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1. Impact of advance directives on the variability between intensivists in the decisions to forgo life-sustaining treatment

Author

Margot Smirdec, Mercé Jourdain, Virginie Guastella, Céline Lambert, Jean-Christophe Richard, Laurent Argaud, Samir Jaber, Kada Klouche, Anne Medard, Jean Reignier, Jean-Philippe Rigaud, Jean-Marc Doise, Russell Chabanne, Bertrand Souweine, Jeremy Bourenne, Julie Delmas, Pierre-Marie Bertrand, Philippe Verdier, Jean-Pierre Quenot, Cecile Aubron, Nathanael Eisenmann, Pierre Asfar, Alexandre Fratani, Jean Dellamonica, Nicolas Terzi, Jean-Michel Constantin, Axelle Van Lander, Renaud Guerin, Bruno Pereira, and Alexandre Lautrette

Subjects
Advance directives, Decisions to forgo life-sustaining treatment, ICU, Medical emergencies. Critical care. Intensive care. First aid, RC86-88.9
Abstract

Abstract Background There is wide variability between intensivists in the decisions to forgo life-sustaining treatment (DFLST). Advance directives (ADs) allow patients to communicate their end-of-life wishes to physicians. We assessed whether ADs reduced variability in DFLSTs between intensivists. Methods We conducted a multicenter, prospective, simulation study. Eight patients expressed their wishes in ADs after being informed about DFLSTs by an intensivist-investigator. The participating intensivists answered ten questions about the DFLSTs of each patient in two scenarios, referring to patients’ characteristics without ADs (round 1) and then with (round 2). DFLST score ranged from 0 (no-DFLST) to 10 (DFLST for all questions). The main outcome was variability in DFLSTs between intensivists, expressed as relative standard deviation (RSD). Results A total of 19,680 decisions made by 123 intensivists from 27 ICUs were analyzed. The DFLST score was higher with ADs than without (6.02 95% CI [5.85; 6.19] vs 4.92 95% CI [4.75; 5.10], p

Published
2020
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4. Impact of advance directives on the variability between intensivists in the decisions to forgo life-sustaining treatment

Author

Jean-Michel Constantin, Axelle Van Lander, Laurent Argaud, Jean-Christophe Richard, Bertrand Souweine, Céline Lambert, Renaud Guérin, Alexandre Fratani, Jean Dellamonica, Russell Chabanne, Jeremy Bourenne, Kada Klouche, Margot Smirdec, Nicolas Terzi, Pierre Asfar, Jean-Pierre Quenot, A Lautrette, Cécile Aubron, Philippe Verdier, Virginie Guastella, Pierre-Marie Bertrand, Anne Medard, Jean-Marc Doise, Nathanael Eisenmann, Samir Jaber, Bruno Pereira, Jean Reignier, Jean-Philippe Rigaud, Mercé Jourdain, Julie Delmas, CHU Clermont-Ferrand, Recherche translationnelle sur le diabète - U 1190 (RTD), Institut Pasteur de Lille, Réseau International des Instituts Pasteur (RIIP)-Réseau International des Instituts Pasteur (RIIP)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Lille-Centre Hospitalier Régional Universitaire [Lille] (CHRU Lille), Unité de Biostatistiques [CHU Clermont-Ferrand], Direction de la recherche clinique et de l’innovation [CHU Clermont-Ferrand] (DRCI), CHU Clermont-Ferrand-CHU Clermont-Ferrand, Service d'Anesthésie et de Soins Intensifs [Hôpital de la Croix-Rousse - HCL], Hôpital de la Croix-Rousse [CHU - HCL], Hospices Civils de Lyon (HCL)-Hospices Civils de Lyon (HCL), Hôpital Edouard Herriot [CHU - HCL], Hospices Civils de Lyon (HCL), Physiologie & médecine expérimentale du Cœur et des Muscles [U 1046] (PhyMedExp), Université de Montpellier (UM)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Centre National de la Recherche Scientifique (CNRS), Centre Hospitalier Régional Universitaire [Montpellier] (CHRU Montpellier), Hôtel-Dieu de Nantes, Centre hospitalier de Dieppe, Centre Hospitalier Chalon-sur-Saône William Morey, Hôpital de la Timone [CHU - APHM] (TIMONE), Centre Hospitalier Rodez, Centre Hospitalier de Cannes, Hôpital de Montluçon, Centre Hospitalier Universitaire de Dijon - Hôpital François Mitterrand (CHU Dijon), Centre Hospitalier Régional Universitaire de Brest (CHRU Brest), Centre Jean Perrin [Clermont-Ferrand] (UNICANCER/CJP), UNICANCER, Centre Hospitalier Universitaire d'Angers (CHU Angers), PRES Université Nantes Angers Le Mans (UNAM), Hopital Saint-Louis [AP-HP] (AP-HP), Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP), Centre Hospitalier Universitaire de Nice (CHU Nice), CHU Grenoble, Service d'Anesthésie réanimation [CHU Pitié-Salpêtrière], CHU Pitié-Salpêtrière [AP-HP], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU)-Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU), AutomédiCation aCcompagnement Pluriprofessionnel PatienT (ACCePPT), Université Clermont Auvergne [2017-2020] (UCA [2017-2020]), Laboratoire de Neurosciences Intégratives et Cliniques - UFC (EA 481) (NEURO), Université de Franche-Comté (UFC), Université Bourgogne Franche-Comté [COMUE] (UBFC)-Université Bourgogne Franche-Comté [COMUE] (UBFC), Laboratoire Microorganismes : Génome et Environnement (LMGE), Université Clermont Auvergne [2017-2020] (UCA [2017-2020])-Centre National de la Recherche Scientifique (CNRS), Centre de Recherche en Acquisition et Traitement de l'Image pour la Santé (CREATIS), Université Claude Bernard Lyon 1 (UCBL), Université de Lyon-Université de Lyon-Institut National des Sciences Appliquées de Lyon (INSA Lyon), Université de Lyon-Institut National des Sciences Appliquées (INSA)-Institut National des Sciences Appliquées (INSA)-Université Jean Monnet - Saint-Étienne (UJM)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Centre National de la Recherche Scientifique (CNRS), Modeling & analysis for medical imaging and Diagnosis (MYRIAD), Université de Lyon-Institut National des Sciences Appliquées (INSA)-Institut National des Sciences Appliquées (INSA)-Université Jean Monnet - Saint-Étienne (UJM)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Centre National de la Recherche Scientifique (CNRS)-Université Claude Bernard Lyon 1 (UCBL), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Montpellier (UM)-Centre National de la Recherche Scientifique (CNRS), Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU), Laboratoire de Neurosciences Intégratives et Cliniques - UFC (UR 481) (NEURO), Université de Lyon-Institut National des Sciences Appliquées (INSA)-Institut National des Sciences Appliquées (INSA)-Hospices Civils de Lyon (HCL)-Université Jean Monnet - Saint-Étienne (UJM)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Centre National de la Recherche Scientifique (CNRS), Université de Lyon-Institut National des Sciences Appliquées (INSA)-Institut National des Sciences Appliquées (INSA)-Hospices Civils de Lyon (HCL)-Université Jean Monnet - Saint-Étienne (UJM)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Centre National de la Recherche Scientifique (CNRS)-Université Claude Bernard Lyon 1 (UCBL), and MORNET, Dominique

Subjects
Adult, Male, medicine.medical_specialty, Critical Care, [SDV]Life Sciences [q-bio], Relative standard deviation, Decision Making, Intensivist, Critical Care and Intensive Care Medicine, Advance directives, 03 medical and health sciences, 0302 clinical medicine, Qualitative analysis, Life sustaining treatment, Physicians, Surveys and Questionnaires, medicine, Humans, 030212 general & internal medicine, Prospective Studies, Trial registration, Fear of pain, business.industry, Research, lcsh:Medical emergencies. Critical care. Intensive care. First aid, lcsh:RC86-88.9, Middle Aged, Decisions to forgo life-sustaining treatment, [SDV] Life Sciences [q-bio], 030228 respiratory system, Withholding Treatment, Emergency medicine, ICU, Female, France, business
Abstract

Background There is wide variability between intensivists in the decisions to forgo life-sustaining treatment (DFLST). Advance directives (ADs) allow patients to communicate their end-of-life wishes to physicians. We assessed whether ADs reduced variability in DFLSTs between intensivists. Methods We conducted a multicenter, prospective, simulation study. Eight patients expressed their wishes in ADs after being informed about DFLSTs by an intensivist-investigator. The participating intensivists answered ten questions about the DFLSTs of each patient in two scenarios, referring to patients’ characteristics without ADs (round 1) and then with (round 2). DFLST score ranged from 0 (no-DFLST) to 10 (DFLST for all questions). The main outcome was variability in DFLSTs between intensivists, expressed as relative standard deviation (RSD). Results A total of 19,680 decisions made by 123 intensivists from 27 ICUs were analyzed. The DFLST score was higher with ADs than without (6.02 95% CI [5.85; 6.19] vs 4.92 95% CI [4.75; 5.10], p p = 0.84). Inter-intensivist agreement on DFLSTs was weak with ADs (intra-class correlation coefficient: 0.28). No factor associated with DFLSTs was identified. A qualitative analysis of ADs showed focus on end-of-life wills, unwanted things and fear of pain. Conclusions ADs increased the DFLST rate but did not reduce variability between the intensivists. In the decision-making process using ADs, the intensivist’s decision took priority. Further research is needed to improve the matching of the physicians’ decision with the patient’s wishes. Trial registration ClinicalTrials.gov Identifier: NCT03013530. Registered 6 January 2017; https://clinicaltrials.gov/ct2/show/NCT03013530.

Published
2020

5. Investigator-initiated, multicentre, open-label, two-arm, randomised controlled trial comparing intubating conditions in 25° head-up position and supine: the InSize25 study protocol

Author

Anne-Sophie Falempin, Margot Smirdec, Fatima Binakdane, Bruno Pereira, and Jean-Etienne Bazin

Subjects
Supine position, medicine.medical_treatment, Laryngoscopy, Population, Video Recording, Anesthesia, General, intubation, law.invention, 25° head-up position, Anaesthesia, Head-Down Tilt, 03 medical and health sciences, 0302 clinical medicine, Randomized controlled trial, Informed consent, law, medicine, Protocol, Intubation, Intratracheal, Supine Position, Intubation, Humans, General anaesthesia, 030212 general & internal medicine, Airway Management, education, Hypoxia, Randomized Controlled Trials as Topic, education.field_of_study, medicine.diagnostic_test, business.industry, Tracheal intubation, view, General Medicine, anaesthetics, Research Design, Anesthesia, glottis, business, 030217 neurology & neurosurgery
Abstract

IntroductionDifficult airway management during tracheal intubation can lead to severe hypoxic sequelae. Routine intubation practice is to use a strict supine position, whereas a 25° head-up or reverse Trendelenburg position increases efficacy of preoxygenation, seems more comfortable for the anaesthetist and may also provide better intubation conditions in direct laryngoscopy. The 25° head-up position could be used for the whole population rather than only for obese patients, but there is no prospective randomised controlled trial with a robust design and large number of patients comparing strict supine against 25° intubation in operating room. The objective of the InSize25 study is to test the effect of these two patient positions on intubation conditions during laryngoscopy in scheduled surgery on non-obese patients.Methods and analysisInSize25 is an investigator-initiated, multicentre, open-label, two-arm, randomised controlled trial. The InSize25 study will randomise 1000 adult patients scheduled for surgery under general anaesthesia requiring intubation with neuromuscular-blocking drugs, candidates for direct laryngoscopy. The primary outcome variable is the view obtained during the first laryngoscopy without any external manipulation assessed using percentage of glottic opening. Important secondary outcomes are: Cormack-Lehane classification, number of attempts at laryngoscopy and at tracheal intubation, use of ancillary equipment (eg, bougies, alternative laryngoscope blades, videolaryngoscope) and manoeuvres (eg, laryngeal manipulation), comfort score for the anaesthetist, episodes of postinduction hypotension or desaturation and mechanical complications of intubation.Ethics and disseminationThe trial received appropriate approval from the ‘CPP Sud-Est II’ ethical review board. Informed consent is required. If the 25° head-up position proves superior for tracheal intubation without more complications, it may become the routine-standard intubation position rather than only for use with obese patients. The final results will be published in a peer-reviewed journal.Trial registration numberClinicaltrials.gov identifier (NCT03339141).

Published
2019

7. La communication non violente au bloc opératoire

Author

Mina Atrmouh, Margot Smirdec, Pôle de Médecine Périopératoire [CHU Clermont-Ferrand], CHU Gabriel Montpied [Clermont-Ferrand], and CHU Clermont-Ferrand-CHU Clermont-Ferrand

Subjects
03 medical and health sciences, 0302 clinical medicine, [SDV]Life Sciences [q-bio], 0502 economics and business, 05 social sciences, Emergency Medicine, 030212 general & internal medicine, Emergency Nursing, Psychology, 050203 business & management
Published
2018

8. Réversion des curares par la néostigmine : cohorte prospective française évaluant l'utilisation de l'atropine

Author

Gruel, Amandine, Faculté de Médecine - Clermont-Auvergne (FM - UCA), Université Clermont Auvergne (UCA), and Margot Smirdec

Subjects
Atropine, Néostigmine, Recommandations, Décurarisation, [SDV.MHEP]Life Sciences [q-bio]/Human health and pathology
Abstract

CONTEXTE : La curarisation résiduelle reste une cause évitable de morbidité au bloc opératoire.OBJECTIF : Évaluer les modalités d’administration de la néostigmine et de l’atropine et leurs répercussions sur les variables hémodynamiques classiquement monitorées lors de l’anesthésie générale.MÉTHODE : De janvier 2019 à octobre 2020, un questionnaire a été mis en ligne et diffusé aux 6395 médecins et 1898 internes d’Anesthésie Réanimation. Il s’intéressait au mode d’administration de la néostigmine, à l’utilisation systématique ou non de l’atropine et aux effets hémodynamiques observés.RÉSULTATS : Sur 1172 réponses recueillies, 860 réponses ont pu être analysées (73%). La néostigmine a été utilisée avec l’atropine dans 768 cas (91%) et sans atropine dans 74 cas (9%). L’incidence des effets indésirables était différente selon le mode et la vitesse d’administration de la néostigmine (261 (43%) en intraveineux direct, 98 (50%) en intraveineux lent à la seringue, 11 (27%) dans une poche de cristalloïdes). En présence d’atropine, 348 des réponses (45%) retrouvaient des effets indésirables contre 22 (29%) en l’absence d’atropine. Une tachycardie était retrouvée dans 321 cas (42%) des décurarisations avec atropine. Une bradycardie était retrouvée dans 37 réponses (4%).CONCLUSION : Malgré les recommandations en vigueur, l’atropine n’était pas toujours utilisée de façon systématique après l’administration de néostigmine. Lorsque l’atropine était utilisée, elle était associée à un nombre d’effets indésirables plus important.

Published
2021

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