Marie Thuong

AGENCE DE LA BIOMÉDECINE, Lutetia Parisorum, Île-de-France, France

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Publications (45)195.44 Total impact

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    ABSTRACT: Providing appropriate training of procedural skills to residents while ensuring patient safety through trainee supervision is a difficult and constant challenge. We sought to determine how effective and safe procedural skill acquisition is in French ICUs and to identify failure and complication risk factors. Multicenter prospective observational study. Invasive procedures performed by residents were recorded during two consecutive semesters. Eighty-four residents. Eighty-four residents. None. Number of invasive procedures performed, failure and complication rates, supervision, and assistance provided. Five thousand six hundred seventeen procedures were prospectively studied: 1,007 tracheal intubations, 1,272 arterial and 2,586 central venous catheter insertions, 457 fiberoptic bronchoscopies, and 295 chest tube insertions. During the semesters, residents performed a median of 10 intubations, 14 arterial catheter insertions, and 26 central venous catheter insertions. Complication rates were low, similar to those in the literature: 8.6% desaturation and 7.4% esophageal placement during intubation; 0.4% and 2.3% pneumothorax with jugular and subclavian central venous catheter insertions, respectively. We identified risk factors for failure and complications. Higher rates of failure and complications for intubation were associated with residents with no or little previous experience (p < 0.001); failure of internal jugular vein catheterization was associated with left-side insertion (p = 0.005) and absence of mechanical ventilation (p = 0.007). Supervision and assistance were more frequent at the beginning of the semester and for intubation and chest tube insertion. Finally, residents had less access to fiberoptic bronchoscopy and chest tube insertion. Procedural skills acquisition by residents in the ICU appears feasible and safe with complication rates comparable to what has previously been reported. We identified specific procedures and situations associated with higher failure and complication rates that could require proactive training. Questions still remain regarding minimal numbers of procedures to attain competence and how best to provide procedural training.
    Critical care medicine 11/2013; 42(4). DOI:10.1097/CCM.0000000000000049 · 6.15 Impact Factor
  • Néphrologie & Thérapeutique 09/2013; 9(5):262-263. DOI:10.1016/j.nephro.2013.07.146 · 0.55 Impact Factor
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    ABSTRACT: Liver transplantation has really been developing since the 1980s and represents today an efficient and widely recognized treatment of end stage liver disease and selected liver tumors. Regulations applied to liver transplantation are common to other organ transplantations and define precisely the organisation of procurement and transplantation activities. From the ethical point of view, specific issues need to be addressed. These issues regard essentially the difficulties of finding a compromise between equity in access to the graft and efficacy, as well as questions raised by the development of liver transplantation from living donors.
    Médecine & Droit 07/2013; 2013(121):125–134. DOI:10.1016/j.meddro.2013.03.001
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    ABSTRACT: The shortage of available donor lungs limits lung transplantation. In 2003, French transplant community set up a new definition of eligibility of lungs for transplantation (Table). In 2011, l’Agence de la biomedicine in collaboration with the transplant teams decided to extensively offer the lungs from extended criteria donors in order to improve utilization of potential lung donors. We report here the effect of this new policy on the number of multiorgan donors in whom lungs were offered and harvested as well as on patient survival.Methods and MaterialsAll brain dead donors (BDDr) from which at least 1 organ was retrieved in France between 2007 and 2011 were included. Descriptive analyses were performed with regard to lung proposal, lung non acceptance and lung procurement number. These descriptions were detailed according to donor category. The main causes for lung non-proposal and lung refusal were also collected. One-year graft survival was studied using Kaplan-Meier estimates.ResultsIn 2011 as compared to 2007 the number of BDDr whose lungs were proposed increased by 58%. This rise was exclusively due to a proposal increase in the ECD group. In the same time, the refusal rate increased slightly (74% in 2007 to 86% in 2011). Eventually the number of lung procured from ECD rose from 195 in 2007 to 297 in 2011, a 52% enhance over the period. One year survival rate was similar for specific donor types: 76% [68.5%-81.2%] for OD and 77% [72.8%-79.8%] for ECD; but was not measurable for CI donor due to small size.Conclusions This study demonstrates that an extensive lung offer policy may be associated with an enhanced use of potential donors with similar post transplantation survival.Optimal Donor (OD)Extended Criteria Donors (ECD)Marginal Donors (MD)*Age < 56 years+ 56 ≤ Age ≤ 70 years+ Age > 70 years* PaO2 > 400 mm Hg+ 200 ≤ PaO2 ≤ 400 mm Hg+ PaO2< 200 mm Hg*Normal chest Xray+ Abnormal chest Xray *No inhalation+ Inhalation *Non smoker *: And + : Or
    The Journal of Heart and Lung Transplantation 04/2013; 32(4):S154. DOI:10.1016/j.healun.2013.01.356 · 5.61 Impact Factor
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    ABSTRACT: La France a atteint un niveau d’activité de 4945 greffes en 2011 versus 200 greffes par an réalisées dans les années 1970 : ces greffes se répartissent en 2976 (60 %) greffes rénales, 1164 (24 %) greffes hépatiques, 398 (8 %) greffes cardiaques et 312 (6,3 %) greffes pulmonaires. Depuis 2008, cette croissance sans précédent s’est ralentie comme dans beaucoup de pays. La source en greffons pour près de 90 % des greffes est assurée par le recensement et le prélèvement des donneurs décédés en état de mort encéphalique (DDME), le reste de l’activité (essentiellement pour la greffe rénale) se partageant entre le don du vivant (10 %) et les donneurs décédés après arrêt cardiaque (DDAC) (2,2 %). Optimiser l’activité du recensement et du prélèvement à partir de DDME suppose un recensement le plus exhaustif possible du potentiel des donneurs en mort encéphalique, une baisse du taux de refus qu’il soit exprimé de son vivant ou par les proches au moment du don. Cette démarche doit être associée à l’analyse des disparités existant entre les régions. Le profil des donneurs s’est modifié du fait de l’épidémiologie des décès, du vieillissement de la population mais aussi d’une politique d’acceptation plus large des équipes de greffe. Les critères de prélevabilité ont évolué : le recours à des donneurs dits à critères élargis (DCE) a participé à la progression d’activité de greffe, essentiellement sur le critère d’âge. Cette stratégie est rendue possible sous la condition d’appariement spécifique entre donneur et receveur. Dans l’attente d’une définition plus précise des besoins qui passent par une meilleure connaissance de l’épidémiologie des insuffisances terminales d’organes, la réponse à la demande croissante (16 371 candidats à la greffe en 2011) nécessite de développer, parallèlement au DDME, les autres sources de greffons, que ce soit à partir d’un don du vivant ou du DDAC. La réflexion sur l’extension au DDAC de la catégorie III de Maastricht est engagée. Le programme de déploiement des machines à perfusion rénale, et dans un avenir proche la même application pour le poumon, le cœur et le foie, a pour objectif l’évaluation et la réhabilitation ex vivo des greffons prélevés permettant ainsi d’élargir le pool de greffons marginaux, autrefois écartés du don, tout en s’assurant de leur viabilité pour la greffe. Le plan greffe (2000–2003) a permis l’essor de la greffe en France. Afin de pouvoir insuffler un nouvel élan pour la greffe, les tutelles ont adopté le nouveau plan greffe en avril 2012.
    La Presse Médicale 03/2013; 42(3):295–308. DOI:10.1016/j.lpm.2012.05.018 · 1.17 Impact Factor
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    ABSTRACT: France has reached a pretty good level of activity, comparable to southern European countries: in 2011, 4945 transplantations (TX) have been performed among them, 2976 (60%) kidney TX, 1164 (24%) liver TX, 398 (8%) heart TX and 312 (6.3%) lung TX. However, the progression has slowed down since 2008 like in many countries. The potential of donors is mainly represented by the donor after brain-death (DBD) (90%), living donor (LD) for kidneys transplantation participates for only 10% of the overall kidney TX, and donor after cardiac death (DCD) activity, just started in 2006, for 2.2%. Current challenges to maximize the existing activity of DBD rely upon the implementation of program aimed to monitor deceased organ donation potential, a comprehensive approach of the regional disparities covering the steps of the detection of the potential donor, the rate of organ procurement and the refusal rate to organ donation. The profile of the donors has changed due to substantial epidemiologic shifts and a growing shortage of organs. The resource of expanded criteria donor (ECD) is widely used, mainly defined by a criteria of age. This policy is acceptable and successful under specific allocation scheme based on a donor-recipient matching. Before the TX needs of the population have been adequately met, the opportunities for improvement should be the development of DCD and LD activities, in addition to DBD activity. The extension to the DCD of the 3rd category of Maastricht is currently devised as a possible option for the future. The development of perfusion machine, available for kidney preservation and soon for the other organs is a new technical challenge that might increase the donor pool to previously discarded grafts. This superior and cost-effective method evaluated for ECD kidney preservation has also a potential of resuscitation and prediction of post-transplant outcome. To give a new launch to the TX activity as it was done in 2000, the Agency together with the professionals, has elaborated a "new action plan" for the next few years, which has been acted on April 2012 by the Minister of health.
    La Presse Médicale 07/2012; · 1.17 Impact Factor
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    ABSTRACT: Une analyse rétrospective de l’accès à la greffe rénale des malades selon leur nationalité ou leur lieu de résidence outre-mer, portant sur la période 2004–2008, a été menée dans la continuité d’une évaluation précédemment réalisée en 2006. Parmi les 14 732 patients inscrits en liste d’attente pendant cette période, 15,3 % sont de nationalité étrangère (3,4 % européenne, 5,9 % d’Afrique du Nord, 3,9 % d’Afrique subsaharienne et 2,9 % autres). Parmi les patients de nationalité française, 3,3 % sont domiciliés dans les départements d’outre-mer. Les malades inscrits en liste d’attente de greffe rénale et non originaires de la France métropolitaine présentent toujours des difficultés d’accès à la greffe, marquées par des durées d’attente prolongées, et ce, malgré l’amélioration constante des règles de répartition des greffons. Par comparaison à la médiane d’attente globale de cette cohorte de 17,6 mois, la médiane d’attente diffère de façon significative entre les différents groupes, allant de 15,7 mois pour les patients français à 36 mois pour les patients d’Afrique subsaharienne. Ces inégalités ne sont que partiellement expliquées par les difficultés d’appariement immunologique liées au groupe sanguin ABO ou à la difficulté d’appariement HLA. Il conviendrait dans l’avenir d’orienter la recherche vers d’autres facteurs explicatifs non médicaux et une approche sur les conditions socioéconomiques et l’accès au système de soins de ces patients.
    Bulletin de la Société de pathologie exotique 05/2012; 105(2). DOI:10.1007/s13149-012-0221-5
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    ABSTRACT: Major catheter-related infection includes catheter-related bloodstream infections and clinical sepsis without bloodstream infection resolving after catheter removal with a positive quantitative tip culture. Insertion site dressings are a major mean to reduce catheter infections by the extraluminal route. However, the importance of dressing disruptions in the occurrence of major catheter-related infection has never been studied in a large cohort of patients. A secondary analysis of a randomized multicenter trial was performed in order to determine the importance of dressing disruption on the risk for development of catheter-related bloodstream infection. Among 1,419 patients (3,275 arterial or central-vein catheters) included, we identified 296 colonized catheters, 29 major catheter-related infections, and 23 catheter-related bloodstream infections. Of the 11,036 dressings changes, 7,347 (67%) were performed before the planned date because of soiling or undressing. Dressing disruption occurred more frequently in patients with higher Sequential Organ Failure Assessment scores and in patients receiving renal replacement therapies; it was less frequent in males and patients admitted for coma. Subclavian access protected from dressing disruption. Dressing cost (especially staff cost) was inversely related to the rate of disruption. The number of dressing disruptions was related to increased risk for colonization of the skin around the catheter at removal (p < .0001). The risk of major catheter-related infection and catheter-related bloodstream infection increased by more than three-fold after the second dressing disruption and by more than ten-fold if the final dressing was disrupted, independently of other risk factors of infection. Disruption of catheter dressings was common and was an important risk factor for catheter-related infections. These data support the preferential use of the subclavian insertion site and enhanced efforts to reduce dressing disruption in postinsertion bundles of care.
    Critical care medicine 04/2012; 40(6):1707-14. DOI:10.1097/CCM.0b013e31824e0d46 · 6.15 Impact Factor
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    ABSTRACT: In France, foreign patients, whether resident or not in France, can register on the national waiting list under administrative and financial conditions. We performed a retrospective analysis to evaluate the access to kidney transplantation on a cohort 2004-2008, using the national registry. Among the 14,732 patients registered during this period, 15.3% are of non-French nationality (3.4% other European, 5.9% North African, 3.9% sub-Saharan African, 2.9% other). Among the 84.6% of French nationality, 3.3% are living in French overseas territories. Compared to the 17.6-month median waiting time of the cohort, median waiting time differs significantly between groups, from 15.7 months for mainland French patients to 36 months for sub-Saharan African patients. Despite the regular development of the allocation rules, these disparities in access to transplantation are mainly, but not completely, explained by blood group or HLA matching difficulties. After adjustment for the other factors known to be significantly linked to a difficult access to transplantation, North and sub-Saharan African patients have the worst difficulties. Future research should consider nonmedical factors, such as socio-economic or socio-cultural factors, potentially relevant to avoid disparities in access to transplantation and should aim at developing specific interventions.
    Bulletin de la Société de pathologie exotique 02/2012; 105(2):115-22.
  • C. Antoine, O. Scatton, M. Thuong
    01/2012; 7(1):1-8. DOI:10.1016/S1155-1976(12)70028-1
  • M. Thuong
    11/2011; 1(6). DOI:10.1007/s13341-011-0118-4
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    ABSTRACT: To test the effects of three multifaceted safety programs designed to decrease insulin administration errors, anticoagulant prescription and administration errors, and errors leading to accidental removal of endotracheal tubes and central venous catheters, respectively. Medical errors and adverse events are associated with increased mortality in intensive care patients, indicating an urgent need for prevention programs. Multicenter cluster-randomized study. One medical intensive care unit in a university hospital and two medical-surgical intensive care units in community hospitals belonging to the Outcomerea Study Group. Consecutive patients >18 yrs admitted from January 2007 to January 2008 to the intensive care units. We tested three multifaceted safety programs vs. standard care in random order, each over 2.5 months, after a 1.5-month observation period. Incidence rates of medical errors/1000 patient-days in the multifaceted safety program and standard-care groups were compared using adjusted hierarchical models. In 2117 patients with 15,014 patient-days, 8520 medical errors (567.5/1000 patient-days) were reported, including 1438 adverse events (16.9%, 95.8/1000 patient-days). The insulin multifaceted safety program significantly decreased errors during implementation (risk ratio 0.65; 95% confidence interval [CI] 0.52-0.82; p = .0003) and after implementation (risk ratio 0.51; 95% CI 0.35-0.73; p = .0004). A significant Hawthorne effect was found. The accidental tube/catheter removal multifaceted safety program decreased errors significantly during implementation (odds ratio [OR] 0.34; 95% CI 0.15-0.81; p = .01]) and nonsignificantly after implementation (OR 1.65; 95% CI 0.78-3.48). The anticoagulation multifaceted safety program was not significantly effective (OR 0.64; 95% CI 0.26-1.59) but produced a significant Hawthorne effect. A multifaceted program was effective in preventing insulin errors and accidental tube/catheter removal. Significant Hawthorne effects occurred, emphasizing the need for appropriately designed studies before definitively implementing strategies. clinicaltrails.gov Identifier: NCT00461461.
    Critical care medicine 09/2011; 40(2):468-76. DOI:10.1097/CCM.0b013e318232d94d · 6.15 Impact Factor
  • Néphrologie & Thérapeutique 09/2011; 7(5):403-403. DOI:10.1016/j.nephro.2011.07.302 · 0.55 Impact Factor
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    ABSTRACT: The renal transplantation is nowadays the reference treatment of ESRD. Living donor kidney transplantation is less often performed in France than in other countries. Nevertheless, numerous French and international surveys have evidenced that it provides the recipients a longer life expectancy and a better quality of life. Donors themselves, what do they become? How are they? For the first time in France, a survey has been implemented to investigate the quality of life of living kidney donor to one of their close relations. This study has been undertaken by the Agency of the biomedecine and the service Clinical Epidemiology and Evaluation (EEC), of the University teaching hospital of Nancy. The main objective was to describe the quality of life of the living donors having given a kidney for more than a year and less than 5 years. The secondary objective was to contribute to the knowledge of the main factors associated to the living kidney donor quality of life, one year after the donation. Participants had to be living in France at the time of the donation which had taken place between June 30(th), 2005 and March 1(st), 2009. A folder gathering various self-administrated questionnaires was sent to the place of residence of the donor between March and April, 2010. These data were completed by medical data collected near the transplantation centres by the Agency of biomedecine within the framework of the register CRISTAL. They included the characteristics of the donation and of the donor at the very time of the donation, 3 months after the donation and at the last annual assessment. Three living donors in four, that is 501 persons, agreed to fully participate. They constituted a representative national sample of all the living donors of this period. The non participants were younger (4.5 years on average) and had a less adequate annual follow-up. The women were more represented (61 %) than men. The median age was 53 years. More of 2/3 were employed at the time of the survey. The three main categories of donors were ascendants (36 %), collateral (33 %) and spouses (26%). The donation decision was taken without hesitation (94 %) and at an early stage of the evolution of the recipient renal disease (64 %). The delivered information was considered globally satisfactory except for the painful consequences and for the scar. The living donors were, long after their donation, in an excellent physical health state according to the SF36 summarized physical score and this especially when they were old as compared to the same age and sex general population. This phenomenon highlights the drastic selection of the potential donors. The only factor influencing the level of long term physical health was the surgical technique: the 261 subjects having undergone a coelioscopy had less often presented post operative pain (OR=0.5; 0.3-0.8; P<0.002) and had more often recovered completely without any residual pain (OR=1.7; 1.2-2.5; P<0.004). The quality of life mental dimension according to the SF36 summarized mental score was very close to that of the same age and sex of the general population although a slightly lower. It is influenced by characteristics related to the way the donation had been lived, particularly the understanding of their donation by their circle of acquaintances (average score 74.2/100), the perception of a feeling of owing on behalf of the recipient (46.5 %) and the fact of having lived a competition to be retained as the donor (for 266 cases another potential donor did exist and 21 lived the donation as a strong competition). More than 84 % of the donors was still followed by a healthcare professional at the time of the survey. The main expressed complaints concern the quality of the medical follow-up (70 donors expressed themselves openly on this topic) and the pain and scar after effects of the intervention. In spite of the surgical complications, of the dissatisfactions regarding their medical follow-up, of dismissals or of necessary adjustments of their professional life (13 %), of their difficulties to carry heavy loads, of sometimes complex relations with the recipient (23 % positive, 10 % negative) or their circle of acquaintances, of expenses non reimbursement and of losses of salary (12 %), they would be 95 % to recommend the donation and if it was to be redone 98 % would do it again! Benefits brought to the recipient won largely over the encountered difficulties. This retrospective and cross-sectional study allows to state recommendations which have to be confirmed by the 2009-2012 longitudinal study: to favour the coelioscopy which offers an advantage in terms of less frequent pain and a better post operative recovery, to better understand the phenomena of competition between potential and donors recipients, to improve the information about the potential consequences of the donation on the pain and on the scar, to inform the donor about the importance to associate the proxies with the decisionmaking or at least with the discussion and finally to improve the society recognition of the donation.
    Néphrologie & Thérapeutique 07/2011; 7 Suppl 1:S1-39. · 0.55 Impact Factor
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    ABSTRACT: The renal transplantation is nowadays the reference treatment of ESRD. Living donor kidney transplantation is less often performed in France than in other countries. Nevertheless, numerous French and international surveys have evidenced that it provides the recipients a longer life expectancy and a better quality of life. Donors themselves, what do they become? How are they? For the first time in France, a survey has been implemented to investigate the quality of life of living kidney donor to one of their close relations. This study has been undertaken by the Agency of the biomedecine and the service Clinical Epidemiology and Evaluation (EEC), of the University teaching hospital of Nancy. The main objective was to describe the quality of life of the living donors having given a kidney for more than a year and less than 5 years. The secondary objective was to contribute to the knowledge of the main factors associated to the living kidney donor quality of life, one year after the donation.Participants had to be living in France at the time of the donation which had taken place between June 30th, 2005 and March 1st, 2009. A folder gathering various self-administrated questionnaires was sent to the place of residence of the donor between March and April, 2010. These data were completed by medical data collected near the transplantation centres by the Agency of biomedecine within the framework of the register CRISTAL. They included the characteristics of the donation and of the donor at the very time of the donation, 3 months after the donation and at the last annual assessment.Three living donors in four, that is 501 persons, agreed to fully participate. They constituted a representative national sample of all the living donors of this period. The non participants were younger (4.5 years on average) and had a less adequate annual follow-up. The women were more represented (61 %) than men. The median age was 53 years. More of 2/3 were employed at the time of the survey. The three main categories of donors were ascendants (36 %), collateral (33 %) and spouses (26%).The donation decision was taken without hesitation (94 %) and at an early stage of the evolution of the recipient renal disease (64 %). The delivered information was considered globally satisfactory except for the painful consequences and for the scar. The living donors were, long after their donation, in an excellent physical health state according to the SF36 summarized physical score and this especially when they were old as compared to the same age and sex general population. This phenomenon highlights the drastic selection of the potential donors. The only factor influencing the level of long term physical health was the surgical technique: the 261 subjects having undergone a cœlioscopy had less often presented post operative pain (OR=0.5; 0.3–0.8; P
    Néphrologie & Thérapeutique 07/2011; 7. DOI:10.1016/S1769-7255(11)70007-4 · 0.55 Impact Factor
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    ABSTRACT: In France, the bioethic law of 2004 authorized the extension of the living donor (LD) pool to members of the extended family and any person justifying of a 2 year-long relationship. The number of living donor kidney transplantation (LDKT) increased until reaching a maximum of 246 grafts in 2006 (9% of total activity). Two years later, in 2008, LKG activity slowed down to 7.6% of the total activity (222 grafts). We analyzed all LDKT carried out in France since 2000 according to various indicators. In addition, a questionnaire was sent to renal transplant teams in order to identify potential causes for the decrease in LKG observed in France. From 2000 to 2006, over 1400 LDKT were performed in France. However, donor to recipient relations show that the large increase observed in 2006 was not linked to the extension of the LD pool. LDKT activity then started decreasing as soon as 2007. The questionnaire was sent back by 40/44 (91%) renal transplant teams. Their answers led to the identification of potential constrain impacting LDKT activity in France. Among these obstacles: workload and time-consuming to prepare the transplantation and the donor, ethical constrains and lack of appropriate communication and information delivered to the professionals. The important increase in LKG activity in 2006 is not clearly understood. However, several approaches to develop the activity in the next years have been identified.
    Néphrologie & Thérapeutique 02/2011; 7(7):535-43. DOI:10.1016/j.nephro.2011.01.001 · 0.55 Impact Factor
  • Marie Thuong
    Néphrologie & Thérapeutique 04/2010; 6(2):138-144. DOI:10.1016/j.nephro.2010.01.007 · 0.55 Impact Factor
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    ABSTRACT: Scheduled replacement of central venous catheters and, by extension, arterial catheters, is not recommended because the daily risk of catheter-related infection is considered constant over time after the first catheter days. Arterial catheters are considered at lower risk for catheter-related infection than central venous catheters in the absence of conclusive evidence. To compare the daily risk and risk factors for colonization and catheter-related infection between arterial catheters and central venous catheters. We used data from a trial of seven intensive care units evaluating different dressing change intervals and a chlorhexidine-impregnated sponge. We determined the daily hazard rate and identified risk factors for colonization using a marginal Cox model for clustered data. We included 3532 catheters and 27,541 catheter-days. Colonization rates did not differ between arterial catheters and central venous catheters (7.9% [11.4/1000 catheter-days] and 9.6% [11.1/1000 catheter-days], respectively). Arterial catheter and central venous catheter catheter-related infection rates were 0.68% (1.0/1000 catheter-days) and 0.94% (1.09/1000 catheter-days), respectively. The daily hazard rate for colonization increased steadily over time for arterial catheters (p = .008) but remained stable for central venous catheters. Independent risk factors for arterial catheter colonization were respiratory failure and femoral insertion. Independent risk factors for central venous catheter colonization were trauma or absence of septic shock at intensive care unit admission, femoral or jugular insertion, and absence of antibiotic treatment at central venous catheter insertion. The risks of colonization and catheter-related infection did not differ between arterial catheters and central venous catheters, indicating that arterial catheter use should receive the same precautions as central venous catheter use. The daily risk was constant over time for central venous catheter after the fifth catheter day but increased significantly over time after the seventh day for arterial catheters. Randomized studies are needed to investigate the impact of scheduled arterial catheter replacement.
    Critical care medicine 02/2010; 38(4):1030-5. DOI:10.1097/CCM.0b013e3181d4502e · 6.15 Impact Factor
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    ABSTRACT: : To build and validate a ventilator-associated pneumonia risk score for benchmarking. The rate of ventilator-associated pneumonia varies widely with case-mix, a fact that has limited its use for measuring intensive care unit performance. : We studied 1856 patients in the OUTCOMEREA database treated at intensive care unit admission by endotracheal intubation followed by mechanical ventilation for >48 hrs; they were allocated randomly to a training data set (n = 1233) or a validation data set (n = 623). Multivariate logistic regression was used. Calibration of the final model was assessed in both data sets, using the Hosmer-Lemeshow chi-square test and receiver operating characteristic curves. : Independent risk factors for ventilator-associated pneumonia were male gender (odds ratio = 1.97, 95% confidence interval = 1.32-2.95); SOFA at intensive care unit admission (<3 [reference value], 3-4 [2.57, 1.39-4.77], 5-8 [7.37, 4.24-12.81], >8 [5.81 (3.2-10.52)], no use within 48 hrs after intensive care unit admission of parenteral nutrition (2.29, 1.52-3.45), no broad-spectrum antimicrobials (2.11, 1.46-3.06); and mechanical ventilation duration (<5 days (); 5-7 days (17.55, 4.01-76.85); 7-15 days (53.01, 12.74-220.56); >15 days (225.6, 54.3-936.7). Tests in the training set showed good calibration and good discrimination (area under the curve-receiver operating characteristic curve = 0.881), and both criteria remained good in the validation set (area under the curve-receiver operating characteristic curve = 0.848) and good calibration (Hosmer-Lemeshow chi-square = 9.98, p = .5). Observed ventilator-associated pneumonia rates varied across intensive care units from 9.7 to 26.1 of 1000 mechanical ventilation days but the ratio of observed over theoretical ventilator-associated pneumonia rates was >1 in only two intensive care units. : The ventilator-associated pneumonia rate may be useful for benchmarking provided the ratio of observed over theoretical rates is used. External validation of our prediction score is needed.
    Critical care medicine 08/2009; 37(9):2545-51. DOI:10.1097/CCM.0b013e3181a38109 · 6.15 Impact Factor
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    ABSTRACT: Use of a chlorhexidine gluconate-impregnated sponge (CHGIS) in intravascular catheter dressings may reduce catheter-related infections (CRIs). Changing catheter dressings every 3 days may be more frequent than necessary. To assess superiority of CHGIS dressings regarding the rate of major CRIs (clinical sepsis with or without bloodstream infection) and noninferiority (less than 3% colonization-rate increase) of 7-day vs 3-day dressing changes. Assessor-blind, 2 x 2 factorial, randomized controlled trial conducted from December 2006 through June 2008 and recruiting patients from 7 intensive care units in 3 university and 2 general hospitals in France. Patients were adults (>18 years) expected to require an arterial catheter, central-vein catheter, or both inserted for 48 hours or longer. Use of CHGIS vs standard dressings (controls). Scheduled change of unsoiled adherent dressings every 3 vs every 7 days, with immediate change of any soiled or leaking dressings. Major CRIs for comparison of CHGIS vs control dressings; colonization rate for comparison of 3- vs 7-day dressing changes. Of 2095 eligible patients, 1636 (3778 catheters, 28,931 catheter-days) could be evaluated. The median duration of catheter insertion was 6 (interquartile range [IQR], 4-10) days. There was no interaction between the interventions. Use of CHGIS dressings decreased the rates of major CRIs (10/1953 [0.5%], 0.6 per 1000 catheter-days vs 19/1825 [1.1%], 1.4 per 1000 catheter-days; hazard ratio [HR], 0.39 [95% confidence interval {CI}, 0.17-0.93]; P = .03) and catheter-related bloodstream infections (6/1953 catheters, 0.40 per 1000 catheter-days vs 17/1825 catheters, 1.3 per 1000 catheter-days; HR, 0.24 [95% CI, 0.09-0.65]). Use of CHGIS dressings was not associated with greater resistance of bacteria in skin samples at catheter removal. Severe CHGIS-associated contact dermatitis occurred in 8 patients (5.3 per 1000 catheters). Use of CHGIS dressings prevented 1 major CRI per 117 catheters. Catheter colonization rates were 142 of 1657 catheters (7.8%) in the 3-day group (10.4 per 1000 catheter-days) and 168 of 1828 catheters (8.6%) in the 7-day group (11.0 per 1000 catheter-days), a mean absolute difference of 0.8% (95% CI, -1.78% to 2.15%) (HR, 0.99; 95% CI, 0.77-1.28), indicating noninferiority of 7-day changes. The median number of dressing changes per catheter was 4 (IQR, 3-6) in the 3-day group and 3 (IQR, 2-5) in the 7-day group (P < .001). Use of CHGIS dressings with intravascular catheters in the intensive care unit reduced risk of infection even when background infection rates were low. Reducing the frequency of changing unsoiled adherent dressings from every 3 days to every 7 days modestly reduces the total number of dressing changes and appears safe. clinicaltrials.gov Identifier: NCT00417235.
    JAMA The Journal of the American Medical Association 04/2009; 301(12):1231-41. DOI:10.1001/jama.2009.376 · 30.39 Impact Factor

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1k Citations
195.44 Total Impact Points

Institutions

  • 2010–2012
    • AGENCE DE LA BIOMÉDECINE
      Lutetia Parisorum, Île-de-France, France
  • 2007
    • University of Paris-Est
      La Haye-Descartes, Centre, France
  • 2003
    • Hôpital Bichat - Claude-Bernard (Hôpitaux Universitaires Paris Nord Val de Seine)
      • Service de Réanimation Médicale et des Maladies Infectieuses
      Lutetia Parisorum, Île-de-France, France