 (dissatisfaction) to 100 (satisfaction). A multivariate analysis with stepwise logistic regression was performed to isolate factors explaining dissatisfaction (VAS score, < 25th percentile). Twenty-two percent of the GPs (1,561) responded. The median satisfaction score was 57 of 100 (interquartile (IQ), 35 to 77]. Five independent factors of dissatisfaction were identified: no information provided to GPs at patient admission (odds ratio (OR) = 2.55 (1.71 to 3.80)); poor quality of family reception in the ICU (OR = 2.06 (1.40 to 3.02)); the ICU's family contact person's identity or function or both is unclear (OR = 1.48 (1.03 to 2.12)), lack of family information (OR = 2.02 (2.48 to 2.75)), and lack of discharge report (OR = 3.39 (1.70 to 6.76)). Three independent factors prevent dissatisfaction: age of GPs ≤45 years (OR = 0.69 (0.51 to 0.94)); the GP is called at patient ICU admission (OR = 0.44 (0.31 to 0.63)); and GP involvement in treatment decisions (OR = 0.17 (0.07 to 0.40)). Considerable improvement in GP/intensivist relationships can be achieved through increased communication measures.

International audience; In a recent issue of Critical Care, 0.5 M sodium lactate infusion for 24 hours was reported to increase cardiac output in patients with acute heart failure. This effect was associated with a concomitant metabolic alkalosis and a negative water balance. Growing data strongly support the role of lactate as a preferential oxidizable substrate to supply energy metabolism leading to improved organ function (heart and brain especially) in ischemic conditions. Due to its sodium/chloride imbalance, this solution prevents hyperchloremic acidosis and limits fluid overload despite the obligatory high sodium load. Sodium lactate solution therefore shows many advantages and appears a very promising means for resuscitation of critically ill patients. Further studies are needed to establish the most appropriate dose and indications for sodium lactate infusion in order to prevent the occurrence of severe hypernatremia and metabolic alkalosis.

Introduction : Recent studies reported a post intensive care syndrome and its consequences on the health-related quality of life (HRQOL). The aim of this study was to evaluate the HRQOL, the prevalence of PTSD, depression and anxiety after hospitalisation in intensive care unit.Patients and Methods : We performed a single-center observational study between November 2012 and June 2018. We summoned ICU-survivor, with an admission Sepsis-related Organ Failure Assessment score higher than 4 or duration of mechanical ventilation > 48 hours, for a post-ICU follow-up 6 months after discharge. We collected demographic data and admissions diagnosis. We evaluated HRQOL, PTSD, anxiety and depression with the questionnaires Short-Form 36 (SF-36), Impact of Event Scale- Revised and the hospital anxiety and depression scale respectively.Results : 354 patients attended the consultation at a median time of 7[6-8] months after ICU discharge. These patients exhibited alterations of the SF-36 score with the lowest for role limitation due to physical health, 0 [0-25] and role limitation related to emotion, 17 [0-50]. The best HRQOL scores were reported in cardiac arrest and neurological patients with a physical component score (PCS) of 58 [38-73] and 48 [34-66] respectively. The lowest values were found in septic shock and trauma patients with PCS of 36 [26-56] and 38 [23-53] respectively. We found a significant prevalence of anxiety (22%), depression (19%) and PTSD (17%). We found that male sex, neurological admission diagnosis, better mental component score MCS and shorter hospital LOS were associated with a PCS score above the median, and that anxiety, depression and better PCS were associated with a MCS above the median.Conclusion : ICU-survivors present a low HRQOL mainly in SF-36 domains RE and RP, 6 months after ICU. Cardiac arrest and neurological patients seem to exhibit the best HRQOL whereas septic shock and trauma patients present the worst. Anxiety, depression and PTSD were found in around one patient in five without difference across admission diagnosis. Male gender, admission for neurological reason, shorter hospital length of stay, absence of anxiety or depression are associated with better HRQOL 6 months after ICU discharge.

OBJECTIFS:L'insuffisance rénale aiguë est une complication classique de l'acidocétose diabétique. Cependant, à notre connaissance, aucune étude n'a rapporté l'incidence et les caractéristiques de la lésion rénale aiguë depuis la définition du consensus.MÉTHODES:Étude rétrospective de tous les cas de kétoacidose diabétique sévère hospitalisés consécutivement dans une UTI tertiaire chirurgicale médicale pendant 10 ans. Les patients ont été dichotomisés avec une IRA et sans IRA à l'admission selon la classification RIFLE. Les paramètres cliniques et biologiques ont été comparés dans ces populations. Les facteurs de risque de présenter une IRA à l'admission ont été recherchés.RÉSULTATS:Quatre-vingt-quatre patients ont été inclus dans l'étude. Selon les critères RIFLE, 47 patients (50%) présentaient une atteinte rénale aiguë à l'admission; La plupart d'entre eux étaient dans la classe de risque (51%). A 12 et 24 heures, le pourcentage de patients atteints d'arthrite a diminué à 26% et 27% respectivement. Au cours des 24 premières heures, 3 patients ont eu besoin d'une thérapie de substitution rénale. L'insuffisance rénale aiguë à l'admission était associée à un âge plus avancé, au SAPS 2 et à des troubles biologiques plus graves. Les traitements n'étaient pas différents entre les groupes, sauf pour la perfusion d'insuline. La régression logistique a révélé 3 facteurs de risque de présenter une IRA à l'admission: l'âge (odds ratio 1,060 [1,020-1,100], p CONCLUSIONS:Une insuffisance rénale aiguë est fréquemment associée à une acidocétose diabétique sévère à l'admission en soins intensifs. La plupart du temps, cette LRA est transitoire et se caractérise par une réactivité en volume à la perfusion de fluide utilisée dans le traitement DKA. L'âge, la glycémie et les protéines sériques sont associés à l'apparition de l'IRA à l'admission aux soins intensifs.