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ABSTRACT: Rationale: Diaphragmatic insults occurring during intensive care unit (ICU) stays have become the focus of intense research. However, diaphragmatic abnormalities at the initial phase of critical illness remain poorly documented in humans. Objective: To determine the incidence, risk factors, and prognostic impact of diaphragmatic impairment on ICU admission. Methods: Prospective, six-month, observational cohort study in two ICUs. Mechanically ventilated patients were studied within 24 hours following intubation (day-1) and 48 hrs later (day-3). Seventeen anesthetized intubated control anesthesia patients were also studied. The diaphragm was assessed by twitch tracheal pressure (Ptr,stim) in response to bilateral anterior magnetic phrenic nerve stimulation. Main Results: Eighty-five consecutive patients aged 62 [54-75] (median [interquartile range]) were evaluated (medical admission 79%; SAPS II, 54 [44-68]). On day 1, Ptr,stim was 8.2 [5.9-12.3] cmH2O and 64% of patients had Ptr,stim <11cmH2O. Independent predictors of low Ptr,stim were sepsis (linear regression coefficient, -3.74; standard error, 1.16; p = 0.002) and SAPS II (linear regression coefficient, -0.07; standard error, 1.69; p = 0.03). Compared to non-survivors, ICU survivors had higher Ptr,stim (9.7 [6.3-13.8] vs. 7.3 [5.5-9.7] cmH2O, p=0.004). This was also true for hospital survivors vs. non-survivors (9.7 [6.3-13.5] vs. 7.8 [5.5-10.1] cmH2O, p=0.004). Day 1 and day 3 Ptr,stim were similar. Conclusions: A reduced capacity of the diaphragm to produce inspiratory pressure (diaphragm dysfunction) is frequent upon ICU admission. It is associated with sepsis and disease severity, suggesting that it may represent another form of organ failure. It is associated with a poor prognosis.
American Journal of Respiratory and Critical Care Medicine 05/2013; · 11.08 Impact Factor
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Noémie Clavieras,
Marc Wysocki,
Yannael Coisel,
Fabrice Galia,
Matthieu Conseil,
Gerald Chanques, Boris Jung,
Jean-Michel Arnal,
Stefan Matecki,
Nicolas Molinari,
Samir Jaber
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ABSTRACT: BACKGROUND:: Intellivent is a new full closed-loop controlled ventilation that automatically adjusts both ventilation and oxygenation parameters. The authors compared gas exchange and breathing pattern variability of Intellivent and pressure support ventilation (PSV). METHODS:: In a prospective, randomized, single-blind design crossover study, 14 patients were ventilated during the weaning phase, with Intellivent or PSV, for two periods of 24 h in a randomized order. Arterial blood gases were obtained after 1, 8, 16, and 24 h with each mode. Ventilatory parameters were recorded continuously in a breath-by-breath basis during the two study periods. The primary endpoint was oxygenation, estimated by the calculation of the difference between the PaO2/FIO2 ratio obtained after 24 h of ventilation and the PaO2/FIO2 ratio obtained at baseline in each mode. The variability in the ventilatory parameters was also evaluated by the coefficient of variation (SD to mean ratio). RESULTS:: There were no adverse events or safety issues requiring premature interruption of both modes. The PaO2/FIO2 (mean ± SD) ratio improved significantly from 245±75 at baseline to 294±123 (P = 0.03) after 24h of Intellivent. The coefficient of variation of inspiratory pressure and positive end-expiratory pressure (median [interquartile range]) were significantly higher with Intellivent, 16 [11-21] and 15 [7-23]%, compared with 6 [5-7] and 7 [5-10]% in PSV. Inspiratory pressure, positive end-expiratory pressure, and FIO2 changes were adjusted significantly more often with Intellivent compared with PSV. CONCLUSIONS:: Compared with PSV, Intellivent during a 24-h period improved the PaO2/FIO2 ratio in parallel with more variability in the ventilatory support and more changes in ventilation settings.
Anesthesiology 04/2013; · 5.36 Impact Factor
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ABSTRACT: INTRODUCTION: A quality-improvement project was conducted to reduce severe pain and stress-related events while moving ICU-patients. METHODS: The Plan-Do-Check-Adjust cycle was studied during four one-month phases, separated by five-month interphases. All consecutive patients staying more than 24 hours were evaluated every morning while being moved for nursing care (bathing, massage, sheet-change, repositioning). Phase 1 was considered as the baseline. Implemented and adjusted quality-interventions were assessed at phases 2 and 3, respectively. An independent post-intervention control-audit was performed at Phase 4. Primary-endpoints were the incidence of severe pain defined by a behavioral pain scale >5 or a 0 to 10 visual numeric rating scale >6, and the incidence of serious adverse events (SAE): cardiac arrest, arrhythmias, tachycardia, bradycardia, hypertension, hypotension, desaturation, bradypnea or ventilatory distress. Pain, SAE, patients' characteristics and analgesia were compared among the phases by a multivariate mixed-effects model for repeated-measurements, adjusted on severity index, age, admission type (medical/surgical), intubation and sedation status. RESULTS: During the four studied phases, 630 care procedures were analyzed in 53, 47, 43 and 50 patients, respectively. Incidence of severe pain decreased significantly from 16% (baseline) to 6% in Phase 3 (odds ratio (OR) = 0.33 (0.11; 0.98), P = 0.04) and 2% in Phase 4 (OR = 0.30 (0.12; 0.95), P = 0.02). Incidence of SAE decreased significantly from 37% (baseline) to 17% in Phase 3 and 21% in Phase 4. In multivariate analysis, SAE were independently associated with Phase 3 (OR = 0.40 (0.23; 0.72), P <0.01), Phase 4 (OR = 0.53 (0.30; 0.92), P = 0.03), intubation status (OR = 1.91 (1.28; 2.85), P <0.01) and severe pain (OR = 2.74 (1.54; 4.89), P <0.001). CONCLUSIONS: Severe pain and serious adverse events are common and strongly associated while moving ICU patients for nursing procedures. Quality improvement of pain management is associated with a decrease of serious adverse events. Careful documentation of pain management during mobilization for nursing procedures could be implemented as a health quality indicator in the ICU.
Critical care (London, England) 04/2013; 17(2):R74. · 4.61 Impact Factor
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ABSTRACT: ABSTRACT BACKGROUND: Obese patients are at risk of developing atelectasis and acute respiratory distress syndrome (ARDS). Prone position (PP) may reduce atelectasis, improves oxygenation and outcome in severe hypoxemic patients in ARDS, but little is known about its effect in obese ARDS patients. METHODS: Morbidly obese patients (body mass index (BMI)≥35kg/m2) in PP with ARDS (PaO2/FiO2 ratio≤200mmHg) were matched to non-obese (BMI<30kg/m2) ARDS patients in a case-control clinical study. The primary endpoints were safety and complications of PP; the second endpoints were the effect on oxygenation (PaO2/FiO2 ratio at the end of PP), length of mechanical ventilation and ICU stay, nosocomial infections and mortality. RESULTS: Between January 2005 and December 2009, 149 patients were admitted for ARDS. Thirty-three obese were matched with 33 non-obese patients. Median PP duration was 9(6-11) hours in obese patients and 8(7-12) hours in non-obese patients (P=0.28). We collected 51 complications, of which 25 in obese and 26 in non-obese patients. Number of patients with at least one complication was similar across groups (n=10, 30%). PaO2/FiO2 ratio increased significantly more in obese patients (from 118±43 to 222±84 mmHg) than in non-obese patients (from 113±43 mmHg to 174±80mmHg, P=0.03). Length of mechanical ventilation, ICU stay and nosocomial infections did not differ significantly, but mortality at 90 days was significantly lower in obese patients (27 vs 48%, P<0.05). CONCLUSIONS: PP seems safe in obese patients and may improve oxygenation more than in non-obese patients. Obese patients could be a subgroup of ARDS patients who may benefit the most of PP.
Chest 02/2013; · 5.25 Impact Factor
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ABSTRACT: INTRODUCTION: Protective ventilation using limited airway pressures and ventilation may result in moderate and prolonged hypercapnic acidosis, as often observed in critically ill patients. Because allow of moderate and prolonged hypercapnia may be considered as a protective measure for the lungs, we hypothesized that moderate and prolonged hypercapnic acidosis may protect diaphragm against ventilator induced diaphragmatic dysfunction (VIDD). The aim of our study was to evaluate the effects of moderate and prolonged (72-h of mechanical ventilation) hypercapnic acidosis on in-vivo diaphragmatic function. METHODS: Two groups of anesthetized piglets were ventilated during a 72-h period. Piglets were assigned to the Normocapnia group (n=6), ventilated in normocapnia, or to the Hypercapnia group (n=6), ventilated with moderate hypercapnic acidosis (PaCO2 from 55 to 70 mmHg) during the 72-h period of the study. Every 12h, we measured transdiaphragmatic pressure (Pdi) after bilateral, supramaximal trans-jugular stimulation of the two phrenic nerves to assess in vivo diaphragmatic contractile force. Pressure-frequency curves were drawn after stimulation from 20 to 120Hz of the phrenic nerves. The protocol was approved our institutional animal care committee's. RESULTS: Moderate and prolonged hypercapnic acidosis was well tolerated during the study period. The baseline pressure-frequency curves of the two groups were not significantly different (Pdi at 20 Hz = 32.7+/-8.7 vs. 34.4+/-8.4 cm H2O; and at 120 Hz = 56.8+/-8.7 vs. 60.8+/-5.7 cm H2O, for Normocapnia and Hypercapnia groups respectively). After 72-h of ventilation, Pdi decreased by 25% of its baseline value in the normocapnia group, whereas Pdi did not decrease in the hypercapnia group. CONCLUSION: Moderate and prolonged hypercapnic acidosis limited the occurrence of VIDD during controlled mechanical ventilation in a healthy piglet model. Consequences of moderate and prolonged hypercapnic acidosis should be better explored with further studies before being tested on patients.
Critical care (London, England) 01/2013; 17(1):R15. · 4.61 Impact Factor
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Audrey De Jong,
Nicolas Molinari,
Nicolas Terzi,
Nicolas Mongardon,
Jean-Michel Arnal,
Christophe Guitton,
Bernard Allaouchiche,
Catherine Paugam-Burtz,
Jean-Michel Constantin,
Jean-Yves Lefrant,
Marc Leone,
Laurent Papazian,
Karim Asehnoune,
Nicolas Maziers,
Elie Azoulay,
Gael Pradel, Boris Jung,
Samir Jaber
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ABSTRACT: RATIONALE: Difficult intubation in ICU is a challenging issue. OBJECTIVES: To develop and validate a simplified score for identifying patients with difficult intubation in ICU and to report related complications. METHODS: Data collected in a prospective multicenter-study from 1000 consecutive intubation from 42 ICU were used to develop a simplified score of difficult intubation, which was then validated externally in 400 consecutive intubation procedures from 18 other ICU and internally by bootstrap on 1000 iterations. MEASUREMENTS AND MAIN RESULTS: In multivariate analysis, the main predictors of difficult intubation (incidence=11.3%) were related to patient (Mallampati score III or IV, obstructive apnea syndrom, reduced mobility of cervical spline, limited mouth opening), to pathology (severe hypoxia, coma) and to operator (non-anesthesiologist). From the β-parameter, a 7-item simplified score (MACOCHA-score) was built, with an area under the curve (AUC) of 0.89 (95%-CI 0.85-0.94). In the validation cohort (prevalence of difficult intubation=8%), the AUC was of 0.86 (95%-CI 0.76-0.96), with a sensitivity of 73%, a specificity of 89%, a negative predictive value of 98% and a positive predictive value of 36%. After internal validation by bootstrap, the AUC was of 0.89 (95% CI 0.86-0.93). Severe life-threatening events (severe hypoxia, collapse, cardiac arrest or death) occurred in 38% of the 1000 cases. Patients with difficult intubation (n=113) had significantly higher severe life-threatening complications than those who had no difficult intubation (51%vs36%, p<0.0001). CONCLUSIONS: Difficult intubation in ICU is strongly associated with severe life-threatening complications. A simple score including seven clinical items provides good prediction of difficult intubation in ICU.
American Journal of Respiratory and Critical Care Medicine 01/2013; · 11.08 Impact Factor
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ABSTRACT: INTRODUCTION: Endotracheal intubation in the intensive care unit is associated with a high incidence of complications. Etomidate use is debated in septic shock because it increases the risk of critical illness-related corticosteroid insufficiency, which may impact outcome. We hypothesized that hydrocortisone, administered in all septic shock in our intensive care unit, and may counteract some negative effects of etomidate. The aim of our study was to compare septic shock patients who received etomidate vs another induction drug both on the short-term safety and the long-term outcomes. METHODS: Single-center observational study. Septic shock patients, treated with hydrocortisone, intubated within the first 48 hours of septic shock. Co-primary end points were life-threatening complications incidence occurring within the first hour after intubation and mortality during intensive care unit stay. Statistic analyses included unmatched and matched cohorts using a propensity score analysis. P<0.05 was considered significant. RESULTS: Sixty patients in the etomidate cohort and 42 in the non-etomidate cohort were included. Critical illness-related corticosteroid insufficiency was 79% in the etomidate cohort and 52% in the non-etomidate cohort (p=0.01). After intubation, life-threatening complications occurred in 36% of the patients whatever the cohort. After adjustment with propensity score analysis, etomidate was a protective factor for death in the intensive care unit both in unmatched (HR, 0.33 (0.15-0.75) (p<0.01)) and matched cohorts (HR, 0.33 (0.112, 0.988), p=0.04). CONCLUSIONS: In septic shock patients treated with hydrocortisone, etomidate did not decrease life-threatening complications following intubation, but when associated with hydrocortisone, did not impair outcome.
Critical care (London, England) 11/2012; 16(6):R224. · 4.61 Impact Factor
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Segolene Mrozek, Boris Jung,
Basil J Petrof,
Marion Pauly,
Stephanie Roberge,
Alain Lacampagne,
Cécile Cassan,
Jerome Thireau,
Nicolas Molinari,
Emmanuel Futier,
Valerie Scheuermann,
Jean Michel Constantin,
Stefan Matecki,
Samir Jaber
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ABSTRACT: Controlled mechanical ventilation is associated with ventilator-induced diaphragmatic dysfunction, which impedes weaning from mechanical ventilation. To design future clinical trials in humans, a better understanding of the molecular mechanisms using knockout models, which exist only in the mouse, is needed. The aims of this study were to ascertain the feasibility of developing a murine model of ventilator-induced diaphragmatic dysfunction and to determine whether atrophy, sarcolemmal injury, and the main proteolysis systems are activated under these conditions.
Healthy adult male C57/BL6 mice were assigned to three groups: (1) mechanical ventilation with end-expiratory positive pressure of 2-4 cm H2O for 6 h (n=6), (2) spontaneous breathing with continuous positive airway pressure of 2-4 cm H2O for 6 h (n=6), and (3) controls with no specific intervention (n=6). Airway pressure and hemodynamic parameters were monitored. Upon euthanasia, arterial blood gases and isometric contractile properties of the diaphragm and extensor digitorum longus were evaluated. Histology and immunoblotting for the main proteolysis pathways were performed.
Hemodynamic parameters and arterial blood gases were comparable between groups and within normal physiologic ranges. Diaphragmatic but not extensor digitorum longus force production declined in the mechanical ventilation group (maximal force decreased by approximately 40%) compared with the control and continuous positive airway pressure groups. No histologic difference was found between groups. In opposition with the calpains, caspase 3 was activated in the mechanical ventilation group.
Controlled mechanical ventilation for 6 h in the mouse is associated with significant diaphragmatic but not limb muscle weakness without atrophy or sarcolemmal injury and activates proteolysis.
Anesthesiology 07/2012; 117(3):560-7. · 5.36 Impact Factor
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Chest 06/2012; 141(6):1637-8; author reply 1638-9. · 5.25 Impact Factor
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Boris Jung,
Thomas Rimmele,
Charlotte Le Goff,
Gérald Chanques,
Philippe Corne,
Olivier Jonquet,
Laurent Muller,
Jean-Yves Lefrant,
Christophe Guervilly,
Laurent Papazian,
Bernard Allaouchiche,
Samir Jaber
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ABSTRACT: In this study, we sought describe the incidence and outcomes of severe metabolic or mixed acidemia in critically ill patients as well as the use of sodium bicarbonate therapy to treat these illnesses.
We conducted a prospective, observational, multiple-center study. Consecutive patients who presented with severe acidemia, defined herein as plasma pH below 7.20, were screened. The incidence, sodium bicarbonate prescription and outcomes of either metabolic or mixed severe acidemia were analyzed.
Among 2, 550 critically ill patients, 200 (8%) presented with severe acidemia, and 155 (6% of the total admissions) met the inclusion criteria. Almost all patients needed mechanical ventilation and vasopressors during their ICU stay, and 20% of them required renal replacement therapy within the first 24 hours of their ICU stay. Severe metabolic or mixed acidemia was associated with a mortality rate of 57% in the ICU. Delay of acidemia recovery as opposed to initial pH value was associated with increased mortality in the ICU. The type of acidemia did not influence the decision to administer sodium bicarbonate.
The incidence of severe metabolic or mixed acidemia in critically ill patients was 6% in the present study, and it was associated with a 57% mortality rate in the ICU. In contradistinction with the initial acid-base parameters, the rapidity of acidemia recovery was an independent risk factor for mortality. Sodium bicarbonate prescription was very heterogeneous between ICUs. Further studies assessing specific treatments may be of interest in this population.
Critical care (London, England) 10/2011; 15(5):R238. · 4.61 Impact Factor
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ABSTRACT: Pulmonary tuberculosis can lead to acute respiratory distress syndrome (ARDS) even in the absence of superinfection, and this condition requires mechanical ventilation. We describe herein the characteristics and outcomes of 8 patients with this association hospitalized in a French teaching hospital between 1997 and 2006.
Scandinavian Journal of Infectious Diseases 09/2011; 44(3):222-4. · 1.72 Impact Factor
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ABSTRACT: : Assessment and management of septic shock associated adrenal function remain controversial. The aim of this study was to explore the prognostic value of adrenal gland volume in adults with septic shock.
: A short cosyntropin test and determination of adrenal volume by computed tomography were performed within 48 h of shock in patients with septic shock (n = 184) and in 2 control groups: 40 ambulatory patients and 15 nonseptic critically ill patients. The primary endpoint was intensive care unit mortality.
: At intensive care unit discharge, 59 patients with septic shock died. Adrenal volume was 12.5 cm [95% CI, 11.3-13.3] and 8 cm [95% CI, 6.8-10.1] in the nonseptic group (P < 0.05 with both septic cohorts) and 7.2 cm [95%CI, 6.3-8.5] in the ambulatory patient group (P < 0.05 in patients with septic shock). In patients with septic shock, adrenal volume less than 10 cm was associated with higher 28-day mortality rates with an area under the receiver operating curve of 0.84 [95% CI, 0.78-0.89]. Adrenal volume above 10 cm was an independent predictor of intensive care unit survival (hazard ratio = 0.014; 95% CI [0.004-0.335]).
: A total adrenal gland volume less than 10 cm during septic shock was associated in univariate and multivariate analysis with mortality at day 28 in patients with septic shock. Whether adrenal gland volume can be a surrogate of adrenal gland function and used to guide hydrocortisone therapy in septic shock patients needs to be further investigated.
Anesthesiology 06/2011; 115(2):334-43. · 5.36 Impact Factor
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ABSTRACT: Diaphragmatic function is a major determinant of the ability to successfully wean patients from mechanical ventilation. However, the use of controlled mechanical ventilation in animal models results in a major reduction of diaphragmatic force-generating capacity together with structural injury and atrophy of diaphragm muscle fibers, a condition termed ventilator-induced diaphragmatic dysfunction (VIDD). Increased oxidative stress and exaggerated proteolysis in the diaphragm have been linked to the development of VIDD in animal models, but much less is known about the extent to which these phenomena occur in humans undergoing mechanical ventilation in the ICU. In the present review, we first briefly summarize the large body of evidence demonstrating the existence of VIDD in animal models, and outline the major cellular mechanisms that have been implicated in this process. We then relate these findings to very recently published data in critically ill patients, which have thus far been found to exhibit a remarkable degree of similarity with the animal model data. Hence, the human studies to date have indicated that mechanical ventilation is associated with increased oxidative stress, atrophy, and injury of diaphragmatic muscle fibers along with a rapid loss of diaphragmatic force production. These changes are, to a large extent, directly proportional to the duration of mechanical ventilation. In the context of these human data, we also review the methods that can be used in the clinical setting to diagnose and/or monitor the development of VIDD in critically ill patients. Finally, we discuss the potential for using different mechanical ventilation strategies and pharmacological approaches to prevent and/or to treat VIDD and suggest promising avenues for future research in this area.
Critical care (London, England) 03/2011; 15(2):206. · 4.61 Impact Factor
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Samir Jaber,
Basil J Petrof, Boris Jung,
Gérald Chanques,
Jean-Philippe Berthet,
Christophe Rabuel,
Hassan Bouyabrine,
Patricia Courouble,
Christelle Koechlin-Ramonatxo,
Mustapha Sebbane,
Thomas Similowski,
Valérie Scheuermann,
Alexandre Mebazaa,
Xavier Capdevila,
Dominique Mornet,
Jacques Mercier,
Alain Lacampagne,
Alexandre Philips,
Stefan Matecki
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ABSTRACT: Diaphragmatic function is a major determinant of the ability to successfully wean patients from mechanical ventilation (MV). Paradoxically, MV itself results in a rapid loss of diaphragmatic strength in animals. However, very little is known about the time course or mechanistic basis for such a phenomenon in humans.
To determine in a prospective fashion the time course for development of diaphragmatic weakness during MV; and the relationship between MV duration and diaphragmatic injury or atrophy, and the status of candidate cellular pathways implicated in these phenomena.
Airway occlusion pressure (TwPtr) generated by the diaphragm during phrenic nerve stimulation was measured in short-term (0.5 h; n = 6) and long-term (>5 d; n = 6) MV groups. Diaphragmatic biopsies obtained during thoracic surgery (MV for 2-3 h; n = 10) and from brain-dead organ donors (MV for 24-249 h; n = 15) were analyzed for ultrastructural injury, atrophy, and expression of proteolysis-related proteins (ubiquitin, nuclear factor-κB, and calpains).
TwPtr decreased progressively during MV, with a mean reduction of 32 ± 6% after 6 days. Longer periods of MV were associated with significantly greater ultrastructural fiber injury (26.2 ± 4.8 vs. 4.7 ± 0.6% area), decreased cross-sectional area of muscle fibers (1,904 ± 220 vs. 3,100 ± 329 μm²), an increase of ubiquitinated proteins (+19%), higher expression of p65 nuclear factor-κB (+77%), and greater levels of the calcium-activated proteases calpain-1, -2, and -3 (+104%, +432%, and +266%, respectively) in the diaphragm.
Diaphragmatic weakness, injury, and atrophy occur rapidly in critically ill patients during MV, and are significantly correlated with the duration of ventilator support.
American Journal of Respiratory and Critical Care Medicine 02/2011; 183(3):364-71. · 11.08 Impact Factor
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ABSTRACT: Unlike wards, where chronic and acute pain are regularly managed, comparisons of the most commonly used self-report pain tools have not been reported for the intensive care unit (ICU) setting. The objective of this study was to compare the feasibility, validity and performance of the Visual Analog Scale (horizontal (VAS-H) and vertical (VAS-V) line orientation), the Verbal Descriptor Scale (VDS), the 0-10 oral Numeric Rating Scale (NRS-O) and the 0-10 visually enlarged laminated NRS (NRS-V) for pain assessment in critically ill patients. One hundred and eleven consecutive patients admitted into a medical-surgical ICU were included as soon as they became alert and were able to follow simple commands. Pain was measured using the 5 scales in a randomized order upon enrollment-(T1) and after-(T2) administration of an analgesic or, in absence of pain upon enrollment, after a nociceptive procedure. The rate of any response obtained both at T1 and T2 (success rate) was significantly higher for NRS-V (91%) compared with NRS-O (83%), VDS (78%), VAS-H (68%) and VAS-V (66%). Pain intensity changed significantly between T1 and T2, showing a good validity and responsiveness for the 5 scales, which correlated well between each other. The negative predictive value calculated from true and false negatives defined by real and false absence of pain was highest for NRS-V (90%). In conclusion, the NRS-V should be the tool of choice for the ICU setting, because it is the most feasible and discriminative self-report scale for measuring critically ill patients' pain intensity.
Pain 12/2010; 151(3):711-21. · 5.78 Impact Factor
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ABSTRACT: Neurally adjusted ventilatory assist (NAVA) is a new mode of mechanical ventilation that delivers ventilatory assist in proportion to the electrical activity of the diaphragm. This study aimed to compare the ventilatory and gas exchange effects between NAVA and pressure support ventilation (PSV) during the weaning phase of critically ill patients who required mechanical ventilation subsequent to surgery.
Fifteen patients, the majority of whom underwent abdominal surgery, were enrolled. They were ventilated with PSV and NAVA for 24 h each in a randomized crossover order. The ventilatory parameters and gas exchange effects produced by the two ventilation modes were compared. The variability of the ventilatory parameters was also evaluated by the coefficient of variation (SD to mean ratio).
Two patients failed to shift to NAVA because of postoperative bilateral diaphragmatic paralysis, and one patient interrupted the study because of worsening of his sickness. In the other 12 cases, the 48 h of the study protocol were completed, using both ventilation modes, with no signs of intolerance or complications. The Pao2/Fio2 (mean ± SD) ratio in NAVA was significantly higher than with PSV (264 ± 71 vs. 230 ± 75 mmHg, P < 0.05). Paco2 did not differ significantly between the two modes. The tidal volume (median [interquartile range]) with NAVA was significantly lower than with PSV (7.0 [6.4-8.6] vs. 6.5 [6.3-7.4] ml/kg predicted body weight, P < 0.05).Variability of insufflation airway pressure, tidal volume, and minute ventilation were significantly higher with NAVA than with PSV. Electrical activity of the diaphragm variability was significantly lower with NAVA than with PSV.
Compared with PSV, respiratory parameter variability was greater with NAVA, probably leading in part to the significant improvement in patient oxygenation.
Anesthesiology 10/2010; 113(4):925-35. · 5.36 Impact Factor
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Boris Jung,
Jean-Michel Constantin,
Nans Rossel,
Charlotte Le Goff,
Mustapha Sebbane,
Yannael Coisel,
Gerald Chanques,
Emmanuel Futier,
Gerald Hugon,
Xavier Capdevila,
Basil Petrof,
Stefan Matecki,
Samir Jaber
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ABSTRACT: Contrary to adaptive support ventilation (ASV), prolonged totally controlled mechanical ventilation (CMV) results in the absence of diaphragm activity and causes ventilator-induced diaphragmatic dysfunction. Because maintaining respiratory muscles at rest is likely a major cause of ventilator-induced diaphragmatic dysfunction, ASV may prevent its occurrence in comparison with CMV. The aim of our study was to compare the effects of ASV with those of CMV on both in vivo and in vitro diaphragmatic properties.
Two groups of six anesthetized piglets were ventilated during a 72-h period. Piglets in the CMV group (n = 6) were ventilated without spontaneous ventilation, and piglets in the ASV group (n = 6) were ventilated with spontaneous breaths. Transdiaphragmatic pressure was measured after bilateral, supramaximal transjugular stimulation of the two phrenic nerves. A pressure-frequency curve was drawn after stimulation from 20 to 120 Hz of the phrenic nerves. Diaphragm fiber proportions and mean sectional area were evaluated.
After 72 h of ventilation, transdiaphragmatic pressure decreased by 30% of its baseline value in the CMV group, whereas it did not decrease in the ASV group. Although CMV was associated with an atrophy of the diaphragm (evaluated by mean cross-sectional area of both the slow and fast myosin chains), atrophy was not detected in the ASV group.
Maintaining diaphragmatic contractile activity by using the ASV mode may protect the diaphragm against the deleterious effect of prolonged CMV, as demonstrated both in vitro and in vivo, in healthy piglets.
Anesthesiology 06/2010; 112(6):1435-43. · 5.36 Impact Factor
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ABSTRACT: Induction of anaesthesia promotes collapse of dependent lung regions in both obese and nonobese patients. We hypothesized that end-expiratory lung volume (EELV) may be more sensitive than oxygenation to evaluate the effects of positive end-expiratory pressure (PEEP) after anaesthesia induction.
Forty patients (20 nonobese patients and 20 obese patients) were prospectively studied. After anaesthesia induction, PEEP was adjusted in a stepwise fashion [zero end-expiratory pressure (ZEEP), PEEP 5 cmH2O and PEEP 10 cmH2O]. At each step, we measured EELV, static elastance, gas exchange and dead space. Other than changing PEEP, respiratory settings were kept constant throughout.
Anaesthesia induction and ZEEP both lowered EELV by 39% in nonobese patients and 59% in obese patients (both P < 0.05), as well as oxygenation (P < 0.05). Compared with ZEEP, in nonobese patients, PEEP 5 cmH2O and PEEP 10 cmH2O improved EELV (+15 and +40%, respectively, P < 0.01) and elastance but not oxygenation. In obese patients, PEEP 10 cmH2O also improved EELV (49% vs. ZEEP and 30% vs. PEEP 5 cmH2O, P < 0.01), elastance and dead-space fraction, with no effect on oxygenation. PEEP-induced changes of EELV correlated with changes of elastance (r = 0.46, P = 0.003), but not with oxygenation.
After induction of anaesthesia, mechanical ventilation with ZEEP is associated with a profound reduction in EELV. PEEP improves efficiently EELV and respiratory mechanics, with no major effect on oxygenation. EELV may be a useful indicator to guide PEEP setting in the operating room.
European Journal of Anaesthesiology 06/2010; 27(6):508-13. · 2.23 Impact Factor
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Boris Jung,
Jean-Michel Constantin,
Nans Rossel,
Charlotte Le Goff,
Mustapha Sebbane,
Yannael Coisel,
Gerald Chanques,
Emmanuel Futier,
Gerald Hugon,
Xavier Capdevila,
Basil Petrof,
Stefan Matecki,
Samir Jaber
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ABSTRACT: Background: Contrary to adaptive support ventilation (ASV), prolonged totally controlled mechanical ventilation (CMV) results in the absence of diaphragm activity and causes ventilator-induced diaphragmatic dysfunction. Because main-taining respiratory muscles at rest is likely a major cause of ventilator-induced diaphragmatic dysfunction, ASV may prevent its occurrence in comparison with CMV. The aim of our study was to compare the effects of ASV with those of CMV on both in vivo and in vitro diaphragmatic properties.
Anesthesiology 05/2010; 112(6):1435-1443. · 5.36 Impact Factor
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ABSTRACT: Early and adequate treatment of ventilator-associated pneumonia (VAP) is mandatory to improve the outcome. The aim of this study was to evaluate, in medical ICU patients, the respective and combined impact of the Clinical Pulmonary Infection Score (CPIS), broncho-alveolar lavage (BAL) gram staining, endotracheal aspirate and a biomarker (procalcitonin) for the early diagnosis of VAP.
Prospective, observational study
A medical intensive care unit in a teaching hospital.
Over an 8-month period, we prospectively included 57 patients suspected of having 86 episodes of VAP.
The day of suspicion, a BAL as well as alveolar and serum procalcitonin determinations and evaluation of CPIS were performed.
Of 86 BAL performed, 48 were considered positive (cutoff of 10(4) cfu ml(-1)). We found no differences in alveolar or serum procalcitonin between VAP and non-VAP patients. Including procalcitonin in the CPIS score did not increase its accuracy (55%) for the diagnosis of VAP. The best tests to predict VAP were modified CPIS (threshold at 6) combined with microbiological data. Indeed, both routinely twice weekly performed endotracheal aspiration at a threshold of 10(5) cfu ml(-1) and BAL gram staining improved pre-test diagnostic accuracy of VAP (77 and 66%, respectively).
This study showed that alveolar procalcitonin performed by BAL does not help the clinician to identify VAP. It confirmed that serum procalcitonin is not an accurate marker of VAP. In contrast, microbiological resources available at the time of VAP suspicion (BAL gram staining, last available endotracheal aspirate) combined or not with CPIS are helpful in distinguishing VAP diagnosed by BAL from patients with a negative BAL.
European Journal of Intensive Care Medicine 03/2010; 36(5):790-8. · 5.17 Impact Factor
