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Background The implementation of computerized monitoring and prescription systems in intensive care has proven to be reliable in reducing the rate of medical error and increasing patient care time. They also showed a benefit in reducing the length of stay in the intensive care unit (ICU). However, this benefit has been poorly studied, with conflicting results. Objective This study aimed to show the impact of computerization on the length of stay in ICUs. Methods This was a before-after retrospective observational study. All patients admitted in the surgical ICU at the Rouen University Hospital were included, from June 1, 2015, to June 1, 2016, for the before period and from August 1, 2016, to August 1, 2017, for the after period. The data were extracted from the hospitalization report and included the following: epidemiological data (age, sex, weight, height, and body mass index), reason for ICU admission, severity score at admission, length of stay and mortality in ICU, mortality in hospital, use of life support during the stay, and ICU readmission during the same hospital stay. The consumption of antibiotics, biological analyses, and the number of chest x-rays during the stay were also analyzed. Results A total of 1600 patients were included: 839 in the before period and 761 in the after period. Only the severity score Simplified Acute Physiology Score II was significantly higher in the postcomputerization period (38 [SD 20] vs 40 [SD 21]; P Conclusions Implementation of an intensive care information system at the Rouen University Hospital in June 2016 did not have an impact on reducing the length of stay.

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.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.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 (p0·001). 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.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.French Ministry of Health (Programme Hospitalier de Recherche Clinique InterRégional 2013).

Needle-free connectors were initially designed and promoted to avoid blood exposure for healthcare workers. Some recent data suggest that the latest generation of connectors (with positive displacement) may be of interest for reducing central venous line infections. We have been using needle-free connectors for several years in our intensive care unit and here we present a protocol for installing these connectors on central venous catheters. After insertion of the catheter and control of the permeability of the lines, the connectors must be purged with 0.9% NaCl before being connected. The connectors replace all disposable caps used on infusion stopcocks and manifolds. All the connectors are changed every 7 days as recommended by the manufacturer (except when there is macroscopic contamination, which requires an immediate change of the connector). Before each injection, the connector must be disinfected for at least 3 seconds with 70% isopropyl alcohol. The connectors must not be disconnected (unless changed), as the injection is done through the device. Setting up the connectors slightly increases the total time required to place the catheter and there is no formal evidence that these connectors reduce the incidence of infectious or thrombotic complications. However, these devices simplify the management of central venous lines and prevent the catheter circuit from "opening" once it has been sterilely installed.

Contains fulltext : 206779.pdf (Publisher’s version ) (Open Access) BACKGROUND: The objective of this study was to assess the cumulative incidence of invasive candidiasis (IC) in intensive care units (ICUs) in Europe. METHODS: A multinational, multicenter, retrospective study was conducted in 23 ICUs in 9 European countries, representing the first phase of the candidemia/intra-abdominal candidiasis in European ICU project (EUCANDICU). RESULTS: During the study period, 570 episodes of ICU-acquired IC were observed, with a cumulative incidence of 7.07 episodes per 1000 ICU admissions, with important between-center variability. Separated, non-mutually exclusive cumulative incidences of candidemia and IAC were 5.52 and 1.84 episodes per 1000 ICU admissions, respectively. Crude 30-day mortality was 42%. Age (odds ratio [OR] 1.04 per year, 95% CI 1.02-1.06, p < 0.001), severe hepatic failure (OR 3.25, 95% 1.31-8.08, p 0.011), SOFA score at the onset of IC (OR 1.11 per point, 95% CI 1.04-1.17, p 0.001), and septic shock (OR 2.12, 95% CI 1.24-3.63, p 0.006) were associated with increased 30-day mortality in a secondary, exploratory analysis. CONCLUSIONS: The cumulative incidence of IC in 23 European ICUs was 7.07 episodes per 1000 ICU admissions. Future in-depth analyses will allow explaining part of the observed between-center variability, with the ultimate aim of helping to improve local infection control and antifungal stewardship projects and interventions.

PURPOSE Veno-arterial Extracoporeal Membrane Oxygenation (VA-ECMO) provides circulatory assistance for patients in cardiogenic shock. Large quantities of fluids are often required, especially during the early stages, but can result in a potentially harmful fluid-overload. The objective was to determine the association of early fluid-balance and mortality. METHODS Retrospective single-center study in 101 VA-ECMO patients between 2013 and 2016. Daily fluid-balance and weight changes over the 5 first days were observed. Analyses between survivors and non-survivors were conducted using Mann-Whitney tests and logistic regression multivariable and Cox hazard-proportional analyses to determine any association with 28-days mortality. RESULTS Mortality was 47.5%. The fluid-balance was higher in non-survivors at day-1 (47.3[18.1-71.9] vs. 19.3[1.5-36.2] mL/kg, P

BACKGROUND The implementation of computerized monitoring and prescription systems in intensive care has proven to be reliable in reducing the rate of medical error and increasing patient care time. They also showed a benefit in reducing the length of stay in the intensive care unit (ICU). However, this benefit has been poorly studied, with conflicting results. OBJECTIVE This study aimed to show the impact of computerization on the length of stay in ICUs. METHODS This was a before-after retrospective observational study. All patients admitted in the surgical ICU at the Rouen University Hospital were included, from June 1, 2015, to June 1, 2016, for the before period and from August 1, 2016, to August 1, 2017, for the after period. The data were extracted from the hospitalization report and included the following: epidemiological data (age, sex, weight, height, and body mass index), reason for ICU admission, severity score at admission, length of stay and mortality in ICU, mortality in hospital, use of life support during the stay, and ICU readmission during the same hospital stay. The consumption of antibiotics, biological analyses, and the number of chest x-rays during the stay were also analyzed. RESULTS A total of 1600 patients were included: 839 in the before period and 761 in the after period. Only the severity score Simplified Acute Physiology Score II was significantly higher in the postcomputerization period (38 [SD 20] vs 40 [SD 21]; P CONCLUSIONS Implementation of an intensive care information system at the Rouen University Hospital in June 2016 did not have an impact on reducing the length of stay.

BACKGROUND Establishing pre- and postoperative contact with patients is part of successful medical management in outpatient surgery. In France, this is mostly done via telephone. Automated information with short message service (SMS) reminders might be an interesting alternative to increase the rate of compliance with preoperative instructions, but no study has shown the safety of this approach. OBJECTIVE The objective of this study was to evaluate the impact of pre- and postoperative automated information with SMS reminders on medical safety in outpatient surgery. METHODS We conducted a retrospective, single-center, nonrandomized, controlled study with a before-after design. All adult patients who had outpatient surgery between September 2016 and December 2017 in our university hospital center were included. Before April 2017, patients were contacted by telephone by an outpatient surgery nurse. After April 2017, patients were contacted by SMS reminder. All patients were contacted the day before and the day after surgery. Patients contacted by SMS reminder were also contacted on day 7 after surgery. The primary end point was the conversion rate to full-time hospitalization. Secondary end points were hospitalization causes (anesthetic, surgical, organizational) and hospitalization costs. RESULTS A total of 4388 patients were included, 2160 before and 2228 after the introduction of SMS reminders. The conversion rate to full-time hospitalization was 34/4388 (0.77%) with a difference between SMS group (8/2228, 0.36%) and telephone group (26/2160, 1.20%). The cost of SMS reminders was estimated as half that of telephone calls. CONCLUSIONS In this work, we report a decrease in the rate of conversion to full-time hospitalization with the use of pre- and postoperative SMS reminders. This new approach could represent a safe and cost-effective method in an outpatient surgery setting.

BackgroundThe WhatsApp smartphone app is the most widely used instant messaging app in the world. Recent studies reported the use of WhatsApp for educational purposes, but there is no prospective study comparing WhatsApp’s pedagogical effectiveness to that of any other teaching modality. ObjectiveThe main objective of this study was to measure the impact of a learning program via WhatsApp on clinical reasoning in medical residents. MethodsThis prospective, randomized, multicenter study was conducted among first- and second-year anesthesiology residents (offline recruitment) from four university hospitals in France. Residents were randomized in two groups of online teaching (WhatsApp and control). The WhatsApp group benefited from daily delivery of teaching documents on the WhatsApp app and a weekly clinical case supervised by a senior physician. In the control group, residents had access to the same documents via a traditional computer electronic learning (e-learning) platform. Medical reasoning was self-assessed online by a script concordance test (SCT; primary parameter), and medical knowledge was assessed using multiple-choice questions (MCQs). The residents also completed an online satisfaction questionnaire. ResultsIn this study, 62 residents were randomized (32 to the WhatsApp group and 30 to the control group) and 22 residents in each group answered the online final evaluation. We found a difference between the WhatsApp and control groups for SCTs (60% [SD 9%] vs 68% [SD 11%]; P=.006) but no difference for MCQs (18/30 [SD 4] vs 16/30 [SD 4]; P=.22). Concerning satisfaction, there was a better global satisfaction rate in the WhatsApp group than in the control group (8/10 [interquartile range 8-9] vs 8/10 [interquartile range 8-8]; P=.049). ConclusionsCompared to traditional e-learning, the use of WhatsApp for teaching residents was associated with worse clinical reasoning despite better global appreciation. The use of WhatsApp probably contributes to the dispersion of attention linked to the use of the smartphone. The impact of smartphones on clinical reasoning should be studied further.

BACKGROUND The WhatsApp® (WA) smartphone application is the most widely used instant messaging application in the world. Recent studies report the use of WA for educational purposes but there is no prospective study comparing WA's pedagogical effectiveness to any other teaching modality. The goal of this study was to evaluate this cross-platform messaging as a pedagogic tool for the teaching of residents. OBJECTIVE The main objective of this study was to evaluate the impact of WA on clinical reasoning. METHODS Prospective, randomized, multicenter study conducted among first and second year anesthesiology residents (online recruitment) from four university hospitals in France. Residents were randomized in two groups of online teaching (WA and control). The WA group benefited from daily delivery on the WA application of teaching documents and a weekly clinical case supervised by a senior physician. In the control group, residents had access to the same documents via a traditional computer e-learning platform. Medical reasoning was self-assessed online by script concordance test (SCT; primary parameter) and medical knowledge by multiple choice questions (MCQ). The residents completed an online satisfaction questionnaire. RESULTS In this study, 62 residents were randomized (32 in WA group, 30 in control group), 22 residents in each group answered the online final evaluation. We found a difference between WA and control groups for SCT (60 ± 9 % vs. 68 ± 11 %, respectively; P = .006) but no difference for MCQ (18 ± 4 /30 vs. 16 ± 4 /30, respectively; P = .22). Concerning satisfaction, there was a better global satisfaction rate in the WA group compared to control (9 ± 1 /10 vs. 8 ± 2 /10; P = .049). CONCLUSIONS In this study, the use of WA compared to traditional e-learning for resident teaching was associated with worse clinical reasoning despite better global appreciation. The use of WA probably contributes to the dispersion of attention linked to the use of the smartphone. The impact of smartphones on clinical reasoning should be further studied.

BACKGROUND The WhatsApp smartphone app is the most widely used instant messaging app in the world. Recent studies reported the use of WhatsApp for educational purposes, but there is no prospective study comparing WhatsApp’s pedagogical effectiveness to that of any other teaching modality. OBJECTIVE The main objective of this study was to measure the impact of a learning program via WhatsApp on clinical reasoning in medical residents. METHODS This prospective, randomized, multicenter study was conducted among first- and second-year anesthesiology residents (offline recruitment) from four university hospitals in France. Residents were randomized in two groups of online teaching (WhatsApp and control). The WhatsApp group benefited from daily delivery of teaching documents on the WhatsApp app and a weekly clinical case supervised by a senior physician. In the control group, residents had access to the same documents via a traditional computer electronic learning (e-learning) platform. Medical reasoning was self-assessed online by a script concordance test (SCT; primary parameter), and medical knowledge was assessed using multiple-choice questions (MCQs). The residents also completed an online satisfaction questionnaire. RESULTS In this study, 62 residents were randomized (32 to the WhatsApp group and 30 to the control group) and 22 residents in each group answered the online final evaluation. We found a difference between the WhatsApp and control groups for SCTs (60% [SD 9%] vs 68% [SD 11%]; P=.006) but no difference for MCQs (18/30 [SD 4] vs 16/30 [SD 4]; P=.22). Concerning satisfaction, there was a better global satisfaction rate in the WhatsApp group than in the control group (8/10 [interquartile range 8-9] vs 8/10 [interquartile range 8-8]; P=.049). CONCLUSIONS Compared to traditional e-learning, the use of WhatsApp for teaching residents was associated with worse clinical reasoning despite better global appreciation. The use of WhatsApp probably contributes to the dispersion of attention linked to the use of the smartphone. The impact of smartphones on clinical reasoning should be studied further.

International audience

International audience; BackgroundCytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is an emerging curative treatment option for patients with peritoneal carcinomatosis. It has a long-term survival benefit but is associated with high rates of morbidity, ranging from 12 % to 65 %, mainly due to infectious complications. We sought to evaluate the clinical relevance of routine intraoperative bacteriological sampling following CRS/HIPEC.Study designBetween November 2010 and December 2014, every patients receiving CRS/HIPEC were included. Three samples were routinely collected from standardized locations for intraperitoneal rinsing liquid bacteriological analysis (RLBA) after completion of HIPEC. The clinical and surgical features, bacteriological results, and short-term outcomes were retrospectively reviewed.ResultsThe overall mortality and morbidity rates were 5 and 45 %, respectively. Among the 75 included patients, 40 % (n = 30) had at least one positive bacterial culture. Risk factors for a positive culture were colorectal resection (adjusted hazard ratio [HR] = 3.072, 95 % CI 1.843–8.004; p = 0.009) and blood loss >1000 mL (HR = 4.272, 95 % CI 1.080–18.141; p = 0.031). Among 26 (35 %) patients with abdominal infectious complications, 13 (17 %) experienced isolated complications. A positive RLBA result was independently associated with abdominal infectious complications (HR = 5.108, 95 % CI 1.220–16.336; p = 0.024) and isolated abdominal infectious complications (HR = 4.199, 95 % CI 1.064–15.961; p = 0.04).ConclusionsForty percent of the RLBA samples obtained following CRS/HIPEC tested positive for bacteria. Bacterial sampling of rinsing liquid should be systematically performed. An aggressive and immediate antibiotic strategy needs to be evaluated.

Resume Cette vignette decrit une situation courante d’un patient admis en reanimation pour defaillance vitale et ayant plusieurs jeunes enfants qui, au bout de quelques jours, souhaitent venir le voir. Depuis quelques annees, les services de reanimation ont progressivement ouvert leurs portes aux familles. Si la plupart des soignants sont d’accord sur le principe de la visite des enfants, ils evoquent souvent des reticences liees a un manque de temps et/ou de preparation qui leur fait craindre de provoquer une souffrance psychologique chez l’enfant. Cette vignette evoque les benefices potentiels de l’accueil des enfants et aboutit a des propositions d’organisation pour faciliter la visite des enfants en reanimation.

Resume Les hypernatremies extremes en reanimation sont frequemment associees a un pronostic tres sombre ; et leur prise en charge therapeutique, lorsqu’elles s’accompagnent d’une insuffisance renale aigue anurique, n’est pas codifiee. Nous rapportons le cas d’un patient âge de 39 ans, hospitalise en reanimation pour un coma toxique, presentant une hypernatremie extreme hyperosmolaire (sodium 180 mmol/L, osmolarite 507 mOsm/L) associee a une insuffisance renale aigue anurique (uree 139,3 mmol/L, creatinine 748 μmol/L) et de nombreux autres troubles hydro-electrolytiques. Le traitement a consiste en l’administration de solutes hypotoniques associee a une epuration extra-renale par hemodiafiltration veino-veineuse continue utilisant un dialysat industriel des le premier jour d’hospitalisation. La vitesse de correction de la natremie a ete controlee par adaptation des apports hydro-sodes par voie intraveineuse aux prelevements biologiques pluriquotidiens. A j10, l’epuration extra-renale a ete arretee et l’examen neurologique realise etait normal. L’utilisation d’une hemodiafiltration veino-veineuse continue dans ce contexte d’hypernatremie extreme peut etre interessante car elle permet une correction progressive et facilement adaptable des desordres hydro-electrolytiques.

Background Establishing pre- and postoperative contact with patients is part of successful medical management in outpatient surgery. In France, this is mostly done via telephone. Automated information with short message service (SMS) reminders might be an interesting alternative to increase the rate of compliance with preoperative instructions, but no study has shown the safety of this approach. Objective The objective of this study was to evaluate the impact of pre- and postoperative automated information with SMS reminders on medical safety in outpatient surgery. Methods We conducted a retrospective, single-center, nonrandomized, controlled study with a before-after design. All adult patients who had outpatient surgery between September 2016 and December 2017 in our university hospital center were included. Before April 2017, patients were contacted by telephone by an outpatient surgery nurse. After April 2017, patients were contacted by SMS reminder. All patients were contacted the day before and the day after surgery. Patients contacted by SMS reminder were also contacted on day 7 after surgery. The primary end point was the conversion rate to full-time hospitalization. Secondary end points were hospitalization causes (anesthetic, surgical, organizational) and hospitalization costs. Results A total of 4388 patients were included, 2160 before and 2228 after the introduction of SMS reminders. The conversion rate to full-time hospitalization was 34/4388 (0.77%) with a difference between SMS group (8/2228, 0.36%) and telephone group (26/2160, 1.20%). The cost of SMS reminders was estimated as half that of telephone calls. Conclusions In this work, we report a decrease in the rate of conversion to full-time hospitalization with the use of pre- and postoperative SMS reminders. This new approach could represent a safe and cost-effective method in an outpatient surgery setting.

International audience; Purpose: Shortening the duration of antibiotic therapy (ABT) is a key measure in antimicrobial stewardship. The optimal duration of ABT for treatment of postoperative intra-abdominal infections (PIAI) in critically ill patients is unknown.Methods: A multicentre prospective randomised trial conducted in 21 French intensive care units (ICU) between May 2011 and February 2015 compared the efficacy and safety of 8-day versus 15-day antibiotic therapy in critically ill patients with PIAI. Among 410 eligible patients (adequate source control and ABT on day 0), 249 patients were randomly assigned on day 8 to either stop ABT immediately (n = 126) or to continue ABT until day 15 (n = 123). The primary endpoint was the number of antibiotic-free days between randomisation (day 8) and day 28. Secondary outcomes were death, ICU and hospital length of stay, emergence of multidrug-resistant (MDR) bacteria and reoperation rate, with 45-day follow-up.Results: Patients treated for 8 days had a higher median number of antibiotic-free days than those treated for 15 days (15 [6–20] vs 12 [6–13] days, respectively; P < 0.0001) (Wilcoxon rank difference 4.99 days [95% CI 2.99–6.00; P < 0.0001). Equivalence was established in terms of 45-day mortality (rate difference 0.038, 95% CI − 0.013 to 0.061). Treatments did not differ in terms of ICU and hospital length of stay, emergence of MDR bacteria or reoperation rate, while subsequent drainages between day 8 and day 45 were observed following short-course ABT (P = 0.041).Conclusion: Short-course antibiotic therapy in critically ill ICU patients with PIAI reduces antibiotic exposure. Continuation of treatment until day 15 is not associated with any clinical benefit

The aim of this study was to evaluate the feasibility of unilateral diaphragmatic reinnervation in humans by the inferior laryngeal nerve. This pilot study included chronically ventilated tetraplegic patients with destruction of phrenic nerve motoneurons. Five patients were included. They all had a high level of tetraplegia, with phrenic nerve motor neuron destruction. They were highly dependent on ventilation, without any possibility of weaning. They did not have other chronic pathologies, especially laryngeal disease. They all had diaphragmatic explorations to diagnose the destruction of the motoneurons of the phrenic nerves and nasoendoscopy to be sure that they did not have laryngeal or pharyngeal disease. Then, surgical anastomosis of the right phrenic nerve was performed with the inferior laryngeal nerve, by a cervical approach. A laryngeal reinnervation was performed at the same time, using the ansa hypoglossi. One patient was excluded because of a functional phrenic nerve and one patient died 6 months after the surgery of a cardiac arrest. The remaining three patients were evaluated after the anastomosis every 6 months. They did not present any swallowing or vocal alterations. In these three patients, the diaphragmatic explorations showed that there was a recovery of the diaphragmatic electromyogram of the right and left hemidiaphragms after 1 year. Two patients had surgical diaphragmatic explorations for diaphragmatic pacing 18–24 months after the reinnervation with excellent results. At 36 months, none of the patients could restore their automatic ventilation. In conclusion, this study demonstrated that diaphragmatic reinnervation by the inferior laryngeal nerve is effective, without any vocal or swallowing complications., Feasibility, safety and usefulness of phrenic neurotisation by the inferior laryngeal nerve in tetraplegic patients http://ow.ly/6S5s30fD2lf

Objective Despite recent efforts, most people are not trained in cardiopulmonary resuscitation (CPR), which has a major impact on survival following cardiac arrest (CA). We have set up a dispatcher-assisted CPR protocol at our call centre, based on international guidelines issued in 2010. The aim of our study was to evaluate the impact of this protocol on CA diagnosis and quantity of recommendations given by telephone dispatchers to untrained witnesses. Methods We performed a ‘before and after’ monocentric observational study. Data were compared before and a short time after (2 months) implementation of the protocol. We included patients presenting as an out-of-hospital CA in the presence of a witness untrained in CPR. Fisher's test was used to compare periods. P < 0.05 was considered significant. Results During the 8 month period before the protocol, 115 victims were potentially eligible for CPR. Diagnosis was achieved in 63.5% of cases and CPR recommendations given in 6.1%. After implementation of the protocol, 130 victims were potentially eligible for CPR. Frequency of CA diagnosis was significantly higher after the protocol with 76% of cases (P = 0.0359). Frequency of CPR recommendations given to witnesses was also significantly higher after the protocol, with a fivefold increase up to 29.2% (P < 0.0001). Conclusion Implementation of a dispatcher-assisted CPR protocol was efficient in improving both CA diagnosis and CPR recommendations given to untrained witnesses for out-of-hospital CA with a very short time of dispatcher training. It is a simple and efficacious measure, at no additional cost and with the promises of improving prognosis following cardiac arrest in a centre not equipped with computerised dispatcher support programmes.

La Presse Medicale - In Press.Proof corrected by the author Available online since mercredi 18 novembre 2015

IntroductionSevere trauma represents the leading cause of mortality worldwide. While 80% of deaths occur within the first 24 hours after trauma, 20% occur later and are mainly due to healthcare-associated infections, including ventilator-associated pneumonia (VAP). Preventing underinflation of the tracheal cuff is recommended to reduce microaspiration, which plays a major role in the pathogenesis of VAP. Automatic devices facilitate the regulation of tracheal cuff pressure, and their implementation has the potential to reduce VAP. The objective of this work is to determine whether continuous regulation of tracheal cuff pressure using a pneumatic device reduces the incidence of VAP compared with intermittent control in severe trauma patients.Methods and analysisThis multicentre randomised controlled and open-label trial will include patients suffering from severe trauma who are admitted within the first 24 hours, who require invasive mechanical ventilation to longer than 48 hours. Their tracheal cuff pressure will be monitored either once every 8 hours (control group) or continuously using a pneumatic device (intervention group). The primary end point is the proportion of patients that develop VAP in the intensive care unit (ICU) at day 28. The secondary end points include the proportion of patients that develop VAP in the ICU, early (≤7 days) or late (>7 days) VAP, time until the first VAP diagnosis, the number of ventilator-free days and antibiotic-free days, the length of stay in the ICU, the proportion of patients with ventilator-associated events and that die during their ICU stay.Ethics and disseminationThis protocol has been approved by the ethics committee of Poitiers University Hospital, and will be carried out according to the principles of the Declaration of Helsinki and the Good Clinical Practice guidelines. The results of this study will be disseminated through presentation at scientific conferences and publication in peer-reviewed journals.Trial registrationClinical TrialsNCT02534974

Blended learning, which combines internet-based platform and lecturing, is used in anaesthesiology and critical care teaching. However, the benefits of this method remain unclear.We conducted a prospective, multicentre, non-randomised work between 2007 and 2014 to study the effect of blended learning on the results of first year anaesthesia and critical care residents in comparison with traditional teaching. Blended learning was implemented in Rouen University Hospital in 2011 and residents affiliated to this university corresponded as the blended learning group. The primary outcome was the resident's results as measured with multiple-choice questions between blended learning and control groups after beginning blended learning (post-interventional stage). The secondary outcomes included residents' results between pre and post-interventional stages and homework's time. Moreover, comparison between control and blended learning group before beginning blended learning (pre-interventional stage) was performed.From 2007 to 2014, 308 residents were included. For the pre-interventional period, the mean score in the blended learning group (n=53) was 176 (CI 95% 163 to 188) whereas the mean score in the control group (n=106) was 167 (CI 95% 160 to 174) (no difference). For the post-interventional period, the mean score in blended learning group (n=54) was 232 on 300 (CI95% 227-237) whereas the mean score in the control group (n=95) is 215 (CI95% 209-220) (P0.001). In the two groups, comparison between pre and post-interventional stages showed the increase of mean score, stronger for blended learning group (32% and 28% in blended learning and control group, P0.05). The average time of homework in the blended learning group was 27h (CI 95% 18.2-35.8) and 10h in the control group (CI 95% 2-18) (P0.05).This work suggests the positive effect of blended learning (associating internet-based learning and flipped classroom) on the anaesthesia and critical care residents' knowledge by increasing their homework's time.

International audience; Conflicting results have been reported on the influence of Polymyxin-B hemoperfusion treatment on systemic inflammation markers. The aim of the study was to assess in a randomized control trial the influence on plasma cytokine concentrations of Polymyxin-B hemoperfusion in septic shock due to peritonitis. A panel of 10 pro- or anti-inflammatory cytokines was measured in 213 patients with peritonitis-induced septic shock enrolled in the randomized trial ABDOMIX testing the impact of 2 Polymyxin-B hemoperfusion sessions with standard treatment. Gram-negative bacteria were identified in 69% of patients. In the overall population, baseline plasma cytokine concentrations were not different between the two groups. Circulating tumor necrosis factor-α, interleukin (IL)-1β, IL-10, IL-6, and IL-1RA decreased significantly over time in both groups (P

La Presse Medicale - In Press.Proof corrected by the author Available online since lundi 26 mars 2018

Hyperthermic intraperitoneal chemotherapy (HIPEC) improves the survival of select patients with peritoneal carcinomatosis. Hemophagocytic syndrome (HS) is a rare and potentially fatal disease. We describe our experience with five patients who developed HS following oxaliplatin HIPEC and propose a management procedure. Hyperthermic intraperitoneal chemotherapy was performed using the open-abdomen technique (43 °C) with oxaliplatin (460 mg/m 2 ) for 30 min. If thrombocytopenia occurred from days 5 to 14, heparin-induced thrombocytopenia was evaluated. For thrombocytopenia with unknown etiology, we performed a bone marrow analysis (BMA). A BMA indicating HS stimulated an extensive infectious disease workup. Herein, we describe “reactive septic HS” and HS of unknown origin. We documented five patients with HS as a result of severe thrombocytopenia. Underlying infections were present in two patients who were treated with antibiotics and survived. For the remaining three patients, we found no underlying etiology of HS; multidisciplinary staff adapted the clinical management daily. Two patients died on postoperative days 40 and 29. The third patient survived after several operations and treatment with the VAC abdominal dressing system. We present these cases to ensure that physicians are aware of the symptoms of HS after HIPEC, which are important for initiating immediate life-saving therapy. This condition is a diagnostic and therapeutic emergency. When HS complicates HIPEC, aggressive, early medical, and surgical management is required. However, the optimal management has not been defined.

Background Existing methods to predict recovery after severe traumatic brain injury lack accuracy. The aim of this study is to determine the prognostic value of quantitative diffusion tensor imaging (DTI). Methods In a multicenter study, the authors prospectively enrolled 105 patients who remained comatose at least 7 days after traumatic brain injury. Patients underwent brain magnetic resonance imaging, including DTI in 20 preselected white matter tracts. Patients were evaluated at 1 yr with a modified Glasgow Outcome Scale. A composite DTI score was constructed for outcome prognostication on this training database and then validated on an independent database (n=38). DTI score was compared with the International Mission for Prognosis and Analysis of Clinical Trials Score. Results Using the DTI score for prediction of unfavorable outcome on the training database, the area under the receiver operating characteristic curve was 0.84 (95% CI: 0.75-0.91). The DTI score had a sensitivity of 64% and a specificity of 95% for the prediction of unfavorable outcome. On the validation-independent database, the area under the receiver operating characteristic curve was 0.80 (95% CI: 0.54-0.94). On the training database, reclassification methods showed significant improvement of classification accuracy (P < 0.05) compared with the International Mission for Prognosis and Analysis of Clinical Trials score. Similar results were observed on the validation database. Conclusions White matter assessment with quantitative DTI increases the accuracy of long-term outcome prediction compared with the available clinical/radiographic prognostic score.

Resume Objectifs La contusion pulmonaire (CP) est frequente chez le polytraumatise. L’objectif de l’etude etait de determiner les facteurs favorisants les surinfections bacteriennes de la CP et d’en effectuer une analyse microbiologique. Type d’etude Etude observationnelle retrospective. Patients et methodes Les dossiers des patients polytraumatises presentant une CP admis en reanimation chirurgicale au CHU de Rouen sur une periode de quatre ans ont ete analyses. Les patients presentant un traumatisme thoracique penetrant, ou decedes dans les 48 premieres heures de leur admission, etaient exclus. Le diagnostic d’infection pulmonaire etait pose devant l’association d’une hyperthermie et d’un prelevement bronchique mettant en evidence au moins un germe a une concentration de 103 UFC/mL. Apres analyse univariee, les variables significativement associees avec une valeur de p Resultats Cent dix-sept patients ont ete inclus et l’incidence des surinfections bacteriennes pulmonaires etait de 33,3 % (39 patients). Les germes les plus frequemment retrouves etaient par ordre de frequence Haemophilus sp., Staphylococcus aureus, les enterobacteries, Pseudomonas sp. et les streptocoques. En analyse multivariee, seule la presence d’une hypothermie a l’admission etait un facteur de risque independant d’infection de la CP (OR = 2,61 ; IC 95 % [4,2–13,3]). Conclusion La CP se surinfectait dans 33,3 % des cas et ce risque etait augmente par la presence d’une hypothermie a l’arrivee du patient. Une etude prospective est necessaire pour valider ces resultats.

Study Objective Clinical reasoning by anesthesiology residents in emergency situations where optimal management is uncertain could be improved by setting up a tutored practice exchange group. This study attempted to evaluate the impact of a practice exchange group (PEG), tutored by a senior anesthesiologist, on anesthesiology residents in emergency situations. Changes in clinical reasoning were measured by script concordance tests (SCT). Design We conducted a controlled, non-randomized study. Setting and Participants Participants are residents in anesthesiology in Rouen, Caen and Amiens University Hospitals. Interventions Two resident groups were made up without randomization. The first group was the control group and consisted of residents from Amiens University Hospital and Caen University Hospital. The second study group (PEG group) consisted of residents from Rouen University Hospital, who followed weekly PEG sessions. Two groups had the same learning objectives except the PEG. Measurements In both the control group and the study group, each resident's clinical reasoning was assessed in the same formal manner by SCT. The primary outcome measurement of this study was to compare SCT results in the study group with PEG training (PEG group) with those without (control group). Main results Performance in the SCT, expressed as degree of concordance with the expert panel (95% CI), was better in the PEG group (64% [62.1%-66%]) than in control group (60% [57.5%-62.8%])) ( P = .004). Conclusion Our study strongly suggests that an expert-directed, peer-conducted educational training program may improve the clinical reasoning of anesthesiology residents as measured by SCT.

Resume Objectif Decrire les conditions de la prise de decision d’admission et de non admission en reanimation par le medecin reanimateur. Type d’etude Etude de cohorte observationnelle non interventionnelle. Patients et methodes Analyse a posteriori des modalites de prise de decision concernant l’admission ou non des patients dans une unite de reanimation chirurgicale de CHU. La prise de decision dans les deux cohortes « admis » et « non admis » a ete comparee. Resultats Que ce soit lors d’une non-admission (149 decisions analysees) ou d’une admission (149 decisions analysees), le processus decisionnel etait peu different. L’instruction des dossiers etait consideree comme collegiale dans pres de 80 % des cas par le reanimateur en charge. La concertation precedant la decision faisait intervenir le plus souvent plusieurs intervenants, mais qui pouvaient etre des internes. La participation du patient et/ou de ses proches, comme celle des personnels paramedicaux etait rare. Aucune personne de confiance ni directive anticipee n’a ete citee. Plus de 50 % des decisions, quelle que soit la cohorte, sont prises dans un delai inferieur a 30 minutes. Les decisions de non admissions etaient jugees plus difficiles que les decisions d’admission. Leur tracabilite n’a pas ete systematique. Conclusions Ainsi, cette etude montre que dans sa forme actuelle les reanimateurs du service estiment que dans la majorite des cas l’instruction des dossiers a ete collegiale. Cependant, les conditions de seniorisation de la decision, le recueil d’avis du patient et/ou de ses proches et la tracabilite sont des pistes d’amelioration a mettre en œuvre dans certaines circonstances d’admission ou de non-admission.

Resume Introduction La mesure non invasive de la saturation pulsee en oxygene (SpO 2 ) est parfois perturbee au niveau des doigts en cas d’etat de choc. D’autres sites sont possibles (orteils, front, nez, oreille). Des capteurs digitaux standard autocollants, non prevus pour ces sites, sont neanmoins souvent utilises dans la pratique courante. Nous avons evalue leur fiabilite pour l’ensemble des sites de mesure. Methode Nous avons etudie des patients en etat de choc stabilise sous catecholamines vasoconstrictrices. Les SpO 2 « index », « orteil », « front », « nez » et « oreille » (capteurs standard autocollants) ont ete comparees a la saturation arterielle en oxygene (SaO 2 ) par la methode de Bland et Altman. La courbe de plethysmographie etait appreciee comme « correcte » ou « mal pulsee ». Resultats Nous avons inclus 110 patients (63 ± 15 ans, IGSII 46 ± 16, catecholamines : 0,6 ± 0,5 μg/kg par minute). Les courbes de plethysmographie sont plus souvent « bien pulsees » aux doigts (90 %) que pour les autres sites (50 a 70 %). Les biais sont negligeables pour tous les sites (−0,1 a +1,5 %). Les limites de concordance sont de ±5 % aux doigts et a l’orteil, mais atteignent jusqu’a ±15 % pour les sites faciaux. En restreignant l’analyse aux seules courbes de plethysmographie « bien pulsees », les limites de concordance etaient inchangees pour les doigts et orteils, et ameliorees (entre ±5 et ±10 %) pour les sites faciaux. Conclusion Chez les patients en etat de choc sous catecholamines, la fiabilite des mesures de SpO 2 avec des capteurs digitaux standard est meilleure au niveau des doigts qu’au niveau des orteils et des sites de mesure faciaux. Ces capteurs ne doivent pas etre utilises pour les sites faciaux du fait de leur faible fiabilite, y compris avec des courbes de plethysmographie apparemment correctes. Il existe des capteurs specifiquement dedies pour chacun des sites faciaux dont la fiabilite devrait etre testee chez les patients sous catecholamines.

Resume Objectif Creer un modele fiable et reproductible de contusion pulmonaire (CP) chez le rat pour evaluer l’influence de la CP sur la proliferation bacterienne intrapulmonaire. Type d’etude Experimentale. Animaux etudies Rats CD mâles albinos. Methode Les animaux ont ete anesthesies puis une CP a ete realisee au moyen d’une barre metallique montee sur ressort. L’existence d’une CP droite isolee a ete confirmee par analyse macroscopique, histologique et radiologique. Ce modele a ensuite ete utilise pour comparer quatre groupes randomises d’animaux. Ceux-ci etaient soit contus soit uniquement anesthesies puis inocules par voie endotracheale avec des concentrations de pneumocoque a 2 ou 4 Log(UFC/mL). Les poumons des animaux etaient preleves a 24 heures pour culture microbiologique quantitative. La variation du compte bacterien par gramme de poumon constituait le critere de jugement principal. Resultats Douze rats ont ete necessaires pour la validation du modele, 84 pour determiner sa morbi-mortalite et sa reproductibilite et 66 pour evaluer la proliferation bacterienne intrapulmonaire. La CP obtenue etait unilaterale et isolee dans 95 % des cas. La mortalite etait de 43 %. Pour un inoculum initial peu concentre (2 Log[UFC/mL]), il existe une proliferation bacterienne beaucoup plus importante dans le groupe contus par rapport au groupe non contus ( p = 0,0017). Cette difference n’a pas ete retrouvee lorsque l’inoculum etait plus concentre. Conclusion Ce modele experimental est fiable et reproductible. Sa mortalite initialement elevee semble diminuer avec l’experience des operateurs. La CP favorise significativement la proliferation bacterienne intrapulmonaire pour un inoculum faible. L’inoculum eleve gomme l’effet de la CP. Ces resultats suggerent qu’un renforcement des mesures de prevention des micro-inhalations pourrait etre benefique en cas de CP.

Objective.To establish whether continuous subglottic suctioning (CSS) could be cost-effective.Design.Cost-benefit analysis, based on a hypothetical replacement of conventional ventilation (CV) with CSS.Setting.A surgical intensive care unit (SICU) of a tertiary care university hospital in France.Patients.All consecutive patients receiving ventilation in the SICU in 2006.Methods.Efficacy data for CSS were obtained from the literature and applied to the SICU of our hospital. Costs for CV and CSS were provided by the hospital pharmacy; costs for ventilator-associated pneumonia (VAP) were obtained from the literature. The cost per averted VAP episode was calculated, and a sensitivity analysis was performed on VAP incidence and on the number of tubes required for each patient.Results.At our SICU in 2006, 416 patients received mechanical ventilation for 3,487 ventilation-days, and 32 VAP episodes were observed (7.9 episodes per 100 ventilated patients; incidence density, 9.2 episodes per 10,000 ventilation-days). Based on the hypothesis of a 29% reduction in the risk of VAP with CSS than CV, 9 VAP episodes could have been averted. The additional cost of CSS for 2006 was estimated to be €10,585.34. The cost per averted VAP episode was €1,176.15. Assuming a VAP cost of €4,387, a total of 3 averted VAP episodes would neutralize the additional cost. For a low VAP incidence of 6.6%, the cost per averted VAP would be €1,323. If each patient required 2 tubes during ventilation, the cost would be €1,383.69 per averted VAP episode.Conclusion.Replacement of CV with CSS was cost-effective even when assuming the most pessimistic scenario of VAP incidence and costs.

Resume Objectifs La prise de decision amenant a une admission ou non en reanimation est complexe. Il s’agit d’analyser avec un regard ethique le processus menant a un refus d’admission et ses consequences. Il est propose une mise en perspective au travers des principes de bienfaisance, non-malfaisance, justice, autonomie et de la loi Leonetti. Patients et methodes Etude prospective en reanimation chirurgicale au CHU de Rouen sur neuf mois (novembre 2007–septembre 2008). Recueil systematique pour chaque patient non admis des caracteres generaux, des modalites de la prise de decision, du devenir immediat et a 48 heures. Constitution de deux groupes : patients pour lesquels une admission en reanimation pourrait etre une situation d’obstination deraisonnable et patients pour lesquels une admission en reanimation ne serait pas de l’ordre du deraisonnable si elle survenait. Resultats Cent cinquante situations ont ete analysees. Le caractere potentiellement deraisonnable d’une admission n’entraine pas forcement une non-admission en reanimation. La question du manque de place et de l’equite dans l’acces aux soins est reelle mais relative en fonction de la typologie des patients. La recherche du respect de l’autonomie du patient est difficile mais pourrait etre facilitee. La loi Leonetti ne parait pouvoir etre qu’un cadre partiel a la situation de non-admission en reanimation. Conclusion Il ne s’agit pas d’aller vers une prise en charge systematique en reanimation de tout patient propose, mais de s’assurer que si non-admission il y a, qu’elle soit realisee selon une demarche ethiquement accepte.

Resume Objectif L’esperance de vie de la population augmentant, contrairement aux ressources en lits de reanimation, la question de l’admission du sujet âge en reanimation est de plus en plus frequente. Nous allons nous interesser au role de l’âge dans la prise de decision medicale. Patients et methodes Un questionnaire a ete envoye aux reanimateurs d’un meme departement, puis la cohorte des sujets refuses au sein d’une reanimation du CHU de ce meme departement a ete etudiee. Resultats L’âge arrive en troisieme place parmi les facteurs de refus d’admission cites. Il ne semble pas etre un critere redhibitoire de prise en charge en reanimation, mais plutot pousser a une evaluation plus approfondie du patient. Cette idee se traduit dans les questions ouvertes comme dans les mises en situation cliniques. L’âge module le recours a l’entree en reanimation. Il tend a s’integrer dans un procede global d’evaluation d’un patient, meme si le consensus n’est pas total... L’analyse de la cohorte des sujets refuses a montre un premier motif de refus qui est le manque de place. L’âge n’est pas cite. Conclusion L’âge ne semble pas etre un element determinant. Il ne peut resoudre la question qui est de savoir si l’admission en reanimation est pertinente ou non pour le patient propose. Plus que l’admission ou non d’un sujet eventuellement âge en reanimation, le probleme reside dans la resolution avec justesse du dilemme aigu qu’est la prise de decision d’admettre ou de refuser un patient quel qu’il soit au benefice de la personne.

Resume En 1999, la Societe francaise d’anesthesie et de reanimation (Sfar) a publie des recommandations sur la sedation a entreprendre au cours et au decours de l’intubation en milieu prehospitalier, en preconisant notamment l’induction en sequence rapide. Le but de cette etude etait de determiner l’impact de ces recommandations sur les pratiques. Patients et methode Il s’agit d’une etude clinique retrospective multicentrique. Les interventions de trois services mobiles d’urgence et de reanimation (Smur) ont ete analysees sur des periodes de quatre mois en 1998, 2000 et 2004. Tous les patients ayant beneficie d’une intubation endotracheale en dehors de l’arret cardiaque ont ete inclus. Les principaux criteres etudies etaient les protocoles d’induction et d’entretien de sedation, le motif d’intubation et la survenue d’evenements indesirables. Cette analyse de dossiers etait completee d’un questionnaire adresse aux medecins des trois Smur. Il visait a determiner leurs habitudes d’intubation, de sedation, leur connaissance de la conference d’experts et leur source d’actualisation des connaissances medicales. Resultats Cinq cent trente et un patients ont ete inclus. Parmi les patients intubes par voie orotracheale (84 %), le taux d’utilisation de l’induction en sequence rapide etait de 23 % en 1998, 45 % en 2000 et 68 % en 2004. L’entretien de la sedation etait conforme aux recommandations dans 45 % des cas en 1998, 68 % en 2000 et 75 % en 2004. Parmi les 62 medecins ayant repondu au questionnaire, 90 % realisent une induction en sequence rapide pour l’intubation orotracheale et 92 % declarent utiliser le protocole de sedation recommande ; 82 % declarent avoir lu le texte court de la conference. Conclusion Il existe une bonne adhesion des cliniciens aux conclusions de la conference d’experts de la Sfar sur la sedation en situation prehospitaliere.

Resume Objectif Evaluer le NT-proBNP comme marqueur biologique diagnostique de la dysfonction myocardique au cours du choc septique. Type d’etude Etude clinique prospective non randomisee avec consentement ecrit. L’analyse des donnees obtenues etait retrospective. Patients et methodes Tous les patients presentant un choc septique en debut d’evolution (moins de 24 heures) etaient inclus dans l’etude. Les patients ayant une pathologie chronique cardiaque, respiratoire, renale ou hepatique etaient exclus. Un dosage plasmatique de NT-proBNP et une echographie cardiaque par voie transthoracique etaient realises a l’inclusion. Les concentrations de NT-proBNP ont ete comparees aux donnees issues de l’echocardiographie. Resultats Trente-trois patients en choc septique ont ete inclus. Sur l’ensemble du collectif, 21 avaient une dysfonction cardiaque a l’echographie mais les concentrations de NT-proBNP n’etaient pas significativement differentes par rapport aux patients sans alteration echocardiographique (11 306 ± 16 196 pg/ml versus 10 697 ± 12 346 pg/ml). Apres exclusion des patients ayant une defaillance renale severe, le NT-proBNP etait augmente mais non significativement en cas de defaillance ventriculaire droite et/ou gauche (5751 ± 4180 pg/ml versus 1256 ± 999 pg/ml). Conclusion Le NT-proBNP pourrait en theorie contribuer a depister la part cardiogenique parfois impliquee dans le tableau de defaillance hemodynamique du choc septique. Cependant, du fait de l’influence de l’insuffisance renale et des defaillances d’organes frequemment associees et de leur impact probable sur sa synthese et son elimination, son usage ne peut etre recommande en pratique quotidienne dans le cadre nosologique du choc septique.

About fifty to sixty percent of patients with septic shock acquire acute adrenal insufficiency. This insufficiency is most often relative, but can sometimes be absolute. Bilateral adrenal haemorrhage is a rare aetiology of absolute acute adrenal insufficiency. It is classically described in patients with severe meningococcemia (purpura fulminans), who commonly present many of the risk factors associated with bilateral adrenal haemorrhage (shock, coagulation disorders, sepsis). We report a case of bilateral adrenal haemorrhage during a peritonitis complicated by a septic shock, with no coagulation disorder. This observation shows up that this bilateral adrenal haemorrhage can complicate severe sepsis of various origins, and not only severe meningococcemia. It can be suspected in face of a septic shock with an unfavourable evolution despite adequate treatment.

Despite recent efforts, most people are not trained in cardiopulmonary resuscitation (CPR), which has a major impact on survival following cardiac arrest (CA). We have set up a dispatcher-assisted CPR protocol at our call centre, based on international guidelines issued in 2010. The aim of our study was to evaluate the impact of this protocol on CA diagnosis and quantity of recommendations given by telephone dispatchers to untrained witnesses.We performed a 'before and after' monocentric observational study. Data were compared before and a short time after (2 months) implementation of the protocol. We included patients presenting as an out-of-hospital CA in the presence of a witness untrained in CPR. Fisher's test was used to compare periods. P0.05 was considered significant.During the 8 month period before the protocol, 115 victims were potentially eligible for CPR. Diagnosis was achieved in 63.5% of cases and CPR recommendations given in 6.1%. After implementation of the protocol, 130 victims were potentially eligible for CPR. Frequency of CA diagnosis was significantly higher after the protocol with 76% of cases (P = 0.0359). Frequency of CPR recommendations given to witnesses was also significantly higher after the protocol, with a fivefold increase up to 29.2% (P0.0001).Implementation of a dispatcher-assisted CPR protocol was efficient in improving both CA diagnosis and CPR recommendations given to untrained witnesses for out-of-hospital CA with a very short time of dispatcher training. It is a simple and efficacious measure, at no additional cost and with the promises of improving prognosis following cardiac arrest in a centre not equipped with computerised dispatcher support programmes.

Resume Objectif Le D-lactate est la forme dextrogyre du lactate habituellement dose en reanimation. Son origine bacterienne pourrait en faire un marqueur de translocation lors de l'ischemie digestive. Le but de l'etude a ete de tester le D-lactate comme marqueur de l'hypoperfusion colique lors de la chirurgie aortique. Type d'etude Etude prospective, observationnelle, ouverte. Patients et mesures Patients operes d'un anevrisme de l'aorte abdominale. Deux groupes de patients etaient constitues selon la pression residuelle de l'artere mesenterique inferieure (PrAMI) mesuree lors de l'operation : groupe hypoperfusion colique peroperatoire (HCop) : patients dont la PrAMI etait inferieure a 40 mmHg. Groupe temoin : patients dont la PrAMI etait superieure ou egale a 40 mmHg. Des donnees generales telles que l'âge, le temps de clampage aortique et l'indice de gravite simplifie (IGS II) ont ete recueillies. Le D-lactate etait dose apres l'operation : lors de l'admission du patient en reanimation puis quotidiennement jusqu'a sa sortie. Le D-lactatemax, definissait le taux de D-lactate le plus eleve parmi l'ensemble des prelevements realises pour un patient. Resultats Vingt-neuf patients ont ete inclus, 23 dans le groupe temoin, six dans le groupe HCop. Les groupes etaient comparables en termes de donnees generales. Le D-lactatemax du groupe HCop etait significativement plus eleve (mediane : 0,13 mmol/l ; min-max : 0,03–0,9 mmol/l) que celui du groupe temoin (0,03 ; 0–0,26 mmol/l, p = 0,007). Conclusion Le D-lactate pourrait etre un marqueur postoperatoire de l'hypoperfusion colique survenant pendant la chirurgie des anevrismes de l'aorte abdominale.

Objective: The clinical significance of Candida cultured from peritoneal fluid specimens remains a matter of debate. None of the studies that have addressed this issue have clearly distinguished between community-acquired peritonitis and nosocomial peritonitis. The current study tried to differentiate the pathogenic role of Candida in these two clinical settings and assess its importance on outcome. Design: A multiple-center, retrospective, case-control study was conducted in intensive care unit patients. The interaction between mortality rates and type of patients was assessed. In the case of a significant interaction, a separate analysis of mortality and morbidity was planned. Setting: Seventeen intensive care units in teaching and nonteaching hospitals. Patients: Cases were patients operated on for peritonitis with Candida cultured from the peritoneal fluid, whereas controls were operated patients free from yeast. Cases and controls were matched for type of infection, Simplified Acute Physiology Score II, age, and time period of hospitalization. Interventions: None. Measurements and Main Results: The following characteristics were collected: demographic variables, underlying disease, severity score, site of infection, microbiological features, and antiinfective treatments. Survival was defined as the main outcome criterion and morbidity variables as secondary criteria. Odds ratios of mortality were calculated. Matching was achieved in 91 cases and 168 controls. Matching criteria, clinical characteristics, and mortality rate were not statistically different between cases and controls. A significant interaction was demonstrated between mortality rates and type of infection, leading to separate analysis of patients with community-acquired peritonitis and nosocomial peritonitis. The subgroup analysis demonstrated an increased mortality rate only in nosocomial peritonitis with fungal isolates (48% vs. 28% in controls, p < .01). Upper gastrointestinal tract site (odds ratio, 4.9; 95% confidence interval, 1.6‐14.8) and isolation of Candida species (odds ratio, 3.0; 95% confidence interval, 1.3‐6.7, p < .001) were found to be independent risk factors of mortality in nosocomial peritonitis patients. Conclusions: Isolation of Candida species appears to be an independent risk factor of mortality in nosocomial peritonitis but not in community-acquired peritonitis. (Crit Care Med 2006; 34:646‐652)

Purpose To test whether the polymyxin B hemoperfusion (PMX HP) fiber column reduces mortality and organ failure in peritonitis-induced septic shock (SS) from abdominal infections. Method Prospective, multicenter, randomized controlled trial in 18 French intensive care units from October 2010 to March 2013, enrolling 243 patients with SS within 12 h after emergency surgery for peritonitis related to organ perforation. The PMX HP group received conventional therapy plus two sessions of PMX HP. Primary outcome was mortality on day 28; secondary outcomes were mortality on day 90 and a reduction in the severity of organ failures based on Sequential Organ Failure Assessment (SOFA) scores. Results Primary outcome: day 28 mortality in the PMX HP group (n = 119) was 27.7 versus 19.5 % in the conventional group (n = 113), p = 0.14 (OR 1.5872, 95 % CI 0.8583–2.935). Secondary endpoints: mortality rate at day 90 was 33.6 % in PMX-HP versus 24 % in conventional groups, p = 0.10 (OR 1.6128, 95 % CI 0.9067–2.8685); reduction in SOFA score from day 0 to day 7 was −5 (−11 to 6) in PMX-HP versus −5 (−11 to 9), p = 0.78. Comparable results were observed in the predefined subgroups (presence of comorbidity; adequacy of surgery

Introduction Recent work has shown that benzodiazepines interact with the immune system and exhibit anti-inflammatory effects. By using in vitro models, researchers in several studies have shown that the peptidergic endogenous ligands of benzodiazepine receptors, named endozepines, are involved in the immune response. All endozepines identified so far derive from diazepam-binding inhibitor (DBI), which generates several biologically active fragments. The aim of the present study was to measure plasma levels of DBI-like immunoreactivity (DBI-LI) in a rat model of sepsis and in patients with systemic inflammation from septic or non-septic origin. Methods Cecal ligation and puncture (CLP) or sham surgery was performed in rats. Blood samples were taken from animals, patients hospitalized for digestive surgery with inflammatory diseases, and healthy volunteers. Measurements of plasma DBI-related peptides were carried out by radioimmunoassay in animal and human samples. Results In the rats, CLP provoked an increase of plasma DBI-LI (+37%) 6 hours postsurgery. In humans, DBI-LI levels were significantly higher in the systemic inflammation group than in the healthy volunteer group (48.6 (32.7 to 77.7) pg/ml versus 11.1 (5.9 to 35.3) pg/ml, P

Resume Introduction. – Le transport intrahospitalier (TIH) d’un malade de reanimation ventile mecaniquement, l’expose a un risque accru de complications. Objectifs. – Le but de ce travail etait d’evaluer chez ces patients, l’incidence des complications survenant au cours des TIH et d’en analyser les causes et les consequences. Patients et methodes. – Tous les TIH de patients intubes et ventiles, hospitalises dans les services de reanimation medicale et chirurgicale d’un CHU, ont ete inclus de maniere prospective pendant trois mois. Les complications etaient classees en deux categories : celles liees au patient (desaturation, agitation, instabilite hemodynamique, extubation) ou au ventilateur (panne ou defaut du materiel). Resultats. – Au total, 123 TIH concernant 64 malades ont ete analyses parmi lesquels 64 TIH realises pour procedure diagnostique (tomodensitometrie) et 59 pour procedure therapeutique (bloc operatoire ou radiologie interventionnelle). Il est survenu au moins un probleme patient au cours de 41 transports (33 %) (desaturation n= 11, agitation n= 21, troubles hemodynamiques n= 19, extubation n= 0). Dans deux cas, ces complications ont evolue vers un arret cardiaque. L’incidence des problemes patients etait plus elevee lors des TIH de patients sedates (66 % p= 0,0001) et lors des TIH pour procedure diagnostique (p= 0,03). Un probleme machine est survenu au cours de 26 transports (21 %), plus frequemment avec les ventilateurs a turbine (p= 0,0056). Conclusion. – Cette etude confirme que le TIH de patients de reanimation ventiles mecaniquement est une procedure a haut risque de complications potentiellement severes. Ceci souligne l’interet des procedures standardisees de prise en charge et d’une medicalisation de la surveillance tout au long du deplacement.

Resume La mortalite des infections fulminantes chez le patient splenectomise est importante (50 a 80 %). L'infection a Capnocytophaga canimorsus, bacterie saprophyte de la cavite buccale des chiens et des chats, est une etiologie rare d'infection chez l'homme. Son pronostic est severe (30 % de mortalite), notamment chez le sujet splenectomise. Nous rapportons le cas d'un patient splenectomise ayant presente un choc septique communautaire d'evolution rapidement defavorable, attribue a une septicemie a C. canimorsus. Le diagnostic etiologique et le mode de contamination n'ont ete connus que plusieurs semaines apres le deces du patient. Ce diagnostic bacteriologique tardif est du a la croissance lente de C. canimorsus in vitro.

Background Hygienic hand disinfection using alcohol-based handrubs (AHRs) is an alternative method to conventional handwashing in hospital wards. Because a documented choice of such products would consider data from in-care evaluation, we designed a comparative study of 9 AHRs both in vitro and in vivo in actual care conditions. Methods The bactericidal activity of AHRs was first measured in vitro against 4 hospital strains exhibiting multiple antibiotic resistance: Acinetobacter baumannii, Staphylococcus aureus, Pseudomonas aeruginosa, and Enterobacter aerogenes . In a second time, AHRs were tested in an intensive care unit for antibacterial activity against the cutaneous flora of personnel hands and for acceptance by the care personnel. Results The 9 AHRs could be classified in 3 groups on the basis of their in vitro activity: products of the first group showed a bactericidal activity higher than 4 log 10 against the 4 strains. Only 1 of these products presented simultaneously an effective antibacterial activity against the cutaneous flora of care personnel hands and a good acceptance by the care personnel. Conclusion The in vitro study allowed the differentiation of the AHRs tested on the basis of bactericidal activity, but evaluation in an in-care situation allowed further discrimination through both antibacterial activity and acceptance. Thus, the combination of in vitro and in vivo evaluations should provide helpful arguments in the choice of AHRs.